A qualitative study exploring factors linked to adolescent athletes’ mental health during sports injury

Abstract

Adolescent athletes have specific developmental risks for sports injury and the onset of mental health problems. Research has typically focused on mental health during specific sports injury phases, such as rehabilitation, with little consideration for factors linked to adolescence. This qualitative study retrospectively explored factors influencing adolescent athletes’ mental health across the injury course, emphasising developmental, social, environmental and sport-cultural contexts. Semistructured interviews were conducted with 27 athletes aged 16–21 years who had sustained a severe time-loss injury in the past 6 months. Participants completed a visual timeline to support reflections on mental health from injury onset to rehabilitation or return to sport. Data were analysed using reflexive thematic analysis, combining inductive and deductive approaches. Five themes described factors linked to fluctuating mental health. ‘Finding my inner strength’ explores how injury introduced vulnerability to developing personal identities, which led to self-blame for injury-risk behaviour, training through pain and social withdrawal. ‘Making sense of my emotions’ describes how injury triggered overwhelming worries, amplified by unexplained pain and losing sport as a coping strategy. ‘Learning to look after myself’ considers how athletes’ growing independence and emotional autonomy can be thwarted by parents during injury, prompting frustration and lowered self-esteem. ‘Accepting peer judgement and support’ explores how worries about peer evaluation led to concealing injury and social withdrawal, and social exclusion prompted lowered mood and self-esteem. ‘Adapting to the system’ describes how diagnostic uncertainty and rigid or unsupportive sport cultures caused frustration and lowered self-esteem, and prevented help-seeking. Cognitive flexibility and emotion regulation skills at the individual level, and social support and mental health literacy at interpersonal and organisational levels, were positive for adolescents’ mental health at challenging points during injury. These factors may make suitable intervention targets to support athlete mental health while injured.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Sports injury is a recognised risk factor for mental health problems in athletes, but research focuses primarily on adults and clinical outcomes such as anxiety and depression at specific injury stages such as rehabilitation.

• Adolescence is a developmental stage characterised by identity formation, cognitive-emotional regulation difficulties, sensitivity to peer judgement and heightened vulnerability to both mental health difficulties and sports injury.

• Existing accounts of adolescent mental health during injury rarely account for how mental health is impacted by developmental contexts or how it fluctuates during injury.

WHAT THIS STUDY ADDS

• This study provides the first in-depth, retrospective exploration of adolescent athletes’ mental health during injury, decoupling mental health from specific injury diagnoses and recovery phases.

• Findings identify five developmental factors influencing mental health: personal identity disruption, cognitive-emotional regulation, threats to emerging independence, the impact of peer judgement and support, and adolescent-specific challenges of navigating club and medical systems.

• Individual flexible thinking skills; adaptive coping strategies; parental emotional validation and neutral advice; peer empathy and social support; and organisational support for planning and health decision-making all promoted mental flourishing.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Future studies should adopt longitudinal approaches to examine how developmental, social, environmental and cultural factors interact over time to impact injury-related mental health.

• Upskilling adolescents with cognitive flexibility through narrative thinking interventions and acceptance-based training has the potential to support cognitive-emotional regulation during injury.

• Interventions to address parental emotional invalidation or ‘toxic positivity’ have potential to support mental health during injury.

• Coaches and medical staff should be trained to support injured adolescents’ mental health through important life transitions such as starting university.

• Organisations should address diagnostic uncertainty by embedding psychological skills to address adolescent worries and support their decisions about symptoms.

Introduction

Adolescence is a period of dynamic biological and psychosocial change¹ with specific risks for the emergence of mental health problems and sports injury. Cognitive development is linked to difficulties with planning and emotion regulation, risky behaviour and preoccupation with peer acceptance, at a time when adolescents are exposed to new, challenging social environments.1,3 Worldwide, almost half of all mental health problems emerge before age 18, with peak onset during mid-teens.⁴ Physical growth and maturation, and coaching trends towards overloading through early specialisation, heighten injury risk among adolescents.⁵ Injury is linked to sport dropout, with potential consequences for long-term health and wellbeing.⁶ The interaction between these factors is unique to adolescence and has implications for young athletes’ injury risk,⁷ sport drop-out⁸ and intervention development.

Research interest in athlete mental health,⁹ and its relationship with injury,¹⁰ is growing, but most evidence is from adult populations and prioritises linear relationships between single injury types such as Anterior Cruciate Ligament (ACL) tears and clinical disorders (eg, anxiety, depression) at specific postinjury timepoints,¹¹ with a focus on rehabilitation adherence.¹² In these studies, injury is associated with psychological responses including loss of athletic identity and fear of re-injury, but the focus on linear processes fails to account for the complex, non-linear nature of recovery and psychological development, so more dynamic models are required.¹³

Adolescent athletes experience similar mental health challenges as typical peers, but they also experience unique stressors including balancing training with studying and managing performance expectations.¹⁴ A recent scoping review¹⁵ suggested that factors impacting adolescent athlete mental health are individual coping skills; the nature of peer, parental and coach relationships; organisational cultures and mental health support.¹⁶ Again, studies in this population have typically examined mental health disorders (anxiety and depression).¹⁵ Emphasising disorders risks missing the highly reactive emotions, thoughts and behaviours that characterise adolescence,¹ which are relevant for identifying early signs of distress and for designing proactive support.

