THE MENTAL SIDE OF ATHLETIC INJURIES

A Coach’s and Athlete’s guide to
psychologically rebounding from injury

You've been involved in your sport longer than you can remember. As you've grown, so have your strength, endurance and technique. You've busted your butt to become as good in your sport as possible and a force to be reckoned with in competitions. Known for your work ethic, consistency and ability to come through in the clutch, you’ve been the one your team has always been able to depend on in crunch time. You live to practice and perform. You have a passion to compete. You flat out love your sport. It’s who you are! It’s how you define yourself. You have dreams to compete at school, maybe get a college scholarship…who knows… maybe even to go beyond to the next level!

Then the unthinkable happens! It seems to have slowly snuck up on you. It’s not like there was any major injury or anything. You didn’t really feel anything pull, pop or break. Perhaps it might have been a lot easier and more straightforward to deal with if you had experienced that. No, this was quite a bit more insidious. After a big competition you noticed some pain and tenderness in your shoulder. “No problem,” you thought to yourself. You’ve dealt with this stuff before. You quickly dismiss it as nothing. The next day in practice you notice that your shoulder still feels tight and sore. “No big deal!” You try to ignore it and push through the pain. When practice ends your shoulder is throbbing and you start realizing that perhaps you were a bit foolish to have forced yourself to work through the pain. That night, when you can't even lift your arm to brush your teeth, you start to get worried for the first time.

You keep telling yourself there's nothing really wrong, but the pain just won't quit. As much as you hate it, the next day you have to go to the coach and tell him you’re a little hurt. He tells you to take a few days off. You’re forced to rest and you absolutely hate it. However, even after you take two days off, the first few movements that you go through in the next practice still kill. In fact, that shoulder feels just as tight and sore as before. But how bad can it really be? Maybe you just need to take a little more time off. However, when the throbbing in your shoulder keeps you up several nights in a row and then out of two more competitions you finally get the message! Something's very wrong here and it's time to drag your butt to the doctor!

Seeing a sports medicine specialist confirms your worst fears. Your shoulder is really bad and he says that you have to be out of action for at least two to three months! He claims that you have some form of tendonitis or maybe some potential rotator cuff problems, but that’s all Greek to you. He doesn't really know how long this is going to take, but what he says next, really gets your attention. Unless you take care of that shoulder and give it enough rest, you may risk doing some permanent damage. What does that mean you ask? He tells you that if you continue to play through the pain, that you may be jeopardizing your athletic career! Is he crazy!! Is he really telling me that I may never play again!! How could that possibly be! Is this guy a quack or what? How could I even survive without my daily dose of this sport?

If you’re a serious athlete and have ever had an experience with an injury, then you KNOW that the physical hurt you feel is only one VERY small part of the overall pain that you have to go through in the rehab process. The psychological pain caused by your injury and the temporary or permanent loss of your sport can be far more devastating than the strained or torn ligaments, pulled muscles, ripped cartilage or broken bones. Unless this psychological pain is directly addressed and "treated", your overall recovery will be slow and incomplete. Coaches and parents who are sensitive to the issues of the injured athlete help speed up the rehab process and significantly lessen the mental anguish that the athlete must struggle with. Coaches and parents who are insensitive to these very critical issues, cause further trauma to the athlete and may compromise the healing process.

To better understand what happens psychologically when an athlete is kept out of action because of an injury, it's important to briefly examine the three major functions that sport plays in the athlete’s life.

THE FUNCTION OF SPORT IN YOUR LIFE

• #1 SENSE OF IDENTITY - If you are a serious athlete and have been competing long enough, then you will soon come to see yourself in terms of your sport. You’re a swimmer, ball player, skater, tennis player, wrestler, gymnast, etc. It's who you are and what you do! With your long-term investment and commitment of time, energy and pain over the years, your sport has become an integral part of who you are. It's how you see yourself and how others see you. Your sport has become an extension of your sense of self. When you compete, this sense of identity further expands to include the role that you play on your team both tactically and socially/emotionally.
  
