Psychological Factors in Sports Injuries

Chapter 1

1.0 Introduction

Most sports injuries occur in competitive sports. In some cases, the injuries are considered usual occurrences regardless of their types and severity. Nonetheless, professionals involved in sports should understand the injuries from the players’ point of view, and this can be achieved through different ways which are mainly personal or subjective in nature. However, from the 70s, researchers have gained an interest in understanding the psychological and theoretical aspects of sports injuries. Consequently, as observed by Olmedilla & Gracia (2009), enough empirical evidence show that various psychological factors influence footballers’ injury occurrence and recovery. A significant scientific breakthrough in the study of sports injuries and its psychological implications were made by the Global Psychological Model of Sportive Injuries (Olmedilla & Gracia, 2009). Ideally, this model draws from the fundamentals of earlier models as well as other models such as the Integrated Model of Response to Sport Injury and Rehabilitation process, which are processes of pain and stress that sustains the cognitive and emotional response during the recovery process (Andersen & Williams 1988, Brewer 1994, Heil 1993). The present study seeks to focus on a different way of understanding sports injury, namely the psychological impacts of sports injury as perceived by footballers. Based on the findings of previous research (Liberal et al 2013, Liberal et al 2014), there is a need to collect research evidence on the various psychological factors involved in sports injury. Furthermore, it is likely that the focus on the psychological impacts of sports injury as perceived by footballers will effectively highlight how the injuries impact on the footballers as perceived by the injured footballers. Thus, the present study evaluates sports injury from a psychological point of view and attempts to identify any perceived impact of previous injuries on their psychological well-being.

1.1 The concept of well-being

Well-being is a term used to define the state of being in a good or positive condition mentally, physically and socially (Huseyin et al, 2015). While traditionally the concept of well-being was viewed from a health point of view, contemporary understanding of well-being span beyond health and covers a range of other aspects such as social satisfaction, physical vitality, personal fulfilment as well as other factors that indicate a sense accomplishment (Kaufman & Barry, 2019). In this study, well-being will be used to denote a sense of wellness that include psychological/ mental health wellbeing that is devoid of stress, depression or other symptoms of poor mental health. Mahl & Vasconcelos-Raposo (2007) define psychological impacts as the extent to which an event leaves an emotional impression on an individual. Applied to the sports context, according to Olmedilla & Garcia-Mas (2009), an athlete’s objective or subjective perception of their injury can affect their perception of general well-being, while the existence of injury may predict the extent of their general emotional well-being. This assumption has particularly been confirmed by sports performance studies Mahl & Vasconcelos-Raposo (2007), which indicate that upon injury, footballers psychologically prepare themselves for future competitions. On the same note, other studies (Rivas et al, 2012) have found that the athlete’s psychological well-being is closely related to their autonomy in decision-making. To better understand the psychological impacts of sports injury on footballers, psychologists often use the multilevel model of sports injury (MMSI), and one of the popular models is the Grief Response Models by Kubler-Ross. According to Kubler-Ross (1969), footballers undergo five psychological stages upon injury, each stage eliciting different reactions. The first stage is denial, whereby the athlete develops shock and fear and is somehow confused of what has just happened to them. Secondly, the footballer angers and become frustrated of their situation and if the injury is severe, they may be so irritated to the extent of being developing anxiety. Anxiety may lead to depression due to a feeling of helplessness. The fourth stage of the model is bargaining, whereby the footballer struggles to find a meaning of their lives and try to reach out to others and telling their story. The last stage of the model is the acceptance stage, whereby the footballer explores various options that may help them move on and get back to their normal lives (Kubler-Ross, 1969).

