dissertation on sports injuries

Tools and Resources
Customer Services
Affective Science
Biological Foundations of Psychology
Clinical Psychology: Disorders and Therapies
Cognitive Psychology/Neuroscience
Developmental Psychology
Educational/School Psychology
Forensic Psychology
Health Psychology
History and Systems of Psychology
Individual Differences
Methods and Approaches in Psychology
Neuropsychology
Organizational and Institutional Psychology
Personality
Psychology and Other Disciplines
Social Psychology
Sports Psychology
Share This Facebook LinkedIn Twitter

Article contents

Psychological responses to sport injury.

Britton W. Brewer Britton W. Brewer Springfield College
https://doi.org/10.1093/acrefore/9780190236557.013.172
Published online: 24 May 2017

In addition to the disruptive impact of sport injury on physical functioning, injury can have psychological effects on athletes. Consistent with contemporary models of psychological response to sport injury, aspects of psychological functioning that can be affected by sport injury include pain, cognition, emotion, and behavior. Part of the fabric of sport and ubiquitous even among “healthy” athletes, pain is a common consequence of sport injury. Postinjury pain is typically of the acute variety and can be exacerbated, at least temporarily, by surgery and some rehabilitation activities. Cognitive responses to sport injury include appraising the implications of the injury for one’s well-being and ability to manage the injury, making attributions for injury occurrence, using cognitive coping strategies, perceiving benefits of injury, and experiencing intrusive injury-related thoughts and images, increased perception of injury risk, reduced self-esteem and self-confidence, and diminished neurocognitive performance. Emotional responses to sport injury tend to progress from a preponderance of negative emotions (e.g., anger, confusion, depression, disappointment, fear, frustration) shortly after injury occurrence to a more positive emotional profile over the course of rehabilitation. A wide variety of personal and situational factors have been found to predict postinjury emotions. In terms of postinjury behavior, athletes have reported initiating coping strategies such as living their lives as normally as possible, distracting themselves, seeking social support, isolating themselves from others, learning about their injuries, adhering to the rehabilitation program, pursuing interests outside sport, consuming alcohol, taking recreational and/or performance-enhancing substances, and, in rare cases, attempting suicide. Psychological readiness to return to sport after injury is an emerging concept that cuts across cognitive, emotional, and behavioral responses to sport injury.

sport injury
rehabilitation
consequences
psychological

Introduction

Inherent in sport participation is the risk of injury. Although the physical effects of sport injury (e.g., tissue damage, initiation of healing processes, increased body mass index and body fat percentage) are especially salient (Myer et al., 2014 ; Prentice, 2011 ), sport injury can also have psychological consequences. Aspects of psychological functioning that can be affected by sport injury include pain, cognition, emotion, behavior, and readiness to return to sport. These aspects can be considered in terms of theoretical, empirical, and practical perspectives.

Theoretical Perspectives

To describe and explain how athletes respond psychologically to injury, researchers have borrowed and, in some cases, adapted theories and models from other areas of psychology. For example, the most comprehensive attempt to represent psychological responses to sport injury and their antecedents conceptually—the integrated model of psychological response to sport injury (Wiese-Bjornstal, Smith, Shaffer, & Morrey, 1998 )—is based largely on principles from the literature on stress and coping (Lazarus & Folkman, 1984 ) and is an extension of several previously adapted models (e.g., Gordon, 1986 ; Weiss & Troxel, 1986 ). In the integrated model, sport injury is conceptualized as a stressor that athletes interpret (or “appraise”) in terms of its impact and their ability to deal with its effects. This cognitive appraisal process is thought to be influenced by a multitude of personal and situational factors. Personal factors include injury characteristics (e.g., severity, type) and individual difference variables in the psychological (e.g., personality, motivation, identity), demographic (e.g., age, gender), and physical (e.g., health status, eating behavior) domains. Situational factors pertain to aspects of the sport (e.g., level of competition, time of the competitive season), social (e.g., family dynamics, social support), and physical (accessibility to rehabilitation, comfort of rehabilitation sessions) environments. The resulting cognitive appraisals are posited to influence cognitive, emotional, and behavioral responses to sport injury, which are themselves proposed to be dynamic, reciprocally related, and potentially influential on injury recovery outcomes (Wiese-Bjornstal et al., 1998 ). Research has provided consistent support for predictions generated from the integrated model (for a review, see Brewer, 2007 ). Although the integrated model does not include pain and psychological readiness to return to sport, it could easily be expanded to do so.

Another group of models has adapted the widely known ideas of Kübler-Ross ( 1969 ) regarding adjustment to terminal illness to psychological responses to sport injury. Such grief-based “stage models” hold that athletes proceed through an invariant, predictable sequence of stages after injury. For example, several authors (Astle, 1986 ; Rotella, 1985 ) proposed that athletes display denial, anger, bargaining, depression, and, finally, acceptance after they become injured. Although athletes have exhibited grief-like reactions to serious injury (Macchi & Crossman, 1996 ) and tended to display more favorable psychological responses over time after injury (e.g., McDonald & Hardy, 1990 ; Smith, Scott, O’Fallon, & Young, 1990 ), the notion of an invariant series of psychological reactions to sport injury has not been supported by research (Brewer, 1994 ). As with the integrated model, stage models do not address pain and psychological readiness to return to sport.

Focused on the types of pain that athletes might encounter both before and after injury, Addison, Kremer, and Bell ( 1998 ) developed a model of sport-related pain that incorporates ideas from the gate control theory of pain (Melzack & Wall, 1965 ), the parallel processing model of pain (Leventhal & Everhart, 1979 ), and the literature on cognitive appraisal processes in stress and coping (Lazarus & Folkman, 1984 ). As specified in the model, which neatly dovetails with the integrated model of Wiese-Bjornstal et al. ( 1998 ), athletes experience postinjury pain when they interpret physiological sensations as indicating a threat to their health and ascribe the sensations to injury. Individual differences in age, attention to bodily symptoms, fitness, and physiology are thought to influence the detection of physiological sensations. Both intrinsic factors (e.g., affect, cognition, pain tolerance, personality) and extrinsic factors (e.g., culture, prior experience, social/situational context) are proposed to affect the appraisal process. The model holds that when athletes with injury appraise physiological sensations as pain due to their injury, their responses (e.g., reducing physical activity, seeking assistance, implementing a coping strategy) are subject to the influence of factors such as culture and motivation. Although the model is of potential utility in understanding pain after the occurrence of sport injury, research support for the model is scant.

One particular behavioral response to sport injury—adherence to sport injury rehabilitation—has been examined from a variety of theoretical perspectives. Because adherence to medical regimens has been a widely studied topic for many decades (Meichenbaum & Turk, 1987 ), investigators of adherence to sport injury rehabilitation have had numerous theories and models of adherence available to guide their research. Among the perspectives that have been applied in studies of sport injury rehabilitation are, in addition to the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998 ), personal investment theory (Maehr & Braskamp, 1986 ), protection motivation theory (Prentice-Dunn & Rogers, 1986 ), self-determination theory (Ryan & Deci, 2000 ), the transtheoretical model (Prochaska & DiClemente, 1983 ), and an adaptation of the theory of planned behavior (Levy, Polman, & Clough, 2008 ). In general, the perspectives have strong cognitive and motivational components, which is not surprising given the effort and persistence that adherence to sport injury rehabilitation programs can require.

Although psychological readiness to return to sport is a concept that is still being defined, it has not been completely atheoretical. In particular, it has been suggested that self-determination theory (SDT; Ryan & Deci, 2000 ) offers a viable explanation for why athletes might or might not be psychologically ready to return to sport after injury. Podlog and his colleagues (e.g., Podlog & Eklund, 2005 , 2007 ; Podlog, Lochbaum, & Stevens, 2010 ) have provided empirical support for the contention that, consistent with SDT, athletes can be considered less psychologically ready to return to sport when their basic psychological needs for competence, relatedness, and autonomy are not being satisfied than when those needs are being met.

Empirical Perspectives

Although the first empirical study on psychological responses to sport injury was conducted by Little ( 1969 ) more than a half-century ago, it wasn’t until the 1990s that a steady stream of empirical investigations began to appear in the literature. Over the past quarter-century, a sizable body of research on the topic has accumulated. The primary foci of scientific studies have varied over time, but pain, cognition, emotion, behavior, and readiness to return to sport have all been examined by investigators.

Pain is ubiquitous in sport. It not only can signal the occurrence of sport injury and feature in its aftermath, but it also can be a central aspect of sport training and competition. Reflecting the prominent role of pain in sport, scholars have investigated multiple aspects of the phenomenon in the context of sport. Research has progressed along four main lines of inquiry. One line of research has examined pain from a sociological perspective, yielding the important finding that sport is a culture in which athletes can be reinforced (or even glorified) for ignoring, denying, and playing through pain and injury (e.g., Hughes & Coakley, 1991 ; Nixon, 1992 ). Pain, therefore, appears to be a socially charged psychological response to sport injury that athletes may be discouraged from expressing, even to those responsible for treating the conditions that precipitated it (Safai, 2003 ; Walk, 1997 ).

A second line of research has compared athletes and nonathletes on laboratory measures of pain tolerance and pain threshold. Results of a meta-analysis of 15 studies indicated that (1) athletes had higher pain tolerance than nonathletes for cold, electrical, heat, ischemic, and pressure stimul; and (2) athletes had higher pain threshold than nonathletes for cold and pressure stimuli (Tesarz, Schuster, Hartmann, Gerhardt, & Eidt, 2012 ). The relevance of these findings for pain in response to sport injury, however, is not clear.

A third line of research has focused on assessing the prevalence and identifying anthropometric, biomechanical, strength, training, and, in rare cases, psychological predictors of pain in athletes. Many of the studies in this area of inquiry have examined pain in particular parts or regions of the body experienced by athletes participating in sports in which such pain is likely. For example, investigators have studied shoulder pain in swimmers (Walker, Gabbe, Wajswelner, Blanch, & Bennell, 2012 ); leg pain in cross country runners (Reinking, Austin, & Hayes, 2010 ); wrist pain in gymnasts (DiFiori, Puffer, Aish, & Dorey, 2002 ); knee pain in athletes across a variety of sports (Hahn & Foldspang, 1998 ); patellofemoral pain in basketball, soccer, and volleyball players (Myer et al., 2015 ); low back pain in cross country skiers, orienteers, and rowers (Foss, Holme, & Bahr, 2012 ); and pain in various body locations in cyclists (Dahlquist, Leisz, & Finkelstein, 2015 ). Although the methods and criteria used to examine pain have varied considerably across studies, prevalence rates in excess of 80% for at least mild pain have been documented (e.g., DiFiori et al., 2002 ; Reinking et al., 2010 ). Overall, the findings in this area of research attest to the ubiquity of pain in sport, but they do not have clear implications for understanding pain as a psychological response to injury because many of the participants who reported experiencing pain were not necessarily injured per se and, even when injured, may have been training as much as those who were not injured (Dahlquist et al., 2015 ).

The fourth main line of research has explored pain experienced by athletes after anterior cruciate ligament (ACL) reconstruction. In addition to examining associations of factors such as surgical procedures (Beck et al., 2004 ; Benea et al., 2014 ; Niki et al., 2012 ), anesthesia (Ekmekci et al., 2013 ), clinical variables (Niki et al., 2012 ), and cryotherapy (Raynor, Pietrobon, Guller, & Higgins, 2005 ) with postoperative pain, researchers have obtained descriptive data on the quality of pain over the first 48 hours postsurgery (Tripp, Stanish, Coady, & Reardon, 2004 ) and the intensity of pain over the first 6 weeks postsurgery (Brewer et al., 2007 ; Oztekin, Boya, Ozcan, Zeren, & Pinar, 2008 Tripp et al., 2004 ; Tripp, Stanish, Reardon, Coady, & Sullivan, 2003 ). Athletes’ endorsement of adjectives to describe their pain (e.g., sharp, tender, throbbing, aching, tiring, pulling) seems to change slightly from 24 to 48 hours postsurgery (Tripp et al., 2004 ), and pain intensity tends to decrease steadily from 24 hours to 6 weeks postsurgery (Brewer et al., 2007 ; Oztekin et al., 2008 ; Tripp et al., 2004 ). Pain intensity is higher for adolescents than adults at 24 hours postsurgery (Tripp et al., 2003 ) but is higher for older individuals than younger individuals over the first 6 weeks postsurgery (Brewer et al., 2007 ). Pain intensity is positively associated with anxiety at 24 hours postsurgery (Tripp et al., 2004 ) and negative mood over the first 6 weeks postsurgery (Brewer et al., 2007 ). In general, research in this line of inquiry is more concentrated on pain as a psychological response than that in the other three lines, but the narrow focus on a single type of injury and approach to treatment limits its generalizability. Thus, although the four lines of research have been informative, limitations with each of them preclude a thorough understanding of pain responses to sport injury.

As noted in the general section on theoretical perspectives, the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998 ) and earlier models emanating from the Lazarus and Folkman ( 1984 ) approach to stress and coping (e.g., Gordon, 1986 ; Weiss & Troxel, 1986 ) ascribe a temporally primary role to cognitive appraisals of the impact or personal relevance of sport injury in determining the cognitive, emotional, and behavioral responses that follow. In light of the physical damage induced by injury and the ramifications of that damage for subsequent sport participation, it is not surprising that interpretations of sport injury as threatening or involving harm or loss are common (Clement & Arvinen-Barrow, 2013 ; Ford & Gordon, 1999 ; Gould, Udry, Bridges, & Beck, 1997a ). Cognitive responses beyond the primary appraisals of the injury can be grouped into three potentially overlapping categories of cognitive content (i.e., injury-related, self-related, and coping-related) and one general category of cognitive processes.

Injury-related content

Given that sport injury is the kind of event that elicits the psychological responses addressed in this article, it is logical to expect the cognitive content of athletes with injuries to reflect their experiences and pertain at least partially to the injuries themselves. The unexpected nature of sport injuries may prompt athletes to engage in attributional thinking (Wong & Weiner, 1981 ) in which they attempt to identify the cause (or causes) of their injuries. A trio of studies identified behavioral factors (San José, 2003 ; Tedder & Biddle, 1998 ) and mechanical/technical factors (Brewer, 1999a ) as common explanations given by athletes for injury occurrence. In addition to cognitions about the causes(s) of their injuries, athletes have reported experiencing recurrent, distress-producing, recurrent, intrusive thoughts and images of the injury event (Newcomer & Perna, 2003 ; Shuer & Dietrich, 1997 ; Vergeer, 2006 ). Later, after the immediate impact of injury has passed, athletes have shown a propensity for experiencing more positively tinged cognitive content, reporting perceptions of benefits they have accrued as a result of their injuries (e.g., Ford & Gordon, 1999 ; Podlog & Eklund, 2006 ; Tracey, 2003 ; Udry, Gould, Bridges, & Beck, 1997 ; Wadey, Evans, Evans, & Mitchell, 2011 ). Common themes of the injury-related benefits identified by athletes include personal growth, psychologically based performance enhancement, and physical/technical development (Udry et al., 1997 ). After experiencing injury, athletes may also harbor negative cognitive content about their prospects with respect to future injury, reporting less confidence in their ability to avoid injury and higher levels of perceived risk of injury and worry about sustaining an injury than athletes without a recent injury (Reuter & Short, 2005 ; Short, Reuter, Brandt, Short, & Kontos, 2004 ).

Self-related content

For many athletes, injury threatens their involvement in a self-defining activity that serves as a significant source of self-worth (Brewer, Van Raalte, & Linder, 1993 ). Consequently, it is reasonable to expect that injury might have an impact on self-related cognitive content. Consistent with this notion, athletes have reported decreases in self-esteem after injury (Leddy, Lambert, & Ogles, 1994 ), increases in self-confidence and self-efficacy over the course of rehabilitation (Quinn & Fallon, 1999 ; Thomeé et al., 2007 ), and decreases in self-identification with the athlete role (Brewer, Cornelius, Stephan, & Van Raalte, 2010 ). Substantial changes in self-definition, which reflects how athletes think about themselves, have been reported by athletes with severe injuries (Vergeer, 2006 ).

Coping-related content

In taking an active role to deal with the adverse physical and psychological effects of injury, athletes have reported that they sometimes initiate cognitive coping strategies. Among the common themes of the cognitive content used by athletes to cope with injury are acceptance of injury, disengagement from injury, imagery, positive thoughts, and recovery (Bianco, Malo, & Orlick, 1999 ; Carson & Polman, 2008 , 2010 ; Gould, Udry, Bridges, & Beck, 1997b ; Ruddock-Hudson, O’Halloran, & Murphy, 2014 ; Tracey, 2003 ; Udry et al., 1997 ). It appears that the cognitive strategies deployed by athletes are at least in part influenced by the specific qualities of the injury-related stressors (e.g., physical symptoms, rehabilitation requirements) with which they are dealing, as the use of various coping strategies fluctuates over the course of rehabilitation (Johnston & Carroll, 2000 ; Udry, 1997 ) and differs as a function of whether athletes have chronic or acute injuries (Wasley & Lox, 1998 ).

