# Motivation and emotion/Book/2023/Long-term injury in high performance field athletes and emotion

* Multimedia presentation (3 min)

## Overview

* Figure 1. ACL Diagram
* Case Study: Suzie, a 25-year-old professional netball player, suffered a severe knee injury during a championship match, jeopardizing her career. The injury necessitated surgery and a lengthy rehabilitation process. Suzie's journey through stages of shock, denial, anxiety, isolation, loss of identity, depression, frustration, and ultimately, resilience and recovery, highlights the profound impact of injuries on an athlete's mental health.
* This case emphasizes the critical need to provide athletes with access to mental health resources, strong support systems, and coping strategies tailored to injury-related challenges. Just as physical rehabilitation is essential, nurturing an athlete's mental well-being is equally vital for their overall recovery and future success.
From January 2022 to August 2023, over 200 professional female soccer players [where?] experienced a concerning trend—ACL tears (see Figure 1). This injury typically entails a 9 to 16-month hiatus from physical activity. These high-level athletes, excelling in their sport's top tiers, now embark on a challenging path to recovery. Recent studies explore the link between mental well-being and injury vulnerability, indicating that an imbalanced mental state can increase susceptibility to injury (Xiao et al., 2022) And what about the other way around?.
As injuries rise among young athletes[factual?], it's crucial to conduct research on mental challenges that accompany prolonged injuries. By addressing these emotional hurdles and developing effective interventions, athletes can be guided toward a more resilient and psychologically sound recovery.
Athletes, when separated from their sport, may experience physical and emotional effects. Anxiety and depression can emerge as they grapple with a shifting identity closely tied to athletic performance, complicating their rehabilitation process. During this period, athletes contend with various internal emotional struggles[factual?]. Noteworthy theories, including the Kubler-Ross model, Social Identity Theory, and Attribution Theory, can aid our understanding and support of their experiences.
Female athletes demonstrate a heightened susceptibility to injuries, as revealed by a study conducted by Lopez Vakenciano et al., see figure 2 What about gender differences in the emotional impacts of sporting injuries?.
Thanks to advancements in technology and medicine:
* 90% of athletes who undergo rehabilitation are able to regain normal function
* 63% of these athletes manage to return to their pre-injury performance levels
* 44% make it back to competitive play (Ardern et al., 2011).
These statistics highlight that factors beyond purely physical aspects of recovery play a significant role in achieving a successful return to sport[how?].

## Reactions to injury - behavioural and emotional responses

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### Isolation and social

In the world of athletics, injuries go beyond physical health, affecting an athlete's emotional well-being. When sidelined by injury, athletes often experience isolation and social challenges.[factual?]
This isolation extends beyond the physical realm. While teammates continue competing, injured athletes are left on the sidelines, no longer part of the team's collective pursuit. This can lead to feelings of loneliness, as they are detached from camaraderie and shared goals that once bound them (Eather et al., 2023).
Professional athletes face isolation, separated not only from teammates but also from coaches, support staff, and the sports community that shaped their identity. Support systems that once fuelled their excellence become distant as they recover.
The impact also ripples through the broader community. Fans may shift focus to newer athletes, creating a sense of replacement or being forgotten. The athlete's absence from the field deprives the community of inspiration (Siegmund et al., 2021).

### Depression

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* Depression's impact: Depression significantly affects athletes recovering from severe injuries, affecting both physical and mental health.[factual?]
* Complex factors: Depression arises from a complex interplay of factors, including physical pain, emotional distress, and limited activities, impacting an athlete's mental well-being.[factual?]
* Persistent pain: Ongoing physical pain, combined with emotional distress, fosters a constant negative mindset that hinders motivation.[factual?]
* Loss of enjoyment: The absence of cherished activities amplifies emotional turmoil as familiar coping methods disappear.[factual?]
* Emotional well-being: In sports, where excellence is paramount, injury-induced limitations can unravel an athlete's emotional well-being (Appaneal et al., 2009).
* Multifaceted recovery: Overcoming injury-related depression requires a multifaceted approach, including a strong support network from coaches to mental health professionals.[factual?]
* Further information: For more insights into depression in athletes, refer to the dedicated chapter on Depression in athletes.

### Loss of identity

Professional athletes have intertwined lives with their sports, where their identity and purpose revolve around their success in their chosen field. However, when injury strikes, it unleashes emotions and profound disorientation.[factual?]
For athletes, their sport serves as the cornerstone of their daily existence, guiding their actions and choices. The intrusion of injury disrupts this foundation, leaving them in a state of uncertainty. Losing their accustomed routine can lead to confusion as they grapple with navigating a life temporarily removed from their well-known path (Pinalto, 2020).
Athletes thrive on structure, adhering to schedules that dictate their training, competition, and recovery[factual?]. When injury forces them away from this structured world, it disrupts their daily activities, creating a void where their athletic pursuits once thrived. The comfort of their routines is replaced by disorientation, intensifying challenges of transitioning to a life where the routine they had mastered is suddenly halted (Renton, Petersen, & Kennedy, 2021).
This profound shift in identity can evoke a range of emotions, from frustration to existential doubt[factual?]. Athletes, accustomed to pushing physical boundaries, now find themselves navigating uncharted psychological territory. The process of redefining themselves beyond the confines of sport can be both daunting and liberating, demanding reflection, support, and a willingness to explore new avenues of self-expression.[factual?]
* Reflection Questions
* What gives you a sense of identity?
* How would it make you feel if you were unable to have that?

