Coping with Injury: The Psychology of Being Sidelined

(Editor’s Note – Allison is not only a psychologist and co-owner of TJ’s Gyms in Northern California, but is also a good friend and great resource to the entire CrossFit community. Please bookmark her website, which provides weekly articles addressing the non-physical aspects of training that we can all improve upon.)

I love to run.  Running offers me an adrenaline rush second to no other form of workout, and it maintains my cardiovascular fitness in ways other workouts don’t.  Yes, I’m a CrossFit athlete, and CrossFit workouts are what I do most often.  But, there are some days when a good run, even if a short one after my gym workout, is just what the doctor ordered.  I lace up my shoes, grab my headphones, step outside, and let the soul feeding begin.

A few weeks ago, I registered for a women’s soccer league and played in my first soccer game since college, over twenty years ago.  I’ve toyed with the idea of soccer re-entry over the past few years, but I’ve always held off, for fear of injury.  For a number of reasons, I decided that now was the time to give soccer a whirl.  During my first game, I had an absolute blast.  Thanks to my decent conditioning from years of CrossFit and relatively good retention of my soccer skills from days gone by (with plenty of touches on the ball over the years as a youth coach), I was a contributor on my team and had a blast.  With just a few minutes left in the game, I felt a sharp sensation in my hamstring as I accelerated towards the ball.  After a moment of panic, thinking I had strained or pulled it, I was able to happily continue playing for the rest of the game.  A few days later, I went out for a morning run and was absolutely unable to make my hamstring work for such purposes.  Today, more than eight weeks later, I’m still sidelined from the activity I love most.  Luckily, as a CrossFit coach and gym owner, I have plenty of other things I can do to maintain my fitness and my sanity, but I’m starting to get antsy, and grouchiness is likely on the horizon.

Injuries can be devastating to individuals who are consistently active and/or are training for an event or ongoing participation in a sport.  The physical repercussions are usually apparent, but the emotional and psychological sequelae are often less obvious.  Back in 2009 while working on my thoracic spine, Dr. Kelly Starrett of MobilityWOD and San Francisco CrossFit and author of Becoming a Supple Leopard discussed the importance of recognizing the psychosocial aspects of physical injury.  He and I chatted about how athletes can quickly experience a feeling of social disconnect when they are injured, especially when they are accustomed to being part of a community of athletes.  Ironically, the same community that provides so much belonging and connection when one is able to participate (e.g. a CrossFit gym or team), can also feel like a source of disconnect when one cannot.

Since starting PsychologyWOD, I’ve received a number of requests for an article about the psychology of injury.  As I reflected on my experience with athletes and immersed myself in the literature on injury and recovery, a few themes emerged, which I’ve highlighted below.  When athletes are injured, they experience a range of emotions that may seem extreme or idiosyncratic but are actually well within the normal range of responses.  Of course, there are many factors affecting the athlete’s injury experience, including severity of injury, extent of sport participation, and pre-injury personality, but it is not uncommon for people to experience some or all of the following:

Isolation:  Athletes often feel isolated and lonely when they are injured.  This is especially true if they had been part of a team prior to injury or if their pursuit involved training with a group of athletes from whom they may now feel disconnected.  (Ruddock-Hudson, O’Halloran, & Murphy, 2012; Peterson, 2009; Russell, 2008).  Along with this experience of isolation may come an unwanted feeling of envy of those who are healthy and able to continue participating in their sport or activity.  Envy is an uncomfortable emotion and is often accompanied by shame or guilt.  Injured athletes should know that envy may be part of their experience, especially when an injury is serious and long-term.

Anxiety:  Athletes may experience heightened levels of anxiety, both regarding their sense of identity and their capacity for healing and recovery.  Some studies even indicate symptoms of post-traumatic stress after an injury (O’Connor Sr., 2011; Brewer and Petitpas, 2005; Podlog and Eklund, 2007; Peterson, 2009; 1; O’Neill, 2008; Appaneal, Perna, & Larkin, 2007).   Athletes who fear re-injury may behave in ways that actually hinder their recovery and lead to re-injury, such as overdoing rehabilitation and recovery training, thereby taxing the injured parts in ways that are harmful instead of helpful  (Andersen, Mubaidin, Tibbert & Morris 2011).

Fear of Re-injury:  Injured athletes often have a heightened experience of vulnerability after an injury.  As they work towards re-entry into their sport or another activity, they may fear getting injured again.   This may hinder full recovery and the possibility of immersion into sport in the future (Stephan, Deroche, Brewer, Caudroit, and Le Scanff, 2009; Peterson, 2009; O’Neill, 2008; Russell, 2008; Andersen, Mubaidin, Tibbert, & Morris, 2011).