The literature suggests that, in addition to affecting cognitive content, sport injury has an adverse effect on cognitive processes such as attention, memory, processing speed, and reaction time (Moser, 2007 ). Postinjury impairment of cognitive functioning has also been found for musculoskeletal injuries in one study (Hutchison, Comper, Mainwaring, & Richards, 2011 ), but not in another (Mrazik, Brooks, Jubinville, Meeuwisse, & Emery, 2016 ). Presumably, the intrusive images of injury occurrence (Shuer & Dietrich, 1997 ; Vergeer, 2006 ) noted in the section on injury-related content occupy some of the cognitive resources that would otherwise be devoted to processing other information and, along with postinjury emotional disturbance, may partially explain how musculoskeletal injuries might produce impaired cognitive functioning.

The largest share of research on the psychological consequences of sport injury has been devoted to emotional responses. Findings from an abundance of qualitative and quantitative studies have converged to produce a rich description of how athletes respond emotionally to injury and identify a variety of personal, situational, cognitive, and behavioral factors associated with those responses.

From a descriptive standpoint, athletes have tended to use a variety of negative terms (e.g., anger, bitterness, confusion, depression, fear, frustration, helplessness, shock) to characterize their emotions after injury (e.g., Bianco et al., 1999 ; Wadey, Evans, Hanton, & Neil, 2012a ). Although common, reports of negative emotions are not inevitable and may fluctuate widely over the course of the rehabilitation (Bianco et al., 1999 ; Carson & Polman, 2008 ; Johnston & Carroll, 1998 ). In general, however, there is evidence that athletes tend to report higher levels of emotional disturbance after sustaining an injury than they do before being injured (Appaneal, Levine, Perna, & Roh, 2009 ; Leddy, Lambert, & Ogles, 1994 ; Mainwaring et al., 2004 ; Mainwaring, Hutchinson, Biscchop, Comper, & Richards, 2010 ; Olmedilla, Ortega, & Goméz, 2014 ; Smith et al., 1993 ) and that athletes with injury tend to report higher levels of emotional disturbance than athletes without injury (Abenza, Olmedilla, & Ortega, 2010 ; Appaneal et al., 2009 ; Brewer & Petrie, 1995 ; Johnson, 1997 , 1998 ; Leddy et al., 1994 ; Mainwaring et al., 2004 ; Pearson & Jones, 1992 ; Smith et al., 1993 ). Estimates of the prevalence of athletes with injury who report clinically meaningful levels of emotional disturbance have ranged from 5 to 42% (Appaneal et al., 2009 ; Brewer, Linder, & Phelps, 1995 ; Brewer, Petitpas, Van Raalte, Sklar, & Ditmar, 1995 ; Brewer & Petrie, 1995 ; Garcia et al., 2015 ; Leddy et al., 1994 ; Manuel et al., 2002 ). Most of the psychological distress reported by athletes would be classified as “subclinical,” lacking the severity and/or duration to be considered a clinical condition.

In addition to the large body of research that has provided a thorough description of emotional responses to sport injury, numerous studies have investigated potential predictors of such responses. As proposed in the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998 ), associations have been documented between postinjury emotional responses and a wide variety of personal and situational factors (which presumably affect emotional responses through cognitive appraisals), cognitive responses, and behavioral responses (the latter of which will be discussed in the section on behavior that follows). Regarding personal factors, positive associations have been obtained between postinjury emotional disturbance and pain (Brewer et al., 2007 ), pain catastrophizing (Baranoff, Hanrahan, & Connor, 2015 ), neuroticism (Brewer et al., 2007 ), impairment in performing daily activities (Crossman & Jamieson, 1985 ), injury acuteness (Alzate, Ramírez, & Artaza, 2004 ; Brewer, Linder, & Phelps, 1995 ), injury severity (Alzate et al., 2004 ; Manuel et al., 2002 ; Smith, Scott, O’Fallon, & Young, 1990 ), self-identification with the athlete role (Baranoff et al., 2015 ; Brewer, 1993 ; Manuel et al., 2002 ), and investment in playing sports professionally (Kleiber & Brock, 1992 ). Negative association has been documented between postinjury emotional disturbance and age (Brewer, Linder, & Phelps, 1995 ; Smith, Scott, O’Fallon, & Young, 1990 ), hardiness (Wadey, Evans, Hanton, & Neil, 2012b ), injury recovery (McDonald & Hardy, 1990 ; Smith, Young, & Scott, 1988 ), and acceptance of uncomfortable experiences (Baranoff et al., 2015 ).

With respect to situational factors, the variable most consistently associated with postinjury emotional responses is the amount of time that has passed since occurrence of the injury. With the exception of a possible increase in the intensity of negative emotions and a decrease in the intensity of positive emotions at the end of rehabilitation with a return to sport looming (Morrey, Stuart, Smith, & Wiese-Bjornstal, 1999 ), negative emotions tend to decrease in intensity, and positive emotions tend to increase in intensity as time passes after injury (Appaneal et al., 2009 ; Brewer et al., 2007 ; Garcia et al., 2015 ; Leddy et al., 1994 ; Macchi & Crossman, 1996 ; Mainwaring et al., 2004 , 2010 ; Manuel et al., 2002 ; McDonald & Hardy, 1990 ; Olmedilla et al., 2014 ; Quinn & Fallon, 1999 ; Smith, Scott, O’Fallon, & Young, 1990 ). Other situational factors for which associations with high levels of emotional disturbance have been documented in multiple studies include high levels of life stress (Albinson & Petrie, 2003 ; Brewer, 1993 ; Brewer et al., 2007 ; Manuel et al., 2002 ) and low levels of both social support for rehabilitation (Brewer, Linder, & Phelps, 1995 ; Rees, Mitchell, Evans, & Hardy, 2010 ) and satisfaction with social support (Green & Weinberg, 2001 ; Manuel et al., 2002 ).

Cognitive responses related to greater postinjury emotional disturbance in athletes include perceptions of being unable to cope with injury (Albinson & Petrie, 2003 ; Daly, Brewer, Van Raalte, Petitpas, & Sklar, 1995 ), high levels of avoidance-focused (Gallagher & Gardner, 2007 ) and low levels of instrumental coping strategies (Wadey, Clark, Podlog, & McCullough, 2013 ), and causal attributions for sport injury occurrence (Brewer, 1999a ; Tedder & Biddle, 1998 ). Emotional disturbance was positively associated with attributing the cause of injury to internal factors in one study (Tedder & Biddle, 1998 ) but negatively associated with attributing the cause of injury to internal and stable factors in a second study (Brewer, 1999a ). Behaviors associated with athletes’ emotional responses to injury are identified next.

Because pain, cognition, and emotion can be readily concealed from view, behavior is undeniably the most overt psychological response to sport injury. Further, even though the behavior of athletes may reflect or be a manifestation of their experience of pain, cognitive, or emotional responses to injury, it is behavioral responses that have the greatest potential to affect the rehabilitation process. Some of the behaviors that athletes have reported themselves as engaging in after injury can be interpreted as attempts to cope with the challenges of the situation. For example, such active, instrumental, “problem-focused” coping behaviors as pursuing rehabilitation vigorously, learning about the injury, trying alternative treatments, building physical strength, and cultivating or enlisting social resources (Bianco et al., 1999 ; Gould et al., 1997b ; Johnston & Carroll, 2000 ; Quinn & Fallon, 1999 ; Ruddock-Hudson et al., 2014 ; Wadey et al., 2012a , 2012b ) tend to be deployed under conditions of elevated stress and mood disturbance (Albinson & Petrie, 2003 ) and conceivably can be of utility in helping athletes to recover from their injury and return to sport. Even some avoidant or “emotion-focused” coping behaviors such as distracting oneself (e.g., keeping busy, watching television) and isolating oneself from others (Bianco et al., 1999 ; Carson & Polman, 2010 ; Gould et al., 1997b ; Ruddock-Hudson et al., 2014 ; Wadey et al., 2012a , 2012b ) may be useful in the regulation of postinjury emotions (Carson & Polman, 2010 ). Other behavioral responses to sport injury, however, such as attempting suicide (Smith & Milliner, 1994 ), engaging in disordered eating (Sundgot-Borgen, 1994 ), consuming banned substances (National Collegiate Athletic Association, 2012 ), and drinking alcohol (Martens, Dams-O’Connor, & Beck, 2006 ) may have less adaptive consequences.

The behavioral response to sport injury that has garnered the most attention from investigators is adherence to rehabilitation. Considered vital to the success of sport injury rehabilitation programs (Fisher, Domm, & Wuest, 1988 ), adherence in this context refers to the extent to which athletes follow the prescribed course of treatment. The specific behaviors involved in adhering to rehabilitation vary substantially across the range of injuries that athletes incur, but some of the more common behavioral requirements of sport injury rehabilitation programs include “attending and actively participating in clinic-based rehabilitation appointments, avoiding potentially harmful activities, wearing therapeutic devices (e.g., orthotics), consuming medications appropriately, and completing home rehabilitation activities (e.g., exercises, therapeutic modalities)” (Brewer, 2004 , pp. 39–40). Although athletes engage in some of the rehabilitation behaviors in supervised clinical settings, they complete other of the behaviors at home, away from the direct oversight of rehabilitation professionals. The considerable variation in average adherence levels reported in research investigations (ranging from 40 to 91%, as reported in a review of the literature [Brewer, 1999b ]) is not surprising in light of the vast array of injuries, rehabilitation programs, clinical settings, and methods of assessment (e.g., self-report, practitioner rating, attendance log) that have been examined. Further complicating the estimation of adherence in the context of sport injury rehabilitation is that some highly motivated athletes may “overadhere” to their rehabilitation program by engaging in rehabilitation activities to a greater extent than recommended by the sports health care professional treating them (Niven, 2007 ; Podlog, Gao et al., 2013 ). Although such behavior is technically nonadherent, it is fundamentally different from failing to complete one or more aspects of a rehabilitation program.

Given the potential importance of adherence in achieving desired sport injury rehabilitation outcomes, investigators have attempted to identify factors associated with adherence to sport injury rehabilitation. As in the general medical literature, in which literally hundreds of predictors of treatment adherence have been identified (Meichenbaum & Turk, 1987 ), research has documented numerous correlates of sport injury rehabilitation adherence that can be grouped into the main conceptual categories of the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998 ). Examples of personal factors for which positive associations with sport injury rehabilitation adherence have been found in multiple studies include (perceived) injury severity (Grindley, Zizzi, & Nasypany, 2008 ; Taylor & May, 1996 ), athletic identity (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003b ; Brewer, Cornelius, Van Raalte, Tennen, & Armeli, 2013 ), pain tolerance (Byerly, Worrell, Gahimer, & Domholdt, 1994 ; Fields, Murphey, Horodyski, & Stopka, 1995 ; Fisher et al., 1988 ), and self-motivation (Brewer, Van Raalte, Cornelius et al., 2000 ; Duda, Smart, & Tappe, 1989 ; Fields et al., 1995 ; Fisher et al., 1988 ; Levy et al., 2008 ). With respect to situational factors, findings from multiple investigations have shown that athletes display higher levels of adherence to sport injury rehabilitation programs when they consider themselves as receiving support from others for their rehabilitation (Byerly et al., 1994 ; Duda et al., 1989 ; Fisher et al., 1988 ; Johnston & Carroll, 2000 ; Levy et al., 2008 ), perceive the clinic setting in which they do their rehabilitation as comfortable, and view their clinic-based rehabilitation appointments as conveniently scheduled (Fields et al., 1995 ; Fisher et al., 1988 ).

Several cognitive and emotional responses have also been found to predict adherence to sport injury rehabilitation programs across multiple studies. From a cognitive standpoint, athletes have demonstrated higher levels of adherence to rehabilitation when they report believing that their treatment will be effective (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003a ; Duda et al., 1989 ; Taylor & May, 1996 ), profess a strong intention to adhere to rehabilitation (Bassett & Prapavessis, 2011 ; Levy et al., 2008 ), and indicate that they are confident that they can cope with their injuries (Daly et al., 1995 ; Levy et al., 2008 ) and complete their rehabilitation program (Brewer, Cornelius, Van Raalte, Petitpas, Sklar et al., 2003a ; Levy et al., 2008 ; Taylor & May, 1996 ; Wesch et al., 2012 ). In terms of emotional responses, negative associations have been documented between mood disturbance and sport injury rehabilitation adherence (Alzate et al., 2004 ; Daly et al., 1995 ).

Psychological Readiness to Return to Sport

The lack of a universally accepted definition of psychological readiness to return to sport after injury has not prevented researchers from investigating the topic through two main approaches. One approach involves comparing athletes who return to sport after injury with those who do not return to sport after injury on psychological variables measured during or after rehabilitation. The other approach involves asking athletes who have returned to sport after injury to describe their experience of returning. Reviews of research in which the two approaches have been implemented have yielded a consistent set of psychological factors associated with athletes’ return to sport after injury (Ardern, Taylor, Feller, & Webster, 2013 ; Czuppon, Racette, Klein, & Harris-Hayes, 2014 ; Podlog & Eklund, 2007 ). Specifically, the empirical findings of prospective and retrospective studies have dovetailed, suggesting that factors involved in psychological readiness to return to sport after injury include a lack of fear or anxiety regarding reinjury, confidence in the injured body part and in one’s ability to perform, and intrinsic motivation to return to sport.

The consequences of an absence of psychological readiness to return to sport are not fully understood. Beyond being less likely to return to sport in the first place, athletes who are not psychologically ready to return to sport but do so anyway may be at increased risk for such consequences as injury (or reinjury), poor sport performance, and a lower quality sport experience. Prospective longitudinal research is needed to investigate these possibilities.

Practical Perspectives

From an applied standpoint, numerous interventions have been implemented to affect athletes’ psychological responses to sport injury. Common treatment approaches for pain differ somewhat from those for problematic cognitive, emotional, and behavioral responses, and treatments designed to enhance psychological readiness to return to sport have not been evaluated explicitly. Consequently, interventions to treat pain and improve psychological readiness to return to sport are discussed separately from the other three main types of psychological response and from each other.

An important aspect of postinjury pain among athletes is that it often can be escaped or reduced by ceasing, reducing, or modifying involvement in activities that produce or exacerbate the pain. For postinjury pain that is especially intense or long-lasting, formal pain management interventions can be initiated. Such interventions are likely to involve a combination of analgesic medications and physical therapies (Kolt, 2004 ). Aspirin, ibuprofen, and paracetamol (acetaminophen) are the analgesic medications most likely to be recommended, with opioids (e.g., codeine) and corticosteroids prescribed less frequently (Garnham, 2007 ). Physical therapies used to treat postinjury pain in athletes include electrophysical agents (e.g., transcutaneous electrical nerve stimulation [TENS], interferential electrical stimulation, ultrasound), manual techniques (e.g., massage, chiropractic manipulation), exercise, cryotherapy, heat, and acupuncture (Kolt, 2007 ; Snyder-Mackler, Schmitt, Rudolph, & Farquhar, 2007 ; Wadsworth, 2006 ). Although a wide variety of psychological techniques have been recommended to help athletes cope with postinjury pain (Kolt, 2004 , 2007 ), the effectiveness of such techniques in the context of sport injury has been evaluated in very few controlled experimental studies (Cupal & Brewer, 2001 ; Ross & Berger, 1996 ). The lack of research on psychological pain management techniques in sport injury rehabilitation suggests that the techniques are not implemented on a widespread basis in clinical settings.

Cognitive, Emotional, and Behavioral Responses

As for postinjury pain, many psychological interventions have been advocated to affect cognitive, emotional, and behavioral responses to sport injury. Only a few of the interventions, however, have received experimental support for influencing cognitive, emotional, and/or behavioral responses in sport injury rehabilitation. Interventions found effective relative to a control condition include goal setting (Evans & Hardy, 2002 ; Penpraze & Mutrie, 1999 ), imagery (Cupal & Brewer, 2001 ), modeling (Maddison, Prapavessis, & Clatworthy, 2006 ), and multimodal interventions (Johnson, 2000 ; Ross & Berger, 1996 ). These interventions (Christakou, Zervas, & Lavallee, 2007 ; Cupal & Brewer, 2001 ; Maddison et al., 2006 , 2012 ; Newsom, Knight, & Balnave, 2003 ; Ross & Berger, 1996 ; Theodorakis, Beneca, Malliou, & Goudas, 1997 ; Theodorakis, Malliou, Papaioannou, Beneca, & Filactakidou, 1996 ) and others, including biofeedback (Silkman & McKeon, 2010 ) and self-talk (Beneka et al., 2013 ), have been found to influence physical outcomes in sport injury rehabilitation.

