Athlete's Mental Health and Quality of Life After Sports Injuries

Abstract

• »Psychological factors significantly influence both the risk and recovery process of sports injuries, with inadequate coping skills and high life stress levels identified as key preinjury risk factors.
• »Postinjury psychological distress, including symptoms of anger, depression, and anxiety, can hinder an athlete's rehabilitation and prolong recovery time.
• »Female athletes demonstrate a higher incidence of sports injuries and tend to experience more severe psychological responses after injury compared with male athletes.
• »Incorporating psychological support and interventions into rehabilitation programs improves outcomes and supports holistic recovery for injured athletes.
• »Recognizing and addressing mental health as a central component of injury management is essential for optimizing athlete well-being and performance.

An athlete is defined as an individual who participates in an organized team or individual sport that involves regular competition, places a high value on excellence and achievement, and requires systematic training¹. Sports participation unquestionably offers myriad health and wellness benefits, but avoiding overlooking potential adverse outcomes is crucial². Despite substantial progress in understanding and treating athletic injuries, concerns regarding the rise in sports injuries have been raised. This increase is attributed to psychological and sociocultural stressors such as anxiety, perfectionism, and social pressure³.

Internationally, athletes sustain approximately 4 million sports-related injuries annually, requiring approximately 2.6 million emergency department visits and costing approximately $2 billion⁴. During the 2020 Summer Olympics, a total of 1,035 injuries and 438 illnesses were reported, corresponding to 9.1 injuries and 3.9 illnesses per 100 athletes⁵.

Adverse events sports participants endure include not only physical injuries but also negative outcomes impacting their physical and mental health, which may be influenced by associated risk factors⁶. The relationship between sports injuries and mental health is bidirectional, highlighting that the comprehensive impact injury has on athletes⁷. For example, mental health disorders, particularly depression, are more prevalent among athletes than in the general population⁸. Concussions and head impacts have been linked to depressive symptoms, and overtraining syndrome can mimic depression⁹. Furthermore, depressive symptoms have been linked to involuntary retirement due to injuries, particularly when athletes experience ongoing pain and possess a strong athletic identity¹⁰. Many athletes who sustain physical injuries concurrently experience psychological distress manifested as anxiety, negative mood, fear of reinjury, or loss of motivation¹¹. Depressive symptoms can lead to physiological and attention-related changes, thereby increasing the risk of musculoskeletal injuries¹².

A comprehensive understanding of the psychological impact of sports injuries on athletes will enable relevant stakeholders, including healthcare professionals, coaches, and physiotherapists, to proactively address and improve both physical and psychological recovery¹³. This underscores the need to fully understand the intricate web of consequences of athletic injuries, particularly their intersection with mental health issues. To our knowledge, no review article has thoroughly examined the bidirectional relationship between sports injuries and mental health. This review aimed to provide an in-depth assessment of the psychological impact of sports injuries, focusing on both preinjury and postinjury measures and emphasizing the role of mental health in the recovery process.

Methods

Literature Search

Medline/PubMed, Google Scholar, Education Resources Information Center, and the Cochrane Database of Systematic Reviews were searched for relevant studies on September 7, 2023. The following keywords were used: “athletes,” “athletic injuries,” “impact,” and “mental health.”

Inclusion and Exclusion Criteria

The retrieved records were initially assessed based on their titles. All included studies were rescreened by the researchers using the full-text articles. The inclusion criteria were all types of studies that addressed athletes who had any form of sports injury and its impact on athletes' mental health or well-being, as well as studies that investigated the psychological factors contributing to sports injuries. Studies exploring the influence of psychological factors during rehabilitation were also included. Studies that focused on interventions or treatments without discussing the psychological impact of the injury itself were excluded. Studies published in languages other than English, book chapters, and critiques were also excluded.

Data Extraction

A standardized extraction form was used to extract data from the articles. The extracted information included the primary author's last name, year of publication, location (city or country), sample size, and significant conclusions. All authors participated in the data extraction and review of studies.