Based on Kubler-Ross’ grief response model, one would expect that any injury suffered by an athlete affects their athletic performance and well-being. However, according to a recent study by Liberal et al (2013), the period after footballers have undergone an injury recovery is characterized by certain psychological changes that influence their performance. Conversely, an athlete’s state of psychological well-being can modulate and enhance their performance. It is also conceivable that the decline or improvement of an athlete’s performance can be used as an indicator of their psychological well-being (Lim, et al., 2009). In this context, the emotional process that the athlete undergoes as a result of the injury can be considered a relevant phenomenon because the valuation of this process can possibly determine the extent to which the athlete is psychologically injured, how the athlete’s state of well-being is affected, and its implication on the athlete’s future sports performance. Footballers involved in various kinds of sports undergo various psychological, social and physiological experiences that affect their well-being. As they participate in sporting activities that involve various levels of aggressiveness and risk-taking, according to Lynda et al (2010), they may suffer from various physiological injuries that consequently affect their psychological well-being – exposing them to the risk of various mental health issues such as depression and anxiety. Furthermore, studies by Sarac et al (2018) recently found that footballers averagely experience a 14% frequency of mental challenges in their lifetime. These assertions confirm the findings by Ellis et al (2015) that footballers who undergo head injuries are more likely to suffer from mental illness than their counterparts who undergo other kinds of injuries. Here, mental illness is conceptualized as any condition that affects the brain by influencing how a person behaves, respond to the environment or feel (Ellis et al, 2015). Nonetheless, these injuries have significant psychological impacts on the victims and require effective medical treatment.

Footballers may also suffer emotional stress characterized by poor decision-making, trouble sleeping, irritability, restlessness and anger as a result of the injury. For instance, Lynda et al (2010) observes that the during the physical activities involved in various kinds of sports, footballers may suffer injuries that cause them to experience various psychological issues such as a loss or alteration of nutritional appetite, a lack of motivation, sleep disturbance, sadness and a general feeling of disengagement. However, there is a paucity of empirical research establishing the existence or the extent of these psychological impacts from the footballers’ perspectives. So far, the existing research such as (McClay & Levitt, 1991) were conducted nearly a decade ago and thus might have outdated results or never consider other factors involved in modern sports. Furthermore, a research gap exists onto how certain psychological theories such as the MMSI apply to modern sports context. Therefore, the aim of the current study is to investigate the athlete’s Psychological Construction of Mental Health as it relates to injury in sport. This will be achieved alongside various research objectives including to investigate the extent of psychological impacts of sports injury on footballers, to explore the relationship between the perceived psychological impact of sports injury and footballers’ performance and to identify footballers’ coping strategies for psychological impacts of sports injury. In the process, the study will answer three major research questions namely to what extent does sports injury affect the psychological well-being of footballers? what is the relationship between the perceived psychological impact of sports injury and footballers’ performance? And what are the coping strategies for these impacts?

The findings of this study will be of great importance to footballers because it will contribute knowledge useful in footballers’ health and well-being through access to reasonable, quality and appropriate mental health services. Furthermore, upon completion, this study will provide the background knowledge for the restoration of footballers’ state of mind for better performance in subsequent completions and enhance the footballers’ ability to develop fulfilling relationships and adjust to their environments for a better performance after sustaining injuries. An footballers’ mental health well-being is not only crucial to their sports performance but also to their interaction with family, friends and colleagues. This study will contribute additional knowledge on the various clinical mental health issues that may affect the footballers’ interaction with these personalities. The study will inform sports psychologists how to handle footballers with a history of injury in a manner that enhances their athletic performance.

Chapter 2

2.0 Research Methodology

2.1 Research Philosophy

Converse (2012) define research philosophy as the ‘how to know’ approach taken by the researcher so that the researcher is aware of the data about the phenomenon under investigation that can be obtained through legitimate ways – also termed as the epistemological or ontological foundation of research. The current study takes an interpretivist ontological approach. According to Converse (2012), interpretivist research philosophy enables the researcher to assess a situation through the perception of the people experiencing it. The main aim of this study is to investigate athlete’s psychological construction of mental health as it relates to Injury in Sport. Therefore, the aim is to understand the true perception of footballers experiencing it. With this regard, Dilley, (2014) argues that the reality is complex, multidimensional and context dependent. Thus, this study argues that understanding the context within which athlete operate is key to understanding their experiences of injury and how it affects their mental well-being. This justifies the use of interpretivist ontological approach.

2.2 Participant Recruitment

The study recruited participants from Football Club Not Alone (FCNA), which has been working alongside other community organizations such as the Campaign Against Living Miserably (CALM). The participant recruitment observed an inclusion criteria of (i) footballers of 18 years and above from FCNA, (ii) had an injury that significantly excluded them from active sports for a period of three consecutive weeks, made them reduce a significant volume of training and reduced their sports performance within the last one year. The choice of three years was based on a previous study (Philip et al, 2018). The researcher sought permission from FCNA coach, who then invited footballers that met the inclusion criteria and were interested to participate by sharing information on their experience of injury. This resulted in two footballers contacted by the researcher, of which both were males. The two footballers were recruited based on convenient sampling technique as they were easily accessible. The researcher developed a semi-structured interview guide and shared with two experienced physiotherapists for validation. The interview questions (Appendix 2) were predominantly targeted at understanding individual psychological experiences of the injury before, during and after the injury.

