Psychological Aspects of Return to Sport for the Female Athlete

Maike van Niekerk; Elizabeth Matzkin; Melissa A Christino

doi:10.1016/j.asmr.2023.04.021

. 2023 Jun 2;5(4):100738. doi: 10.1016/j.asmr.2023.04.021

Psychological Aspects of Return to Sport for the Female Athlete

Maike van Niekerk ^a, Elizabeth Matzkin ^b, Melissa A Christino ^c,^∗

PMCID: PMC10461158 PMID: 37645384

Abstract

Female athletes represent a unique population of competitors who face distinct stressors when compared with male athletes. These include sport inequities, violence, abuse, body image concerns, disordered eating, relative energy deficiency, family planning challenges, hormonal challenges, and mental distress. When combined with sports injuries, these stressors can negatively impact the mental health of female athletes as well as their injury recovery and return to sports. It is essential for orthopaedic surgeons to be familiar with the unique aspects inherent to being a female athlete, along with the psychological aspects of sports injuries. By integrating questions about female athletes’ psychological well-being into their routine practice and collaborating with a multidisciplinary team, orthopaedic surgeons can better address these unique stressors, support female athletes in achieving optimal outcomes, and enhance return to sport rates.

Level of Evidence

V, expert opinion.

Participation in sports has increased exponentially in female athletes, in part due to federal legislation such as Title IX, enacted in 1972 to eliminate sex-based discrimination in federally funded educational activities.¹^,² Sport participation can yield tremendous physical and psychosocial benefits; however, increases in sport participation and specialization are associated with increased risk of injuries, overtraining, and burnout among athletes, as highlighted by consensus statements from the American Academy of Pediatrics, the International Olympic Committee, the American Medical Society for Sports Medicine, and the American Orthopaedics Society for Sports Medicine.³

In addition to stressors inherent to sport participation, female athletes are at risk for a number of additional unique stressors, including greater rates of inequities within sports, violence, abuse, and body image concerns.⁴^,⁵ Such stressors may place female athletes at increased risk of experiencing psychological distress, which can be further exacerbated by sports injuries, such as anterior cruciate ligament (ACL) injuries, patellofemoral joint problems, and stress fractures, for which female athletes are already at greater risk.⁴^,⁶^,⁷ In the face of sports injuries, female athletes have been found to have lower rates of return to sports compared with male athletes.⁷^,⁸

In order to optimize physical and psychological outcomes among female athletes after sports injuries, it is important for orthopaedic surgeons to be aware of the experiences of this unique patient population. This paper aims to describe the psychological aspects of return to sport for the female athlete by describing (1) the unique stressors female athletes face; (2) the psychological factors that affect postinjury outcomes among female athletes; and (3) the ways orthopaedic surgeons can improve female athletes’ psychological well-being in the face of sports injuries. We use the term “female” to refer to all athletes who identify as female, acknowledging that much of the existing literature in the field has not clearly defined its use of the term.

Unique Stressors for Female Athletes

In addition to reporting greater rates of a number of sports-related injuries highlighted previously,⁶ female athletes more commonly report unique psychosocial stressors of which orthopaedic surgeons should be aware. Sport inequities, violence, abuse, body image concerns, disordered eating, relative energy deficiencies, family planning challenges, hormonal challenges, and mental distress are among these stressors (Fig 1).⁴^,⁵

Fig 1 — Female athletes face a number of unique stressors, including sports inequities, violence and abuse, body image concerns, disordered eating, relative energy deficiencies in sports, family planning issues, hormonal challenges, and mental distress.