Patient and Public Involvement

Patients and/or the public were not involved in the design, conduct, or reporting of this research.

Results

A total of 400 studies were identified. After removing duplicates, this number decreased to 388. The researchers conducted title screening to determine eligibility for inclusion. Studies deemed irrelevant or published in languages other than English were excluded, resulting in a final count of 191 studies. During eligibility screening, full-text articles of studies involving young and college athletes, as well as those primarily focusing on interventions or treatments without addressing the psychological impact of the injury itself, were excluded, leaving 51 studies for analysis (Fig. 1). Among the included studies, 15 discussed preinjury psychological factors, 25 focused on psychological distress after sports injuries, and 12 addressed the role of psychological factors in rehabilitation.

Fig. 1.

Flowchart summarizing the identification and selection of articles.

Discussion

Understanding sports injuries has evolved with methodological improvements in research design and measurements, shedding light on the significant role of psychosocial factors in injury risk and management. Despite having similar physical conditions and situations, athletes may vary in their susceptibility to injuries. Overtraining syndrome, commonly known as “burnout,” exemplifies the interaction of both physical and psychological symptoms¹⁴. Personality types have also been suggested as potential contributors to injury proneness, with stress and coping mechanisms playing crucial roles in sports injury outcomes^12,14. Life stress is also associated with a higher likelihood of injury¹⁵.

Studies have revealed that inadequate coping resources are a strong predictor of injuries among athletes, emphasizing the importance of psychosocial support¹³. Furthermore, the relationships among social support, coping skills, and injury vulnerability underscore the nuanced nature of these interactions¹⁶. Among uninjured athletes, mood dimensions such as anger, confusion, fatigue, tension, uncertainty, stress, and depression have been identified as significant contributors to sports injuries^17,18. Beyond the glory of success, elite athletes face darker consequences, including overtraining, burnout, and an increased risk of various noncardiovascular conditions. When disrupted, a high athletic identity is linked to psychological distress, overtraining, and burnout^19,20. In addition, elite sports literature highlights vulnerabilities, such as disordered eating and risk-taking behaviors among athletes¹⁴. Therefore, injury is a continuum, beginning with preinjury stress responses and extending through acute sports injuries, influenced by personal and situational factors²¹.

Preinjury Psychological Models

Numerous models in the literature have highlighted the profound impact of psychological factors—such as stress levels, mood states, personality traits, and coping resources that can influence an athlete's susceptibility to injury²²—during the preinjury phase. For instance, Andersen and Williams formulated a stress theory model, emphasizing athletes' responses to stressful situations as pivotal in injury likelihood²². Their model highlighted the predictive power of major life event stress on injury occurrence, particularly when combined with limited coping resources²². Similarly, Wiese-Bjornstal's comprehensive analysis of the current literature related to high-intensity athletes highlighted the significant role of psychological factors in shaping athletes' vulnerability and predisposition to injury, although the immediate cause often lies beyond psychological factors²³. Galambos et al.¹⁶ reviewed annual health screening data from 845 athletes ranging in age from 11 to 41 years. Their report further elucidated the intricate connections between psychological factors and physiological states, shedding light on the complex interplay that shapes injury occurrence¹⁶. Moreover, the Wiese-Bjornstal model²³ emphasizes the need to consider diverse elements, such as training protocols, body composition, and social pressures, to assess an athlete's injury risk profile, offering a holistic framework for injury prevention²⁴.