The interviews were carried out from Mid-March 2020 and each interview lasted for an average 30 minutes. Before participating in the interviews, each participant singed an informed consent form that informed them of the purpose of the study and why it was important to participate. The form also informed each participant of their freedom to quit the study at will. The interviews were tape-recorded. The researcher indevoured to use open-ended questions that led to the other probing questions to obtain in-depth information from the interviewees. The interview processes revealed the usefulness of qualitative research approaches that give the flexibility needed for the researcher to gather as much information as possible from the respondent.

2.3 Data Analysis

The researcher used thematic analysis technique of data analysis, whereby the content of each interview transcript was analyzed using inductive approaches as described by (Green, et al., 2007). The thematic analysis was a five-step process that involved familiarization with the data, initial development of codes, identification of themes, review of the identified themes, and theme definition (Hussong, Curran, & Bauer, 2013). Initially, the researcher read each interview transcript then used inductive approaches to code meanings from the text i.e. by identifying statements and words relevant to research objectives. The codes were then condensed into themes through an iterative process that entailed discussions and comparison of the selected themes to evaluate whether they were meaningful to the study aims.

2.4 Trustworthiness

The focus of qualitative research is the trustworthiness of the data as opposed to the data itself. Thus, researchers who have used qualitative approaches must consider the four main elements of qualitative research which include conformability, transferability, credibility and dependability (Onwuegbuzie & Combs, 2011). With regards to credibility, the researcher asked the participants to review the research report and verify if the findings give a true picture of the data they presented during interviews. On the other hand, transferability was observed by evaluating if the study findings, based on the data interpretations; are transferable. Because the study used interpretative ontological approach that give preference to participant’s context, the study findings were considered relatively transferable. Researchers who qualitative approaches must consider the confirmability of data by ensuring an internal consistency of the data categories (Johnson, Dunlap, & Benoit, 2010). The confirmability of this study is evident by the fact that its findings replicated the findings of other pieces of research such as Philip et al (2018).

Chapter 3

3.0 Results

The interview data revealed various perceived psychological impacts of sports injury that could be categorized into three main themes after conducting an inductive thematic analysis. The first theme was the motivational impact of sports injury, followed by the identity impact of sports injury, then coping strategies for sports injury. In this chapter, the study discusses the themes with reference to specific responses given by the interviewees.

3.1 The motivational impact of injury

Most of the respondents acknowledged that sustaining sports injury motivated and gave them the spirit to fight on and get back to their normal lives. To do so, as revealed by some responses, they sought more knowledge about the injury and developed skills of preventing further injury. They reflected on how they were motivated, developed better self-confidence and became mentally stronger after undergoing rehabilitation treatment. For instance:

Amesh: My injury has made me more motivated I can’t wait to get back on my feet an achieve my best performance in the next season…. for the past few months that I have been down, I have been more on my computer learning better skills and strategies for avoiding similar injury when I finally get to the pitch again. The best thing I can do to myself is to become more motivated and have the confidence to play again.

Simon: I have learnt that the more I stay out of the pitch, the more I develop the confidence and courage to play alongside my team members again. This injury has really been a motivation to me.

Interviewer: Did the injury help you become a stronger athlete, if so how?

Amesh: Massively, it gave me time to reflect as (touch wood) that is the worst injury I have had, and I see other people who have more injuries more regularly.