As an emerging construct, psychological readiness to return to sport after injury has received minimal attention from researchers attempting to evaluate the effectiveness of interventions designed explicitly to foster psychological readiness in athletes resuming sport participation after injury. Nevertheless, interventions that have produced increases in confidence (e.g., Maddison et al., 2006 ) and decreases in anxiety (e.g., Cupal & Brewer, 2001 ; Ross & Berger, 1996 ), for example, may have enhanced the readiness of the athletes receiving the interventions to return to sport with or without the intention of actually doing so. As a fuller understanding of the composition of what it means to be psychologically ready to return to sport emerges, inquiry into the effects of interventions developed to enhance readiness is likely to ensue.

Conclusions

Sport injury can affect athletes both physically and psychologically. Pain, cognition, emotion, and behavior are primary areas of psychological functioning affected by injury. Psychological responses to sport injury tend to be strongest in close temporal proximity to injury occurrence and fluctuate over the course of rehabilitation. Psychological readiness to return to sport after injury is an emerging concept that incorporates aspects of cognition, emotion, and behavior, including anxiety, confidence, motivation, and postreturn expectations. A variety of theoretical perspectives have been used to guide a body of research on psychological responses to sport injury. Relatively few controlled investigations of interventions designed to influence psychological responses to sport injury have been conducted.