Depression:  When an individual’s primary source of enjoyment is removed via injury, it is not surprising that mood will be affected.  There is often a component of negative affect and depression associated with injury timeouts.  This can be especially true when the athlete’s identity and/or full-time career is at stake, such as for professional athletes and Olympians.  Should one’s depressive symptoms become severe, professional help via therapy and/or medication should be part of the athlete’s overall recovery plan (Appaneal, Levine, Perna, and Roh, 2009; Evans and Hardy, 1995; Peterson, 2009; Russell, 2008, Tracey, 2003).

Low Self-Esteem:  Related to one’s identity, self-esteem can suffer when one is injured.  If an athlete’s sense of him/herself is challenged, esteem can take a plunge, and feelings of worthlessness can emerge (Tracey, 2003; Wasley & Lox, 1998).  The more serious and committed one is an athlete, the more one’s sport is wrapped up in one’s identity, and the more likely self-worth will be diminished when that identity is challenged via injury.

Paradoxical Sense of Relief:  In some cases, when an athlete has been under a great deal of pressure and strain to perform in his/her sport, being forced to take a break because of an injury can bring an unexpected sense of relief and even joy, even if this is not conscious.  The relief may be a source of conflict for the athlete though, and he/she may not be able to simply enjoy it.  Rather, he/she may feel guilty for having such feelings and may try to hide them from others, especially coaches and teammates.  As one author puts it, an injury “may function as an ‘honorable discharge’ for [athletes] looking for an excuse to leave their sport” (Peterson, 2009, p. 230).

Given these potential repercussions of injury, as well as other possible emotional experiences related to injury, what are some ways of coping?  Below is a list of some helpful tips.  This list is by no means comprehensive, but it’s a start.

Social Support:  One theme that emerges with vigor in the research on the psychology of injury is the importance of social support during the rehabilitation phase.  This includes coaches and athletic trainers, but also refers to general social support systems (Yang, Corinne, Heiden, Foster, 2010; O’Neill, 2008; Podlog & Eklund, 2007; Dupcak, 2000; Belger, 2012; Green and Weinberg, 2001; Mainwaring, 1999).  The importance of social support for responding to stressful life events and for our overall health and wellness is discussed in great detail in my book.  There is no ambiguity here: social support and community connections absolutely benefit our physical and mental health and well-being (Belger, 2012).  It is critical that injured athletes maintain a social support crew that will help them get through difficult times.  Non-injured, active athletes can keep a list of go-to people who can serve this purpose, should an injury arise.  Unfortunately, for many athletes, their built-in support network may be too involved in their training or sport to be objectively helpful during the most trying of times (Peterson, 2009).

Specific Strategies:  A number of strategies have been shown to be helpful for athletes in the midst of injury. These include:

*Imagery: Visualizing one’s body healing and seeing oneself back on the playing field.

*Journaling: Writing down emotional content related to one’s injury.  Doing so with consistency and commitment can be a helpful way to manage the slew of emotions one experiences when injured.  It can also be a great resource for the athlete in the future, should another setback arise, as it can serve as a reminder of how he/she persevered through bleak times.

*Goal-Setting:  Much like with one’s regular training, setting and tracking goals when injured can be a beneficial strategy.  Goals should be reasonable and realistic and should include both long-term and short-term views, so progress can be monitored in an ongoing way.  Flexibility with goals and their attainment is especially important when injured, since rehab progress is often unpredictable.

Acknowledging Feelings and Reality:  Avoiding the reality of one’s feelings and situation isn’t a great coping style in general.  This is especially the case when athletes are injured; avoidant coping styles (ignoring feelings and trying to distract oneself from facing unwanted realities) have been found to be maladaptive and not beneficial when dealing with injury.  (O’Connor Sr., 2011; Gallagher and Gardner, 2007; Evans, Hardy, and Fleming, 2000).  Interestingly, but not surprisingly, those with limited coping resources are also the most susceptible to injury in the first place (Williams, 1996), making effective coping skills (those that acknowledge and deal with emotions and problems) important for both injury prevention and rehabilitation.

Counseling: In many cases, working with a psychologist can be helpful when one is injured and the emotional ramifications are significant.  Support from coaches is also critical, but there are times when a coach is too close to the situation and outside assistance is warranted and most likely to help.

Find a Way to Stay Connected to the Sport and/or Find an Alternative Outlet If you can manage to become a spectator, cheerleader, or coach for teammates or other athletes during your down time, this is sometimes a good way to remain involved.  However, it may be too emotionally painful if you are seriously injured.  It is also important to engage in other activities and be social with non-athletes.  At the risk of redundancy, social connection is critical when an athlete is sidelined.  Recovery periods may be a good time to pursue alternative endeavors and take advantage of some down time that can be hard to come by when training is in full force.