Little is known about adolescent mental health during injury, or the mechanisms linking them.⁷ A review of qualitative studies found common negative emotional responses were fear of re-injury, feelings of isolation and low mood, while positive responses were optimism and motivation to rehabilitate and return to sport.¹⁷ The review found popular coping strategies were to ignore symptoms, modify activity levels or seek support. Sixteen included studies were narrowly focused (eight on ACL injuries and four on concussion), and none were in the UK. Broader social, environmental and sport-cultural contexts remain under-explored in the context of injury, especially among adolescents.¹⁸

One framework that accounts for dynamic recovery processes is the adapted Integrated Model of Psychological Response to Sports Injury (IMPRSI).¹⁹ Personal and situational factors influence affective responses, cognitive appraisals and behavioural coping postinjury. The interdependent relationships between them are in turn associated with postinjury physical, psychological and social outcomes. The IMPRSI is widely used, yet much research remains focused on isolated factors (eg, injury history), and their impact on psychological responses (eg, rehabilitation adherence) at specific postinjury timepoints.²⁰

A model that accounts for biopsychosocial processes in dynamic mental health is the Mental Health Continuum model, which proposes that mental health and mental illness are two related but distinct dimensions and describes a spectrum of feeling and functioning in life, from flourishing to languishing.²¹ Athletes move back and forth along this scale over time in response to life stresses and coping resources.²² This broader perspective also allows for Sport Injury-Related Growth (SIRG), a theory which describes how athletes can positively adapt to injury challenges and move towards the ‘flourishing’ end of the continuum.²³

Qualitative, retrospective studies are required to explore adolescents’ characteristically reactive psychological responses to challenging experiences; to better understand factors and processes unique to this age group that might influence fluctuating mental health; and for subsequent intervention design.²² Using the continuum model, which accounts for fluctuations in mental health, and guided by the IMPRSI, which aligns with a continuum approach by focusing on dynamic, cyclical processes and allowing for the influence of personal and situational factors unique to adolescence, this study aimed to explore adolescent mental health during the injury course, with an emphasis on factors related to this developmental stage.

Methods

Study design

This was a qualitative study, reported in accordance with Consolidated Criteria for Reporting Qualitative Research (see online supplemental file 1).²⁴ Researchers adopted a relativist ontological perspective, reflecting a belief that participants were making sense of their own unique experiences and constructing their own subjective realities. The epistemological framework was constructivist, acknowledging researchers’ roles in making sense of the data during analysis and presentation. Youth athlete focus groups informed the research question.

Participants

Gatekeepers (school heads of Physical Education (PE); leaders of sport and coaching organisations, n=32) distributed email invitations to take part in the study. We sought a heterogeneous sample of adolescents, aged 16–21 years, from a background of regular competition in sport, with diversity across gender, ethnicity, sport played and competition level (from intraschool to international) to explore whether factors linked to adolescence were common across a range of backgrounds. Contemporary definitions of adolescence²⁵ propose an age range of 10–24 years, acknowledging ongoing brain development and role transitions taking place during early 20s. We reflected this emerging discourse by setting an upper age limit of 21 years to capture key social milestones including university and sport academy transitions. Participants were required to have sustained a sports injury in the past 6 months, which either had, or was expected to, prevent them from training and competing for >28 days. These timeframes were chosen to minimise recall bias and to capture ‘severe’ time-loss injuries.²⁶ A target sample range was guided by expected information power.²⁷ Broad study aims (mental impacts of injury), low sample specificity (broad range of contexts and experiences), and a within-case and cross-case analysis strategy indicated low information power, while the application of established theory and the strong quality of dialogue from experienced interviewers and participants with mental health awareness indicated higher information power. Together, these suggested moderate-to-low information power: a sample range of 25–30 was therefore considered sufficient.²⁷ Volunteers were screened for inclusion using an online form to obtain a purposive sample maximising representativeness of gender, ethnicity, sport, age group (dichotomised; 16–18 and 19–21 years) and competition level. Using a sampling matrix, eligible volunteers were invited to participate in the order their interest form was received. All participants gave informed consent to take part in the research prior to study commencement.

Data collection

Prior to the interview, participants were asked to complete a visual timeline plotting mental health at key personal events and injury stages: the moments after injury; at diagnosis; during rehabilitation; and, where applicable, at return to training or competition (see online supplemental file 1). Data collection involved online semi-structured interviews which took place between November 2024 and February 2025 via Microsoft Teams. One-to-one interviews were conducted by a female researcher (CW) and two female postgraduate students (LJC and EJS) trained in qualitative methods and not previously known to participants. The topic guide (see online supplemental file 1), which drew on the IMPRSI,²⁸ asked participants to reflect on their emotional, cognitive and behavioural responses at different stages through the injury course. Co-authors critically reviewed question content and phrasing, which were simplified after pilot interviews with two adolescents not involved in the main study. Co-authors discussed minor adaptations to interview schedules over the data collection period to constrain interview length where required. Interviewers used timelines to prompt recollections of psychological responses (see online supplemental file 1). This allowed participants to guide discussions towards salient experiences and helped interviewers to carefully approach points where negative thoughts and emotions were indicated. During moments of distress, participants were given the option to terminate the interview. They were debriefed postinterview and signposted to available mental health support. Each received a £25 honorarium for participation. Interviews were digitally recorded, then transcribed verbatim and pseudonymised.