### Fear and anxiety

* Case Study:
* After spraining her wrist during a rock climbing fall, Claire struggled to shake off the fear. Every time she reached for a hold, an image of her injury flashed in her mind, causing hesitation and anxiety. The fear of re-injury started affecting her performance, making her doubt her abilities and hold back during climbs.
In the wake of serious injuries, athletes wrestle with a shadow of fear and anxiety. Their minds become entwined with concerns about regaining professional status and the looming threat of reinjury.[factual?]
Severe injuries unleash a surge of worry that extends beyond physical healing. Athletes, deeply linked to their sport, confront an unsettling fear of the unknown, questioning if they can regain their peak performance (Hsu, et al, 2016).
Anxiety stemming from the dread of re-injury further complicates recovery. The spectrum of setbacks and physical vulnerability can weigh heavily.[factual?]
Navigating this demands a nuanced approach. Balancing caution with resilience is key. Athletes must nurture their mental well-being with strategies fostering confidence, resilience, and calculated risk-taking. Professional guidance from psychologists and medical experts is vital in reducing the anxiety's barriers.[factual?]
Stepping back into sport requires a balance between fear and courage. Athletes must move past anxiety, embracing vulnerability and challenges.
* Reflection Questions
* What are you most afraid of when you are playing sport?
* What techniques do you use to ease your anxiety and fear?

### Motivation to continue

* Fun Fact about Motivation
* The concept of "rallying" in tennis, particularly in doubles, involves a team's ability to motivate and uplift each other during challenging moments. This psychological support can significantly impact their performance and momentum on the court. Explain how this relates to the topic
Sustaining motivation throughout the rehabilitation journey can prove challenging, especially if progress is slow. This challenge intensifies when individuals grapple with a prolonged timeline. Adapting to a new schedule is particularly taxing for those accustomed to routines, a hallmark of athletes.[factual?]
Athletes must summon unwavering motivation to beat the hurdles of recovery otherwise there is a change of stagnation. Navigating this intricate path demands perseverance, as each step toward healing is a small victory. The struggle to maintain motivation is a formidable challenge, yet it's also an opportunity for athletes to explore their inner reserves of resilience and determination (Jacob & Jose, 2021).
Redefining success within the context of rehabilitation, rather than a process to return to prior abilities, can infuse purpose into the journey. Breaking down each milestone, celebrating minor triumphs, and acknowledging progress no matter how modest can be powerful sources of motivation[factual?]. A support network including medical professionals, coaches, teammates, and loved ones can provide the encouragement needed[factual?].
* Reflection Questions
* What motivates you to push your boundaries?
* Is there a relationship between motivation and success in sport?
* Tailor these questions more specifically to the topic

### Post traumatic growth

Amidst the emotions that accompany a long term injury, there exists a potential for a positive transformation, exemplified by post-traumatic growth (PTG). Athletes can emerge from adversity with emotional resilience and an expanded perspective.
Athletes, confronted by the challenge, demonstrate a resolute spirit that pushes personal growth. This resilience becomes a testament to their inner strength, highlighting a new field of coping skills previously unexplored. In climbing the obstacles, they forge an unwavering belief in their ability to overcome adversity (Kampman, 2020).
PTG extends beyond the confines of the playing field. As athletes navigate the aftermath of injury, they uncover new areas of their character, embracing newfound dimensions of selfhood and strength. The progress of recovery, though rife with challenges, can become a new space for athletes to become more resilient, adaptable, and insightful individuals.[factual?]

## Theories associated with the removal from sport

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### The Kubler-Ross model

When athletes find themselves being removed from a sport they love, it often becomes an emotional experience that can be paralleled with the stages of grief[factual?]. Although it may not equate to losing a loved one, the emotional process resembles grieving a cherished part of life and a way of living.
Dr. Elizabeth Kubler-Ross introduced a model in 1969 (see Figure 3) that outlines the psychological stages of grief.
The five stages are denial, anger, bargaining, depression, and acceptance.
Denial serves as a common defence mechanism, offering a shield against reality. Individuals may resist acknowledging their new circumstances and exhibit a lack of comprehension. The stage of anger might manifest as the person blames others for their situation, which could include coaches, teammates, or loved ones. Recognising anger as a natural response can facilitate a better progression through this phase (Smaldone,2013).
Bargaining involves attempts to regain control over the situation. These efforts may be both rational and irrational thoughts, as the athlete strives to alter the outcome. This stage is marked by a new desire to influence the chain of events. The beginning of depression signifies the inevitable confrontation with reality. Having shielded themselves from pain in the previous stages, athletes may now face the raw reality of their circumstances.
Acceptance signifies a moment of embracing the truth about the injury and its prognosis. Athletes utilise this phase to create a plan and come to terms [missing something?]. It is advisable for athletes to spend quality time with their loved ones during this period, drawing strength from their support and connection.[factual?]

