Athletes face intense pressure to return to play when they are injured but the challenge for physicians is to have them return safely. This author explains the importance of social support and having a strong grasp of the motivations and fears of the injured athlete in order to facilitate rehabilitation of the injury and a successful return to the field of play.
Athletes are supposed to be tough and maintain a positive attitude while regularly playing through pain.1 When they are forced to sit out because of an injury, they should be focused and driven to return to play as quickly as possible. They should rest, rehabilitate and then trust that their bodies are ready to go full speed upon their return.
This is the idealistic view of sport and injury. However, the reality is that injuries are an unavoidable byproduct of being an athlete and the transition from “active athlete” to “injured athlete” and back to “active athlete” does not always occur without complications.
Injured athletes struggle with fear, frustration, anger and sometimes depression during their time away from sport, which may even prevent them from following their rehabilitation program effectively.2 Additionally, the return to sport itself yields a new set of adversities as athletes must navigate through personal fears and a desire to return to their pre-injury state along with team, family and coaching-related issues.
Over the years, I have worked with numerous injured athletes and it is clear from our conversations that their perception regarding social support is significant to their overall well-being, attitude and effort toward returning. Athletes sometimes feel neglected and useless during their time away from sport. As a result, they may distance themselves further from those who could actually provide the support needed to improve their mood and determination to continue.
Social support comes in various forms, ranging from emotional support to task challenge support.3 Some injured athletes need a caring person just to listen to their fears while others may prefer a challenging push to work harder during rehabilitation. Regardless of the type of support, research has found connections between social support, decreased athlete stress and improved psychological well-being.4 Studies looking at the provision of social support have found that athletes feel most satisfied with the support provided by athletic trainers in comparison to support provided by coaches or teammates.5,6
It would appear obvious that athletes would desire support from those in a position to assist with the injury recovery process. In a college setting, this extra support is possible since teams have access to athletic trainers. However, injuries are not unique to the collegiate population, making it important to address who is or should be providing this support to younger athletes.
Researchers who directly addressed athletes’ preferences from healthcare professionals found a desire for more information about the injury, a clearer timeline for return to play and an open environment in which athletes felt comfortable asking questions.7 In regard to athletes not fully understanding their injuries, they noted that they would have appreciated the use of models and more detailed explanations from their doctors. Respondents talked about doctors who did not talk to them and others who seemed frustrated by their questions.
Russell and Tracey also found that injured athletes wanted their doctors to ask about their emotions and psychological reaction to the injury.7 Although that is what athletes wanted, that was not what they received and the players’ overall conclusion was that doctors did not have time for them.
Although healthcare providers are busy, it is essential that someone takes the time to help these injured athletes through the injury and return to play experience. The process is not easy and it does not end the moment an athlete is cleared to return. In fact, that can be the time when it gets even harder. Athletes return to the fields and coaches and teammates expect them to be the same as they were prior to the injury.
Although a full return may be possible in time, it will not happen immediately and the athletes, parents, teammates and coaches need to understand this. Athletes who have missed numerous practices or those who have been inactive for any period of time will require a slow progression back to their previous level. This is frustrating for coaches who may “need” that athlete and for the athlete who wants to return so as not to let down the team, coach or themselves. This desire to return triggers an internal struggle as the athlete wants to run hard and participate fully, but fears re-injury. Additionally, the athlete may want to listen to doctors and trainers while simultaneously appeasing the team and coach.
Therefore, one must provide social support in several ways throughout the recovery and return to play process. Richman, Rosenfeld and Hardy identified the following eight types of support: emotional support, emotional challenge support, reality confirmation support, task appreciation support, task challenge support, tangible support, personal assistance support and listening support.3
Emotional support and listening support can be helpful when athletes are explaining their feelings. This type of support helps the athlete feel relevant and cared for. If this type of support occurs early in the process, it is then easier to get a productive response when initiating emotional challenge support, which is intended to help recipients evaluate their attitude, values and feelings. Sometimes injured athletes get overly consumed in their own negativity, thus skewing their view of reality. It may take an outsider to challenge their views and help them see their personal responsibilities in their recovery.
This also speaks to the benefits of task challenge support, which is intended to challenge recipients to be more involved. Social support providers can challenge injured athletes to get more involved in their rehabilitation and find alternate ways of working with their teams. The type and amount of support required may differ per person, but the importance of it to one’s psychological recovery and emotional well-being is undeniable.