Data analysis

Researchers used reflexive thematic analysis to identify patterns of meaning in the data.²⁹ After data familiarisation, CW and RHM coded to prespecified broad concepts: emotional, cognitive and behavioural responses to injury, personal and situational factors. Participants’ language around interactions between psychological responses and related factors was used to interpret semantic and latent meaning. For example, we coded “I didn’t quite listen to him [physio]…but he said it was fine,” as choosing to understand I could keep training. Sensitising concepts linked to psychosocial development guided our attention but did not predetermine themes. For example, adolescent predisposition to immediate reward-seeking¹ did not prove fruitful. Dependability was addressed by organising initial codes and analytical reflections in Excel.¹⁶ CW and RHM addressed credibility by comparing initial impressions and early coding of a selection of transcripts. Discussions (CW and RHM) confirmed that initial coding of psychological responses did not map clearly and consistently onto injury phases and that decoupling physical and psychological processes aided sense-making. CW used an inductive lens to construct initial candidate themes, aggregating meaning across the dataset, keeping a reflexive diary to note ideas (e.g. approach to injury risk; mental health awareness) and theme development. These were reviewed by RA, LM, CM and LJC, who encouraged critical reflections on how CW’s assumptions as a parent and researcher who is personally invested in adolescent mental health influenced her approach to data analysis. Early themes were collapsed into overarching themes: for example, an initial theme ‘future hopes’ was discarded, and the subtheme ‘health information is power’ was collapsed into ‘adapting to the system’. Themes were revised and refined in discussion with co-authors who served as CW’s critical friends, challenging methodological integrity and knowledge construction.

Results

Participant characteristics

There were 111 expressions of interest. Of the 61 volunteers invited to interview, 23 did not respond; eight did not meet inclusion criteria on further inquiry; two responded after recruitment closed and one declined to participate due to examinations. No clear patterns or characteristics distinguished those who participated from those who did not. This resulted in 27 participants (women=15; men=12) who were interviewed (table 1). Interview length ranged from 30 to 88 min (M=61.9±10.1 min). Five themes were developed describing factors linked to dynamic adolescent mental health during injury. Themes, including points of mental health challenge and support through the injury course, are illustrated in figure 1 and described with illustrative, pseudonymised quotes in table 2.

Table 1. Participant characteristics (n=27).

Characteristic	Overall (n=27)	Women (n=15)	Men (n=12)
Age group:
16–18 years	10 (37%)	6 (40%)	4 (33%)
19–21 years	17 (63%)	9 (60%)	8 (67%)
Ethnicity:
White	23 (85%)	12 (80%)	11 (92%)
Asian/Asian British	2 (7%)	2 (13%)	0 (0%)
Mixed/Multiple ethnic groups	2 (7%)	1 (7%)	1 (8%)
Highest level of competition:*
‘Higher level’	21 (78%)	11 (73%)	10 (83%)
‘Lower level’	6 (22%)	4 (27%)	2 (17%)
Main sport:
Athletics	5 (19%)	1 (7%)	4 (33%)
Badminton	2 (7%)	2 (13%)	0 (0%)
Basketball	1 (4%)	0 (0%)	1 (8%)
Field hockey	3 (11%)	3 (20%)	0 (0%)
Football	4 (15%)	2 (13%)	2 (17%)
Orienteering	1 (4%)	1 (7%)	0 (0%)
Rounders	1 (4%)	1 (7%)	0 (0%)
Rowing	1 (4%)	1 (7%)	0 (0%)
Rugby union	5 (19%)	3 (20%)	2 (17%)
Squash	1 (4%)	0 (0%)	1 (8%)
Swimming	1 (4%)	1 (7%)	0 (0%)
Touch rugby	1 (4%)	0 (0%)	1 (8%)
Water polo	1 (4%)	0 (0%)	1 (8%)
Injury status:†
‘Injured’	16 (59%)	9 (60%)	7 (58%)
‘Healed’	11 (41%)	6 (40%)	5 (42%)
Injured body region:
Upper limb	3 (11%)	2 (13%)	1 (8%)
Lower limb	18 (67%)	9 (60%)	9 (75%)
Trunk	2 (7%)	2 (13%)	0 (0%)
Multiple regions	4 (15%)	2 (13%)	2 (17%)

^*Participant responses were grouped as follows: ‘higher level’ (ie, youth talent programme or academy; professional club; national; and/or international) or ‘lower level’ (ie, intraschool; interschool; interuniversity; grassroots club; county; and/or regional).

^†Injury status at time of interview: (1)‘injured’ (ie, not training or competing) or (2) healed’ (ie, at various stages of returning to sport or competing). All injuries had been confirmed by a healthcare professional (surgeon, doctor or physiotherapist) at the time of interview. N.B., due to rounding, not all percentages add up to 100%

Figure 1. Thematic map showing main themes and challenge and support points for mental health.