Sport Inequities

Sport inequities continue to be notable stressors for female athletes, despite significant progress made through Title IX.⁴ Female athletes continue to be hypersexualized and devalued in many athletic communities,⁴ and transgender female athletes face particular challenges, with several bills around the world still limiting or prohibiting their participation in women’s athletics.⁹ Access for women’s sports has even been found to be limited even at youth levels, particularly among those from low-income households.¹⁰ Clear discrepancies also exist with regard to financial compensation between female and male athletes, especially at the elite level, where male athletes tend to be compensated at much greater rates.⁵ Women are also underrepresented in leadership positions within sports, such as being head coaches or having positions on sports governing bodies.⁵ Media coverage also contributes to this culture of inequity, through its limited coverage of female athletes, compared with male athletes, and tendency to both objectify and trivialize female athletes’ athletic accomplishments.⁵

Violence and Abuse

Female athletes are also more likely to experience violence and abuse than their male counterparts, especially those facing intersecting forms of oppression such as racism, homophobia, biphobia, transphobia, and/or ableism, among others.⁵ Research has found female athletes are at a greater risk of being subjected to harassment and exploitation than male athletes, with reports of sexual violence being 4 times as common.⁵ Such experiences can contribute to a range of psychological disorders (including depressive disorders, anxiety disorders, and eating disorders) and require orthopaedic surgeons to be equipped to provide trauma-informed care.⁵ Further, female athletes face significant barriers when disclosing incidents of violence and abuse due to numerous factors, including cultural pressures within athlete communities that promote attitudes such as “no pain, no gain,” entrenched power imbalances in sports, and inadequate action by sports authorities following reports of abuse, as well as potential retaliation against those who report abuse.¹¹ A case in point is the United States gymnastics sexual abuse scandal involving Larry Nassar, the long-term gymnastics team doctor who sexually abused young female athletes under the guise of medical treatment.¹¹ In an effort to better protect athletes, the American Orthopedic Society for Sports Medicine has collaborated with the U.S. Center for SafeSport to create a series of educational modules designed to provide those that provide medical care to athletes with the tools to recognize and properly respond to issues related to sexual abuse and harassment.¹²^,¹³

Body Image Concerns and Relative Energy Deficiency in Sports (RED-S)

Body image concerns and disordered eating are also prevalent among female athletes, particularly during their adolescent years and at the elite level.⁴ In comparison with female nonathletes and male athletes, female athletes suffer from eating disorders at 3 and 5 times the rate respectively, with upwards of 62% reporting a history of disordered eating.⁴^,⁶^,¹⁴ Orthopaedic surgeons should be aware that participation in sports that involve subjective judgment (such as dancing, gymnastics, and figure skating) and emphasize low body mass and leanness (such as track and field) especially place female athletes at increased risk for developing body image concerns and disordered eating.² There are also a number of athlete-specific psychological factors that contribute to disordered eating of which orthopaedic surgeons should be mindful, including low self-esteem, poor coping skills, past sexual or physical abuse, perfectionism, and the perception of loss of control.⁶

The health consequences of disordered eating can be significant. The traditional concept of the “Female Athlete Triad” (eating disorders, menstrual abnormalities, and low bone mineral density)² has subsequently evolved into the more robust construct, “Relative Energy Deficiency in Sports” (RED-S). RED-S was defined by the International Olympic Committee in 2014 as a syndrome of impaired physiological function due to an imbalance between dietary intake and energy expenditure (Fig 2).¹⁵ Multiple systems can contribute to suboptimal physiologic functioning due to low energy availability, including menstrual function, immunity, as well as bone, cardiovascular, psychological, and gastrointestinal health, among others.¹⁵ It is particularly important to monitor female adolescents for sequelae of low energy availability, as they experience important biological transitions during adolescence, including increases in bone mass and the onset of menstrual cycles among cisgender women.⁶^,¹⁶

Fig 2 — The traditional concept of the “female athlete triad” (highlighted by the red circles) has evolved into the more robust construct “Relative Energy Deficiency in Sports” (RED-S), defined as a syndrome of impaired physiological function due to an imbalance between dietary intake and energy expenditure. Figure was developed from Mountjoy et al.¹⁵

Family Planning Challenges and Hormonal Challenges

Female athletes often face unique family planning challenges and hormonal challenges that may contribute to psychological distress.⁵ For example, cisgender female athletes are at least 2 to 3 times as likely to experience menstrual dysfunction than their nonathletic counterparts, with 10% to 15% suffering from amenorrhea or oligomenorrhea.⁶ This can have significant implications for energy availability and bone health. In addition, the use of certain fertility drugs are not compliant with the World Anti-Doping Agency regulations, creating disparities and stress for some athletes trying to conceive.⁵^,¹⁷ This can have significant implications for energy availability and bone health.

