Written by Julie Hubbard

As many of you know, the National Alliance on Mental Illness sponsors Mental Illness Awareness Week during the first full week in October every year. This year, from October 4-10th, the NAMI promoted the theme “What People with Mental Illness Want You to Know” throughout all awareness events. In honor of such (and, by special request from a number of you on the Just4Kicks Boston Instagram), I’ve decided to write this week’s post on the psychology of being sidelined. Athletes that sustain injuries can battle psychological and mental health issues, including depression and anxiety. Injuries and mental health are an important topic to talk about and is often overlooked by coaches and healthcare practitioners alike. 

I’d like to start this post by first pointing out that I am not a psychologist, psychiatrist, or licensed clinical social worker. I am a Doctor of Physical Therapy by trade but have also completed some formal education in the realm of sport psychology. At UConn, I wrote my Master’s thesis on voluntary and involuntary career termination or retirement from the sport, and the havoc this transition can wreak on an athlete’s life. That being said, I will try to keep this post as evidence-based as possible, but I will also be sharing a little bit of my own story. I’ve gone back and forth in my head on how vulnerable I am willing to make myself, and I’ve decided to meet you guys halfway. I’m not going to air out all of my dirty laundry per se, but I will share some of my experiences with you, and if it helps even just one person, then I will have succeeded. 

Last week, I was talking with another DPT about different career development opportunities. She said, “I can’t believe that some people waste their time at continuing education courses on things like psychology, when they could be learning valuable manual techniques or other modalities they could immediately apply in the clinic.” Lately, I’ve been working on my transparency and communication with others, but I couldn’t help but just smile and laugh. What an ignorant statement. She literally couldn’t be further off base. 

Last year, I “wasted” my time at the Micheli Lecture at Boston Children’s Hospital on the Psychology of Sports Injury and Rehabilitation. It was absolutely refreshing to see a room full of MD’s, DPT’s, ATC’s, RN’s, NP’s, etc. sitting down and talking to each other about the mental and emotional side of injury. When a patient walks through the clinic door, we can’t just see him/her as an injured body part. Sure – manual therapy and therapeutic exercise is extremely important, but I might argue that the humanistic aspect of treatment is often the most beneficial for patients. Great clinicians are those who are able to meet their patients where they are, and then empower them to take control over their own recovery process. I’ve been super blessed to have encountered a number of great clinicians throughout the course of my athletic career, and if it wasn’t for their encouragement and support, I’m not sure I would have bounced back from injury as many times as I did. Now, I’m trying my best to pay it forward and be that clinician for someone else. 

Mental Health & Sports

So – let’s talk about mental health. One in five Americans is affected by mental illness. There is a plethora of research supporting the causative relationship between athletic injury and depression/anxiety. With an estimated 40-50% of collegiate student-athletes sustaining an injury during participation in NCAA-sanctioned sports, it is no mystery that a large portion of them also suffer from subsequent depression or anxiety after an injury occurs. The National College Health Assessment Survey showed that about 31% of male and 48% of female NCAA student-athletes reported either anxiety or depressive symptoms annually during the 2008 and 2012 academic years. That’s insane. That means that almost one-third and one-half of all NCAA male and female student-athletes have experienced, or are currently experiencing, anxiety or depressive symptoms. Unfortunately, the stigma associated with mental health disorders often shames athletes into silence and prevents them from seeking formal help. This toxic environment of shame, fear, and silence won’t change unless we consciously act to change it. So let’s change it. 

We all know that soccer can be a pretty brutal contact sport. Over the years, I’ve taken hundreds of goal kicks, corner kicks, 50/50 balls, and other player’s heads to the dome. New research is alluding to the fact that there may be a possible dose-response relationship between sport-related concussion (SRC) and depression. In fact, there is a 2-3x greater risk of depression after an athlete sustains three concussions. There is also a 2.9x greater incidence in depression and anxiety in athletes who sustain musculoskeletal (MSK) injury while participating in their respective sport. So… If I’ve tallied four SRC and four ACL tears, where does that put me? I’m not a mathematician, but you could probably guess that I deal with my fair share of depression and anxiety. Spoiler alert: I’m a loose cannon. 

PHEW! Now that I have that off my chest, let’s talk about some of the common psychological issues athletes face when recovering from injury.