Table 2. Themes, points of challenge or support for mental health during the injury course and illustrative quotes.

Theme	Challenge or support points	Illustrative quotes
Finding my inner strength	Preinjury identity includes invulnerability	“(…)if anything was hurting I’d just be like, ‘It’s going to be fine’” (Patrick) “I always had this thought that, ‘Oh, it could never happen to me”. (Eva)
	Negative self-evaluation after injury-risk behaviour	“I took a lot out on myself as well for getting injured. Because I knew that I shouldn’t have got injured, I should have taken a break”. (Mo) “I was very angry at myself. No one has more power over my body than me, and no one will bear the consequences but me”. (Kyle)
	Rigid athletic identities and inflexible thinking linked to languishing	“It just feels like everything’s gone wrong(…)I can’t just walk away from it because I’ve put too much time into the sport”. (Scott) “Things happen for a reason, I guess, and I’ve just yet to work out what that reason’s going to be(…)I’ve said this to a lot of people when I’ve been chatting about how sad I am”. (Saira) “(…)it was very turbulent, I’d lost all my bearings in terms of I wasn’t an athlete anymore, I wasn’t playing football, I wasn’t getting my fix from any exercises”. (Kyle)
	Exploring new identities and flexible thinking linked to flourishing	“Just giving back was so great(…)seeing other people succeeding”. (Aisha)
	Flexible thinking skills linked to adaptive health behaviour	“It’s actually made me think about long-term health, which I never really thought about before”. (Omar) “It just gave me a bit of perspective about not abusing my body and not leaving it up to chance”. (Kyle)
Making sense of my emotions	Difficulties regulating negative thoughts and feelings	“I was just so worried(…)it was constantly going through my head, and it was sending me overboard”. (Zara) “(…)it was just stress, disappointment and frustration(…)” (Adam) “When you put our heart and soul into something, and it keeps coming to a dead end, it’s really frustrating”. (Aisha)
	Pain, inactivity and social withdrawal encourage rumination	“I ended up thinking about it the whole time and I think the reason it was like quite bad mentally is just because it was constantly painful”. (Lina) “I needed some way to fill that time and you know maybe overthinking or maybe like digging myself in that hole was just sort of there(…)It (the injury))was the key in the ignition”. (Nathan) “(…)it was just me and my thoughts. I think that just yeah made me so much more sad”. (Saira)
	Acceptance strategies reduce distress	“(…)times that I’ve been feeling extremely down or extremely low, I would write in the diary just to sort of release my emotions”. (Eva) “(writing helps me with))understanding like what I’m actually thinking”. (Flora)
	Reappraisal strategies reduce distress	“It would be a case of, ‘you know what, it (injury))is normal, it’s part of the sport”. (Adam) “I’ve been trying to think about the fact that I’m dedicating a lot of time to the gym and, you know, that’s never a bad thing. Like, I might come out of this stronger”. (Patrick) “(…)instead of tunnel vision, just open up and go that’s a minor part of my life, and that’s kind of how I deal with it”. (Liam)
Learning to look after myself	Parents’ first reactions to injury influence emotional responses.	“When your parents start to worry(…)you instantly worry as well”. (Simeon) “It wasn’t my fault, but something that I did had caused that (disappointment and guilt)”. (Adam) “So the first emotional thing that it’s really straining, that you have to call your mum and tell her that it’s happened again, and the disappointment in her voice is really bad”. (Eva)
	Injury prompts renewed dependence on parents, harming self-esteem	“I felt properly like a 5 year-old again(…)that was not so enjoyable”. (Saira) “I’m not dependent on them (my family))at all. And I found myself being really dependent on them(…)I was on the phone at any free moment just for that sense of security and normality”. (Tara)
	‘Toxic positivity’ leads to emotional suppression or frustration	“If I do tell them, they kind of, they see it from another point of view rather than like letting me tell them how it is(…)like points of improvement on it rather than just letting me say how it is”. (Scott) “(When my father told me not to worry about injury))that just really got under my skin, because that’s just such a bad thing to say”. (Will) My mum would always be like ‘Oh it looks better than it did’. I was thinking, ‘It’s just the same’. She was like ‘Oh the swelling’s gone down’. I’m like, ‘Well I don’t think it has’. (Darcy)
	Parent thwart or support autonomy leading to languishing or flourishing	“I kind of agreed because that’s what I was being told would be the best option, rather than I wanted to have surgery”. (Eva) “I just kept losing the plot every time he used to try to tell me to do something and I was trying to do it but my body wasn’t working the same way I wanted it to work”. (Scott)
		“My mum was…Always just checking in, and making sure that I am OK. I think the importance of talking to her was crucial, actually being able to speak about it…My dad also, because him being a runner, we talked heavily about the injury, and what it must be like. He was super-helpful for the rehab side of things” (Patrick)
	Injury is an opportunity to reset parent–child relationship boundaries	“…it was almost like I was trying to push away the support that I was getting but I had to try and push away the support for the greater good. So that was a very difficult. (Mo) “They progressively got more helpful as they started to realise and listen(… there was)a lot of pressure which I’ve spoken to them about and they have since apologised”. (Mo) “…when I’ve been feeling low, because she’s sort of had to be there like, she’d sleep next, like on the bed bedside me in case during the night I needed help to go to the toilet or anything. So I think, because of that forced proximity almost, I’ve sort of opened up to her more about how I was feeling”. (Eva)
Accepting peer judgement and support	Peer perceptions of weakness or vulnerability cause frustration.	I was on crutches(…)and all anyone would say to me to start conversations is, ‘What have you done to your leg?’ which was quite tough”. (Flynn) “(…)most people react with a bit of pity…so that’s really tough”. (Kyle)
	Fear of negative peer evaluation leads to social withdrawal.	““Normally when I’m in a social scenario I’m actually quite comfortable. With this injury I didn’t want anyone to look at me(…)I wanted to fly under the radar”. (Kyle)
	Exclusion from teams and affinity groups linked to languishing	“Once you’re out, you’re kind of forgotten about(…)they kind of moved on and I like lost quite a lot of good friendships through it”. (Flora) “It was definitely like one of the saddest points(…)in my lectures as well, because everyone does sport in my lectures, sort of groups had formed already purely from people knowing each other from preseason” (Simeon)
	Concealing injury to maintain peer acceptance linked to languishing.	I didn’t want to be boring fresher just because I was in pain(… but injury)knocked my mood, my confidence, my motivation”. (Tara) “I started to lose the impression I was giving the other girls, which also massively bothered me(…)I was so keen to impress, because that is literally what being a fresher is about”. (Tara)
	Peer empathy linked to flourishing	“We supported each other and we both laughed about it(…)trying not to get ourselves down”. (Darcy)
Adapting to the system	Diagnostic uncertainty linked to helplessness and frustration.	“I had absolutely no idea what to think about it”. (Omar) “(…)a real experience of ‘I have no idea what’s going on’(…)a lot of it wasn’t properly explained to me(…)being really uncertain about an injury doesn’t help, especially when it’s going on so long”. (Saira)
	Knowledge and certainty about injury supports reappraisal	“Seeing other people and their recovery, I think it did help”. (Imogen) “I completely just told them exactly why I couldn’t run and just start playing again, because I feel more confident in like I know what’s going on”. (Vicki)
	Cultural pressure to conceal pain or distress prevents help-seeking.	“I didn’t want anyone to know(…)Which looking back on it now like obviously I shouldn’t really have any shame in it(…)It’s quite hard in that environment, especially for someone who’s quite young to it and quite new to it, still to be able to stand up and be like ‘Look, I’m actually struggling a little bit here’”. (Brett)
	Perceived institutional neglect linked to languishing	“I lost a bit of faith in the Uni(…)It was pretty obvious (the coach))didn’t care about anyone who wasn’t in the squad(…)which was annoying, it was definitely annoying”. (Kyle) “I ended up messaging the coach at the time and I said it would be good to have a chat and he didn’t reply(…)I think him not really caring and me not training well(…)the lack of support from any angle was just like I just, I think I had the attitude oh no one’s going to support me, why would I support myself”. (Tara)
	Rehabilitation plans support reappraisal and linked to flourishing	“I got, I’d say, more and more positive. It felt good knowing that I was getting some help”. (Simeon) “It gave me a lot of control back(…)that was probably the most effective thing at improving my mental health”. (Kyle)