3.2 Identity impact of sports injury

The second theme that emerged from the interviews is the impact of injury on footballers’ identity at a psychological level. Most of the footballers begun to question whether they should continue with elite soccer. These responses revealed the complexities associated with athletic identity and how withdrawing from regular soccer participation affects that identity. Furthermore, the respondents expressed their desire to still be considered as part of their teams as well as how they desired to still receive admiration and attention from both fans and team members despite withdrawing from active sports; where such recognitions are regularly received. Nonetheless, the footballers expressed much concerns over the loss of identity as a sports personality, a finding that ties back to the bargaining stage of Kubler-Ross’ grief response model where the athlete struggles to find a meaning to their lives: Amesh: The most stressful part is the feeling that my colleagues are training, and I cannot be part of them, I am just here alone like anybody else. People are almost forgetting that I was a star midfielder before I got injured. …. I am no longer available to celebrate the goals with my colleagues again, rather than be cheered by my fans, I am the one who now cheers my team from home. This is so saddening! Amos: I really miss being on the pitch and being considered one of the most aggressive attackers. It’s been long since I saw my fund lift banners with, my name on it. It demoralizes me every day. The respondents also revealed the importance of friends’ perception as the participants narrated how they sought recognition from their teammates as ‘normal’ team members and not as ‘injured’ ones for example: Amos: Team members should pay a visit to their injured colleagues because when my colleagues visit and talk to me, they involve in conversations regarding other things apart from my injury and this makes me feel as though I am still part of them. These responses reveal how injury psychologically affect the identity of footballers i.e. the perceived loss of identity as well as other individual factors (e.g. perception by friends) that footballers associate with injury because they are no longer part of their teams.

3.3 Coping strategies

The respondents also associated the injuries with positive coping strategies that ended up improving their perceived psychological well-being and their ability to perform better in the subsequent games. When asked how they managed to cope with the injuries and whether the injury affected their mental health, most of the respondents asserted that even though coping was challenging, they generally managed to cope and associated their coping strategies to positive outcomes. For example: Interviewer: Did this affect your mental health? If so, in what way? If not, then how has it affected you being a part of FCNA? Simon: The injury stops me sleeping sometimes, as you can’t sleep on that shoulder so if you roll on it during the night you wake up in pain. I have to take painkillers before going to bed, which is something I would never usually do. Even though before I said I get anxious at work for asking for help, sometimes it’s good to take a step back and just take it easy, as work can be very chaotic, which has more of effect on my mental health than anything else. Before playing for FCNA I hadn’t played for a team since before uni (10 years ago) so I have really been enjoying it as they are a great group of lads and we’re on a winning streak, but when I haven’t played because of the injury I have felt left out and also like I’m letting the team down as it is hard to find a replacement goalkeeper.

Generally, the study results indicate that the footballers’ performance after the injury were better than before. Even though the respondents recognized a difficulty in developing effective coping strategies (some experiencing stress and anxiety), there was a perceived positive impact of sports injury on footballers’ performance. Amesh: Coping strategies were tough. I found it hard to eat healthily as I was sat down resting all the time. I began learning different skills e.g. French with my free time and rather engaged my brain over my body.

Chapter 4

4.0 Discussion

To the best of our knowledge, this is one of the few studies addressing the perception of sports personalities on the psychological impacts of sports injury. An exploration of footballers’ perceptions led to three major themes namely the motivational impacts of sports injury, identity impacts of sports injury and coping strategies for sports injuries. One of the key findings of this study is that from a psychological standpoint, sports injury contributes to identity issues as a result of social isolation and the inability to participate with team members. These results are discussed with a specific focus on various actions that can be taken to rehabilitate injured footballers as well as the strategies that can be developed to prevent long-term psychological consequences of sports injury. The findings on diminished identity after a sports injury or when footballers can no longer participate in sports has been explored by various studies including Brewer et al (1999), Sparkes et al (1998), and Brewer & Cornelius (2010). In the present study, the emerging theme of sports injury threat to identity `indicate that footballers might begin to question their self-identity or lose track of that identity when they no longer participate in active sports. Similar findings were made by Grindstaff et al (2010), who adds that while sports injury might have such perceived impacts on adult footballers, these findings may be more crucial in the context of adolescent footballers because identity exploration is an important character of individuals at this stage. These findings corroborate with the findings of similar studies (von Rosen et al 2016a and von Rosen et al 2016b) on young footballers that used online questionnaires and quantitative data analysis approaches. The two studies suggested that some young footballers derive their self-esteem and identity from competition results, performance and athletic experience. This explains why they may begin to experience a sense of diminishing self-identity and self-esteem when they are injured and can no longer participate in active sports for at least the period of rehabilitation. The serious psychological impacts of the loss of identity highlight the important role of effective rehabilitation of injured footballers. While this study did not make any substantial findings on the injured footballers’ rehabilitation process, Potter et al (2003) argue that the rehabilitation process must be adjusted to the address their current life situation. Furthermore, injured footballers should receive an early diagnosis to pave way for earlier rehabilitation efforts.