  
• #2 MAJOR SOURCE OF SELF-ESTEEM - As a young tennis player growing up in a family with distant and uninvolved parents, tennis served (no pun intended) as my sole source of self-esteem. It was one of the only things that I did that brought me recognition. I learned quickly, steadily excelled and, with each of my accomplishments, my ego was built up by my friends, coaches, other players and the media. It was the one place in the world where I knew beyond a shadow of a doubt that I was O.K. For most serious athletes, your sport provides you with this same continual source of positive reinforcement and feedback. There is enjoyment and self-satisfaction in mastering new skills, overcoming ever more challenging obstacles and progressively getting stronger and better. Furthermore, the outside recognition of your accomplishments by friends, family and your community stoke the fires of self-esteem so that they bum even brighter within you. Having a great game, race or match feels fantastic and provides concrete evidence that your hard work is paying off and that you are "special".
  
  
• #3 A CONSTRUCTIVE WAY TO COPE WITH STRESS - There is absolutely no question that physical exercise helps you better handle stress of all kinds. Individuals who have no physical outlets in their life tend to internalize their stress. Since they have no way of getting it out of their bodies, the stress stays there and may emerge as stomach problems, headaches, or other physical symptoms. The individual without a way to physically “burn” stress out of his body may even turn to drugs, alcohol or some other addictive, self-destructive behavior to help him cope. (This is not to say that exercise can't itself be used addictively and in a self-destructive manner because, of course it can.). Furthermore, many athletes discover that their involvement in their sport is a constructive way to escape from the stress of a dysfunctional family or deprived environment. Their sport offers them a safe and constructive way to channel their frustrations and aggression. Along these same lines, your sport can provide you as an athlete with a vehicle to a better life. If you're good enough, your sport can get you a college scholarship and open up a door that might have been otherwise closed to you.
  

THE PSYCHOLOGICAL CONSEQUENCES OF INJURY

So what happens to all of these psychological goodies when you're suddenly sidelined by an injury? To put it simply, you become overwhelmed by a variety of internal and external losses. As the athlete struggles with the impact of these losses, all hell breaks loose! If the injury is significant enough to keep you out of commission for a good chunk of time, the first thing that you lose is your identity as an athlete and team member. You lose your place and role on the team. "Identity confusion" sets in. Translated into understandable English, this means that you start to question who you are if you're not constantly in the pool, out on the field, course or court practicing and competing in your sport.
An Olympic gymnast permanently sidelined from her sport because of a career-ending injury put it quite clearly. "I've been doing gymnastics since I was 6 years old. It's all I know. It’s who I am and what I do. If I'm not a gymnast then who am I really"?

Without your sport, with its’ frequent practices and competitions, you suddenly have a potentially significant vacuum in your sense of self that you have to try to fill. This is only less extreme if you have been able to expand your involvement into other activities in other areas of your life. Unfortunately, most serious athletes commit so much of their free time to excelling in their sport that other, non-athletic activities are virtually impossible.

This individual identity confusion is compounded by the fact that your injury has suddenly changed your identity and place on the team! You are no longer the leader, workhorse or clutch performer. Now your position is on the deck, bench, or sidelines with the coach and your role on the team is suddenly unclear and questionable!

Hand in hand with this sense of identity confusion comes 2 other significant losses: First, you lose you physical health and sense of invincibility. Many athletes are used to being independent and relying upon their bodies to respond as trained and directed. With the injury, you have to face the cold hard fact that your body has somehow failed you. This can be a tough pill to swallow. Furthermore, injuries frequently make you dependent upon others, i.e. doctors, trainers, physical therapists, etc.; Most athletes have a strong independent streak and hate having to depend on anyone other than themselves.

Second, you lose a major source of your self-esteem. If you get your goodies from being faster than everyone else, hitting the ball harder, throwing touchdowns or shutting an opposing player down, then you’ll get precious few good feelings from standing on the sidelines helplessly watching the action. Suddenly, you’re plagued with self-doubts and have to struggle with questions of your own self-worth. If you're not pushing others in practice, working hard on your game, and helping your team in competitions, then what real value do you have on the team? For many athletes this is probably the hardest part of their injury. It's a huge blow to your ego. Suddenly, slower or weaker athletes are taking your place and doing what you should be doing, but can no longer do.

The other significant feeling that accompanies these losses is a sense of alienation and isolation. Robbed of the limelight, unable to fulfill your old role on the team, and unable to even practice with the rest of the team, it's common to struggle with feelings that now you are suddenly very different, that you no longer fit in.

In H.G. Bissinger's "Friday Night Lights", the story of the Permian Panthers High School football team from Odessa, Texas, the author tells about the experience of Booby Miles, the team's star running back. A young man with tremendous promise and pro potential, Booby is suddenly sidelined by a career-ending injury. Instead of capturing the limelight, he now captures splinters on the bench. He becomes a forgotten man on the sidelines. With his injury, his stock on the team and in the community suddenly plummets to zero as the media, coaches and fellow teammates contribute to his sense of isolation and alienation by completely ignoring him.