During the Injury and Afterward

Sports hold a prominent position in society, not merely because of their widespread popularity but also because of their substantial health benefits. In recent decades, participation in master's sports has notably increased, with older adults engaging in organized athletic competition not only for physical health but also for social connection, self-expression, and to challenge age-related stereotypes²⁵. Despite the myriad benefits that sports offer athletes, injuries remain a significant obstacle that many participants encounter. Sports-related injuries are on a sharp rise across various categories and modalities, a trend attributed to heightened professionalization, competitiveness, and extended practice sessions within the sporting realm²⁶. Health-related issues pose a recurrent challenge for athletes, given their frequent exposure to physically and psychologically demanding circumstances. Notably, although the detrimental effects of elite sports are often overshadowed, recent evidence suggests that elite athletes frequently report mental health issues throughout their careers²⁷. In their study among 1,401 professional football athletes (current and retired), those with hip osteoarthritis (OA) scored significantly lower in health-related quality of life (HRQoL). The pivotal role of psychological processes in both the occurrence of and recovery from injuries has been well established. This has prompted an increased emphasis on elite athletes' mental well-being^28-31, including interventions rooted in sports psychology³². Careful consideration of the timing, nature, providers, and framing of psychological interventions can help ensure that the interests of athletes with injuries are best served³³.

Mental health is a crucial determinant of athletic performance and progression. Simultaneously, athletes face unique mental health risk factors compared with the nonathletic population, including intense training regimes, competitive pressures, and the demanding nature of their lifestyles. The physical demands of sports, including rigorous training and injury risks, can precipitate various psychological effects. These effects can affect cognitive, emotional, and behavioral domains²¹. Certain injuries and medical conditions may have detrimental effect in this population, as we discuss next.

Effect of Medical Conditions/Physical Injury

Anterior cruciate ligament (ACL) injuries are considered debilitating. They can have long-term adverse consequences, including reduced physical activity, disability, increased risk of knee OA, and poor perceived knee-related quality of life (QoL). Psychological impairments during ACL injury rehabilitation may include frustration, lack of motivation, fear of reinjury, loss of athletic identity, anxiety, and disordered eating. These psychological factors may culminate in serious physical consequences³⁴.

Back pain is a prevalent health issue among athletes and is characterized by functional limitations and psychological strain. Its prevalence rates vary across different sports, ranging from 31% for soccer to 89% in divers³⁰. In their review, they noted the scarcity of back pain studies that include psychological aspects other than stress.

Concussion is another injury athletes are at risk for, especially those engaged in contact and collision sports. These athletes have an elevated risk of concussion compared with the general population³⁵. The increasing focus on concussions stems from the fact that brain injuries account for the highest rate of fatalities in sports. In addition, elevated rates of depression and suicide have been associated with athletes in sports such as American football, ice hockey, rugby, and soccer²⁰. Athletes exhibiting an anxious profile at baseline are more likely to experience a greater symptom burden after a concussion³⁶. Concussions are considered a factor that reduces QoL³⁷.

Different sports are associated with different injury patterns. For example, basketball, a globally practiced team sport, exhibits an injury incidence of 71.3%. These injuries predominantly affect the lower limbs, thereby decreasing HRQoL across the physical and mental domains³⁸. In football, injuries are more prevalent during matches, which are characterized by frequent physical contact. The ankle (25%) is the most commonly affected site, followed by the knee (20.1%)³⁹. In a cross-sectional study of 270 athletes, Marshall et al.⁴⁰ found that those with a history of severe ankle injuries had significantly lower functional (Foot and Ankle Ability Measure) and mental health (Short Form-12) scores compared with those with mild or no injuries, highlighting a lasting impact on HRQoL. Furthermore, football players are susceptible to degenerative bone diseases, with a reported prevalence of hip OA of 2% to 8% among former professional football players. Both current and former professional footballers with hip OA exhibited significantly lower levels of hip function, physical health, and HRQoL than those without hip OA or the control group²⁷.

Sex-Specific Disparities

As the involvement of women in sports across all levels of proficiency and competition continues to grow, nuanced comprehension of the psychology specific to female athletes becomes essential. This understanding can aid in bolstering their athletic achievements, injury recovery, and enhancing overall health and wellness⁴¹. Male and female athletes exhibiting preseason anxiety symptoms were found to have 2.5 and 1.9 times higher injury rates, respectively⁴². Notably, female athletes engaging in sports and fitness activities have a 4 to 6 times higher incidence of knee injuries than their male counterparts. In addition to adversely affecting knee function, these injuries have negative repercussions on physical and emotional well-being, as well as vitality, social functioning, and QoL^43,44. Granito⁴⁵, in a study examining gender differences in psychological responses to athletic injury, found that female athletes not only viewed their coaches more negatively regarding postinjury treatment but also expressed greater emotional distress, lower perceived social support, and heightened concern about the long-term impact of their injury on future health and sports participation compared with their male counterparts. Factors such as social support, coping mechanisms, and cultural expectations may contribute to this discrepancy⁴⁶. Female athletes tend to report lower scores than male athletes on various aspects of the Short Form-12, underscoring the necessity to consider sex when evaluating postinjury HRQoL⁴⁰.