Abenza, L. , Olmedilla, A. , & Ortega, E. (2010). Efectos de las lesiónes sobre las variables psicológicas en fubolistas juveniles [Effect of injuries on psychological variables among under-19 soccer players.]. Revista Latinoamericana de Psicología , 42 , 265–277.
Addison, T. , Kremer, J. , & Bell, R. (1998). Understanding the psychology of pain in sport. Irish Journal of Psychology , 19 , 486–503.
Albinson, C. B. , & Petrie, T. (2003). Cognitive appraisals, stress, and coping: Preinjury and postinjury factors influencing psychological adjustment to athletic injury. Journal of Sport Rehabilitation , 12 , 306–322.
Alzate, R. , Ramírez, A. , & Artaza, J. L. (2004). The effect of psychological response on recovery of sport injury . Research in Sports Medicine , 12 , 15–31.
Appaneal, R. N. , Levine, B. R. , Perna, F. M. , & Roh, J. L. (2009). Measuring postinjury depression among male and female competitive athletes. Journal of Sport and Exercise Psychology , 31 , 60–76.
Ardern, C. L. , Taylor, N. F. , Feller, J. A. , & Webster, K. E. (2013). A systematic review of the psychological factors associated with returning to sport following injury . British Journal of Sports Medicine , 47 , 1120–1126.
Astle, S. J. (1986). The experience of loss in athletes. Journal of Sports Medicine and Physical Fitness , 26 , 279–284.
Baranoff, J. , Hanrahan, S. J. , & Connor, J. P. (2015). The roles of acceptance and catastrophizing in rehabilitation following anterior cruciate ligament reconstruction . Journal of Science and Medicine in Sport , 18 , 250–254.
Bassett, S. F. , & Prapavessis, H. (2011). A test of an adherence-enhancing adjunct to physiotherapy steeped in the protection motivation theory . Physiotherapy Theory and Practice , 27 , 360–372.
Beck, P. R. , Nho, S. J. , Balin, J. , Badnrinath, S. K. , Bush-Joseph, C. A. , Bach, B. R., Jr. , et al. (2004). Postoperative pain management after anterior cruciate ligament reconstruction. Journal of Knee Surgery , 17 , 18–23.
Benea, H. , d’Astorg, H. , Klouche, S. , Bauer, T. , Tomoaia, G. , & Hardy, P. (2014). Pain evaluation after all-inside anterior cruciate ligament reconstruction and short term functional results of a prospective randomized study . The Knee , 21 , 102–106.
Beneka, A. , Malliou, P. , Gioftsidou, A. , Kofotolis, N. , Rokka, S. , Mavromoustakos, S. , et al. (2013). Effects of instructional and motivational self-talk on balance performance in knee injured . European Journal of Physiotherapy , 15 , 56–63.
Bianco, T. , Malo, S. , & Orlick, T. (1999). Sport injury and illness: Elite skiers describe their experiences. Research Quarterly for Exercise and Sport , 70 , 157–169.
Brewer, B. W. (1993). Self-identity and specific vulnerability to depressed mood. Journal of Personality , 61 , 343–364.
Brewer, B. W. (1994). Review and critique of models of psychological adjustment to athletic injury. Journal of Applied Sport Psychology , 6 , 87–100.
Brewer, B. W. (1999a). Causal attribution dimensions and adjustment to sport injury. Journal of Personal and Interpersonal Loss , 4 , 215–224.
Brewer, B. W. (1999b). Adherence to sport injury rehabilitation regimens. In S. J. Bull (Ed.), Adherence issues in sport and exercise (pp. 145–168). Chichester, U.K.: Wiley.
Brewer, B. W. (2004). Psychological aspects of rehabilitation. In G. S. Kolt & M. B. Andersen (Eds.), Psychology in the physical and manual therapies (pp. 39–53). Edinburgh: Churchill Livingstone.
Brewer, B. W. (2007). Psychology of sport injury rehabilitation. In G. Tenenbaum & R. C. Eklund (Eds.), Handbook of sport psychology (3d ed., pp. 404–424). New York: Wiley.
Brewer, B. W. , Cornelius, A. E. , Sklar, J. H. , Van Raalte, J. L. , Tennen, H. , Armeli, S. , et al. (2007). Pain and negative mood during rehabilitation after anterior cruciate ligament reconstruction: A daily process analysis . Scandinavian Journal of Medicine and Science in Sports , 17 , 520–529.
Brewer, B. W. , Cornelius, A. E. , Stephan, Y. , & Van Raalte, J. L. (2010). Self-protective changes in athletic identity following ACL reconstruction. Psychology of Sport and Exercise , 11 , 1–5.
Brewer, B. W. , Cornelius, A. E. , Van Raalte, J. L. , Petitpas, A. J. , Sklar, J. H. , Pohlman, M. H. , et al. (2003a). Protection motivation theory and sport injury rehabilitation adherence revisited. The Sport Psychologist , 17 , 95–103.
Brewer, B. W. , Cornelius, A. E. , Van Raalte, J. L. , Petitpas, A. J. , Sklar, J. H. , Pohlman, M. H. , et al. (2003b). Age-related differences in predictors of adherence to rehabilitation after anterior cruciate ligament reconstruction. Journal of Athletic Training , 38 , 158–162.
Brewer, B. W. , Cornelius, A. E. , Van Raalte, J. L. , Tennen, H. , & Armeli, S. (2013). Predictors of adherence to home rehabilitation exercises following anterior cruciate ligament reconstruction. Rehabilitation Psychology , 58 , 64–72.
Brewer, B. W. , Linder, D. E. , & Phelps, C. M. (1995). Situational correlates of emotional adjustment to athletic injury. Clinical Journal of Sport Medicine , 5 , 241–245.
Brewer, B. W. , Petitpas, A. J. , Van Raalte, J. L. , Sklar, J. H. , & Ditmar, T. D. (1995). Prevalence of psychological distress among patients at a physical therapy clinic specializing in sports medicine . Sports Medicine, Training and Rehabilitation , 6 , 139–145.
Brewer, B. W. , & Petrie, T. A. (1995). A comparison between injured and uninjured football players on selected psychosocial variables. Academic Athletic Journal , 10 , 11–18.
Brewer, B. W. , Van Raalte, J. L. , Cornelius, A. E. , Petitpas, A. J. , Sklar, J. H. , Pohlman, M. H. , et al. (2000). Psychological factors, rehabilitation adherence, and rehabilitation outcome after anterior cruciate ligament reconstruction . Rehabilitation Psychology , 45 , 20–37.
Brewer, B. W. , Van Raalte, J. L. , & Linder, D. E. (1993). Athletic identity: Hercules’ muscles or Achilles heel? International Journal of Sport Psychology , 24 , 237–254.
Byerly, P. N. , Worrell, T. , Gahimer, J. , & Domholdt, E. (1994). Rehabilitation compliance in an athletic training environment. Journal of Athletic Training , 29 , 352–355.
Carson, F. , & Polman, R. (2010). The facilitative nature of avoidance coping within sports injury rehabilitation . Scandinavian Journal of Medicine & Science in Sports , 20 , 235–240.
Carson, F. , & Polman, R. C. J. (2008). ACL injury rehabilitation: A psychological case study of a professional rugby union player. Journal of Clinical Sport Psychology , 2 , 71–90.
Christakou, A. , Zervas, Y. , & Lavallee, D. (2007). The adjunctive role of imagery on the functional rehabilitation of a grade II ankle sprain . Journal of Human Movement , 26 , 141–154.
Clement, D. , & Arvinen-Barrow, M. (2013, October). Psychosocial responses during different phase of sport injury rehabilitation: A qualitative study . Paper presented at the annual meeting of the Association for Applied Psychology, New Orleans, LA.
Crossman, J. , & Jamieson, J. (1985). Differences in perceptions of seriousness and disrupting effects of athletic injury as viewed by athletes and their trainer. Perceptual and Motor Skills , 61 , 1131–1134.
Cupal, D. D. , & Brewer, B. W. (2001). Effects of relaxation and guided imagery on knee strength, reinjury anxiety, and pain following anterior cruciate ligament reconstruction . Rehabilitation Psychology , 46 , 28–43.
Czuppon, S. , Racette, B. A. , Klein, S. E. , & Harris-Hayes, M. (2014). Variables associated with return to sport following anterior cruciate ligament reconstruction: A systematic review . British Journal of Sports Medicine , 48 , 356–364.
Dahlquist M. , Leisz, M. C. , & Finkelstein, M. (2015). The club-level road cyclist: Injury, pain, and performance . Clinical Journal of Sport Medicine , 25 , 88–94.
Daly, J. M. , Brewer, B. W. , Van Raalte, J. L. , Petitpas, A. J. , & Sklar, J. H. (1995). Cognitive appraisal, emotional adjustment, and adherence to rehabilitation following knee surgery. Journal of Sport Rehabilitation , 4 , 23–30.
DiFiori, J. P. , Puffer, J. C. , Aish, B. , & Dorey, F. (2002). Wrist pain, distal radial physical injury, and ulnar variance in young gymnasts: Does a relationship exist? American Journal of Sports Medicine , 30 , 879–885.
Duda, J. L. , Smart, A. E. , & Tappe, M. K. (1989). Predictors of adherence in rehabilitation of athletic injuries: An application of personal investment theory. Journal of Sport and Exercise Psychology , 11 , 367–381.
Ekmekci, P. , Bengisun, Z. K. , Akan, B. , Kazbek, B. K. , Ozkan, K. S. , & Suer, A. H. (2013). The effect of magnesium added to levobupivacaine for femoral nerve block on postoperative analgesia in patients undergoing ACL reconstruction . Knee Surgery, Sports Traumatology, Arthroscopy , 21 , 1119–1124.
Evans, L. , & Hardy, L. (2002). Injury rehabilitation: A goal-setting intervention study. Research Quarterly for Exercise and Sport , 73 , 310–319.
Fields, J. , Murphey, M. , Horodyski, M. , & Stopka, C. (1995). Factors associated with adherence to sport injury rehabilitation in college-age recreational athletes. Journal of Sport Rehabilitation , 4 , 172–180.
Fisher, A. C. , Domm, M. A. , & Wuest, D. A. (1988). Adherence to sports-injury rehabilitation programs. The Physician and Sportsmedicine , 16 (7), 47–52.
Ford, I. W. , & Gordon, S. (1999). Coping with sport injury: Resource loss and the role of social support. Journal of Personal and Interpersonal Loss , 4 , 243–256.
Foss, I. S. , Holme, I. M. K. , & Bahr, R. (2012). The prevalence of low back pain among form erelite cross-country skiers, rowers, orienteerers, and nonathletes: A 10-year cohort study . American Journal of Sports Medicine , 40 , 2610–2616.
Gallagher, B. V. , & Gardner, F. L. (2007). An examination of the relationship between early maladaptive schemas, coping, and emotional response to athletic injury. Journal of Clinical Sport Psychology , 1 , 47–67.
Garcia, G. H. , Wu, H. H. , Park, M. J. , Tjoumakaris, F. P. , Tucker, B. S. , Kelly, J. D. 4th , et al. (2015). Depression symptomatology and anterior cruciate ligament injury: Incidence and effect on functional outcome—A prospective cohort study . American Journal of Sports Medicine , 44 , 572–579.
Garnham, A. (2007). Pharmacological agents in sport and exercise. In G. S. Kolt & L. Snyder-Mackler (Eds.), Physical therapies in sport and exercise (pp. 541–557). Edinburgh: Churchill Livingstone.
Gordon, S. (1986, March). Sport psychology and the injured athlete: A cognitive-behavioral approach to injury response and injury rehabilitation. Science Periodical on Research and Technology in Sport , 1–10.
Gould, D. , Udry, E. , Bridges, D. , & Beck, L. (1997a). Stress sources encountered when rehabilitating from season-ending ski injuries. The Sport Psychologist , 11 , 361–378.
Gould, D. , Udry, E. , Bridges, D. , & Beck, L. (1997b). Coping with season-ending injuries. The Sport Psychologist , 11 , 379–399.
Green, S. L. , & Weinberg, R. S. (2001). Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational participants. Journal of Applied Sport Psychology , 13 , 40–59.
Grindley, E. J. , Zizzi, S. J. , & Nasypany, A. M. (2008). Use of protection motivation theory, affect and barriers to understand and predict adherence to outpatient rehabilitation . Physical Therapy , 88 , 1529–1540.
Hahn, T. , & Foldspang, A. (1998). Prevalent knee pain and sport. Scandinavian Journal of Social Medicine , 26 , 44–52.
Hughes, R. H. , & Coakley, J. (1991). Positive deviance among athletes: The implications of overconformity to the sport ethic. Sociology of Sport Journal , 8 , 307–325.
Hutchison, M. , Comper, P. , Mainwaring, L. , & Richards, D. (2011). The influence of musculoskeletal injury on cognition: Implications for concussion research . American Journal of Sports Medicine , 39 , 2331–2337.
Hutchison, M. , Comper, P. , Mainwaring, L. , Richards, D. , & Bisschop, S. M. (2009). Differential emotional responses of varsity athletes to concussion and musculoskeletal injuries . Clinical Journal of Sport Medicine , 19 , 13–19.
Johnson, U. (1997). Coping strategies among long-term injured competitive athletes. A study of 81 men and women in team and individual sports . Scandinavian Journal of Medicine Science in Sports , 7 , 367–372.
Johnson, U. (1998). Psychological risk factors during the rehabilitation of competitive male soccer players with serious knee injuries [Abstract]. Journal of Sports Sciences , 16 , 391–392.
Johnson, U. (2000). Short-term psychological intervention: A study of long-term-injured competitive athletes. Journal of Sport Rehabilitation , 9 , 207–218.
Johnston, L. H. , & Carroll, D. (1998). The context of emotional responses to athletic injury: A qualitative analysis. Journal of Sport Rehabilitation , 7 , 206–220.
Johnston, L. H. , & Carroll, D. (2000). Coping, social support, and injury: Changes over time and the effects of level of sports involvement. Journal of Sport Rehabilitation , 9 , 290–303.
Kleiber, D. A. , & Brock, S. C. (1992). The effect of career-ending injuries on the subsequent well-being of elite college athletes. Sociology of Sport Journal , 9 , 70–75.
Kolt, G. S. (2004). Pain and its management. In G. S. Kolt & M. B. Andersen (Eds.), Psychology in the physical and manual therapies (pp. 141–161). Edinburgh: Churchill Livingstone.
Kolt, G. S. (2007). Pain. In G. S. Kolt & L. Snyder-Mackler (Eds.), Physical therapies in sport and exercise (pp. 133–148). Edinburgh: Churchill Livingstone.
Kübler-Ross, E. (1969). On death and dying . New York: Macmillan.
Lazarus, R. S. , & Folkman, S. (1984). Stress, appraisal, and coping . NewYork: Springer.
Leddy, M. H. , Lambert, M. J. , & Ogles, B. M. (1994). Psychological consequences of athletic injury among high-level competitors. Research Quarterly for Exercise and Sport , 65 , 347–354.
Leventhal, H. , & Everhart, D. (1979). Emotion, pain, and physical illness. In C. E. Izard (Ed.), Emotions in personality and psychopathology (pp. 263–299). New York: Plenum.
Levy, A. R. , Polman, R. C. J. , & Clough, P. J. (2008). Adherence to sport injury rehabilitation programs: An integrated psycho-social approach . Scandinavian Journal of Medicine and Science in Sport , 18 , 798–809.
Little, J. C. (1969). The athlete’s neurosis—A deprivation crisis. Acta Psychiatrica Scandinavia , 45 , 187–197.
Macchi, R. , & Crossman, J. (1996). After the fall: Reflections of injured classical ballet dancers. Journal of Sport Behavior , 19 , 221–234.
Maddison, R. , Prapavessis, H. , & Clatworthy, M. (2006). Modeling and rehabilitation following anterior cruciate ligament reconstruction . Annals of Behavior Medicine , 31 , 89–98.
Maddison, R. , Prapavessis, H. , Clatworthy, M. , Hall, C. , Foley, L. , Harper, T. , et al. (2012). Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: Randomized-controlled pilot trial. Scandinavian Journal of Medicine and Science in Sports , 22 , 816–821.
Maehr, M. , & Braskamp, L. (1986). The motivation factor: A theory of personal investment . Lexington, MA: Lexington Books.
Mainwaring, L. M. , Bisschop, S. M. , Green, R. E. A. , Antoniazzi, M. , Comper, P. , Kristman, V et al. (2004). Emotional reaction of varsity athletes to sport-related concussion. Journal of Sport and Exercise Psychology , 26 , 119–135.
Mainwaring, L. M. , Hutchison, M. , Bisschop, S. M. , Comper, P. , & Richards, D. W. (2010). Emotional response to sport concussion compared to ACL injury . Brain Injury , 24 , 589–597.
Manuel, J. C. , Shilt, J. S. , Curl, W. W. , Smith, J. A. , DuRant, R. H. , Lester, L. , et al. (2002). Coping with sports injuries: An examination of the adolescent athlete. Journal of Adolescent Health , 31 , 391–393.
Martens, M. P. , Dams-O’Connor, K. , & Beck, N. C. (2006). A systematic review of college student-athlete drinking: Prevalence rates, sport-related factors, and interventions. Journal of Substance Abuse Treatment , 31 , 305–316.
McDonald, S. A. , & Hardy, C. J. (1990). Affective response patterns of the injured athlete: An exploratory analysis. The Sport Psychologist , 4 , 261–274.
Meichenbaum, D. , & Turk, D. C. (1987). Facilitating treatment adherence . New York: Plenum.
Melzack, R. , & Wall, P. D. (1965). Pain mechanisms: A new theory. Science , 150 , 971–979.
Morrey, M. A. , Stuart, M. J. , Smith, A. M. , & Wiese-Bjornstal, D. M. (1999). A longitudinal examination of athletes’ emotional and cognitive responses to anterior cruciate ligament injury. Clinical Journal of Sport Medicine , 9 , 63–69.
Moser, R. S. (2007). The growing public health concern of sports concussion: The new psychology practice frontier . Professional Psychology: Research and Practice , 38 , 699–704.
Mrazik, M. , Brooks, B. L. , Jubinville, A. , Meeuwisse, W. H. , & Emery, C. A. (2016). Psychosocial outcomes of sport concussions in youth hockey players . Archives of Clinical Neuropsychology , 31 , 297–304.
Myer, G. D. , Faigenbaum, A. D. , Foss, K. B. , Xu, Y. , Khoury, J. , Dolan, L. M. , et al. (2014). Injury initiates unfavourable weight gain and obesity markers in youth . British Journal of Sports Medicine , 48 , 1477–1481.
Myer G. D. , Ford, K. R , Di Stasi, S. L. , Foss, K. D. , Micheli, L. J. , & Hewett, T. E. (2015). High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: Is PFP itself a predictor for subsequent ACL injury? . British Journal of Sports Medicine , 49 , 118–122.
National Collegiate Athletic Association . (2012). National study of substance abuse trends among NCAA college student-athletes . Retrieved from http://ncaapublications.com/p-4266-research-substance-use-national-study-of-substance-use-trends-among-ncaa-college-student-athletes.aspx .
Newcomer, R. R. , & Perna, F. M. (2003). Features of posttraumatic stress among adolescent athletes. Journal of Athletic Training , 38 , 163–166.
Newsom, J. , Knight, P. , & Balnave, R. (2003). Use of mental imagery to limit strength loss after immobilization. Journal of Sport Rehabilitation , 12 , 249–258.
Niki, Y. , Hakozaki A. , Iwamoto W. , Kanagawa H. , Matsumoto H. , Toyama Y. , et al. (2012). Factors affecting anterior knee pain following anatomic double-bundle anterior cruciate ligament reconstruction . Knee Surgery Sports Traumatology Arthroscopy , 20 , 1543–1549.
Niven, A. (2007). Rehabilitation adherence in sport injury: Sport physiotherapists’ perceptions. Journal of Sport Rehabilitation , 16 , 93–110.
Nixon, H. L., II. (1992). A social network analysis of influences on athletes to play with pain and injuries . Journal of Sport and Social Issues , 16 , 127–135.
Olmedilla, A. , Ortega, E. , & Gómez, J. M. (2014). Influencia de la lesión deportiva en los cambios del estado de ánimo y de la ansiedad precompetitiva en futbolistas [Influence of sports injury changes in mood and precompetitive anxiety in soccer players]. Cuadernos de Psicología Del Deporte , 14 , 55–61.
Oztekin, H. H. , Boya, H. , Ozcan, O. , Zeren, B. , & Pinar, P. (2008). Pain and affective distress before and after ACL surgery: A comparison of amateur and professional male soccer players in the early postoperative period . The Knee , 15 , 368–372.
Pearson, L. , & Jones, G. (1992). Emotional effects of sports injuries: Implications for physiotherapists. Physiotherapy , 78 , 762–770.
Penpraze, V. , & Mutrie, N. (1999). Effectiveness of goal setting in an injury rehabilitation programme for increasing patient understanding and compliance [Abstract]. British Journal of Sports Medicine , 33 , 60.
Podlog, L. , & Eklund, R. C. (2005). Return to sport after serious injury: A retrospective examination of motivation and psychological outcomes. Journal of Sport Rehabilitation , 14 , 20–34.
Podlog, L. , & Eklund, R. C. (2006). A longitudinal investigation of competitive athletes’ return to sport following serious injury . Journal of Applied Sport Psychology , 18 , 44–68.
Podlog, L. , & Eklund, R. C. (2007). The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective . Psychology of Sport and Exercise , 10 , 535–544.
Podlog, L. , Gao, Z. , Kenow, L. , Kleinert, J. , Granquist, M. , Newton, M. , et al. (2013). Injury rehabilitation overadherence: Preliminary scale validation and relationships with athletic identity and self-presentation concerns . Journal of Athletic Training , 48 , 372–381.
Podlog, L. , Lochbaum, M. , & Stevens, T. (2010). Need satisfaction, well-being, and perceived return-to-sport outcomes among injured athletes . Journal of Applied Sport Psychology , 22 , 167–182.
Prentice, W. E. (2011). Principles of athletic training: A competency-based approach (14th ed.). New York: McGraw-Hill.
Prentice-Dunn, S. , & Rogers, R. W. (1986). Protection motivation theory and preventive health: Beyond the health belief model. Health Education Research , 1 , 153–161.
Prochaska, J. O. , & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrated model of change. Journal of Consulting and Clinical Psychology , 51 , 390–395.
Quinn, A. M. , & Fallon, B. J. (1999). The changes in psychological characteristics and reactions of elite athletes from injury onset until full recovery . Journal of Applied Sport Psychology , 11 , 210–229.
Raynor, M. C. , Pietrobon, R. , Guller, U. , & Higgins, L. D. (2005). Cryotherapy after ACL reconstruction: A meta-analysis. Journal of Knee Surgery , 18 , 123–129.
Rees, T. , Mitchell, I. , Evans, L. , & Hardy, L. (2010). Stressors, social support and psychological responses to sport injury in high- and low-performance standard participants . Psychology of Sport and Exercise , 11 , 505–512.
Reinking, M. F. , Austin, T. M. , & Hayes, A. M. (2010). Risk factors for self-reported exercise related leg pain in high school cross-country athletes. Journal of Athletic Training , 45 , 51–57.
Reuter, J. M. , & Short, S. E. (2005). The relationship among three components of perceived risk of injury, previous injuries and gender in non-contact/limited contact sport athletes. Athletic Insight: The Online Journal of Sport Psychology , 7 , 20–42.
Ross, M. J. , & Berger, R. S. (1996). Effects of stress inoculation on athletes’ postsurgical pain and rehabilitation after orthopedic injury. Journal of Consulting and Clinical Psychology , 64 , 406–410.
Rotella, B. (1985). The psychological care of the injured athlete. In L. K. Bunker , R. J. Rotella , & A. S. Reilly (Eds.), Sport psychology: Psychological considerations in maximizing sport performance (pp. 273–287). Ann Arbor, MI: Mouvement.
Ruddock-Hudson, M. , O’Halloran, P. , & Murphy, G. (2014). Long-term athletic injury: The psychological impact on Australian Football League (AFL) players . Journal of Applied Sport Psychology , 26 , 377–394.
Ryan, R. M. , & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist , 55 , 68–78.
Safai, P. (2003). Healing the body in the “culture of risk”: Examining the negotiation of treatment between sport medicine clinicians and injured athletes in Canadian intercollegiate sport. Sociology of Sport Journal , 20 , 127–146.
San José, A. (2003). Injury of elite athletes: Sport- and gender- related representations. International Journal of Sport and Exercise Psychology , 1 , 434–459.
Short, S. E. , Reuter, J. , Brandt, J. , Short M. W. , & Kontos, A. P. (2004). The relationships among three components of perceived risk of injury, previous injuries and gender in contact sport athletes. Athletic Insight , 6 , 38–46.
Shuer, M. L. , & Dietrich, M. S. (1997). Psychological effects of chronic injury in elite athletes. Western Journal of Medicine , 166 , 104–109.
Silkman, C. , & McKeon, J. (2010). The effectiveness of electromyographic biofeedback supplementation during knee rehabilitation after injury. Journal of Sport Rehabilitation , 19 , 343–351.
Smith, A. M. , & Milliner, E. K. (1994). Injured athletes and the risk of suicide. Journal of Athletic Training , 29 , 337–341.
Smith, A. M. , Scott, S. G. , O’Fallon, W. M. , & Young, M. L. (1990). Emotional responses of athletes to injury. Mayo Clinic Proceedings , 65 , 38–50.
Smith, A. M. , Stuart, M. J. , Wiese-Bjornstal, D. M. , Milliner, E. K. , O’Fallon, W. M. , & Crowson, C. S. (1993). Competitive athletes: Preinjury and postinjury mood state and self-esteem. Mayo Clinic Proceedings , 68 , 939–947.
Smith, A. M. , Young, M. L. , & Scott, S. G. (1988). The emotional responses of athletes to injury. Canadian Journal of Sport Sciences , 13 (Suppl.), 84P–85P.
Snyder-Mackler, L. , Schmitt, L. A. , Rudolph, K. , & Farquhar, S. (2007). Electrophysical agents in sport and exercise injury management. In G. S. Kolt & L. Snyder-Mackler (Eds.), Physical therapies in sport and exercise (pp. 220–235). Edinburgh: Churchill Livingstone.
Sundgot-Borgen, J. (1994). Risk and trigger factors for the development of eating disorders in female elite athletes. Medicine and Science in Sports and Exercise , 26 , 414–419.
Taylor, A. H. , & May, S. (1996). Threat and coping appraisal as determinants of compliance to sports injury rehabilitation: An application of protection motivation theory . Journal of Sports Sciences , 14 , 471–482.
Tedder, S. , & Biddle, S. J. H. (1998). Psychological processes involved during sports injury rehabilitation: An attribution-emotion investigation [Abstract]. Journal of Sports Sciences , 16 , 106–107.
Tesarz, J. , Schuster, A. K. , Hartmann, M. , Gerhardt, A. , & Eich, W. (2012). Pain perception in athletes compared to normally active controls: A systematic review with meta-analysis . Pain , 153 , 1253–1262.
Theodorakis, Y. , Beneca, A. , Malliou, P. , & Goudas, M. (1997). Examining psychological factors during injury rehabilitation. Journal of Sport Rehabilitation , 6 , 355–363.
Theodorakis, Y. , Malliou, P. , Papaioannou, A. , Beneca, A. , & Filactakidou, A. (1996). The effect of personal goals, self-efficacy, and self-satisfaction on injury rehabilitation. Journal of Sport Rehabilitation , 5 , 214–223.
Thomeé, P. , Wahrborg, M. , Börjesson, R. , Thomeé, R. , Eriksson, B. I. , & Karlsson, J. (2007). Self-efficacy, symptoms and physical activity in patients with an anterior cruciate ligament injury: A prospective study . Scandinavian Journal of Medicine & Science in Sports , 17 , 238–245.
Tracey, J. (2003). The emotional response to the injury and rehabilitation process . Journal of Applied Sport Psychology , 15 , 279–293.
Tripp, D. A. , Stanish, W. D. , Coady, C. , & Reardon, G. (2004). The subjective pain experience of athletes following anterior cruciate ligament surgery. Psychology of Sport and Exercise , 5 , 339–354.
Tripp, D. A. , Stanish, W. D. , Reardon, G. , Coady, C. , & Sullivan, M. J. L. (2003). Comparing postoperative pain experiences of the adolescent and adult athlete after anterior cruciate ligament surgery. Journal of Athletic Training , 38 , 154–157.
Udry, E. (1997). Coping and social support among injured athletes following surgery. Journal of Sport and Exercise Psychology , 19 , 71–90.
Udry, E. , Gould, D. , Bridges, D. , & Beck, L. (1997). Down but not out: Athlete responses to season-ending injuries. Journal of Sport and Exercise Psychology , 19 , 229–248.
Vergeer, I. (2006). Exploring the mental representation of athletic injury: A longitudinal study . Psychology of Sport and Exercise , 7 , 99–114.
Wadey, R. , Clark, S. , Podlog, L. , & McCullough, D. (2013). Coaches’ perceptions of athletes’ stress-related growth following sport injury . Psychology of Sport and Exercise , 14 , 125–135.
Wadey, R. , Evans, L. , Evans, K. , & Mitchell, I. (2011). Perceived benefits following sport injury: A qualitative examination of their antecedents and underlying mechanisms . Journal of Applied Sport Psychology , 23 , 142–158.
Wadey, R. , Evans, L. , Hanton, S. , & Neil, R. (2012a). An examination of hardiness throughout the sport-injury process: A qualitative follow-up study . British Journal of Health Psychology , 17 , 872–893.
Wadey, R. , Evans, L. , Hanton, S. , & Neil, R. (2012b). An examination of hardiness throughout the sport injury process . British Journal of Health Psychology , 17 , 103–128.
Wadsworth, L. T. (2006). Acupuncture in sports medicine. Current Sports Medicine Reports , 5 , 1–3.
Walk, S. R. (1997). Peers in pain: The experiences of student athletic trainers. Sociology of Sport Journal , 14 , 22–56.
Walker, H. , Gabbe, B. , Wajswelner, H. , Blanch, P. , & Bennell, K. (2012). Shoulder pain in swimmers: A 12-month prospective cohort study of incidence and risk factors. Physical Therapy in Sport , 13 , 243–249.
Wasley, D. , & Lox, C. L. (1998). Self-esteem and coping responses of athletes with acute versus chronic injuries. Perceptual and Motor Skills , 86 , 1402.
Weiss, M. R. , & Troxel, R. K. (1986). Psychology of the injured athlete. Athletic Training , 21 , 104–109, 154.
Wesch, N. , Hall, C. , Prapavessis, H. , Maddison, R. , Bassett, S. , Foley, L. , et al. (2012). Self-efficacy, imagery use, and adherence during injury rehabilitation. Scandinavian Journal of Medicine and Science in Sports , 22 , 695–703.
Wiese-Bjornstal, D. M. , Smith, A. M. , Shaffer, S. M. , & Morrey, M. A. (1998). An integrated model of response to sport injury: Psychological and sociological dimensions . Journal of Applied Sport Psychology , 10 , 46–69.
Wong, P. T. P. , & Weiner, B. (1981). When people ask “why” questions, and the heuristics of attributional search . Journal of Personality and Social Psychology , 40 , 650–663.