One final note about preventing injury in the first place:

In addition to physical issues related to keeping oneself well as an athlete, it is critical to remember that emotional and psychological well-being is also protective against physical injury.  Significant life stressors can predispose athletes and make them vulnerable to injury, especially when their coping mechanisms are less than optimal.  In one study along these lines, Kerr and Minden (1988) reported that stressful life events were related to both number and severity of injury within a sample of 41 elite female gymnasts.  This is a good reminder for athletes to be especially attuned to their bodies and their recovery during times of stress outside of their training.  If your emotional regulation or psychological coping is taxed or challenged outside of the gym, your body will be more susceptible inside the gym.  Ignoring stress and its potential physical consequences is a risky proposition.  Don’t do it!

Stay tuned for a future article on the psychology of sticking with a rehab plan!  

References:

Appaneal, R.N., Levine, B.R. Perna, F,N., & Roh, J.  (2009). Measuring postinjury depression among male and female competitive athletes. Journal of Sport & Exercise Psychology, 31:1, 60-76.

Appaneal, R.N., Perna, F.M., & Larkin, K.T. (2007).  Psychophysiological response to severe sport injury among competitive male athletes: A preliminary investigation.  Journal of Clinical Sport Psychology: 1:1, 68-88.

Andersen, M.B.,  Mubaidin, Q.H., Tibbert, S., & Morris, T. (2011). Injury recovery research issues: questions about anxiety, imagery, and mental toughness in rehabilitation.  12th European Congress of Sport Psychology.

Belger, A. (2012).  The Power of Community: CrossFit and the Force of Human Connection. Victory Belt Publishing: California.  Returning to Self: The Anxieties of Coming Back After Injury.  In Andersen, Mark B. (Ed), (2005). Sport psychology in practice, pp. 93-108. Human Kinetics: Champaign, IL, US.

Dupcak, S.S. (2000). After the fall: The development of a coaches’ manual identifying the psychological issues facing injured athletes. Dissertation Abstracts International. Section B: The Sciences and Engineering, 2754.

Evans, L., & Hardy, L. (1995).  Sport injury and grief responses: A review.  Journal of Sport and Exercise Psychology, 17:3, 227-245.

Evans, L., Hardy, L., & Fleming, S. (2000).  Intervention strategies with injured athletes: An action research study.  The Sport Psychologist, 14:2, 188-206.

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, 1:1, 47-67.

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, 13:1.

Kerr, G., & Minden, H. (1988).  Psychological factors related to the occurrence of athletic injuries. Journal of Sport & Exercise Psychology, 10:2, 167-173.

Mainwaring, L. (1999). Restoration of self: A model for the psychological response of athletes to severe knee injuries.  Canadian Journal of Rehabilitation,  12:3, 145-154.

O’Connor Sr., J.W. (2011).  Emotional trauma in athletic injury and the relationship among coping skills, injury severity, and post traumatic stress. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 71(10-B).

O’Neill (2008).   Injury contagion in Alpine ski racing: The effect of injury on teammates’ performance. Journal of Clinical Sport Psychology, Vol 2:3.

Peterson, K. (2009).  Overtraining, burnout, injury, and retirement. In Hays, Kate F. (Ed), (2009).Performance psychology in action: A casebook for working with athletes, performing artists, business leaders, and professionals in high-risk occupations, 225-243. American Psychological Association: Washington, DC, US.

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, 8:4, 535-566.

Ruddock-Hudson, M., O’Halloran, P.,, & Murphy, G. (2012).  Exploring psychological reactions to injury in the Australian Football League (AFL).  Journal of Applied Sport Psychology, 24:4), 375-390.

Russell, P. (2008).  The psychological impact of sports injury.  Fitpro Network web article. 

Stephan, Y., Deroche, T., Brewer, B.W.,  Caudroit, J., & Le Scanff, C. (2009). Predictors of perceived susceptibility to sport-related injury among competitive runners: The role of previous experience, neuroticism, and passion for running.  Applied Psychology: An International Review, 58:4, 672-687.

Tracey, J. (2003). The emotional response to the injury and rehabilitation process.  Journal of Applied Sport Psychology, 15:4, 279-293.

Wasley, D. & Lox, C.L. (1998).  Self-esteem and coping responses of athletes with acute versus chronic injuries. Perceptual and Motor Skills,  86:3-2, 1402.

Williams, J.M. (1996).  Stress, coping resources, and injury risk.  International Journal of Stress Management, 3:4, 209-221.

Yang, J, Peek-Asa, Lowe, J/B. C., Heiden, E. Foster, D. (2010). Social patterns of collegiate athletes before and after injury.  Journal of Athletic Training, 45:4, 372-379.