Psychological Distress and Disorders

Trauma-related mental-health disorders may manifest disproportionately among elite athletes, with prevalence rates potentially surpassing those in the general population⁴⁷. Athletes may encounter traumatic experiences at various stages of their lives, including childhood, active sports participation, and throughout their athletic careers. Notably, rates of posttraumatic stress disorder among elite athletes may exceed those observed in the general population. Certain sports demonstrate even higher prevalence rates, with rates of up to 25% among professional and preprofessional dancers.

Upon reaching elite competition levels, athletes contemplating retirement are afforded the opportunity to develop and execute retirement plans. However, unforeseen retirements, often precipitated by career-ending injuries, can pose formidable challenges for athletes transitioning out of sports, affecting their physical, mental, and social well-being⁴⁸. The peak age for the onset of mental health disorders among athletes coincides with their peak competitive years due to the intense mental and physical demands they endure²⁰. Notably, 75% of all lifetime mental health conditions commence by the age of 24 years, aligning with the peak years of athletic performance¹⁰. The severity of the psychological response to an injury may vary, and not all cases result in a formal psychological diagnosis, such as depression³⁴. Stress exhibits a robust association with sports injuries as a preinjury factor, with the immediate postinjury period often characterized by heightened anxiety, frustration, depression, and poor mood states^10,49,50.

Previous studies involving athletes reported an annual incidence of sports injuries ranging from 65% to 75%⁵¹. When an injury occurs, the attributions athletes make regarding its cause can influence the rehabilitation and recovery processes²⁰.

Sports Rehabilitation

Understanding the multidimensional emotional experiences athletes undergo during the injury recovery period is a critical priority in rehabilitation²⁸. Smith et al. found that injured athletes experienced significantly higher levels of psychological symptoms, such as depression, tension, and confusion, indicating the need to address these issues during physiotherapy²⁸. Physical therapists play an integral role in addressing the psychological aspects of injury recovery, highlighting the importance of integrating psychological factors into rehabilitation programs⁵². The Emotional Responses of Athletes to Injury Questionnaire serves as a valuable tool for assessing athlete emotions during rehabilitation and developing coping strategies⁵³.

Sleep quality is the second most important determinant of athletes' likelihood of regaining full strength and maintaining mental stability^54,55. Sleep disturbances can hinder recovery and affect mental status. Therefore, implementing sleep hygiene practices is essential to the rehabilitation process.

Management

Table I presents the different psychological management modalities used in sports rehabilitation. Evidence-based psychological treatments, such as mindfulness-based stress reduction training, acceptance and commitment training, and motivational enhancement training, offer promising avenues for psychological support for injured athletes^56,57. Moreover, concrete, problem-focused, and behaviorally oriented programs that minimize uncertainty are considered ideal for injured athletes⁵⁸. Notably, the literature has reported positive psychological reactions, such as increased motivation, confidence, and reduced fear, which are associated with a quicker return to previous sports performance levels⁵⁹.

TABLE I.