Bullying in Sport and Performance Psychology
Burnout in Sport and Performance
Injury Prevention in Sport and Performance Psychology
Psychological Aspects of Athletic Training
Sociocultural Aspects of Sport Injury and Recovery

Printed from Oxford Research Encyclopedias, Psychology. Under the terms of the licence agreement, an individual user may print out a single article for personal use (for details see Privacy Policy and Legal Notice).

date: 18 April 2024

Cookie Policy
Privacy Policy
Legal Notice
Accessibility
[66.249.64.20|185.39.149.46]
185.39.149.46

Character limit 500 /500

Log in using your username and password

Search More Search for this keyword Advanced search
Latest content
Current issue
For authors
New editors
BMJ Journals More You are viewing from: Google Indexer

Margot Putukian 1 , 2
1 Department of Athletic Medicine , University Health Services, Princeton University , Princeton, New Jersey , USA
2 Rutgers—Robert Wood Johnson Medical School, University Health Services, Princeton University , Princeton, New Jersey , USA
Correspondence to Dr Margot Putukian, Department of Athletic Medicine, University Health Services, Princeton University, Princeton, NJ 08540, USA; putukian{at}Princeton.edu

Background Injury is a major stressor for athletes and one that can pose significant challenges. Student athletes must handle rigorous academic as well as athletic demands that require time as well as significant physical requirements. Trying to perform and succeed in the classroom and on the playing field has become more difficult as the demands and expectations have increased. If an athlete is injured, these stressors increase.

Main thesis Stress is an important antecedent to injuries and can play a role in the response to, rehabilitation and return to play after injury. The psychological response to injury can trigger and/or unmask mental health issues including depression and suicidal ideation, anxiety, disordered eating, and substance use/abuse. There are barriers to mental health treatment in athletes. They often consider seeking help as a sign of weakness, feeling that they should be able to ‘push through’ psychological obstacles as they do physical ones. Athletes may not have developed healthy coping behaviours making response to injury especially challenging.

Purpose I discuss the current state of knowledge regarding the psychological response to injury and delineate resources necessary to direct the injured athlete to a mental health care provider if appropriate.

https://doi.org/10.1136/bjsports-2015-095586

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Introduction

Whether participation in sport is protective or harmful to mental health remains unclear. Though exercise and participation in sport is generally favourable, improving mood and self-esteem, at the extremes of exercise we see increased stress and burnout and the potential for adverse effects. 1–5 Growing research is dedicated to understanding the relationship between exercise and mental health disorders 1 as well as to chronic stress and mental health. 6 Mental health concerns such as eating disorders, depression and suicide, anxiety, gambling and substance use are among the most important in college-aged students, both athletes and non-athletes. 7–12 Some data exist that certain concerns, such as performance anxiety, eating disorders and binge drinking may be more common in athletes than their non-athletic peers. 13–15 Symptoms of depression are not uncommon in athletes 16 , 17 and in one study symptoms were reported in 21% of collegiate athletes with women, freshman and those that self-reported pain had a significantly increased risk for reporting depressive symptoms. 16 Depression in some athletes may also be related with performance failure, and elite athletes may be at a greater risk for depression than less elite athletes. 18

Injuries: antecedents and the emotional response

Injuries are common in athletes and the psychological response to injury can include normal as well as problematic responses,. 19–22 Preinjury factors, including biological, physical, psychological sociocultural, and most importantly stress, can increase an athlete's risk of injury and poor recovery. 19–23 After injury, several factors such as cognition, affect and behaviour are all inter-related and can also affect each other in the short and long term. 21

Stress can cause attentional changes, distraction and increased self-consciousness that all can interfere with performance and predispose an athlete to injury. 20 , 21 , 24 , 25 Chronic stress increases hair cortisol levels in a wide range of contexts/situations such as endurance athletes and pain as well as in patients with major depression. 6 Stress increases muscle tension and coordination that can increase the risk for injury; decreasing stress can actually decrease injury and illness rates. 20 , 24 , 26 , 27

Adolescents who have ‘high mental toughness’ were more resilient to stress and reported a lower number of depressive symptoms. 28 Adolescents with higher ‘resilience’ scores predicted lower scores on levels of depression, anxiety, stress and obsessive-compulsive symptoms after controlling for age and sex. 29 This underscores the importance of identifying which stressors apply to student athletes in general as well as which are at play in individual athlete and are modifiable. These data also emphasise the importance of considering stress reduction techniques in an attempt to decrease the risk for injury and improve performance.

Emotional response to injury (modified from American College of Sports Medicine et al 20 )

Lack of motivation

Frustration

Changes in appetite

Sleep disturbance

Disengagement

Athletes differ in their response to injury. The response to injury extends from the time immediately after injury through to the postinjury phase and then rehabilitation and ultimately with return to activity. For the majority of injuries and illness return to preinjury levels of activity occur. With more serious illness or injury, a career ending injury is possible, and the health care provider should be prepared to address these issues. The Team Physician is ultimately responsible for the return to play decision and addressing psychological issues is a very important component of this decision. 33 , 34

Injuries: problematic responses

Problematic emotional reactions (modified from american college of sports medicine et al 20 ).

Persistent symptoms

Alterations of appetite

Irritability

Worsening symptoms

Alterations of appetite leading to disordered eating

Sadness leading to depression

Lack of motivation leading to apathy

Disengagement leading to alienation

Excessive symptoms

Pain behaviours

Excessive anger or rage

Frequent crying or emotional outbursts

Substance abuse

Examples of problematic reactions include injured athletes who restrict their caloric intake because they feel since they are injured they ‘don't deserve’ to eat, with the restrictive eating then triggering disordered eating. In an athlete already at risk for disordered eating patterns and eating disorders, injury can increase the vulnerability to this problematic response.

Another problematic response to injury is depression. It can be a significant warning sign as it can magnify other responses and can also impact recovery from injury.

Substance use and abuse is a common problematic response and different substances are often used as a method of modulating emotions. For example; cocaine is used to provide stimulation and modify depression, and alcohol is often used to counter mania. Alcohol as well as other recreational drugs or prescription narcotics are often used to self-medicate in an attempt to improve mood in depression.

Gambling and legal problems or fighting are also problematic responses that occur in student athletes, and it is important to understand that it is not infrequent to have several problematic responses occurring concurrently, such as alcohol abuse and depression, depression and eating disorders and alcohol and fighting. 10–13 , 15–18 , 20 , 36

In a review of depression and alcohol use in 262 collegiate athletes, 36 21% reported high alcohol use and problems associated with alcohol. There was a correlation between self-reported symptoms of depression and alcohol abuse. Those athletes with severe depression and psychological symptoms had a significantly greater rate of alcohol abuse than those with low depression and low psychological symptoms. Furthermore, in a review of five collegiate athletes who completed suicide, common factors included (1) considerable success before injury, (2) serious injury requiring surgery (3) long rehabilitation with restriction from play (4) inability to return to the prior level of play and (5) being replaced in their position by a teammate. 37 Of these the greatest predictor was the severity of injury. Other risk factors, such as stressful life events (including injury), chronic mental illness, personality traits with maladjustment, family history of suicidal tendency and psychiatric disorder /other issues (eg, homosexuality, drug use, previous suicide attempts, chronic low self-esteem) were overlapping risk factors.

After a significant time loss injury, athletes can suffer physically as well as emotionally with a decrease in quality of life measures. 38 , 39 The emotional response to an ACL injury can be more significant than that experienced after concussion. 40 When Olympic skier Picabo Street sustained significant leg and knee injuries in March of 1998, she battled significant depression during her recovery. She stated “I went through a huge depression. I went all the way to rock bottom. I never thought that I would ever experience anything like that in my life. I think it was a combination of the atrophying of my legs, the new scars, and feeling like a caged animal”. 41 She ultimately received treatment and returned to skiing before retiring. Kenny McKinley played as a wide receiver professionally for the Denver Broncos Football team. He was found dead of a self-inflicted gunshot wound in September of 2010, after growing despondent after a knee injury. He had undergone surgery expected to sideline for a season and had made statements about being unsure what he would do without football and reportedly sharing thoughts that he should kill himself. 41 These case examples demonstrate how injury can often trigger significant depression and suicidal ideation.

Concussion can be particularly challenging for student athletes to handle emotionally, increasingly common in a variety of contact and collision sports; an injury that is occasionally associated with significant time loss or retirement from sport. 42–46 For the athlete with a severe knee injury, such as an ACL tear requiring surgery, one can often provide a predictable timeline and modified exercise (swimming or biking) options early in recovery. Concussion is difficult because a discrete timeline for recovery and return to play is unknown. In addition, the initial management of concussion includes cognitive and physical rest and the latter is something that many athletes often depend on to handle stressors. They are not able to exercise, and given the emotional and cognitive symptoms associated with concussion, often also struggle with academics as well as the emotional response to injury. In addition, depression and anxiety are felt to be modifiers of concussive injury, further prolonging recovery from injury. 43 , 47 There is limited data to suggest an increased incidence of depression in athletes with a higher history of self-reported concussion. 48 , 49 For the concussed athlete it is especially important to watch for problematic response from injury as well as understand the resources for treatment. Finally, with the recent description of chronic traumatic encephalopathy (CTE), with as of yet significantly more unknown than known, 50–52 athletes are often concerned that they may develop CTE even after a mild concussive injury. This fear for what might occur in the future amplifies the importance of recognising and managing concussive injury and addressing these concerns.

Obstacles to seeking care

There are several obstacles to seeking care for mental health issues in athletes. It is important to understand that athletes are less likely to seek help for mental health issues than non-athletes. 53 , 54 For college mental health service providers it is also important to understand that student athletes are often a unique population with specific obstacles to seeking care. Accessibility is important often there is a ‘teaching moment’ where getting an athlete to consider treatment can be challenging and therefore expediting an evaluation can be essential. It is also important to realise that privacy issues can be different; coaches, athletic trainers and team physicians often play an important role in the support network for the athlete. Including these providers in the discussion of significant issues can be helpful in providing care to the athlete.

Athletes may be at greater risk for mental health issues in that they are less likely to seek treatment, may be afraid to reveal symptoms, may see seeking counselling as a sign of weakness, are accustomed to working through pain, may have a sense of entitlement and never had to struggle, and/or may not have developed healthy coping mechanisms to deal with failure. In addition, many athletes have not developed their identity outside of that as an athlete and therefore if this role is threatened by injury or illness, they may experience a significant ‘loss’. As discussed previously, exercise is often an escape or coping mechanism for many athletes, so if injury occurs and they cannot exercise, it can result in a problematic response.

Barriers and facilitators to help seeking (modified from Gulliver et al 54 )

Barriers (ranked from most common to least, top to bottom)

Lack of problem awareness

Difficulty in or not willing to express emotion

Lack of time

Denial of problem

Not sure who to ask for help

Fear of what might happen

Worried about affecting ability to play / train

Belief that it would not help

Not accessible

Facilitators

Education and awareness of mental health issues and/or services

Social support

Encouragement from others

Accessibility (eg, money, transport, location)

Positive relationship with service staff

Confidentiality

Integration into athlete life

Positive past experiences

Ease of expressing emotion and openness

Facilitating treatment and support

As an athletic trainer, team physician or other healthcare provider, it is important to recognise the common signs and symptoms for various mental health concerns and understand the resources available for treatment and management. 55–59 It is a responsibility of the athletic trainer and team physician to do everything possible to ‘demystify’ mental health concerns and help athletes understand that mental health concerns are as important to recognise and treat as other medical and musculoskeletal issues. Underscoring the availability of athletic medicine staffs to provide early referral and management of mental health concerns is essential.

Also essential is a basic understanding of what measures can make a difference in terms of treating mental health concerns as well as improving general wellness and performance. 20 , 55–59 Treatment that can improve resilience and mental toughness can be expected to help mitigate stress and potentially minimise depressive symptoms. 28 , 29 A systematic review evaluated 983 athletes and 15 psychological factors identified that three psychological elements (self-determination theory-autonomy, competence and relatedness) as the factors most important in positive rehabilitation and return to preinjury level of play. 34 In addition, another study demonstrated that there may be a role for internet-based interventions in demystifying mental health issues and providing education regarding common signs and symptoms as well as the benefits for seeking help. 53

It is important for coaches, athletic trainers and team physicians to provide support for injured athletes and keep athletes involved and part of the team. This might include keeping athletes engaged and encouraging athletes to seek help instead of ‘tough it out’. For coaches one of the most powerful actions is to ‘give the athlete permission’ and encourage them to seek care. 53 , 54 Having programmes available to educate athletes as well as athletic medicine and administrative staffs regarding the resources available and the importance of collaborative programming is helpful in providing care. 20 , 21 , 55–58 , 60–62

Including screening questions during the preparticipation examination and interim physicals performed at the high school and college level that address mental health concerns is an opportunity to detect issues early. 55–57 Considering more comprehensive questionnaires such as the Generalized Anxiety Disorder screen (GAD-7) 63 and the Patient Health Questionnaire (PHQ-9) 64 as a screen for anxiety and depression, respectively, may be useful at baseline as well as during return to activity. 65 In addition, by including these measures as part of the sports physical, it can normalise mental health issues as important and potentially decrease the stigma for discussing these issues.

Future directions/conclusions

Injury is a stressor that has physical as well as psychological responses. The psychological response to injury is important and although emotional responses to injury are common, problematic responses can be those that are persistent, worsen or appear excessive. At times, problematic responses can trigger more serious mental health issues including depression, anxiety, eating disorders, substance use.

There are obstacles to treatment of mental health concerns in athletes, and athletic trainers, team physicians and other healthcare providers play an essential role in recognising and identifying athletes at risk for mental health concerns. Having a comprehensive plan in place to screen for, detect and manage student athletes with problematic response to injury is important. Several positive coping mechanisms and interventions can help to manage the student athlete with problematic responses. Understanding the mental health resources available, making timely referrals, and providing support for help-seeking behaviours are essential for the sports medicine team.

Matta Mello Portugal E ,
Sobral Monteiro-Junior R , et al
Schulz KH ,
Snyder AR ,
Martinez JC ,
Armstrong S ,
Oomen-Early J
Staufenbiel SM ,
Penninx BW ,
Spijker AT , et al
Weigand S ,
Merenstein D
Lindqvist AS ,
Ehrnborg C , et al
Jacobs DF ,
Derevensky JL , et al
Weinstock J ,
Whelan JP ,
Meyers AW , et al
Wolanin A ,
Loucks AB ,
Manore MM , et al.
Puffer JC ,
Peek-Asa C ,
Corlette JD , et al
Proctor SL ,
Boan-Lenzo C
Hammond T ,
Gialloreto C ,
Kubas H , et al
↵ American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons , et al . Psychological issues related to injury in athletes and the team physician: a consensus statement . Med Sci Sports Exerc 2006 ; 38 : 2030 – 4 . doi:10.1249/mss.0b013e31802b37a6 OpenUrl CrossRef PubMed Web of Science
Wiese-Bjornstal EM
Thatcher J ,
Nippert AH ,
Williams JM ,
Andersen MB
Ivarsson A ,
Johnson U ,
Lindwall M , et al
Antoni MH ,
Baum A , et al
Lemola S , et al
Hjemdal O ,
Solem S , et al
Brewer BW ,
Appaneal RN ,
Rockhill-Levine BR ,
Perna FM , et al
Lambert MJ ,
Herring SA ,
Kibler WB ,
Putukian M , et al
Ardern CL ,
Taylor NF ,
Feller JA , et al
Wiese-Bjornstal DM ,
Shaffer SM , et al
Miller BE ,
Miller MN ,
Verhegge R , et al
Milliner EK
McGuine TA ,
Winterstein A ,
Carr K , et al
Valovich McLeod RC ,
Parsons JT , et al
Mainwaring LM ,
Hutchison M ,
Bisschop SM , et al
↵ http://sportsillustrated.cnn.com/vault/article/magazine/MAG1029764/index.htm (accessed 26 Nov 2013 ).
McCrory P ,
Meeuwisse W ,
Aubry M , et al
Herring S ,
Guskiewicz KM , et al
Drezner JA ,
Gammons M , et al
Meeuwisse WH ,
Echemendia RJ , et al
Makdissi M ,
Jordan B , et al
Guskiewicz KM ,
Marshall SW ,
Bailes J , et al
Harding HP , et al
Kutcher JS , et al
Karantzoulis S ,
Hazrati LN ,
Tartaglia MC ,
Diamandis P , et al
Gulliver A ,
Griffiths KM ,
Christensen H , et al
Christensen H
Diamond AB ,
Goldman S , et al
↵ National Collegiate Athletic Association . 2013–2014 sports medicine handbook. http://www.ncaapublications.com/p-4328–2013–14-ncaa-sports-medicine-handbook.aspx (accessed 26 Nov 2013 ).
↵ National Collegiate Athletic Association . Managing student-athletes’ mental health issues. http://www.princeton.edu/uhs/pdfs/NCAA%20Managing%20Student-Athletes%20Mental%20Health%20Issues.pdf (accessed 26 Nov 2013 ).
Hamson-Utley JJ ,
↵ http://www.ncaa.org/health-and-safety/sport-science-institute/prevention-programming
↵ http://stepupprogram.org/
↵ http://uhs.princeton.edu/medical-services/athletic-medicine/varsity-student-athlete-wellness-resources
Spitzer RL ,
Kroenke K ,
Williams JB , et al
Spitzer R ,
Putukian M ,
Echemendia R ,
Dettwiler-Danspeckgruber A , et al