Nonetheless, Philip et al (2018) observe that this population experience various barriers to early diagnosis because some soccer teams do not have the financial capacity to employ or have direct access to health personnel. Rather, footballers are left to make contacts with health personnel on their own. Increased cooperation between coaches and medical personnel makes it quicker and smoother for footballers to get an early diagnosis. This will have positive impacts on the rehabilitation process and increases the odds of footballers undergoing complete rehabilitation before resuming to sports. In the social context, family and friends are important to young people (Philip et al, 2018). In the present study, some injured footballers expressed how they suffered from social isolation and felt lonely upon losing their positions in the team. This reveals the importance of involving injured footballers physically demanding activities such as sports theory and skill demonstration. Besides, it reveals that injured footballers can have psychological benefits when encouraged to perform certain rehabilitative procedures among team members during training sessions. Even if they cannot have full participation in the sports, engaging in some activities with their team members may help them reclaim their place as ‘footballers’ within the sports environment rather than viewing themselves as ‘former footballers’. This would help meet the psychological needs of footballers in the fourth stage of Kubler-Ross’ grief response model, whereby the footballer tries to look out for others to share his story and avoid social exclusion. The findings of this study reveal that different footballers have different perspectives of how injury impacts their psychological well-being. While some were demoralized at some point, others were highly motivated to develop new skills and perform better when they get back to active sports. This gives a reflection of different perspectives held by coaches, footballers and other sports stakeholders who are affected by various aspects of the relationship between physical and psychological of sports injury, thereby making it hard to decide on the footballers’ game participation. Nonetheless, these results also show how useful it is to assess an athlete’s psychological well-being as part of the rehabilitative efforts particularly because injury involves various situational and personal factors that influence the footballers’ response (Wiese-Bjornstal et al, 1998). Furthermore, these findings reveal the importance of assessing footballers’ previous injuries and holistically capturing their experiences; not only considering the negative aspects such as disability or pain but also the positive aspects their ability to control and learn from the pain.

Instead of assessing footballers only at their time of injury, Soccer teams should consider holistically assessing footballers’ injury process for a broader understanding of their psychological and physical situation. Moreover, holistic assessment may have a positive impact on the footballers’ perception of their skills and ability to cope with the injuries, which is good for their psychological well-being and more importantly their future performance. By making a holistic assessment of footballers’ injury process, it is not only possible to assess the perceived psychological impact of footballers’ injury but also their abilities to deal with injuries. The findings of this study also point to the level of information needs and support that should be awarded to footballers undergoing injury recovery. As revealed in the interview responses, the injured footballers got involved in alternative activities as they waited to recover. However, from a practical standpoint, they may have required more information on the alternative activities to maintain their physical fitness (Verhagen, Stralen, & Mechelen, 2010). Besides, they may require specific information on rehabilitation to regain their previous physical capabilities. This is particularly important because high performance footballers, at the end of their recovery, may still be confused as they may perceive themselves as still a long way from regaining their state of physical fitness they had before injury. From the study results, it is evident that compared to non-injured footballers, injured footballers have a relatively perceived mismatch between their current physical fitness status and the status they were in prior to the injury. This implies that sports physiotherapists should have enough training on the information needs of injured footballers. Earlier research by Wiese-Bjornstal & Smith (1993) show that sports physiotherapists are mostly placed to provide psychological support to injure footballers. Yet, other pieces of research (Ford & Gordin 1994; Wiese et al 1991) also show that personnel’s responsible for sports injury rehabilitation have a greater preference to psychological factors during their training. Recent studies by Gordon et al (1998) in Australia highlighted the importance of providing psychoeducational curriculum to sports injury rehabilitation personnel. While sports injury rehabilitation professionals in the UK do not receive the level of training on psychoeducational training proposed for Australia, the Australian prototype may be useful as a guide for future implementation in the UK. However, the curriculum must be adapted to the UK culture for it to be more effective.

Chapter 5

5.0 Conclusion

To conclude, injured footballers can enhance their well-being not only by relieving negative physical impacts of the injuries but also by being motivated to develop various personal skills. Therefore, the injury can be considered the beginning of a quest for personal development by enabling a personal assessment and reflection of what the injury means. By taking this approach, the footballers shall have developed appositive relationship between personal growth dimension and perceived impact of psychological well-being. With this regard, this study concludes that footballers can achieve a significant improvement in performance in their after-math sports career if proper rehabilitation process is adopted. However, based on the limited number of samples involved in this study, future studies should consider investigating other variables that relate to sports injury and footballers’ psychological well-being.

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