Management Modalities in Sports Rehabilitation

Management Modality	Brief Description
Mindfulness-based stress reduction training	Uses mindfulness meditation strategies, including breathing and cognitive techniques, to manage stress and regulate cognitive and emotional responses
Acceptance and commitment training	Employs mindfulness and committed action, based on core values rather than goals, to enhance psychological flexibility
Motivational enhancement training	Centered on motivational interviewing, aims to bolster personal motivation and commitment toward a specific goal by exploring individual reasons for change within a supportive and compassionate environment
Psychological support programs	Includes concrete, problem-focused, and behaviorally oriented programs to minimize uncertainty and enhance recovery
Social support	Involves collaboration among athletes, medical professionals, and coaches to provide a supportive environment

Building a supportive environment with collaboration among athletes, medical professionals, and coaches is critical for successful rehabilitation⁶⁰. Sports medicine professionals must understand the psychosocial principles underlying athletes' injury processes and their impact⁶¹. Social support is instrumental in helping athletes successfully handle the rehabilitation phase⁶². By integrating these techniques into rehabilitation plans, healthcare professionals can support athletes manage their emotional responses, improve mood self-efficacy, and foster a positive mindset for successful recovery and return to sports.

Preventive Measures

Table II lists some preventive techniques for sports injuries. Several studies have addressed various methods and techniques for preventing sports injuries. For instance, Ahern and Lohr¹⁴ advocated integrating cognitive techniques, such as positive self-talk, relaxation methods, and meditation, to mitigate the negative thoughts that may predispose athletes to injury risk¹⁴. Furthermore, the critical role of sleep in optimizing athletes' training, recovery, and performance cannot be overstated because it intricately influences both physiological and psychological processes^55,63. In addition, Chan and Hagger conducted research on the transcontextual process of motivation between sports participation and sports injury prevention⁶⁴. They surveyed 533 elite athletes participating in various sports at different levels, from regional to international. Their findings suggest that athletes exhibiting autonomous motivational orientations in sports are more inclined to engage in behaviors that prevent sports injuries⁶⁴. Moreover, personality traits and coping resources have been identified as influential factors in sports injury risk. These factors affect injury outcomes both directly and by moderating the impact of life stress³¹. Conversely, social support appears to act as a buffer in the relationship between life stress and sports injury outcomes; athletes with robust social support networks demonstrate greater resilience to injury amid high levels of life stress than those with limited social support³¹.

TABLE II.

Preventive Techniques

Technique	Brief Description
Cognitive techniques	Includes positive self-talk, relaxation methods, and meditation to mitigate negative thoughts
Sleep optimization	Emphasizes the critical role of sleep in training, recovery, and performance
Motivational orientation	Promotes autonomous motivational orientation to encourage injury-prevention behaviors
Social support	Acts as buffer in the relationship between life stress and injury outcomes, enhancing resilience

Limitations

This narrative review has some limitations, particularly the heterogeneity of study designs and sample populations, which may affect the generalizability of findings. The exclusion of non-English studies may have also limited the scope of the review. Furthermore, although findings support the existence of a relationship between mental health and injury, clear cause and effect cannot be established.

Conclusion and Future Direction

This review demonstrates the role of mental health in the assessment, management, and prevention of injuries in athletes. The literature has highlighted the critical influence of psychosocial factors on athletes' injury susceptibility, from preinjury stress responses to psychological distress after injury. Hence, understanding how psychosocial aspects can influence the risk of injury is essential for creating suitable strategies to protect athletes against injuries. In addition, sex disparities in both the type and frequency of injuries highlight the need for sex-specific approaches in injury prevention and rehabilitation. The literature indicates the integration of cognitive techniques, such as positive self-talk and relaxation methods, into injury prevention programs to limit negative thoughts that have been shown to predispose athletes to injury.

In summary, promoting good sleep hygiene and enhancing psychological orientation toward autonomy in athletes will result in more effective injury prevention behaviors. The literature also indicates that providing social support and developing coping skills among athletes can reduce the incidence of injuries. Sports organizations should embrace an adjusted strategy that involves approaches from 2 perspectives, physical and psychological, to help enhance athletes' health, performance, and QoL. Future research should not only investigate the long-term psychological effects of sports injuries and the efficacy of psychological interventions but also develop tailored and integrated strategies to address needs for injury prevention and rehabilitation as well as mental health and physical recovery in diverse athletic populations.

Sources of Funding

No funding was provided in the investigation of this study.