Contributors This article was planned and completed by the sole author, MP.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Search Menu
Browse content in Arts and Humanities
Browse content in Archaeology
Anglo-Saxon and Medieval Archaeology
Archaeological Methodology and Techniques
Archaeology by Region
Archaeology of Religion
Archaeology of Trade and Exchange
Biblical Archaeology
Contemporary and Public Archaeology
Environmental Archaeology
Historical Archaeology
History and Theory of Archaeology
Industrial Archaeology
Landscape Archaeology
Mortuary Archaeology
Prehistoric Archaeology
Underwater Archaeology
Urban Archaeology
Zooarchaeology
Browse content in Architecture
Architectural Structure and Design
History of Architecture
Residential and Domestic Buildings
Theory of Architecture
Browse content in Art
Art Subjects and Themes
History of Art
Industrial and Commercial Art
Theory of Art
Biographical Studies
Byzantine Studies
Browse content in Classical Studies
Classical History
Classical Philosophy
Classical Mythology
Classical Literature
Classical Reception
Classical Art and Architecture
Classical Oratory and Rhetoric
Greek and Roman Papyrology
Greek and Roman Epigraphy
Greek and Roman Law
Greek and Roman Archaeology
Late Antiquity
Religion in the Ancient World
Digital Humanities
Browse content in History
Colonialism and Imperialism
Diplomatic History
Environmental History
Genealogy, Heraldry, Names, and Honours
Genocide and Ethnic Cleansing
Historical Geography
History by Period
History of Emotions
History of Agriculture
History of Education
History of Gender and Sexuality
Industrial History
Intellectual History
International History
Labour History
Legal and Constitutional History
Local and Family History
Maritime History
Military History
National Liberation and Post-Colonialism
Oral History
Political History
Public History
Regional and National History
Revolutions and Rebellions
Slavery and Abolition of Slavery
Social and Cultural History
Theory, Methods, and Historiography
Urban History
World History
Browse content in Language Teaching and Learning
Language Learning (Specific Skills)
Language Teaching Theory and Methods
Browse content in Linguistics
Applied Linguistics
Cognitive Linguistics
Computational Linguistics
Forensic Linguistics
Grammar, Syntax and Morphology
Historical and Diachronic Linguistics
History of English
Language Evolution
Language Reference
Language Acquisition
Language Variation
Language Families
Lexicography
Linguistic Anthropology
Linguistic Theories
Linguistic Typology
Phonetics and Phonology
Psycholinguistics
Sociolinguistics
Translation and Interpretation
Writing Systems
Browse content in Literature
Bibliography
Children's Literature Studies
Literary Studies (Romanticism)
Literary Studies (American)
Literary Studies (Asian)
Literary Studies (European)
Literary Studies (Eco-criticism)
Literary Studies (Modernism)
Literary Studies - World
Literary Studies (1500 to 1800)
Literary Studies (19th Century)
Literary Studies (20th Century onwards)
Literary Studies (African American Literature)
Literary Studies (British and Irish)
Literary Studies (Early and Medieval)
Literary Studies (Fiction, Novelists, and Prose Writers)
Literary Studies (Gender Studies)
Literary Studies (Graphic Novels)
Literary Studies (History of the Book)
Literary Studies (Plays and Playwrights)
Literary Studies (Poetry and Poets)
Literary Studies (Postcolonial Literature)
Literary Studies (Queer Studies)
Literary Studies (Science Fiction)
Literary Studies (Travel Literature)
Literary Studies (War Literature)
Literary Studies (Women's Writing)
Literary Theory and Cultural Studies
Mythology and Folklore
Shakespeare Studies and Criticism
Browse content in Media Studies
Browse content in Music
Applied Music
Dance and Music
Ethics in Music
Ethnomusicology
Gender and Sexuality in Music
Medicine and Music
Music Cultures
Music and Media
Music and Religion
Music and Culture
Music Education and Pedagogy
Music Theory and Analysis
Musical Scores, Lyrics, and Libretti
Musical Structures, Styles, and Techniques
Musicology and Music History
Performance Practice and Studies
Race and Ethnicity in Music
Sound Studies
Browse content in Performing Arts
Browse content in Philosophy
Aesthetics and Philosophy of Art
Epistemology
Feminist Philosophy
History of Western Philosophy
Metaphysics
Moral Philosophy
Non-Western Philosophy
Philosophy of Language
Philosophy of Mind
Philosophy of Perception
Philosophy of Science
Philosophy of Action
Philosophy of Law
Philosophy of Religion
Philosophy of Mathematics and Logic
Practical Ethics
Social and Political Philosophy
Browse content in Religion
Biblical Studies
Christianity
East Asian Religions
History of Religion
Judaism and Jewish Studies
Qumran Studies
Religion and Education
Religion and Health
Religion and Politics
Religion and Science
Religion and Law
Religion and Art, Literature, and Music
Religious Studies
Browse content in Society and Culture
Cookery, Food, and Drink
Cultural Studies
Customs and Traditions
Ethical Issues and Debates
Hobbies, Games, Arts and Crafts
Lifestyle, Home, and Garden
Natural world, Country Life, and Pets
Popular Beliefs and Controversial Knowledge
Sports and Outdoor Recreation
Technology and Society
Travel and Holiday
Visual Culture
Browse content in Law
Arbitration
Browse content in Company and Commercial Law
Commercial Law
Company Law
Browse content in Comparative Law
Systems of Law
Competition Law
Browse content in Constitutional and Administrative Law
Government Powers
Judicial Review
Local Government Law
Military and Defence Law
Parliamentary and Legislative Practice
Construction Law
Contract Law
Browse content in Criminal Law
Criminal Procedure
Criminal Evidence Law
Sentencing and Punishment
Employment and Labour Law
Environment and Energy Law
Browse content in Financial Law
Banking Law
Insolvency Law
History of Law
Human Rights and Immigration
Intellectual Property Law
Browse content in International Law
Private International Law and Conflict of Laws
Public International Law
IT and Communications Law
Jurisprudence and Philosophy of Law
Law and Politics
Law and Society
Browse content in Legal System and Practice
Courts and Procedure
Legal Skills and Practice
Primary Sources of Law
Regulation of Legal Profession
Medical and Healthcare Law
Browse content in Policing
Criminal Investigation and Detection
Police and Security Services
Police Procedure and Law
Police Regional Planning
Browse content in Property Law
Personal Property Law
Study and Revision
Terrorism and National Security Law
Browse content in Trusts Law
Wills and Probate or Succession
Browse content in Medicine and Health
Browse content in Allied Health Professions
Arts Therapies
Clinical Science
Dietetics and Nutrition
Occupational Therapy
Operating Department Practice
Physiotherapy
Radiography
Speech and Language Therapy
Browse content in Anaesthetics
General Anaesthesia
Neuroanaesthesia
Clinical Neuroscience
Browse content in Clinical Medicine
Acute Medicine
Cardiovascular Medicine
Clinical Genetics
Clinical Pharmacology and Therapeutics
Dermatology
Endocrinology and Diabetes
Gastroenterology
Genito-urinary Medicine
Geriatric Medicine
Infectious Diseases
Medical Toxicology
Medical Oncology
Pain Medicine
Palliative Medicine
Rehabilitation Medicine
Respiratory Medicine and Pulmonology
Rheumatology
Sleep Medicine
Sports and Exercise Medicine
Community Medical Services
Critical Care
Emergency Medicine
Forensic Medicine
Haematology
History of Medicine
Browse content in Medical Skills
Clinical Skills
Communication Skills
Nursing Skills
Surgical Skills
Browse content in Medical Dentistry
Oral and Maxillofacial Surgery
Paediatric Dentistry
Restorative Dentistry and Orthodontics
Surgical Dentistry
Medical Ethics
Medical Statistics and Methodology
Browse content in Neurology
Clinical Neurophysiology
Neuropathology
Nursing Studies
Browse content in Obstetrics and Gynaecology
Gynaecology
Occupational Medicine
Ophthalmology
Otolaryngology (ENT)
Browse content in Paediatrics
Neonatology
Browse content in Pathology
Chemical Pathology
Clinical Cytogenetics and Molecular Genetics
Histopathology
Medical Microbiology and Virology
Patient Education and Information
Browse content in Pharmacology
Psychopharmacology
Browse content in Popular Health
Caring for Others
Complementary and Alternative Medicine
Self-help and Personal Development
Browse content in Preclinical Medicine
Cell Biology
Molecular Biology and Genetics
Reproduction, Growth and Development
Primary Care
Professional Development in Medicine
Browse content in Psychiatry
Addiction Medicine
Child and Adolescent Psychiatry
Forensic Psychiatry
Learning Disabilities
Old Age Psychiatry
Psychotherapy
Browse content in Public Health and Epidemiology
Epidemiology
Public Health
Browse content in Radiology
Clinical Radiology
Interventional Radiology
Nuclear Medicine
Radiation Oncology
Reproductive Medicine
Browse content in Surgery
Cardiothoracic Surgery
Gastro-intestinal and Colorectal Surgery
General Surgery
Neurosurgery
Paediatric Surgery
Peri-operative Care
Plastic and Reconstructive Surgery
Surgical Oncology
Transplant Surgery
Trauma and Orthopaedic Surgery
Vascular Surgery
Browse content in Science and Mathematics
Browse content in Biological Sciences
Aquatic Biology
Biochemistry
Bioinformatics and Computational Biology
Developmental Biology
Ecology and Conservation
Evolutionary Biology
Genetics and Genomics
Microbiology
Molecular and Cell Biology
Natural History
Plant Sciences and Forestry
Research Methods in Life Sciences
Structural Biology
Systems Biology
Zoology and Animal Sciences
Browse content in Chemistry
Analytical Chemistry
Computational Chemistry
Crystallography
Environmental Chemistry
Industrial Chemistry
Inorganic Chemistry
Materials Chemistry
Medicinal Chemistry
Mineralogy and Gems
Organic Chemistry
Physical Chemistry
Polymer Chemistry
Study and Communication Skills in Chemistry
Theoretical Chemistry
Browse content in Computer Science
Artificial Intelligence
Computer Architecture and Logic Design
Game Studies
Human-Computer Interaction
Mathematical Theory of Computation
Programming Languages
Software Engineering
Systems Analysis and Design
Virtual Reality
Browse content in Computing
Business Applications
Computer Security
Computer Games
Computer Networking and Communications
Digital Lifestyle
Graphical and Digital Media Applications
Operating Systems
Browse content in Earth Sciences and Geography
Atmospheric Sciences
Environmental Geography
Geology and the Lithosphere
Maps and Map-making
Meteorology and Climatology
Oceanography and Hydrology
Palaeontology
Physical Geography and Topography
Regional Geography
Soil Science
Urban Geography
Browse content in Engineering and Technology
Agriculture and Farming
Biological Engineering
Civil Engineering, Surveying, and Building
Electronics and Communications Engineering
Energy Technology
Engineering (General)
Environmental Science, Engineering, and Technology
History of Engineering and Technology
Mechanical Engineering and Materials
Technology of Industrial Chemistry
Transport Technology and Trades
Browse content in Environmental Science
Applied Ecology (Environmental Science)
Conservation of the Environment (Environmental Science)
Environmental Sustainability
Environmentalist Thought and Ideology (Environmental Science)
Management of Land and Natural Resources (Environmental Science)
Natural Disasters (Environmental Science)
Nuclear Issues (Environmental Science)
Pollution and Threats to the Environment (Environmental Science)
Social Impact of Environmental Issues (Environmental Science)
History of Science and Technology
Browse content in Materials Science
Ceramics and Glasses
Composite Materials
Metals, Alloying, and Corrosion
Nanotechnology
Browse content in Mathematics
Applied Mathematics
Biomathematics and Statistics
History of Mathematics
Mathematical Education
Mathematical Finance
Mathematical Analysis
Numerical and Computational Mathematics
Probability and Statistics
Pure Mathematics
Browse content in Neuroscience
Cognition and Behavioural Neuroscience
Development of the Nervous System
Disorders of the Nervous System
History of Neuroscience
Invertebrate Neurobiology
Molecular and Cellular Systems
Neuroendocrinology and Autonomic Nervous System
Neuroscientific Techniques
Sensory and Motor Systems
Browse content in Physics
Astronomy and Astrophysics
Atomic, Molecular, and Optical Physics
Biological and Medical Physics
Classical Mechanics
Computational Physics
Condensed Matter Physics
Electromagnetism, Optics, and Acoustics
History of Physics
Mathematical and Statistical Physics
Measurement Science
Nuclear Physics
Particles and Fields
Plasma Physics
Quantum Physics
Relativity and Gravitation
Semiconductor and Mesoscopic Physics
Browse content in Psychology
Affective Sciences
Clinical Psychology
Cognitive Psychology
Cognitive Neuroscience
Criminal and Forensic Psychology
Developmental Psychology
Educational Psychology
Evolutionary Psychology
Health Psychology
History and Systems in Psychology
Music Psychology
Neuropsychology
Organizational Psychology
Psychological Assessment and Testing
Psychology of Human-Technology Interaction
Psychology Professional Development and Training
Research Methods in Psychology
Social Psychology
Browse content in Social Sciences
Browse content in Anthropology
Anthropology of Religion
Human Evolution
Medical Anthropology
Physical Anthropology
Regional Anthropology
Social and Cultural Anthropology
Theory and Practice of Anthropology
Browse content in Business and Management
Business Ethics
Business Strategy
Business History
Business and Technology
Business and Government
Business and the Environment
Comparative Management
Corporate Governance
Corporate Social Responsibility
Entrepreneurship
Health Management
Human Resource Management
Industrial and Employment Relations
Industry Studies
Information and Communication Technologies
International Business
Knowledge Management
Management and Management Techniques
Operations Management
Organizational Theory and Behaviour
Pensions and Pension Management
Public and Nonprofit Management
Strategic Management
Supply Chain Management
Browse content in Criminology and Criminal Justice
Criminal Justice
Criminology
Forms of Crime
International and Comparative Criminology
Youth Violence and Juvenile Justice
Development Studies
Browse content in Economics
Agricultural, Environmental, and Natural Resource Economics
Asian Economics
Behavioural Finance
Behavioural Economics and Neuroeconomics
Econometrics and Mathematical Economics
Economic History
Economic Systems
Economic Methodology
Economic Development and Growth
Financial Markets
Financial Institutions and Services
General Economics and Teaching
Health, Education, and Welfare
History of Economic Thought
International Economics
Labour and Demographic Economics
Law and Economics
Macroeconomics and Monetary Economics
Microeconomics
Public Economics
Urban, Rural, and Regional Economics
Welfare Economics
Browse content in Education
Adult Education and Continuous Learning
Care and Counselling of Students
Early Childhood and Elementary Education
Educational Equipment and Technology
Educational Strategies and Policy
Higher and Further Education
Organization and Management of Education
Philosophy and Theory of Education
Schools Studies
Secondary Education
Teaching of a Specific Subject
Teaching of Specific Groups and Special Educational Needs
Teaching Skills and Techniques
Browse content in Environment
Applied Ecology (Social Science)
Climate Change
Conservation of the Environment (Social Science)
Environmentalist Thought and Ideology (Social Science)
Natural Disasters (Environment)
Social Impact of Environmental Issues (Social Science)
Browse content in Human Geography
Cultural Geography
Economic Geography
Political Geography
Browse content in Interdisciplinary Studies
Communication Studies
Museums, Libraries, and Information Sciences
Browse content in Politics
African Politics
Asian Politics
Chinese Politics
Comparative Politics
Conflict Politics
Elections and Electoral Studies
Environmental Politics
European Union
Foreign Policy
Gender and Politics
Human Rights and Politics
Indian Politics
International Relations
International Organization (Politics)
International Political Economy
Irish Politics
Latin American Politics
Middle Eastern Politics
Political Behaviour
Political Economy
Political Institutions
Political Methodology
Political Communication
Political Philosophy
Political Sociology
Political Theory
Politics and Law
Public Policy
Public Administration
Quantitative Political Methodology
Regional Political Studies
Russian Politics
Security Studies
State and Local Government
UK Politics
US Politics
Browse content in Regional and Area Studies
African Studies
Asian Studies
East Asian Studies
Japanese Studies
Latin American Studies
Middle Eastern Studies
Native American Studies
Scottish Studies
Browse content in Research and Information
Research Methods
Browse content in Social Work
Addictions and Substance Misuse
Adoption and Fostering
Care of the Elderly
Child and Adolescent Social Work
Couple and Family Social Work
Developmental and Physical Disabilities Social Work
Direct Practice and Clinical Social Work
Emergency Services
Human Behaviour and the Social Environment
International and Global Issues in Social Work
Mental and Behavioural Health
Social Justice and Human Rights
Social Policy and Advocacy
Social Work and Crime and Justice
Social Work Macro Practice
Social Work Practice Settings
Social Work Research and Evidence-based Practice
Welfare and Benefit Systems
Browse content in Sociology
Childhood Studies
Community Development
Comparative and Historical Sociology
Economic Sociology
Gender and Sexuality
Gerontology and Ageing
Health, Illness, and Medicine
Marriage and the Family
Migration Studies
Occupations, Professions, and Work
Organizations
Population and Demography
Race and Ethnicity
Social Theory
Social Movements and Social Change
Social Research and Statistics
Social Stratification, Inequality, and Mobility
Sociology of Religion
Sociology of Education
Sport and Leisure
Urban and Rural Studies
Browse content in Warfare and Defence
Defence Strategy, Planning, and Research
Land Forces and Warfare
Military Administration
Military Life and Institutions
Naval Forces and Warfare
Other Warfare and Defence Issues
Peace Studies and Conflict Resolution
Weapons and Equipment