N.B.: all participant names (presented in brackets) are pseudonyms.

Theme 1: finding my inner strength

This theme describes how injury influences the adolescent process of identity development, prompting negative emotions and behaviour, but also adaptive responses. Strong athletic identities, sometimes incorporating future performance careers, were evident in all participants. Youth and fitness encouraged feelings of invulnerability until the shock of injury. Eva admitted that “I always had this thought that, ‘Oh, it could never happen to me’”. Mo found that making sense of his new, more vulnerable self by reflecting on past risk behaviours prompted anger and self-blame: “I took a lot out on myself for getting injured. Because I knew I shouldn’t have got injured, I should have taken a break”. Initially, some participants struggled to reconcile their current self with their previous athletic identity. Cassie found the process “depressing” while Brett (injured) wanted “the old me back”. Aisha could not accept her limitation and continued to train through pain: “I’m not doing it because I want to hurt myself. It’s just, that’s just me, I guess”. Kyle (injured), who had just started University after being a popular player at school, experienced disruption in his self-identity, with negative mental health consequences:

I felt like quite a significant change in my personality, breeding into a bit of an identity crisis… stuff’s happening too fast, I don’t really recognise myself…

For Kate (injured), injury was ‘a humbling experience’. To protect her athletic identity, she projected self-sufficiency, despite pain and incapacity. In her reality, physical and psychological strength were intertwined because “sport…has actually framed my whole life and is the reason I’m so strong…so resilient”. Her approach prevented help-seeking. “I don’t want to worry anyone…But I think some days if I’m having like a really down day then I do feel alone”. By contrast, participants’ success at re-forming identities, which appeared dependent on available support and cognitive flexibility, had consequences for mental health. Some explored alternative sporting roles, notably coaching. Aisha (injured) was positive: “…just giving back was such, was so great. Like just seeing other people like succeeding”. But Cassie found “…it’s really stressful to coach, because…if I would have been in place I would have hit that shot”. Scott (injured), who swapped sport for partying and alcohol until friends intervened, struggled to adapt his plans, harming his mental health:

It just feels like everything’s gone wrong…I can’t…just walk away from it because I’ve put too much of my time and everything into the sport…even though 90% of my brain is saying it’s not going to get any better.