Transgender female athletes undergoing hormone therapy also encounter immense challenges, as they must apply for therapeutic exemptions before competitions for medications that are included on the prohibited substances list.¹⁸^,¹⁹ There is also evidence of female athletes being more likely to end their careers due to family-related matters than male athletes.⁵ Although choosing to forgo athletic pursuits may be a personal choice for some female athletes, others may not have had a choice due to the documented lack of family support available to athletes.⁵ Research on the return to sport following childbirth is limited and requires further investigation to enhance our understanding.⁵

Mental Distress

Mental distress and disorders, particularly internalizing disorders such as depression and anxiety, are more common in female than male athletes.⁴^,²⁰^,²¹ Minoritized identities—including racial, ethnic, and sexual minorities, as well as athletes with disabilities—are especially vulnerable to poor mental health outcomes.⁴^,¹⁹ Such findings are significant for physical health outcomes: the presence of anxiety among female athletes, for example, is associated with twice the likelihood of sustaining a sports injury.⁴ The coronavirus disease 2019 pandemic has further compounded the mental distress experienced by female athletes. Mounting evidence has demonstrated that coronavirus disease 2019 has resulted in significant deteriorations in both the mental and physical health of athletes, with a noteworthy gendered difference of female athletes reporting significantly greater rates of depressive symptoms, worse physical activity, and lower health-related quality of life than their male counterparts.²²^,²³ Orthopaedic surgeons can help improve the mental health of female athletes by adopting a holistic care approach (Fig 3).

Fig 3 — Holistic approach to improving care for female athletes.

Psychological Responses to Sports Injuries Among Female Athletes

In caring for female athletes, orthopaedic surgeons should be aware of the relationship between sports injuries and psychological problems: not only can poor mental health outcomes increase the risk of sports injuries, but sports injuries can aggravate psychological issues among female athletes.⁴^,²⁰ For example, depression (for which female athletes are at twice the risk compared with male athletes⁴) is one of the most common reactions to sports injuries.³ Nearly one half of injured athletes suffer from at least mild depression, and those unable to participate in sports for at least 30 days have reported prolonged feelings of depression, loss, frustration, anger, and self-esteem issues.³ Anxiety and fear of reinjury are also common responses to sports injuries.³^,⁴ In fact, more than 3 in 4 patients have been found to experience symptoms of posttraumatic stress disorder after sustaining ACL injuries, including feelings of avoidance, intrusive thoughts, and hyperarousal, with female patients reporting significantly greater disturbances.³^,²⁴ In addition, sports injuries can exacerbate body image concerns that are already prevalent among female athletes. An abrupt suspension of physical activity, for example, can trigger intense weight gain fears and feelings of unworthiness and loss of control, further worsening preexisting body image concerns.³ The negative psychological responses experienced by many female athletes after sports injuries can contribute to significant barriers in their rehabilitative progress and return to sports, creating unique opportunities for orthopaedic surgeons to intervene to improve outcomes.

Impact of Psychological Factors on Postinjury Outcomes Among Female Athletes

While orthopaedic surgeons are likely aware of the literature focused on improving surgical techniques to enhance postoperative outcomes after sports injuries, they may be less familiar with the psychological literature affecting return to sports.³ It has been found, for example, that rates of return to sport in patients who underwent ACL reconstruction range from 45% to 65%,²⁵^,²⁶ despite reports of 90% achieving normal knee function based on objective outcome measurement.²⁶ Female athletes have been found to have lower rates of return to sport when compared with male athletes after ACL reconstruction.⁸^,²⁷

Psychological factors can both facilitate and hinder an athlete’s recovery, and it is important to understand how these factors may differ in female athletes compared with male athletes. To follow, we discuss factors associated with optimal recovery (including psychosocial readiness to return to sport, self-efficacy and self-esteem, internal locus of control, and athletic identity) as well as factors associated with suboptimal recovery (including fear of reinjury and kinesiophobia, psychological distress, and unrealistic expectations) (Fig 4).³^,²⁸