Sports Injury Research

Cite Icon Cite
Permissions Icon Permissions

With the increasing focus on tackling obesity and other lifestyle-related illnesses and conditions, participation in sports and physical activity is growing. The consequences are that injuries and unwanted side-effects of healthy activity are becoming major health problems. Prevention is crucial to health gain, both in the short-term (preventing immediate injury), and in the longer term (reducing the risk of recurrence and prolonged periods of impairment). Prevention follows four main steps: 1) the sports injury problem must be described in incidence and severity; 2) the etiological risk factors and mechanisms underlying the occurrence of injury are identified; 3) preventive methods that are likely to work can be developed and introduced; and 4) the effectiveness and cost-effectiveness of such measures are evaluated.

Signed in as

Institutional accounts.

GoogleCrawler [DO NOT DELETE]
Google Scholar Indexing

Personal account

Sign in with email/username & password
Get email alerts
Save searches
Purchase content
Activate your purchase/trial code

Institutional access

Sign in with a library card Sign in with username/password Recommend to your librarian
Institutional account management
Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Sign in through your institution

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institutionâ€™s website and Oxford Academic.

Click Sign in through your institution.
Select your institution from the list provided, which will take you to your institution's website to sign in.
When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institutionâ€™s website, please contact your librarian or administrator.

Sign in with a library card

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see â€˜Sign in through society siteâ€™ in the sign in pane within a journal:

Click Sign in through society site.
When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

View your signed in personal account and access account management features.
View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

About Oxford Academic
Publish journals with us
University press partners
What we publish
New features
Open access
Rights and permissions
Accessibility
Advertising
Media enquiries
Oxford University Press
Oxford Languages
University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

Copyright © 2024 Oxford University Press
Cookie settings
Cookie policy
Privacy policy
Legal notice

This Feature Is Available To Subscribers Only

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List
BMJ Open Sport Exerc Med
v.4(1); 2018

Prevention of sports injuries in children at school: a systematic review of policies

Anya göpfert.

1 Centre for Child and Adolescent Health, University of Bristol, Bristol, UK

Maria Van Hove

2 Acute Medical Unit, Southmead Hospital, Bristol, UK

Julie Mytton

3 Centre for Child and Adolescent Health, University of the West of England, Bristol, UK

Associated Data

bmjsem-2018-000346supp001.pdf

bmjsem-2018-000346supp002.pdf

bmjsem-2018-000346supp003.pdf

bmjsem-2018-000346supp004.pdf

Participation in sports as a child improves physical and psychological health. Schools need to promote sport while protecting against injury. It is not clear whether increasing evidence on injury prevention generated from professional sport is influencing school sports practices. This study reviewed policies promoting sport safety in schools to determine whether exposure to injury risk is recognised and whether evidence based prevention and management are included.

A search strategy to identify policies for children aged 4–18 years was applied to electronic databases and grey literature sources. Safeguarding policies were excluded. Included policies were critically appraised and synthesised using modified framework analysis.

Twenty-six policies were analysed. Most (57.7%) were from the USA. Ten (38.5%) focused solely on concussion. Synthesis identified primary, secondary and tertiary injury prevention measures relating to people (staff, students and parents), systems, school physical environment and national-level factors.

Conclusions

Robust, evidence-based policies for reducing injury risk in school sports are limited. Guidelines with the largest evidence base were focused on concussion, with other school sport guidelines showing limited inclusion of evidence. Where included, evidence focused on injury management rather than prevention and frequently applied evidence from adult to children. Guidance was not specific to the child’s age, gender or developmental stage.

What is already known on this topic?

Sporting injuries can have significant effects on society and individuals. Schools often follow health and safety guidance, yet practice is infrequently based on research evidence. Effective interventions for preventing injuries exist.

What are the main findings?

In this original overview of existing polices on the prevention of sports injuries for schools, we found a paucity of evidence-based guidelines.
The need to evaluate the effectiveness of guidelines and to establish injury surveillance were not adequately recognised.
The review highlights the need for guidelines that incorporate existing and emerging evidence on effective school sports injury prevention.
Further research should explore the impact of age, gender and stage of development on the effectiveness of new interventions for children.

Participation of children and young people in sport helps prevent obesity, improves physical and mental health 1–3 and is associated with higher physical activity levels as an adult. 4 5 Consequently, governments internationally are producing strategies to increase sports participation. 6–8 Sports are an important cause of injuries among children, and injuries can lead to reduced participation in, or withdrawal from, sports. 9 10 Although it is often assumed that sports injuries are the results of ‘accidents’, they are more often the result of circumstances that predictably lead to injuries. Routine injury surveillance data are not available in the UK, 11 but estimates show that 8% of children drop out of sport altogether due to injuries. 12 Furthermore, sports injuries generate significant costs for the National Health Service 9 and indirect costs through parents taking time off to care for injured children. 9 13 There have been calls for effective policies and interventions aimed at reducing injury rates to be introduced alongside or integrated into policies promoting participation in sport. 9 10

Schools have a direct duty of care towards children and have responsibility to both encourage physical activity and protect children from injury. The school environment offers all children an opportunity to participate in sport. 14 However, school sport has particular risks for injury due to the wide range of experience and fitness of participants, and multiple providers, both school teachers and external coaches, organising and facilitating training. 15 Students with less experience, decreased endurance or previous injuries are at higher risk of becoming injured. 16

Head injuries associated with concussion have received more attention than other sports injuries. Pollock et al have argued for greater injury surveillance of concussive injuries to inform policy and practice, highlighting the issue to the public media. 17 18 Increased awareness of chronic traumatic encephalopathy in American football players alerted the rugby game to the risks of concussion. There has been a resultant increase in concussion guidelines in UK rugby. 19 Evidence shows that exercise-based injury prevention schemes for children and adolescents can reduce injury by up to 46%, 10 but there is little known about how changes within the professional game have influenced sports undertaken within the school environment.

Schools need clear guidance on how to optimise safe and widespread participation in sports. In the absence of published summaries of policies available for schools to help them provide safe sports for children, we undertook a study to systematically identify and review policies, guidelines and consensus statements designed to enable schools to deliver school sports safely. This review aimed to better understand the extent to which such policies are informed by the scientific evidence base and to identify areas for focused research and policy improvements.

Inclusion criteria

Policies, guidelines and consensus statements on school sport injury prevention were all eligible for inclusion. To improve sensitivity of the search strategy, all terms were used to identify any document that may provide guidance for schools and were not primary research intervention studies. Policies, guidelines and consensus statements (hereafter referred to as ‘guidelines’ as this was the most common document type included) focusing on sports for children aged 4–18 years undertaken as a compulsory part of the school curriculum and that reported actions to enable the reduction and/or monitoring of physical sports-related injuries were included. We sought guidelines aimed at professionals working in either state or private schools that addressed injury risks across a range of different sports. All-age guidelines (ie, adults and children) were included provided child-specific recommendations were available or could be extracted separately.

Exclusion criteria

We excluded guidelines published before 1990, the year the National Curriculum was introduced in Great Britain 20 to ensure that guidelines were relevant within the current school environment. An English language restriction was applied. Exclusions included guidelines focusing on safeguarding as these were outside the scope of the review and older versions of current guidelines in order to avoid duplication of findings. In addition, guidelines specifically written to optimise clinical care pathways were excluded as these are not applicable within schools. Guidelines focusing on only one sport, such as the ‘Headcase’ resources from Rugby England, 21 were also outside the scope of the review as we focused on guidelines for school sports generally.

Search strategy

A search strategy was developed in Embase, adapted for nine other electronic databases (see online supplementary appendix 1 ) and incorporated published search filters where possible. The following databases were searched between August and October 2016: Embase (1974–2016), MEDLINE (1980–2016), Social Policy and Practice (1981–2016), Sports Discus (1990–2016), Cumulative Index to Nursing and Allied Health Literature (1982–2016), Educational Resources Information Center (1980–2016), Physiotherapy Evidence Database (1980–2016), Cochrane Database of Systematic Reviews (1980–2016), Evidence for Policy and Practice Information and Co-ordinating Centre (1990–2016) and Safety Lit (1990–2016). A comprehensive grey literature search was developed that included searching reference lists of included guidelines, proceedings of injury conferences and websites of relevant UK Government, sports and non-governmental organisations. To identify grey literature from other Organisation for Economic Co-operation and Development (OECD) countries, we searched the internet using the terms ‘country name’ and ‘safe school sports’ or ‘sports injury prevention’ ( online supplementary appendix 2 ).

online supplementary appendix 1.

Online supplementary appendix 2., online supplementary appendix 3., online supplementary appendix 4..

Titles and abstracts of potentially eligible documents were screened to identify guidelines meeting inclusion criteria. Full texts were obtained where necessary. Guidelines of uncertain eligibility were discussed within the research team. Authors were contacted for clarification where possible. The initial list of included guidelines was reviewed by two independent expert contacts; no omissions or additional texts were identified. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews were followed. 22

Quality appraisal

Guidelines meeting all inclusion criteria were quality appraised against seven criteria using a modified TAPUPAS framework, 23 24 which enabled a maximum score of 21 ( online supplementary appendix 3 ). All guidelines were scored by AG, and quality scores were independently verified by JM. Guidelines scoring below 11 were deemed to be at higher risk of bias and were discussed with all authors before exclusion from the synthesis. If guideline development methods were poorly reported, authors were emailed, and the quality score was adjusted if additional methods were supplied.

Synthesis was achieved using a modified framework analysis method developed from the framework analysis described by Brunton et al 25 and modified to fit the context considering key injury prevention opportunities identified by Dougherty. 15 The framework consists of primary (reduction of injury risk/prevention of injury event), secondary (minimisation of injury sustained) and tertiary (minimisation of impact from injury) prevention measures classified into people factors (staff, students and parents), system factors, school physical environment factors and national-level factors. AG coded all included guidelines. Fifteen per cent were double coded by MVH to ensure consistency in application of the coding framework.

A total of 27 policies, guidelines and consensus statements were identified meeting the inclusion criteria ( online supplementary appendix 4 ). One document was excluded due to a quality score of 10. Of the remaining 26 documents, the majority were described by authors as guidelines (n=21), 26–46 with two position statements, 47 48 one policy 49 and two consensus statements. 50 51 See figure 1 for PRISMA diagram.

An external file that holds a picture, illustration, etc.
Object name is bmjsem-2018-000346f01.jpg

PRISMA flow diagram illustrating identification of included guidelines. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Guidelines were heterogenous with regards to scope, length (2–500 pages), level of detail reported, country of origin and methods of development. Four guidelines specifically referred to physical education classes, 26–28 44 52 with six broadly covering safe sports in the school environment. 29–32 38 49 Three guidelines produced by the National Athletic Trainers Association in the USA focused only on emergency planning, ‘accountability for the management of emergencies’. 34 35 50 Sixteen guidelines included guidance on prevention of concussion and were therefore afforded a concussion-specific analysis.

Guidelines originated from the USA (n=15), 29 31–38 43 45–48 50 the UK (n=3), 26 39 40 Canada (n=5), 27 28 41 42 44 52 Australia (n=1), 30 New Zealand (n=1) 49 and one international consensus statement. 51 Documents were produced by national professional associations (n=9), 26 31 33–36 46 47 50 health organisations (n=5), 30 37 38 43 48 national sports organisations (n=3), 32 39 40 research organisations (n=2), 41 42 statutory bodies (n=3), 29 45 49 non-profit organisations (n=3) 27 28 44 52 and one international consensus statement, 51 Guidelines used a range of methods, including literature review and expert consultation (n=12), 29 33–36 41 42 45 46 48 50 51 expert consultation and case law review (n=5) 26–28 31 44 52 or expert consultation only (n=1). 40 The remaining guidelines did not report methods of development. 30 32 37–39 43 47 49

Table 1 illustrates key findings in the framework analysis. Consistent recommendations to reduce injury risk included the need for appropriately trained staff and sessions that include a warm-up, cool-down and skills progression (through both the session and the season) appropriate to the level of the participants. Little evidence was referenced to support these recommendations.

Injury and injury event prevention methods reported across >1 guideline

An empty cell indicates that no guideline referred to a strategy for this section. Individual rows within the table show related areas for prevention.

n, number of guidelines.

Two themes cut across more than one source, or level of prevention: distribution of responsibilities for injury prevention and emergency planning.

The responsibility for sports injury prevention varied throughout the included guidelines. Nine documents recommended that staff should be aware of students’ medical histories with either parents or teachers responsible for providing the information. 27 28 30–32 35 37 38 50 Furthermore, there is inconsistency between guidelines as to who is responsible for providing personal protective equipment with schools (n=3) 29 35 38 or parents (n=1) 32 suggested. However, some guidelines are vague with no specific responsibility attributed for these roles.

Nine guidelines made recommendations for emergency planning. The common themes for a successful emergency action plan included developing the plan in conjunction with schools, teachers and local emergency services (n=7), 27 28 33–35 47 49 communicating and distributing the plan to all stakeholders (n=5) 30 32 34 35 49 and including regular staff education of management of an emergency (n=4). 32 34 35 49

A concussion-specific analysis was completed as this was the topic with most evidence for policy. Ten guidelines referred solely to concussion, 39–46 48 51 52 with a further six guidelines referring to aspects of concussion prevention, identification and management. 26 29–32 35 Some guidelines contained 1–2 sentences on concussion, 30 32 where others were entire guidelines focusing on only one aspect such as safely returning children to school or activity after concussion. 41–43

There is consensus that there should be immediate removal from play of any participant with suspected concussion and that any child with a suspected concussion should not return to play that day (n=13). 26 29–32 35 39 40 44–46 48 51 52 Seven guidelines discuss the use of specific assessment tools for players with suspected concussion including Maddock’s questions, 39 Standardised Assessment of Concussion (SAC), 48 Balance Error Scoring System (BESS), 48 Sport Concussion Assessment Tool 3 (SCAT3), 35 51 Sensory Organisation Test (SOT), 48 Post-concussion Scale 48 and a graded symptom checklist. 48 It was outside the scope of this review to analyse these tools.

Regarding returning to learning and activity after concussion, most guidelines detailed the need for individualised return to learning (n=10) 26 32 39–41 43–46 51 52 and return to activity (n=13) 26 29 32 35 39 40 42–46 48 51 52 plans for children with concussion, developed jointly between parents, medical staff and school staff. Return to any activity was not recommended until return to learning had been completed. 26 39 40 42 51

A five-step plan was commonly recommended for return to learning, and a six-step plan for return to activity (see figure 2 ). DeMatteo et al ’s 41 protocol was the only guideline to limit step 1 to 2 weeks due to risk of depression for children kept away from school.

An external file that holds a picture, illustration, etc.
Object name is bmjsem-2018-000346f02.jpg

A typical return to learning and return to activity plan. 38 39 At each stage a child should be symptom free for 24 hours before progressing to the next stage.