The final loss that accompanies a physical injury lies in the athlete's inability to constructively cope with stress. If your sport has been a vehicle for you to tame chronic low self-esteem or manage psychic stress, an injury suddenly robs you of this familiar and comfortable coping mechanism. As a consequence you are now in an even more vulnerable position and further susceptible to the negative affects of stress and depression.

For example, a distance runner was sidelined for 4 months for the very first time in his life because of broken ribs. After he was finally given the doctor's go-ahead to resume training he was distressed to find that he was continually plagued by an inexplicable shortness of breath and feelings of intense anxiety, both of which were so bad that they actually prevented him from running the way he had before his injury. Despite the fact that the doctors had ruled out any medical reasons for his breathing problems, he continued to suffer from these symptoms.

After meeting with him I learned that he had grown up in a very abusive home and from the time that he could remember, he had dealt with his problems by literally running away from them. When his best and only way of psychologically coping, running, had been temporarily taken away by the rib injury, a lot of the problems he'd been avoiding for all those years finally caught up to him. In fact, those problems were so upsetting and anxiety provoking that they literally "took his breath away" and forced him to finally face them head on.

So what does all this loss mean to you as an athlete or to your coach? If you want to speed up the rehab process as much as possible, then you need to EXPECT certain feelings and behaviors to emerge as a result of your injury. You need to understand that these feelings and behaviors are absolutely NORMAL and a natural part of successfully coping. As with any kinds of loss, the athlete may go through a number of stages directly related to mourning. Some sport psychologists feel that these stages parallel Kubler-Ross's five stages in her discussion of death and dying: Denial; Anger; Bargaining; Depression; Acceptance.

Many athletes first meet their injury with outright denial. They may downplay or ignore the seriousness of the injury, falsely believing that everything's O.K. As a consequence they may continue to train through the injury, only making matters worse. Frequently the injury is often accompanied by feelings of intense anger. The athlete may adopt a "why me, why now" attitude and act hostile and resentful to coaches, teammates, parents and friends. Some athletes then get into an internal bargaining with themselves, i.e. "if I do this and that, then maybe I'll be able to get back out there". At some point in this whole process, depression finally sets in as the athlete comes to directly realize the nature and seriousness of his/her injury and loss. The depression may entail a loss of interest in or withdrawal from once favored activities, sleep and eating disturbances (sleeping too much/insomnia, overeating/loss of appetite), low energy and possibly even suicidal thoughts and feelings. At the end of this depression stage, the athlete comes to accept his/her situation and make the best of it.

So what is the best way to handle injury so that the psychological pain is minimized?

ATHLETE STRATEGIES FOR COPING WITH INJURIES:

• #1 BE SAD - Allow yourself to mourn and feel whatever loss you are experiencing. Being "macho", "strong" or "brave" by burying or hiding your feelings in this situation is not only a WASTE OF ENERGY, but will interfere with you effectively coping and recovering. Feeling is an important part of the healing process. Remember that! Feeling is part of healing!
  
  
• #2 DEAL WITH WHAT IS - Injured athletes have a tendency to focus on the "could 'a beens", "should 'a beens" and the "way it was" IF ONLY they hadn't gotten hurt. The fact of the matter is no amount of wishing upon a star will change the reality of your situation. Yes it sucks that you got injured. Yes, it’s thrown a monkey wrench into all your plans and dreams. Unfortunately, this is your reality right now and you have to allow yourself to deal with where you are, right NOW!
  
  
• #3 SET NEW, MORE REALISTIC GOALS FOR YOURSELF - As you begin the recovery process, you may very well have to learn to measure your successes very differently than ever before, perhaps in millimeters now instead of meters the way it was before your injury. It may mean that you also have to start all over again back at “square one” to build up arm or leg strength and endurance. Keep focused on your NEW goals and leave the old ones in the PAST for now where they belong. Once you’ve come all the way back from your injury you can start entertaining your old goals.
  