Adam, 6 months postinjury, appeared willing to adapt to an alternative future: “.that’s definitely something I’m starting to think about more and more…If [sport] didn’t exist, what would I be doing?” Simeon had learned to accept his vulnerability “It’s actually made me think about long-term health, which I never really thought about before”.

Theme 2: making sense of my emotions

This theme captures how developing cognitive and emotional regulation skills were linked to mental health during injury. Participants experienced overwhelming feelings, sometimes because of disruption to non-sport lives. Zara, new to university, experienced ‘going into a full-blown panic’ with physical symptoms including shaking and hyperventilating immediately postinjury. She struggled to regulate her emotions, staying in her room with noise-cancelling headphones. Mental exhaustion led to sleeping more, eating less and finally going home to recover:

I was just so worried because I was like, ‘What have I done?’ That was just constantly going through my head, and it was just sending me overboard.

In Lina’s mind, undiagnosed knee pain before exams was a serious injury, increasing her distress. “I’d like catastrophise it…I think the reason it was like quite bad mentally is just because it was constantly painful”. Hearing her physiotherapist’s explanation of how stress can amplify pain improved both symptoms. Some noted lowered well-being early in their injury, because they could not use sport to cope with daily stresses. In Nathan’s (injured) experience, physical inactivity created space for negative feelings and thoughts: “I needed some way to fill that time and you know maybe overthinking or maybe like digging myself in that hole was just sort of there… It [injury] was the key in the ignition”. After periods of negative thinking, some participants reframed time off sport as neutral or positive. Liam (injured) constructed a reality where friends and study assumed equal importance with sport: “…instead of tunnel vision, just open up and go, ‘that’s a minor part of my life,’ and that’s kind of how I deal with it”. Flynn (injured) knew injury was a chance to broaden his interests and friendship groups, but commitment to his team conflicted with the flexibility required to explore and adapt. Some felt mindfulness meditations and journalling helped them achieve emotional acceptance of injury. Eva (injured) described how keeping a diary would ‘release my emotions’, while Flora (injured) experienced writing as a way of ‘understanding, like, what I’m actually thinking’.

Theme 3: learning to look after myself

This theme describes how adolescent athletes’ growing need for emotional autonomy and independence can be thwarted or enhanced by parental responses during injury, with consequences for mental health. Initially, some felt their emotional response to injury was influenced by parental reactions. Simeon found his parents’ anxiety infectious: “When your parents start to worry about something, you instantly, you know, worry as well”. Others were frustrated when they perceived parental attempts to comfort as invalidating or insincere. Scott felt his parents were ‘mocking’ him with optimism about his recovery and ignoring his distress:

If I do tell them, they kind of, they see it from another point of view rather than like letting me tell them how it is…like points of improvement on it rather than just letting me say how it is.

Injury forced Tara, also new to university, to become reliant again on her parents’ emotional support: “I found myself being really dependent on them…I was on the phone at any free moment just for that sense of security”. Early on during injury, some felt relief at going home to be cared for, especially towards the end of a tiring term. Others felt frustration and low self-esteem. In Saira’s (injured) experience, she was infantilised by relying on parents to wash and dress her: “I felt properly like a five year-old again…that was not so enjoyable”. Loss of volition was felt when parents—typically fathers—exerted control over treatment and rehabilitation. Zara felt frustrated on being ‘bombarded’ by rehabilitation exercise videos. Eva (aged 16) felt panic and fear on the morning of an operation to which she felt she had not consented. By contrast, Patrick felt supported and motivated by his father, an experienced runner, who listened without judgement and offered informed advice. Participants described how parent-child relationships could be redefined by injury, with consequences for long-term mental health. Eva became closer to her care-giving mother during rehabilitation, while losing a bond with her coach-father, to whom she was only “close because of sport”. Mo (injured), whose parents pressured him to compete with pain, experienced injury as “stirring my emotions with my parents” and as a chance to reset relationship boundaries: “They progressively got more helpful as they started to realise and listen…[There was] a lot of pressure which I’ve spoken to them about and they have since apologised”.

Theme 4: accepting peer judgement and support

This theme describes how peer evaluations and the presence or absence of peer support during injury and return to sport impacted self-esteem, and prompted social withdrawal, a mental health risk factor. Concerns about how peers judged postinjury appearance and capabilities were common. Flynn, new to university, felt frustrated at being perceived as vulnerable: “I was on crutches…and all anyone would say to me to start conversations is, ‘What have you done to your leg?’ which was quite tough”. In Kyle’s reality, peer pity undermined the strong image he wanted to project, leading him to withdraw socially: “…with this injury I didn’t want anyone to look at me…I wanted to fly under the radar”. Participants who identified with a club, or a social group based on shared athletic values, felt “disconnected” after injury. Flora felt excluded after missing out on a tour: “Once you’re out you’re kind of forgotten about…they kind of moved on and I like lost quite a lot of good friendships through it”. Simeon missed university trials through injury, and, like Flora, experienced low mood as a consequence of feeling excluded even in non-sport settings:

It was definitely like one of the saddest points…in my lectures as well, because everyone does sport in my lectures, sort of groups had formed already purely from people knowing each other from preseason

For Tara, team selection and peer acceptance were important enough for her to conceal injury in her first weeks at university. Pain became a barrier to normal social functioning: “I started to lose the impression I was giving the other girls, which also massively bothered me…I was so keen to impress, because that is literally what being a fresher is about”. She described breaking down mentally and going home. But empathy and informed support from peers and team-mates were positive for mood, self-esteem and motivation. Darcy and her friend had the same injury: “We supported each other and we both laughed about it…trying not to get ourselves down about it”. Some participants found rehabilitating with peers fostered motivation and acceptance. For Lina, it was “quite a big factor about how I felt”. When Nathan returned to sport, a team-mate noticed his mood and energy were still low: “…he could just tell, and he’d say ‘Yeah, tomorrow, coffee, we’re chatting about this’”. In Nathan’s reality, sincere social support boosted his self-esteem.

Theme 5: adapting to the system

This theme describes how support offered, and expectations communicated, by organisations and cultures impacted adolescent mental health during injury. For some, the early stages involved long waits for clinical appointments, undiagnosed pain and misdiagnoses, leading to frustration and helplessness. Omar received conflicting diagnoses and had “absolutely no idea what to think about it”. For Saira, this stage was “…a real experience of ‘I have no idea what’s going on’…a lot of it wasn’t properly explained to me…being really uncertain about an injury doesn’t help, especially when it’s going on so long”. Imogen (injured) found relief from confusion and disempowerment by researching injury trajectories online: “Seeing other people and their recovery, I think it did help”. Some participants experienced sport-cultural pressure to ignore injury and its mental health consequences. In Vicki’s (injured) reality, a formal diagnosis felt “validating”, giving her confidence to rebut pressure to “harden up”. She said: “To start with [the teasing] would upset me because [the injury] was very fresh,” adding that “I completely just told them exactly why I couldn’t run and just start playing again, because I feel more confident in like I know what’s going on”. Brett (injured) feared revealing his powerful feelings of wanting to “go into my shell and then want to like explode” to his professional club. In his reality, a robust persona was important in its culture of “toxic masculinity”, yet he blamed himself for not seeking help:

I didn’t want anyone to know…Which looking back on it now like obviously I shouldn’t really have any shame in it…It’s quite hard in that environment, especially for someone who’s quite young to it and quite new to it, still to be able to stand up and be like ‘Look, I’m actually struggling a little bit here’.

Other participants felt adapted training sessions, spectating and coaching opportunities organised by their clubs helped them feel valued and socially connected, supporting positive self-esteem. For example, Darcy maintained connections with team-mates through a players’ coffee club organised for her by her coach. Simeon’s mood improved after finding a physiotherapist and making rehabilitation plans: “I got, I’d say, more and more positive. It felt good knowing that I was getting some help”. Kyle’s rehabilitation plan gave him goals, and hope, for return-to-sport: “It gave me a lot of control back, a lot of good feeling in my body…that was probably the most effective thing at improving my mental health”.

Discussion

This study explored adolescents’ fluctuating mental health during injury, emphasising developmental, social, environmental and sport-cultural factors. Five themes illustrated how sports injury intersected with identity formation, cognitive-emotion regulation, parent-athlete relationships, peer relationships and organisational-cultural systems. These appeared to interact with one another (eg, personal identity disruption and coaching opportunities; parent-athlete relationships and the presence or absence of adaptive coping skills) to impact affect (eg, confusion, anger, hope); cognitive appraisals (eg, perceived autonomy and self-esteem) and behaviour (eg, concealing injury, developing new interests). These, in turn, influenced languishing and flourishing during injury. While these are not universal mechanisms, and some participants experienced these processes differently during injury, the findings suggest new research directions by linking mental health outcomes of injury with developmental factors rather than specific injury phases. Results also indicate how injury-related mental health could be supported by psychological skills and mental health awareness targeting novel factors including life transitions and emotional invalidation or ‘toxic positivity’.

Personal identity

Injury challenged personal identity development, a key task of adolescence.³⁰ Negative self-evaluations after injury-risk behaviour, rigid athletic identities and inflexible thinking prompted maladaptive behaviours including social withdrawal, playing through pain and avoiding help-seeking. These results align with evidence that stronger athletic identity is linked with increased risk of postinjury depression.³¹ Later, some participants struggled to reconstruct postinjury identities, demonstrating cognitive inflexibility typical of this developmental phase, with negative consequences for mental health.³² By contrast, and extending evidence from SIRG literature,²³ opportunities to explore new activities such as coaching, combined with flexible thinking skills, enabled others to explore new roles, adaptive health behaviours and alternative futures, with potential for long-term flourishing.