The most frequently recommended method for the primary prevention of concussion was education (n=10) 31 35 39 42–46 48 51 52 ‘education of athletes, colleagues and the public is the mainstay of progress in (the field of concussive injury)’. 51 Additional primary prevention methods include rule changes and adherence to rules during games. There is consensus among guidelines that equipment such as helmets are not universally protective against concussion (n=6). 35 44–46 48 51 52

Two physical education specific guidelines 26 44 recommended that schools develop a concussion policy or incorporate concussion policy into existing head injury policies. Two guidelines recommend surveillance of sports injuries among children. 45 48

Main findings of this study

This review identified 26 school sports injury prevention guidelines that met our inclusion criteria. A range of primary, secondary and tertiary injury prevention activities and interventions were identified, and the degree to which identified activities were supported by other existing evidence varied.

First, few guidelines referenced original scientific research to support their recommendations. Concussion-specific guidelines are however better supported by evidence than other guidelines. Nevertheless, many included guidelines make assumptions for children based on evidence generated from adults. Therefore, the overall quality of evidence used to generate guidelines was considered to be poor. For example, with regards to concussion, the biochemistry of a developing brain is different from an adult brain, and children are more susceptible to physical trauma. 53 Although there are likely to be similarities in effective injury prevention across age groups, additional research specifically for children is required in order to establish the efficacy of interventions with children and whether alternative interventions may be required.

Preparticipation examinations and introducing defibrillators at schools were suggested in guidelines from the US guidelines. UK guidelines did not advise preparticipation examinations, in line with UK Screening Committee recommendations. 54 UK guidelines also did not advise defibrillators in schools; recent guidance from the Department of Education (UK), however, encourages schools to purchase automated external defibrillator (AEDs). 55 Currently, the specific benefit of AEDs in school settings is unclear and needs further research to establish for whom, and in what circumstances, the presence of AEDs in school settings are an effective intervention.

Primary prevention measures were commonly reported including rule changes for specific sports, the use of protective equipment and education of involved stakeholders. Education, involving families and school staff, is the most commonly mentioned primary prevention intervention. The evidence reviewed in this study supports the use of education as a prevention measure for sports injury. Nevertheless in the UK, clear guidance on who is responsible for providing such education, and to whom it should be offered, needs to be developed. Guidelines would be strengthened by referencing of research evidence underpinning prevention recommendations. Further comprehensive evaluation of the most effective education content and strategies is also necessary.

There is evidence that rule changes, such as mandatory use of protective equipment or rules limiting dangerous play, are an effective method of primary prevention; Vriend et al identified that over 75% of rule change studies reported a significant effect on injuries. 56 57 Yet, this is only mentioned in a few of the included guidelines in this review. Vriend et al 56 identified a paucity of research on rule-change interventions (14 studies) compared with other sports injury prevention interventions, which is likely to have contributed to infrequency of reporting the potential value of rule changes within school guidelines. Therefore, the effectiveness of rule change would be an area for further focus in developing future guidelines for preventing injury in school sport.

Helmets are an example of protective equipment, which is recommended in some included guidelines. The effectiveness of helmets for prevention sports injuries including concussion remains unclear, and even if helmets are effective protection in one sport, this evidence may not be applicable to other sports. Much of the evidence on helmet use is generalised from adult professional American football. In addition, the positive effects of protective equipment may be outweighed by concurrent riskier behaviour patterns. Further research is needed to evaluate the degree to which ‘risk compensation’ (ie, risky behaviour among children and adolescents once wearing helmets) influences their likelihood of concussion. 51 Evidence generated with children within the UK context is required to ensure findings can be generalised to across school sports policies.

Secondary and tertiary measures to prevent and mitigate consequences of injuries are discussed throughout the studied guidelines. Effective first response to injury is likely to minimise the short-term and longer term consequences of injuries for players. First aid training is commonly mentioned in guidelines, but there was insufficient detail to compare recommendations across guidelines, and recommendations were poorly referenced with research evidence. Sideline concussion assessment tools are often recommended for triaging concussive injuries. Guidelines lack consensus on which tools are appropriate for assessing children (as opposed to adults), or on which tools are suitable for use by non-clinicians. Therefore, guidelines for schools should include guidance on the use of suitable concussion assessment tools. 58

There were three guidelines specifically focusing on tertiary prevention such as return to learn and return to activity plans following concussion. 41–43 We did not identify guidance for returning to activity after other common sports injuries such as sprains or fractures. The New Zealand government health and safety policy 49 reviewed in this study provides broad guidelines for schools and could provide a model for other governments. The policy includes guidance on managing the risk of sport provided by multiple providers, checklists for event organisation and guidance for the head-teacher specifically relating to national law. Principles for safe return to sport after any injury type could be included in such a policy. There was no mention of monitoring the efficacy of the policy, a component that should be inherent to all such policies so that effective injury prevention strategies can be identified.

Clearly defining roles and responsibilities is a key component of effective policy making 59 60 yet was lacking in the reviewed guidelines. Not defining these roles in injury prevention risks a lack of accountability for safety initiatives. The lack of accountability in the UK has been acknowledged, and the government is currently drafting ‘duty of care’ guidance for sport. The content and how this guidance may be applied to schools remains to be seen.

Only two guidelines 45 48 included a recommendation for injury surveillance. Currently, there is no national data collection of child injuries in the UK. Developing any effective injury prevention strategy requires an understanding of the burden of sports injuries. In turn, this would permit monitoring the effectiveness of interventions or guidelines that have been introduced to reduce injuries. Such a surveillance system should include documentation on the type of injury obtained and the type of sport that caused the injury, as recommended by the WHO. 61 Effective sports injury prevention in the UK will remain challenging in the absence of effective monitoring systems. We wait with interest to determine the degree to which the Emergency Care Data Set, due for introduction in October 2017, can provide the required level of detail, 62 although recognise that this system will only capture injuries presenting to emergency departments.

Finally, none of the included documents acknowledged that there is differential risk between girls and boys for some injuries. New work investigating anterior cruciate ligament injuries is one example for the importance of this 63 and needs to be considered in further research into sports injury prevention and subsequently incorporated into policies and guidelines for schools.

In conclusion, high-quality guidance for schools on this topic is sparse, and we have specified key areas that merit further research and attention. Importantly, interventions such as rule changes, introduced within the last few years in professional and youth games, have not yet been considered in school sport guidelines. The findings of the review have implications for policy, practice and research. A national policy is required specifically for schools, building on recent attention to concussion as a public health problem. Any new policy or guideline must incorporate existing and emerging research on sports injury prevention. In practice, existing guidelines reviewed in this study need to be publicised and adopted by schools. Finally, further research is required to develop an understanding of the effectiveness of child-specific injury prevention interventions. When assessing effective sport injury prevention interventions for children, the age, stage of development and gender of the child must be taken into account.

Limitations

Despite efforts to develop a comprehensive electronic database and grey literature search strategy, we are aware that further guidelines meeting our inclusion criteria may exist. Polices, guidelines and consensus statements are infrequently indexed in electronic databases making identification challenging. We limited our search to the English language and to OECD countries to identify guidelines with the potential to be relevant in the UK. The heterogeneity of guidelines and policies meant synthesis was limited to narrative process.

Acknowledgments

The authors would like to thank Caroline Finch, Keith Stokes, Mike England, Ginny Brunton, Angela James and all the authors of guidelines who assisted with data gathering for the project. This study was conducted by AG as part of a Severn Deanery Foundation Programme Year 2 placement under the supervision of JM and AE and supported by MVH.

AGöp and MVH are joint first authors.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient consent: Not required.

Contributors: This study was conducted by AG as part of a Severn Deanery Academic Foundation Programme Year 2 research placement under the supervision of JM and AE and supported by MvH.

Data sharing statement: There are no unpublished data.

IMAGES

A Dissertation on The Impact of Physiotherapy Interventions in the
(PDF) Managing Sports Injuries: Fourth Edition
The Anatomy of Sports Injuries, Second Edition by Brad Walker
(PDF) Sport injuries: A review of outcomes
(PDF) Psychology of sport injury rehabilitation: A review of models and
Types of Sports Injuries and How to Protect Yourself From Possible Risks

VIDEO

Treatment of Acute Sports Injuries
#NCAA bracket "dissertation",#NFL off season,Joe & Glo for 2024?, plus #SignOfTheTimes- SpinTheBlock
The process and qualities of a doctoral dissertation
Sports injuries in kids
Effectiveness Assessment Of Community Engagement In Sports Interventions
Essay on the role of Sports and games in students ' life

COMMENTS

Sport injuries: a review of outcomes
These were more common during competition compared with training and fractures accounted for 16% of these injuries, whereas concussions (15.8%) and ligament sprains (15.7%) were almost as common. 40. Sports trauma commonly affects joints of the extremities (knee, ankle, hip, shoulder, elbow, wrist) or the spine.
Youth sport injury research: a narrative review and the potential of
To prevent sports injuries, researchers have aimed to understand injury aetiology from both the natural and social sciences and through applying different methodologies. This research has produced strong disciplinary knowledge and a number of injury prevention programmes. Yet, the injury rate continues to be high, especially in youth sport and ...
Psychosocial Impacts of Sports-related Injuries in Adolescen ...
Sports injuries have been shown to have both acute and chronic psychosocial impacts on adult athletes, particularly if the injury is severe, but there is less information available regarding the impact on adolescent athletes. Health-related QOL is a patient-reported measure used to gain a better understanding of a person's multidimensional well ...
Athlete Mental Health & Psychological Impact of Sport Injury
In fact, 75% of all lifetime mental health conditions begin by age 24, 1 which corresponds with peak years of athletic performance. Athletes experience a range of stressors that can impact mental health ranging from typical life stress to sport-specific stress, such as performance demands, competitive failure, injury, and retirement from sport.
A Comprehensive Summary of Systematic Reviews on Sports Injury
In the United States, approximately 4.3 million nonfatal sports or recreation-related injuries are seen annually in the emergency department. 81 The highest rates of sports injuries for both boys and girls occur in adolescents aged 10 to 14 years, which is likely due to increased participation in sports among this age group. 81 The lower extremity is most commonly injured during sports ...
Psychological Responses to Sport Injury
Introduction. Inherent in sport participation is the risk of injury. Although the physical effects of sport injury (e.g., tissue damage, initiation of healing processes, increased body mass index and body fat percentage) are especially salient (Myer et al., 2014; Prentice, 2011), sport injury can also have psychological consequences.Aspects of psychological functioning that can be affected by ...
Athlete Mental Health & Psychological Impact of Sport Injury
At the time of this analysis, 756 athletes between the ages of 6 and 18 years had undergone a sports injury prevention evaluation. Most athletes were White (85%) and there was a slight female ...
Sport injury prevention in-school and out-of-school? A qualitative
Sport injury prevention programs are provided for youth both in-school and out-of-school . Yet, the prevention of sport injury is a behavior that requires motivation and perseverance to maintain [12-14], particularly when students are unsupervised in out-of-school contexts (e.g., playing physically active games, leisure sport events). It is ...
A Comprehensive Summary of Systematic Reviews on Sports Injury
This comprehensive review provides a thorough and con-cise summary of all systematic reviews and meta-analyses on the topic of sports injury prevention in general and for specific sports and injury types. The majority of "all injury" articles pertained to sports and exercise in general (15.5%) and soccer (10.2%).
A Review of the Sport Injury and Rehabilitation Literature: From
Barbara B. Meyer. University of Wisconsin-Milwaukee. Despite advancements in sport-injury rehabilitation theory and intervention design, return-to-play outcomes remain suboptimal. To explore the ...
The psychological response to injury in student athletes: a narrative
If an athlete is injured, these stressors increase. Main thesis Stress is an important antecedent to injuries and can play a role in the response to, rehabilitation and return to play after injury. ... increasingly common in a variety of contact and collision sports; an injury that is occasionally associated with significant time loss or ...
(PDF) Common sports injuries
Sports injuries result from acute trauma or repetitive stress associated with athletic activities. Sports injuries can affect bones or soft tissue (ligaments, muscles, tendons). ... Dissertations ...
IJERPH
The present study aimed to determine the epidemiology of sport-related injuries in amateur and professional adolescent athletes and the incidence of different risk factors on those injuries. Four hundred ninety-eight athletes aged 14 to 21 voluntarily participated in this prospective injury surveillance, conducted from 1 January 2019 to 31 December 2019. The information collected included ...
PDF SPORTS INJURIES IN STUDENTS ATHLETES
determine the current state of sports injuries in student sports. To realize the goal are placed the following tasks: to conduct a survey with students athletes on sports injuries; to process and analyze the results of the survey; to draw concrete conclusions from the survey; to make recommendations for practice.
Great Challenges Toward Sports Injury Prevention and Rehabilitation
This term is well-known and recognized as a banner of work which aims to protect the health of athletes, especially injuries and illnesses, perhaps thanks to the important efforts of the Oslo Sports Trauma Research Center and the IOC toward injury and illness prevention (Engebretsen and Bahr, 2005; Ljungqvist, 2008; Engebretsen et al., 2014 ).
Sports Injury Research
Prevention is crucial to health gain, both in the short-term (preventing immediate injury), and in the longer term (reducing the risk of recurrence and prolonged periods of impairment). Prevention follows four main steps: 1) the sports injury problem must be described in incidence and severity; 2) the etiological risk factors and mechanisms ...
PHD THESIS: Applying qualitative methods in sports injury prevention
Applying qualitative methods to understand the sports injury in context. This thesis aimed to explore by means of qualitative research how injury prevention is executed in practice, and to describe the perspectives of various stakeholders with regard to sports injury and its prevention. This thesis describes research in 3 different high ...
(PDF) Sports Injuries Prevention and Treatment
Sports Injuries Prevention and Tr eatment Ann Physiother Occup Ther. Sports Injuries Prev ention and T reatment. Gumusdag H*. Faculty of Sport Sciences, Bozok University, T urkey. *Corresponding ...
Analyzing injuries among university-level athletes: prevalence
Further, the injury profile appears to differ according to type of sport, with acute injuries being more common in team sports and overuse injuries in individual sports. The high prevalence of injuries among university-based athletes should be of concern to athletes, coaches and sport administrators as all have an important role to play in ...
(PDF) Undergraduate Dissertation
PDF | Undergraduate dissertation in Physiology and Sports Science investigating current ACL injury prevention techniques in female soccer players | Find, read and cite all the research you need on ...
Sports Dissertations
Injury Experiences and Psychological Responses of Athletes as a result of Sports Injuries. Dissertation Examples. The aim of this study was to further explore the phenomenon of sports injuries, five university students were interviewed regarding their injury experiences, in particular the psychological responses they had when their injury had ...
Prevention of sports injuries in children at school: a systematic
Background. Participation of children and young people in sport helps prevent obesity, improves physical and mental health 1-3 and is associated with higher physical activity levels as an adult. 4 5 Consequently, governments internationally are producing strategies to increase sports participation. 6-8 Sports are an important cause of injuries among children, and injuries can lead to ...
(PDF) SPORTS INJURIES IN STUDENTS
Dissertation, NSA, 2007. 3. Bozhkova, ... Sports injuries are common, although apart from high-level sportsmanship, sport is practiced mostly as a means of health prevention. Injuries in ...

Article contents

Introduction

Theoretical Perspectives

Empirical Perspectives

Injury-related content

Self-related content

Coping-related content

Psychological Readiness to Return to Sport

Practical Perspectives

Cognitive, Emotional, and Behavioral Responses

Conclusions

Related Articles

Log in using your username and password

You are here

Statistics from Altmetric.com

Introduction

Injuries: antecedents and the emotional response

Emotional response to injury (modified from American College of Sports Medicine et al 20 )

Injuries: problematic responses

Obstacles to seeking care

Barriers and facilitators to help seeking (modified from Gulliver et al 54 )

Facilitating treatment and support

Future directions/conclusions

Read the full text or download the PDF:

Sports Injury Research

Signed in as

Personal account

Institutional access

IP based access

Sign in through your institution

Sign in with a library card

Society Members

Sign in through society site

Sign in using a personal account

Viewing your signed in accounts

Signed in but can't access content

This Feature Is Available To Subscribers Only

Prevention of sports injuries in children at school: a systematic review of policies

Maria Van Hove

Julie Mytton

Associated Data

Conclusions

What is already known on this topic?

What are the main findings?

Inclusion criteria

Exclusion criteria

Search strategy

online supplementary appendix 1.

Quality appraisal

Main findings of this study

Limitations

Acknowledgments

IMAGES

VIDEO

COMMENTS