  
• #4 MAINTAIN A POSITIVE ATTITUDE, NO MATTER WHAT – As difficult as this will be, try to stay as positive as possible. Understand that “IF IT IS TO BE, IT IS UP TO ME.” In other words, your attitude and outlook is ABSOLUTELY EVERYTHING! When positive, your attitude can speed up the healing process and lessen the emotional pain that you have to go through. However, when you’re negative you’ll slow the rehab process down to a screeching halt and make yourself miserable in the process. It's all up to you. Avoid being negative because nothing good ever comes from negativity. Negativity will only bring you and everyone else around you down.
  
  
• #5 TAKE AN ACTIVE PART IN YOUR HEALING – Be conscientious about your physical therapy. Follow the doctor's advice closely. Don’t cut corners. Work as hard with your rehab as you did in your training. In addition, practice using healing imagery on a daily basis. If you're recovering from a broken bone or separated shoulder, spend 5-10 minutes imagining that bone or shoulder beginning to heal. "See" in your mind's eye a healthy supply of red blood cells surrounding that area and facilitating the mending process. I can't scientifically guarantee that this will speed up your healing. However, I can promise you that this will make you feel less helpless, more in control and much more positive. These attitudinal changes in themselves will speed up your healing.
  
  
• #6 CONTINUE TO "PRACTICE" AND "WORK OUT". If your injury allows you to still continue any part of your training, do so! If not, "practice" mentally. Use mental rehearsal on a daily basis (5 -10 minutes at a time) to see, hear and feel yourself performing in your sport, executing flawlessly with perfect timing. Take this time to also mentally work on your weaknesses. You might even want to show up for some of the regular practices and mentally rehearse what the team is doing while they’re working out. Regular mental rehearsal of your skills will keep the neuromuscular connections activated so that when you are able to actually begin physical practice, you will not have lost as much.
  
  
• #7 SEEK OUT THE SUPPORT OF YOUR TEAMMATES - Participate in team functions. FIGHT the urge to isolate yourself. You may feel worthless and suddenly different, but chances are good that you're probably the ONLY one on the team that shares that opinion. The worst thing for you to do when you’re in a vulnerable state is to separate yourself from your group. Make a serious effort to reach out rather than pull in!
  
  
• #8 THINK ABOUT HOW TO USE YOUR SPORTS LEARNING AND EXPERIENCE IN OTHER AREAS OF YOUR LIFE - If your injury forces you into permanent retirement, you may feel that you have little to no skills or expertise that you can transfer from your sport to other endeavors. NOTHING COULD BE FURTHER FROM THE TRUTH! To excel as an athlete in your sport you have gradually developed over time some pretty powerful success skills like dedication, commitment, persistence, motivation, the ability to manage time, “reboundability” from setbacks and failures, as well as a whole host of other valuable LIFE skills. These success skills can be readily harnessed to other challenges that you pursue in your life outside of sports. Don’t think for a minute that much of what you’ve learned and mastered is irrelevant to the “real world.”
  
  
• #9 IF NECESSARY, SEEK OUT A COUNSELOR- If you are really depressed for an extended period of time, have lost interest in things that use to excite you, have noticed that your sleep and eating patterns have changed and/or you are having suicidal thoughts, seek professional help! Don’t fool around here. If you’re having these kinds of symptoms this means that you have really lost perspective and you are in need of some qualified, outside support. Seeking out the help of a professional therapist or counselor is NOT a sign of weakness. On the contrary, it’s a sign of strength.
  
  
• #10 BE PATIENT– If your injury is temporary, allow yourself enough time to heal properly. If you're over anxious to get back to the court, field, course or pool and rush the healing process, then you may set yourself up for another, more serious injury which may cost you even more time. Rushing the healing process so that you can get back a week or two earlier is “penny wise, pound foolish.” That is, you might get back a few days earlier, but because you didn’t wait those extra days to heal properly, you may end up developing a chronic injury that could keep you out for extra weeks and even months. Remember, sometimes the fastest way of coming back is the slowest. GO SLOWER, ARRIVE SOONER!

COACHING STRATEGIES FOR HELPING THE INJURED ATHLETE COPE:

• #1 BE EMPATHIC- Let your athletes know that YOU understand what THEY are feeling and having to go through. Understand where their anger, frustration and disappointment comes from and allow them time to mourn. Do NOT expect them to just "suck it up", "shake it off and "be strong!" Instead, let them have their feelings without indulging them in self-pity. One of the more powerful things that you can do as a coach is to care enough about your player so that you take the time to really understand what they are feeling and going through. Your genuine empathy and caring will go a long way towards strengthening the coach-athlete relationship and aiding the healing process.
  