The “what ifs” are likely harder than the actual situations once an athlete returns to play. Many athletes fear re-injury, continued pain or the possibility of not reaching their long-term goals.8 Athletes have expressed worries about not meeting others’ expectations and ultimately letting down their teammates and coaches. These fears lead some athletes to conjure up the worst case scenarios regarding their return before even setting foot on the field.
For example, Brian was convinced that his coach no longer wanted him on the team because he was injured. He was certain there was no connection between his behaviors and his eventual status on the team because his coach had already replaced him. In reality, the coach did give another athlete a chance during Brian’s time away from the field of play but he also gave Brian a chance to earn his position once he was healthy. Rather than seeing the situation as a positive challenge, Brian chose to see it as an uncontrollable obstacle.
In general, it is very difficult for athletes to see they are physically replaceable. In other words, there is always a chance that someone will be able to take their spot on the team. Accordingly, during the rehabilitation of an injury, it is critical to discuss the athlete’s other qualities with him or her.
An athlete may be an amazing midfielder on the soccer team but discussing her abilities to make strong cuts, change her speed and score with both feet are not as important as her work ethic, positive attitude and leadership skills. When she returns to the field, it is her work ethic and positive attitude that will allow her to push herself, and put in the time and practice needed to put her in a position to eventually to regain her place on the field. In addition, it is her leadership skills that will allow her to make an impact even when she is not playing. Brian’s thoughts led to complacency because he did not want to work for a position he felt he deserved.
Not every injured athlete has the same drive and determination to return. Sometimes the mindset changes because of the injury. At other times, the mindset is merely illuminated because of the injury. In other words, some athletes will do whatever it takes to return. Those are the athletes you need to put on a short leash so they do not re-injure themselves. Other athletes take the injury as their “way out.” There is nothing wrong with taking an “out” from a sport that you truly do not want to play anymore. However, it is important to identify whether that person truly wants to quit the sport or whether he or she is just scared or unwilling to put in the hard work necessary to return.
Injured athletes sometimes create the belief in their minds that everyone is against them when, in reality, coaches and teammates have always wanted the same thing: athletes who work hard and perform effectively. Injured athletes only see that they are not included or that they are not the “go-to” athletes anymore. This typically happens as a result of inexperience or a lack of awareness on the part of coaches and teammates with regard to best practices with injured athletes. Although injured athletes translate their behaviors as a lack of concern or dislike, most coaches I interviewed regarding their perception of injured athletes explained it as a lack of knowledge concerning what to say to these individuals.
Still, there are times when a real incident incites an athlete’s feeling of frustration. For example, a runner had broken her foot and after a long and arduous rehab, she returned to the track. Her runs were constantly painful and her coach thought she was “playing possum.” This is a common phrase used by coaches about athletes who they feel are “faking it.” Interestingly, this athlete’s parent was close with her coach and the two influenced one another. This athlete recognized her coach’s and her parents’ frustrations, and she tried to return even faster and harder. Needless to say, her fear of disappointing others led to risky behaviors and ultimately re-injury.
It truly is a fuzzy line between working hard and working too hard. It is important to differentiate when an athlete is doing everything he or she should be doing versus doing too much. Similarly, it is important for an athlete to recognize when his or her mind is negatively influencing his or her chances for a full recovery. Taken together, the mind influences the behavior, making it critical to know that one’s mind is focused on recovery and a healthy return, not the fear of disappointing others or frustration over being left out.
Coaches and parents both want athletes healed and returning to play as quickly as possible. More often than not, athletes want that same result. The problem is that all these people are pushing and pushing to get back without considering the difficulties and adjustments that need to happen upon one’s return.
Starters may not necessarily be starters anymore. The fastest athlete on the team may not be able to run. Ultimately, everyone involved needs to shift their attention from “who he or she was before” to “who he or she is now.” This is not a mindset of acceptance and inaction, but rather acceptance and planning to put one in the position to get better and stronger in the coming days, months and years if necessary.
These shifts in one’s mindset do not happen overnight and they do not happen independently. Injured athletes must work on recognizing their thoughts and readjusting their thinking to benefit rather than hurt their ultimate return. They must first accept that they are injured. Later, they must accept that they are healed but not 100 percent. Throughout the process of a full return to play, these athletes should be setting small goals to ensure they keep getting better.