Psychological Issues Athletes Face Recovering from Injury

Hurt athletes often experience fear, isolation, loss of identity, loss of purpose, depression, and/or anxiety. Cognitive, emotional, and behavioral responses have been well-documented throughout the course of injury, and while there are general trends that emerge in the research, it is important to note that there is tremendous variability in how an athlete responds psychologically during rehabilitation.

In general, self-efficacy and perceived “percent rehabilitated” tends to increase over the course of rehabilitation. Pain and emotional distress (including stress, depression, frustration, and anxiety) tend to decrease over the course of rehabilitation. However, some athletes are predisposed to experience higher emotional distress than others. Athletes who demonstrate high levels of self-identification with the athlete role, pain, pain catastrophizing, and/or neuroticism (i.e. baseline depression/anxiety) tend to experience more emotional distress with an ACL injury, for example.

While strong self-identification with the athlete role can have its downs, it is also predictive of adherence to rehabilitation and home exercise programming. Rehab professionals can predict which patients will be compliant with their therapy by identifying those with strong athletic identity, self-motivation, openness to experience, belief in efficacy of treatment, self-efficacy, and those who participate in goal-setting, positive self-talk, or imagery. 

Did you know that, on average, only 81% of people return to sport following ACL reconstruction, 65% return to their pre-injury level of sport, and 55% return to competitive-level sport after surgery? Multiple narratives and systematic reviews of literature have been conducted suggesting that athletes are less likely to return to sport after significant injury if, during rehab, they display re-injury anxiety/fear of re-injury, low self-motivation, lack of confidence, or low “psychological readiness” to return to sport. Interestingly enough, research also shows that athletes who are supported by athletic trainers or other sports medicine staff members experience an 87% decrease in depression and a 78% decrease in anxiety when returning to sport. 

PTSD and Injury in Athletes

Post-Traumatic Stress Disorder (PTSD) is also a common manifestation in athletes attempting to return to sport after a significant injury. PTSD is a constellation of symptoms including reliving the traumatic experience, needing to “hash out” the injury, ruminating over injury, nightmares, and/or hallucinations. One in 3 kids develops Acute Stress Disorder (ASD) following musculoskeletal injury, which basically means that the aforementioned symptoms occur for less than 30 days. Once you cross the one-month mark, it can now be deemed PTSD. One in 6 kids with musculoskeletal injury develop PTSD and have increased difficulty recovering from a psychological standpoint. This can manifest in increased heart rate or nervous sweats just from lacing up your cleats. I’ve seen statistics as high as 33% of patients with minor orthopaedic injuries developing some sort of PTSD, with even higher statistics for athletes experiencing repeat ACL tears (*cough* you know who you are *cough*). 

Athletes are sometimes forced into involuntary athletic retirement due to “career-ending” injuries. I’ve done some qualitative research in this domain and can tell you from both a scientific and personal standpoint that career-ending injuries are a different kind of beast. I tore my ACL for the fourth time two years ago today. Physically, anyone can rehab an ACL tear. The body will inevitably heal in 9-12 months. The spirit, however, can take a little bit longer. 

My Story

After playing 20+ years of soccer in my youth and into my young adult years, I’ve decided that I should no longer play soccer. I often joke about having PTSD when a soccer ball rolls by, but honestly, part of that is true. I spent the first two decades of my life perfecting a craft that I can no longer play. I’ve been working through this reality for the past 730 days, and I’m still not there yet. When interviewing the participants of my thesis research back at UConn, there were a couple of themes that emerged in athletes who experienced a positive transition from the sport. They were: staying involved in sport, divesting from athletic identity, and finding a new focus. I have attempted to put some of these ideas into practice by getting involved in coaching youth soccer, exploring new hobbies, and starting Just4Kicks Boston. 

If, for some reason, picking up fitness boxing or starting an educational blog is not for you – stay tuned for The Psychology of Being Sidelined: Part II, where I will be discussing the signs and symptoms of mental illness, as well as different treatment strategies to get you out of that funk and back onto the field. 

If you or anyone you know is struggling with thoughts of depression or suicide, call the NAMI helpline at 800-950-6264 or text ‘NAMI’ to 741741.