  
• #2 WORK WITH THEIR SELF-ESTEEM - Understand that the injured athlete has just suffered a major blow to his feelings of self-worth and is therefore feeling quite vulnerable. Let him know in BOTH your actions and words that you still value him as a person, NOT just as an athlete. Do NOT avoid or act disinterested in that individual. Remember, it is YOUR responsibility to reach out to him, not vice versa. You are the “qualified adult and professional. You must act like one. Far too many coaches completely ignore the injured athlete, which ends up truly destroying his already shaky self-esteem. Reach out and help that athlete feel important and valuable.
  
  
• #3 GIVE THEM A ROLE ON THE TEAM- Help the injured athlete fight the their feelings of worthlessness and identity confusion by giving them another role on the team. Assign them a job as "assistant coach" or consultant into team functioning. Seek out their opinion and “advice” during practices or competitions. In fact, your injured athlete may have some valuable insight into the inner workings of the team. Actively utilize his “expertise” in this area. Make him feel important and that he still has a vital role to play on the squad.
  
  
• #4 DON’T ALLOW THE ATHLETE TO ISOLATE HIMSELF FROM THE TEAM - Insist that the athlete continue to function as an important member/part of the team. Assign other athletes on the squad to monitor the injured athlete's involvement and to intervene whenever that athlete begins to withdraw and/or isolate him/herself. As mentioned previously, take it upon yourself as the coach to actively reach out to this individual. The coach can have a powerfully positive impact on the injured athlete’s feelings of inclusion. Be there for him and do not allow him to withdraw.
  
  
• #5 LET YOUR ATHLETE KNOW THAT YOU CARE – Increase contact and communication with the injured athlete. Call him if he is unable to show up at practice. If he is recovering from surgery, visit him in the hospital. A little of your time at this point in the recovery process will dramatically help ease the emotional and psychological pain that the athlete is experiencing.
  
  
• #6 WHEN APPROPRIATE, EXPECT THE ATHLETE TO "PRACTICE" - Whether it’s limited physical or purely mental, let the injured athlete know that you expect her to continue her training, however modified. When possible, assign her a special workout that fits the limitation of her injury. Take an interest in her “training” and regularly check on how it’s going.
  
  
• #7 HELP THE ATHLETE GET IN TOUCH WITH OTHER AREAS OF PERSONAL STRENGTH - Help the injured athlete understand that excelling in her sport demands a tremendous amount of success and life skills that she has already developed and that she can learn to transfer to other areas in her life. Clearly spell out for her what these areas are and help her begin to see their application in other arenas.
  
  
• #8 IF THE ATHLETE'S DEPRESSION DOES NOT LIFT OR IF THERE ARE WARNING SIGNS IMMEDIATELY REFER HIM/HER TO A PROFESSIONAL- If the athlete is seriously depressed (has lost interest in activities, shows changes in eating and sleeping habits, or is having suicidal thoughts or feelings), it is critically important that you refer him/her for professional counseling. If you are particularly concerned about your athlete, you may need to play a forceful, advocate role where you enlist the parents’ aid in helping their son or daughter get the professional help that is needed. The eating/sleeping warning signs of depression must be taken very seriously.

CONCLUSION

Athletic injury, whether temporary or permanent, is and always will be a painfully disruptive and uncontrollable interruption in an athlete's life. If you follow some of the guidelines put forth in this article you can speed up the rehab process and lessen the psychological and emotional pain that normally accompanies most athletic injuries. Keep in mind though that the rehab process is more often times than not very slow and painful.

Understand also that when you as an athlete first get back out there on the field or court you will naturally be preoccupied with worries about hurting yourself again. Don’t be alarmed by this. Fear of re-injury is absolutely normal. It's also pretty common for the recently recovered athlete to find herself mentally replaying the injury over and over again in her mind’s eye. This tendency to focus on "what you are afraid will happen" will distract you from the task at hand and leave you performing physically tight. In this condition, you’re actually far more vulnerable to re-injury! To counteract this natural tendency, discipline yourself to concentrate on what you WANT to have happen, NOT what you’re afraid will. Focus on what you need to do in order to execute perfectly. While this may be far easier said then done in the beginning, discipline yourself to maintain a positive focus on your performance.

Remember also that if your fear of re-injury does not diminish, or if your performance after the injury is significantly sub-par, you may be suffering from Sports PTSD (Post Traumatic Stress Disorder).