Throughout the rehabilitation process, athletes should set small goals, adjust their mindset, surround themselves with supportive people and develop their patience.9 It is important for others like doctors, parents and coaches to understand the process, and provide athletes with support and resources to help them build in these areas. Simple strategies like setting daily rehabilitation goals followed by daily practice goals can help athletes experience small successes and ultimately build their confidence.
Every injured athlete wants to return to 100 percent but it will take time to get to that level. If they do not see small improvements over time, they are likely to lose the motivation and drive to continue. Once on the practice fields, the athlete has to set small goals based on his or her current as opposed to former status. The athlete will then see small daily improvements leading him or her in the direction of better performances in the future.
Building and/or maintaining confidence is essential, and it cannot be connected solely to results. Athletes should not be confident because they are starters on the team. Rather, athletes must recognize that confidence helps them push through failures, and keeps them trying even when situations are not going their way. Confidence is a way of thinking and acting that should be evident in everything one does regardless of the outcome.
In addition to building confidence, injured athletes must work on their overall outlook with regard to personal interactions. Injured athletes must recognize that they get what they give.9 If athletes separate themselves from the team and coaches during an injury or if athletes act sullen and quiet around teammates, they will likely get a similar response. It is always difficult to be injured.
Accordingly, the mind of an injured athlete tends to be focused inside. Injured athletes must learn to focus outward more and recognize not just how they feel, but also how others around them feel. During their time off the field, they can be better helpers, supporters and learners. Ultimately, you get what you give and if you wait for others to support and help you, the wait may be long.
Finally, although it is not good to wait for others to support you, it is important to ask for support when you need it. Parents, coaches and doctors do not always know when someone needs more information, a push or a word of support. Although it may be hard to do, it is so important for athletes to seek the support they need. Accordingly, it is helpful for doctors, parents and coaches to know who or what resources are available to help their injured athletes through such a difficult experience.
Research shows that most healthcare providers rarely or never refer injured athletes to a sport psychologist.10 These are the experts in the field who handle these situations daily and they should be part of the rehabilitation process.
Given the intense emotions and possible negative effects associated with injury, it is clear that more education is necessary to ensure positive results for all involved. Injuries are unavoidable but they do not have to be completely devastating to one’s life and well-being if handled effectively. It is clear that injured athletes experience adversity because of the injury itself and because of the overall change to their lives and daily routines. The physical healing is sometimes easier than the mental return to play because the bone may heal and the tear may be fixed, but the mind does not change as readily.
Therefore, it is important for all involved to understand that mending an injured athlete requires attention to both the body and the mind. One can accomplish this with better awareness, education and effort of doctors, coaches, parents and athletes alike.
Dr. Robbins is a Sport Psychology Consultant and an Assistant Professor in the Department of Human Performance and Sports Sciences at Winston-Salem State University in Winston-Salem, N.C.
1. Heil J. Psychology of sport injury. Human Kinetics, Champaign, IL, 1993.
2. Taylor J, Taylor S. Psychological approaches to sport injury rehabilitation. Aspen Publications, Gaithersburg, MD, 1997.
3. Richman JM, Rosenfeld LB, Hardy CH. The social support survey: a validation study of a clinical measure of the social support process. Research Social Work Practice. 1993; 3(3):288-311.
4. Hardy CJ, Richman JM, Rosenfeld LB. The role of social support in the life stress/injury relationship. Sport Psychology. 1991; 5(2):128-139.
5. Clement D, Shannon VR. Injured athletes’ perceptions about social support. J Sport Rehab. 2011; 20(4):457-470.
6. Robbins J, Rosenfeld L. Athletes perceptions of social support provided by their head coach, assistant coach and athletic trainer pre-injury and during rehabilitation. J Sport Behavior. 2001; 24, 277-297.
7. Russell H, Tracey J. What do injured athletes want from their health care professionals? International J Athletic Therapy Training. 2011; 16(5):18-21.
8. Podlog L, Eklund RC. A longitudinal investigation of competitive athletes’ return to sport following serious injury. J Applied Sport Psychology. 2006; 18(1):44-68.
9. Dale GA, Robbins JE. It’s a Mental Thing! 5 Keys to Improving Performance & Enjoying Sport. BW&A Books Inc., Durham, NC, 2010.
10. Mann BJ, Grana WA, Indelicato PA, O’Neill DF, George SZ. A survey of sports medicine physicians regarding psychological issues in patient-athletes. Am J Sports Med. 2007; 35(12):2140-2147.
For further reading, see “Key Insights On Returning Athletes To Sport After Injury” in the April 2010 issue of Podiatry Today.