Cognitive-emotional regulation

Injury prompted fear and anxiety, accompanied by maladaptive regulation strategies, including rumination and social withdrawal, which appeared have a bidirectional link. Unexplained pain, and loss of sport as a distraction, appeared to amplify rumination. These strong cognitive-emotional responses are characteristic of a developmental stage when internal regulation skills remain limited but external family support becomes less valued.^{33 34} Poor regulation strategies were linked with low mood, aligning with evidence from adolescent psychology.³⁵ Reappraising injury as an opportunity to explore new interests and social groups appeared dependent on cognitive flexibility, a skill which develops during adolescence and is supportive of adaptive problem-solving and mental health.³⁶ Reflective and acceptance-based techniques were helpful for reducing distress and reappraising injury experiences as opportunities, underlining the value of these practices for supporting mental health in adolescent sport contexts.³⁷

Autonomy and choice

Injury disrupted physical and emotional separation from parents, another developmental task. Some participants described lack of choice in treatment and rehabilitation, leading to frustration and fear. Parents’ controlling behaviour can exacerbate adolescent distress after injury,³⁸ but here adolescents experienced a wider loss of autonomy, which, aligning with basic psychological needs theory (BPNT), was linked to languishing mental health.³⁹ Some felt infantilised by renewed dependence on parents. Others described emotional invalidation from pressures to conform to recovery expectations: the negative emotional consequences of ‘toxic positivity’ may have implications for practice. By contrast, neutral advice supporting independent decision-making promoted mental flourishing. Later, injury was an opportunity for adolescents to reset parent–child relationship boundaries, emphasising the need for support rather than over-protection. Mental health awareness was required for these conversations to have positive outcomes, indicating a potential intervention target.

Peer evaluation and support

Injured athletes were sensitive to being perceived as vulnerable or incapable by sport and social peers, especially during life transitions such as changing clubs or moving to university. They employed maladaptive emotional regulation strategies to cope with frustration and low self-esteem, including social withdrawal and disguising injury by playing through pain. Postinjury social exclusion, a key determinant of athlete mental health,⁴⁰ was evident in club settings, supporting existing quantitative research.⁴¹ Participants also reported exclusion from sport-based social groups during life transitions, extending the evidence base. In line with BPNT,³⁹ training with injured peers or socialising with team-mates promoted relatedness and mental flourishing, emphasising the importance of social support for injury-related mental health.

Organisations and cultures

Navigating health systems and sport cultures while injured posed challenges for adolescent athletes. Many experienced diagnostic uncertainty, which was associated with emotional distress including helplessness and frustration.⁴² Undiagnosed injury exposed participants to sociocultural pressure, normalised in some sports, to play through pain and conceal associated mental health problems.⁴³ Without a diagnosis, adolescents lacked self-efficacy to confront cultural norms and make independent decisions about their symptoms, leading to shame and preventing adaptive help-seeking. Support for such conversations could be a novel intervention target, in combination with psychologically-informed environments. Empathetic coaches and clear rehabilitation plans supported relatedness, autonomy and competence, promoting mental flourishing, aligned with BPNT.³⁹

Implications for research and practice

Our findings have implications for research and for practitioners who support adolescent athletes. Evidence of dynamic mental health during the injury course, linked to both developmental and social, environmental and sport-cultural factors, points to longitudinal qualitative studies using multiple interviews or ecological momentary assessment to examine how factors interact over time, rather than relying on cross-sectional studies of factors and psychological responses.^{20 44 45} Studies could include long-term follow-up to explore outcomes among athletes who struggle to reconstruct personal identity, an important predictor of adult mental ill health.⁴⁶ Drawing on the IMPRSI,²⁸ findings could inform a developmentally and contextually grounded model of injury-related mental health.

Upskilling adolescents with cognitive flexibility through narrative thinking interventions and acceptance-based training has the potential to support cognitive-emotional regulation and identity reconstruction postinjury. Peer support groups could encourage injured athletes to share experiences and avoid social exclusion, promoting mental health flourishing. For practitioners, developing psychological skills and mental health awareness to support adolescents during life transitions or to manage adults’ emotional invalidation in relation to injury and its consequences could improve outcomes.

Embedding mental health literacy and injury follow-up procedures in clubs and medical teams could address diagnostic uncertainty and prevent sport disengagement. By addressing these gaps, researchers and practitioners can support injury-related mental health during a critical developmental period, promoting sport participation and long-term health.

Study limitations

This study used a novel temporal approach to explore dynamic mental health, employing timelining to support recollections, but interviews at multiple timepoints would more accurately capture fluctuating mental health during injury. We interviewed a large, diverse UK sample during injury from a variety of sport backgrounds, supporting a comprehensive understanding of relevant factors, but our pragmatic sampling strategy may have excluded adolescents whose mental health prevented them from volunteering. Time since injury may influence recollections, but we did not record the date of injury; only that it happened less than 6 months prior to volunteering.

Conclusions

Adolescents’ mental health can move between flourishing and languishing while injured. Fluctuations were related to key developmental factors and their interaction with social, environmental and sport-cultural factors. Injury impacted personal identity formation, challenged cognitive-emotional regulation skills, tested relationships with parents, elicited peer judgement and introduced adolescents to the task of navigating complex and challenging systems and cultures. Adaptive and maladaptive emotional, cognitive and behavioural responses impacted mood and self-esteem. Individual cognitive flexibility and mental health awareness at interpersonal and organisational levels appeared positive for mental health and should be addressed with future research and practice.

Data availability statement

Data are available on reasonable request.