Fig 4 — Factors associated with optimal recovery as well as suboptimal recovery after female athletes sustain injuries. Figure developed from Daley et al.³ and Sims and Mulcahey.²⁸

Favorable Factors

Psychological readiness has been found to be a key predictor of returning to sports that is influenced by confidence in sports performance, emotions related to returning to sports, and assessment of reinjury risk.²⁹ A study of 187 athletes who underwent ACL reconstruction, for example, found that athletes who returned to their preinjury level of sports performance after 12 months had significantly greater psychological readiness preoperatively (at 4 months) and postoperatively compared with those who did not.³⁰ Self-efficacy and self-esteem also impact athletes’ recoveries after sports injuries, with greater levels being associated with improved rehabilitation compliance, as well as better physical, mental, and social functioning following ACL reconstruction.³^,²⁸^,³¹ All 3 factors—psychological readiness, self-efficacy, and self-esteem—have been found to be significantly lower in female athletes than male athletes.⁸^,²⁸^,²⁹^,32, 33, 34 Whether female athletes actually have lower levels of these traits or simply have different reporting styles compared with male athletes has yet to be determined. However, orthopaedic surgeons can use their knowledge of this difference to actively try to help build up female athletes’ self-esteem and encourage them to return to sports when it is safe to do so, thereby helping them to overcome psychological obstacles that may be hindering them.

Having a greater internal locus of control is also linked to improved outcomes after sports injuries among athletes. In the case of ACL reconstruction, a greater internal locus of control has been associated with improved subjective knee function, physical and mental well-being, and vitality.³^,³¹ Although female athletes have been found to be more self-directed and outcome-driven, male athletes have been found to be more influenced by others.²⁸ Female athletes may therefore be more self-guided and devoted during the postinjury rehabilitation process, of which orthopaedic surgeons and physical therapists can take advantage. An athlete’s athletic identity (that is, how much they identify with their athletic role) also contributes to their recovery after sports injuries, particularly among elite athletes.³^,²⁸ Strong athletic identities have been associated with increased adherence to rehabilitation, possibly due to an increased desire to return to active sports participation.³^,³¹ However, strong athletic identities also have been linked to increased psychological distress following an injury, as an integral part of the athlete’s identity has essentially been “torn away” with an injury.³^,³¹ Compared with their male counterparts, who may be susceptible to overidentifying with their athletic role, evidence suggests female athletes may have greater potential to preserve their overall sense of self-worth following an athletic injury.²⁸ Although this may benefit their psychological well-being postinjury, it may also reduce their desire to return to sports as quickly as possible. Orthopaedic surgeons can draw on female athletes’ tendencies to maintain their overall self-worth after sports injuries as a key strength to preserve their mental well-being, and their greater levels of self-directedness to facilitate their rehabilitation progress and appropriate return to sport.

Unfavorable Factors

Fear of reinjury and kinesiophobia (fear of physical movement) are major contributors to subpar outcomes after sports injuries.³^,²⁸ In a meta-analysis examining 48 studies of 5,770 patients, less than 1 in 2 patients who underwent ACL reconstructions returned to competitive sports after a mean follow-up of 3.5 years, with fear of reinjury being the leading reason for reduced participation.²⁵ Kinesiophobia has also been found to result in 4 times lower activity levels after sports injuries, as well as greater reinjury rates and worse quality of life.³^,²⁸^,³⁵^,³⁶ Orthopaedic surgeons should be on the lookout for fear of reinjury and kinesiophobia in all athletes, as there is no consistent evidence of significant differences in levels of these outcomes by gender.²⁸

Psychological distress and unrealistic expectations also are associated with suboptimal injury recovery.³ Heightened psychological distress is concerning for its association with pain intolerance and catastrophizing, as well as its negative correlation with self-esteem levels.³¹ Orthopaedic surgeons can use the knowledge of female athletes being more prone to psychological distress (with greater rates of emotional distress postoperatively and greater use of emotionally-oriented coping strategies²⁸) to guide them toward accessible resources that will help to strengthen their mental well-being (such as referrals to sports psychologists). Orthopaedic surgeons can help female athletes to create realistic expectations for their postinjury recovery by educating them on the nature of their injuries and the expected recovery process.³ Doing so can prevent female athletes from becoming frustrated with themselves and feeling guilty that their recovery process is taking longer than they expected.

