“When’s he gonna play?” The role of psychology in returning from injury.

Derrick Rose sitting on the Chicago Bulls’ bench in a suit and tie became a familiar sight towards the end of the 2012-13 NBA season.

One-time league MVP, Rose, underwent surgery to repair a torn anterior cruciate ligament in May, 2012, after getting injured in that year’s playoffs. But after several weeks of “will he/won’t he” speculation, Rose did not make his much anticipated return to the Bulls’ line-up, despite being delared medically fit to play.

Recovery from injury is not just about the physical rehabilitation of the athlete. Injury can have a psychological impact too, so returning to play can be a difficult time for any athlete, with not being able to perform as well as before, and the fear of re-injury both being legitimate concerns. In fact, research has shown that fear of re-injury can be a significant source of stress for athletes returning to their sport¹.

If that isn’t enough, there is also a cultural pressure on athletes to play through pain and injury, linked to something called ‘The Sport Ethic’.

According to Hughes and Coakley², The Sport Ethic is a value system that emphasises making sacrifices for ‘the game’, striving for distinction, accepting risks and playing through pain, and refusing to accept limits in the pursuit of possibilities.

Commentators, journalists, coaches, and athletes themselves seem to have accepted that these are all characteristics of a “real athlete”, yet in an attempt to conform to these essentially positive characteristics, athletes can cause themselves problems by attempting to return from injury before they’re psychologically (or indeed physically) ready to do so.

Articles like this one by journalist, Mike North, certainly don’t help. He seems to be (and by “seems to be”, I mean “is”) suggesting that Rose was “soft” because he didn’t want to play after a potentially career ending injury until he was 100% ready.

Rose’s coaches and team-mates were making the right noises. Coach, Tom Thibodeau said “it’s too important a decision for him to rush. Until he’s completely comfortable, we don’t want him out there.” while his then teammate Joakim Noah said, “I’m really proud of him because he has dealt with it great with all the pressure coming from a lot of people.”

Yet Rose must still have felt the pressure to play, not least from certain sections of the media.

Injury and motivation

Researchers Leslie Podlog and Robert Eklund³ suggested that there might be a wide range of factors that motivate athletes to return to play following injury. There may well be pressure from coaches, feelings of guilt for letting team-mates and fans down, or pressure to be a “real athlete” and play with two broken legs because it’s the playoffs.

Podlog and Eklund also suggested that what ultimately motivates athletes to return to play can have an impact on how successfully they cope psychologically with such a difficult period in their careers.

According to Self Determination Theory (see Box 1), there are several different types of motivation that can influence performance, well-being, and personal experience. 

Intrinsic motivation (engaging in an activity for the pleasure of doing so) has been linked with positive emotions, and psychological well-being. In fact those with high levels of intrinsic motivation have more excitement, confidence, and greater levels of interest than those whose motivation is primarily extrinsic (engaging in an activity to gain reward or avoid punishment)⁴.

It stands to reason, therefore, that athletes who return to sport for primarily intrinsic reasons will have more positive experiences than those who do so for extrinsic reasons.

Sure enough, Podlog and Eklund found that athletes returning to sport primarily due to pressure from outside sources (external regulation), experienced more negative psychological outcomes, such as greater fear of re-injury, reduced confidence, and increased anxiety about their athletic performance.

Helping athletes return to sport

So if we can accept that SDT is a useful framework for considering the return to sport process for injured athletes, what can we do to help them make the transition from the physio’s table to the court?

Autonomy

To satisfy athletes’ autonomy needs, we should try to minimise any pressure on them to return from injury. Coaches and team-mates should be encouraging (see relatedness), but should be aware that even asking questions about when the athlete might be coming back, no matter how positively those questions are framed, could result in the athlete feeling pressure to return early.

I don’t think there’s much we can do about the pervasiveness of The Sport Ethic in the media, but we can alert athletes to the negative consequences of an early return. If an athlete wants to wait until they’re 100% ready (110% is a mathematical impossibility so we probably shouldn’t wait for that), then that’s only a good thing.

Relatedness

In order to avoid isolation and foster a sense of belonging, injured athletes should be encouraged to remain as involved in the team environment as possible. Obviously there are some athletes who won’t want to sit on the sidelines and watch if they can’t join in, and that’s important to consider (see autonomy), but that’s not to say they shouldn’t be encouraged to take part in other team activities.

Perhaps they can do their rehab exercises in the training environment, surrounded by team-mates, as opposed to away from the team, in the treatment room. But never underestimate just how important social support is for injured athletes.

Competence

As mentioned earlier, athletes often experience fears associated with not being able to perform to pre-injury levels. It’s important to be able to allay some of these fears and build an athlete’s confidence in their ability to return successfully.

Examples of athletes who have made successful returns from similar injuries can be provided. Setting specific performance goals and having the athlete involved in the goal-setting process (autonomy again) is also important for developing an athlete’s confidence in their ability to successfully return to sport.

Acknowledging and addressing the ‘negative’ thoughts an athlete will invariably have can also be effective in increasing athletes’ feelings of competence.

Summary

It’s important to recognise that there is a huge psychological element involved in returning to action following an injury, and that different athletes will deal with this process in different ways.

But there are also things a number of ways in which coaches, team-mates, physios, trainers, friends etc., can help athletes make their return from injury a successful one.

What are your experiences of returning to play following injury? Are you coaching an athlete who is about to make their return, or a physio who works with injured athletes every day? What are you doing to support your athletes? Leave a comment below to share your experiences.

References

• ¹Gould D., Udry E., Bridges D., & Beck L. (date). Stress sources encountered when rehabilitating from season-ending ski injuries. The Sport Psychologist,11,361-378.
• ²Hughes, R. & Coakley, J. (1991). Positive deviance among athletes: The implications of overconforming to the sport ethic. Sociology of Sport, 8, 307-325.
• ³Podlog, L., & Eklund, R.C. (date). Return to sport after serious injury: A retrospective examination of motivation and psychological outcomes. Journal of Sport Rehabilitation, 14, 20-34.
• ⁴Ryan, 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.