Hazardous Times

As a Septuagenarian, my view is that the World of 2023 poses daunting challenges for adults. To start with, 3 years of COVID brought several aspects of life to a halt and changed daily habits for good. Working from home is now commonplace, and I am not sure if we will ever be allowed in healthcare facilities again without a mask. Vaccines and boosters will continue to be central to annual healthcare maintenance.

As the burden of COVID began to ease in early 2022, the shock of Russia’s brutal invasion of Ukraine reminded us of the horrors of world war that our parents and grandparents experienced in the 20th century. For most of us, it is hard to imagine the horrible conditions imposed upon the Ukrainians.

The war and several related factors have spiked inflation and set the American economy on an uncertain path, making life much more difficult for many. Complicating discussions of all these current issues are our partisan politics, which stress relationships.

In a proper world order, kids rely on adults to add stability to their lives. First and foremost, parents and extended family, but also teachers and coaches, can help support, guide, and calm shaky psyches. Unfortunately, when the adult mentors in children’s lives are themselves stressed, kids can sense the unease, making their world much more challenging. Add to their environment the perturbations of the Internet and social media, and I can see why the kids of today are growing up in a much more hazardous environment.

Consider for instance, the ‘National Crisis’ of Gen Z (those born between 1997 and 2012), described as an aura of extraordinarily high rates of anxiety, depression, self-harm, suicide, and fragility. Jonathan Haidt attributes this crisis to a Culture of Victimhood and social media. ⁷ His research clearly shows that rates of depression began to rise in 2013, especially in teenage girls. Interestingly, that was the year Facebook acquired Instagram and teenagers flocked to that site. ⁷ The world has changed dramatically for the youth of today over the last 10 years, and it has not been solely for the better. Today’s youth have been warned about the detrimental side of social media and I am certain a significant percentage recognize its negatives and addictive capacity. Unfortunately, it is very difficult for them to escape. It is where their world and friends live. I think I have mentioned it before, but I will say it again because it is true: from about age 9 until around 14 my biggest worry in life was hitting a curveball when I got older. It was a simpler, safer world, even in Detroit in the 1950s and 1960s.

Because of this, there is no doubt that family life is increasingly critical to personal development, especially during childhood. Despite the challenges of today’s digital world, athletic activities can also provide an oasis for the struggling youngster. As children discover athletic activities, good coaches can provide the framework to develop physical and social skills and teamwork that helps build confident, resilient personalities. These attributes serve children well through both the tumult of their teenage years and later in life. From my personal viewpoint, athletic participation is an incredibly valuable component of mental and psychological development. Nothing in my estimation puts the future challenges of life in better perspective for kids than individual and team sports. Both forms of athletic participation can contribute significantly to personality and psychological development.

The flipside of this critical path in adolescent development that athletics provides is the risk of injury. Depending upon the mental maturity of the athlete, injuries can foster further psychological growth and development, or they can be devastating and defeating. Much depends on the injured athlete, but the treating clinician plays a critical role.

For the clinician seeing an injured young athlete for the first time in 2023, several factors are important to assess besides the details of the injured body part. Understanding the environment in which an athlete lives, their support structure, and where he or she sits on the psychological spectrum will go a long way toward understanding the athlete’s response to treatment and their potential for recovery. In 2023’s fast-paced, stress-filled world, evaluating, understanding, and treating the mental and physical components of musculoskeletal injury is crucial to achieving optimal outcomes in sports medicine. While much has been written about the physical parameters to evaluate after common sports injuries like anterior cruciate ligament (ACL) tears and concussions, our evaluation and understanding of the athlete’s psyche appears deficient.

Taking concussion as an example, a review by O’Connor et al ³ in this issue of Sports Health documents the concerns that Irish collegiate athletes have about concussion even before sustaining that injury. Women displayed more negative perceptions, and those who had already experienced a concussion downplayed the benefits of treatment, suggesting a loss of confidence in their medical care. This is a very concerning trend. A possible explanation for the loss of confidence may be the all-accessible Internet medical experts who often represent the fringes of medical care standards. Why listen to the old, traditional expert in the room when you can get the real, cutting-edge advice online? Those Irish collegiate athletes that lacked a clear understanding of the injury presented with the greatest degree of anxiety. To this day, identification of the injury and immediate removal from play has been the focus of educational efforts on concussion, leaving much room for improved educational efforts beyond the initial stages of diagnosis and treatment.

In a prospective cohort study also in this issue of Sports Health, Fish et al ² collected anxiety and depression data on 282 adolescents. Comparing 111 concussed athletes within 28 days of their injury with 171 nonconcussed athletes between the ages of 13 and 18 years, concussed athletes had above-average symptoms of anxiety and depression, demonstrating the compounding effect concussion has on today’s fragile youth.

Turning from the concussion setting to the ACL injury scenario again demonstrates the role of mental stability in surviving injury and treatment, even beyond the teenage years. In a cross-sectional study of 131 participants who had undergone ACL reconstruction at least 6 months previously, Tavares et al ⁶ found that the variables related to knee functional status and psychosocial factors were the predictors of quality of life. This is further concrete evidence that mental health is as important as achieving objective knee stability in the quest for good outcomes.

For athletes struggling through the rehabilitation demands of ACL reconstruction, the end goal is return to sports. Sports participation is a complex biopsychosocial activity, which requires a positive interaction between many factors, including physical, psychological, social, and functional performance. ¹ In a systematic review in this issue of Sports Health, de Queiroz et al ¹ emphasize the deficiencies of clinical practice guidelines in assessing the biopsychosocial model domain of return to sports after ACL injury. They promote the functionality mode advocated by the World Health Organization as a much more holistic approach to injury recovery.^4,5

Both ACL tears and concussions point to the need for a more complete approach to sports injury and treatment. For orthopaedic surgeons, and especially team physicians, this can be a daunting task. Certainly, residency training in surgery did not prepare us to adequately evaluate the psyche of injured athletes. Yet the success of our outcomes seems more and more dependent on our ability to evaluate and treat more than the musculoskeletal system. There are numerous tools available to improve our evaluation and treatment of injured athletes.^4,5 These tools can help us understand the youth of today and the environment in which many of them struggle.

Edward Wojtys, MD
Editor-in-Chief