Improving Postinjury Psychological Well-Being in Female Athletes

Orthopaedic surgeons can play a vital role in caring for female athletes, not only in supporting their physical health but also their mental well-being. Despite having briefly discussed unique aspects of female athlete recovery, perhaps the simplest and most meaningful way to help this patient population is to adopt a more holistic approach to caring for female athletes. Although orthopaedic surgeons may not be able to provide full psychiatric care to their patients, they can ask patients questions about their well-being that can yield valuable insight into how a patient is doing. Suggestions for such conversation starting questions can be seen in Figure 5³¹ and can make patients feel heard, help to understand patients’ emotional perspectives, and aid the surgeon in identifying the needs for psychological resources in their patients.

Fig 5 — Screening questions for orthopaedic surgeons to use to assess the psychological well-being of athletes. Figure adapted and expanded from Christino et al.³¹

Finally, although the content of this paper has emphasized the role orthopaedic surgeons may play in improving the psychological well-being of female athletes, it is vital to underscore the importance of multidisciplinary approaches to care for these patients. We can ensure that female athletes receive the best-possible outcomes through close collaborations between diverse providers (including physical therapists, athletic trainers, nurses, and sports psychologists) that maximize the skills and expertise of all members of the team.

Conclusions

In summary, female athletes face distinct stressors that can impact their mental health, injury recovery, and return to sport. Orthopaedic surgeons play a vital role in their care and should be aware of female athletes’ unique experiences. Despite similar functional outcomes, female athletes have been found to have lower rates of return to sport than their male counterparts. Orthopaedic surgeons should be aware of the psychosocial factors that contribute to and help to overcome this trend. By integrating questions about psychological well-being and collaborating with a multidisciplinary team, orthopaedic surgeons can support female athletes in achieving optimal mental and physical health outcomes.

Acknowledgments

Figures were developed by Maike van Niekerk on BioRender.

Footnotes

The authors report the following potential conflicts of interest or sources of funding: E.M. reports editorial board, Arthroscopy. M.C. reports board of directors, Pediatric Research in Sports Medicine. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

Supplementary Data

ICMJE author disclosure forms

mmc1.pdf^{(502.5KB, pdf)}

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Supplementary Materials

ICMJE author disclosure forms

mmc1.pdf^{(502.5KB, pdf)}

[bib1] 1.U.S. Department of Labor. Title IX of the Education Amendments of 1972. Published online November 13, 2000. https://www.justice.gov/crt/title-ix-education-amendments-1972. Accessed February 19, 2023.

[bib2] 2.Matzkin E., Curry E.J., Whitlock K. Female athlete triad: Past, present, and future. J Am Acad Orthop Surg. 2015;23:424–432. doi: 10.5435/JAAOS-D-14-00168. [DOI] [PubMed] [Google Scholar]

[bib3] 3.Daley M.M., Griffith K., Milewski M.D., Christino M.A. The mental side of the injured athlete. J Am Acad Orthop Surg. 2021;29:499–506. doi: 10.5435/JAAOS-D-20-00974. [DOI] [PubMed] [Google Scholar]

[bib4] 4.McManama O’Brien K.H., Rowan M., Willoughby K., Griffith K., Christino M.A. Psychological resilience in young female athletes. Int J Environ Res Public Health. 2021;18:8668. doi: 10.3390/ijerph18168668. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib5] 5.Pascoe M., Pankowiak A., Woessner M., et al. Gender-specific psychosocial stressors influencing mental health among women elite and semielite athletes: A narrative review. Br J Sports Med. 2022;56:1381–1387. doi: 10.1136/bjsports-2022-105540. [DOI] [PubMed] [Google Scholar]

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PERMALINK

Psychological Aspects of Return to Sport for the Female Athlete

Maike van Niekerk, Ph.D.

Elizabeth Matzkin, M.D.

Melissa A Christino, M.D.