### Self-determination theory

The Self-Determination Theory (SDT) is applied across various domains such as sports, health, and education, serving as a cornerstone of motivation theory. Motivation, the force behind goal-directed behaviour's[grammar?] holds significant relevance within the sports industry. SDT accentuates three fundamental psychological needs: Autonomy, Competence, and Relatedness (see Figure 4). When an individual's support system aligns with these needs, motivation is heightened, enabling the pursuit of goals, whether in sports or other realms (Standage, 2020).
Autonomy encompasses the sense of choice and influence over outcomes. Athletes grappling with enforced rest due to injuries may encounter challenges in asserting autonomy, as their ability to control initial stages is limited. This challenge can be reduced by adopting fresh perspectives on the injury, such as redirecting focus towards strengthening unexplored areas of the body.
Competence pertains to one's perceived effectiveness within their chosen sport or skill. Establishing a strong sense of competence fuels motivation. Athletes who feel comfortable in their abilities are more inclined to persist and strive for excellence.
Relatedness extends its influence to various facets of one's detachment from a situation. It encompasses the need for meaningful connections and a sense of belonging. This connection can be forged with fellow athletes, staff, and family members.
The SDT serves as a dynamic framework applied across different sectors, underpinning motivation theory. By addressing the psychological needs of autonomy, competence, and relatedness, SDT enhances motivation, propelling individuals toward achieving their goals.

### Social identity theory

Social Identity Theory (SIT) is a psychological concept that delves into how an individual's sense of self and their membership within a particular group intertwine, shaping their perceptions of others. It can be viewed as an individual's self-concept formed through their affiliation with a group. For instance, in the case of professional athletes, this might relate to how the fans of their team perceive them.
Originally formulated by Henri Tajfel and John Turner in the 1970s, SIT explains how people naturally classify themselves and others into various social groups based on shared attributes like race, gender, nationality, or religion. This theory proposes that a person's self-esteem and identity are linked to the groups they identify with (Rees, Alexander Haslam, Coffee, & Lavallee, 2015).
In the realm of professional athletes, SIT provides valuable insights into the intricacies of how athletes form connections with their teams, and how this connection in turn shapes their behaviour, performance, and interactions. This theory, when applied to sports psychology, has a wide-ranging impact on various aspects.
The identities of athletes are intricately linked to the extent of their involvement and influence within their sport. Over time, this involvement moulds their emotional well-being, leading to the cultivation of a profound sense of belonging within their athletic sphere. This sense of belonging becomes a key driving force in their motivation and dedication.
It's important to emphasise that the support athletes receive from their teammates play a pivotal role in shaping athletes[grammar?] emotional state. Positive reinforcement from these quarters can significantly uplift an athlete's emotional well-being, thereby impacting their performance. Conversely, negative interactions, whether from fans or teammates, can have adverse effects on an athlete's emotional state, potentially disrupting their ability to perform at their best.[factual?]

### Attribution theory

Attribution theory, developed by Fritz Heider in 1958, explains how individuals interpret the causes behind their behaviour's[grammar?] in response to specific events. For example, an athlete may attribute their actions to factors like a long-term injury, which helps them justify their reactions and emotions in various situations. This theory focuses on how people, as social perceivers, create explanations for events by gathering information and using it to form judgments about a situation.[factual?]
The attribution model operates in both positive and negative contexts. In a positive context, an athlete might attribute their tournament success to factors like tradition or consistent performance, establishing a cause-and-effect relationship. Conversely, in a negative context, an athlete may attribute their injury to the absence of certain factors (Encyclopedia of Sport and Exercise Psychology, 2014).
This theory primarily examines two key components:
* 1. Locus of Control: This can be divided into internal factors (within an athlete's control) and external factors (beyond their control). The extent to which an athlete believes a result is influenced by specific factors affects their attributions.
* 2. Outcome: This refers to the ultimate result, whether it's success or failure. Attribution plays a crucial role in shaping athletes' expectations, providing a foundation for anticipating future outcomes based on these attributions.
* Attributions are highly significant in the world of athletics because they directly impact athletes' expectations. By attributing success or failure to particular factors, athletes gain insights into what to expect in the future.

### Achievement goal theory

Achievement Goal theory (AGT), based on Nicholls' 1984 developmental concepts, explores the evolving understanding among young individuals of the concept of ability as it gradually separates factors such as effort, task difficulty, and luck.
From a theoretical standpoint, achievement goals, specifically task versus ego involvement, within a given situation are shaped by a complex interplay between one's dispositional goal orientations at the intrapersonal level and the broader motivational context at the situational level, which is influenced by significant social factors such as coaches, parents, and peers (Harwood & Thrower, 2020).
AGT suggests that, during the pursuit of achievement-related tasks, individuals can experience fluctuations in their level of engagement with task-oriented or ego-oriented goals. In other words, they can be more or less focused on task achievement and self-image enhancement at different points during task engagement.
For instance, after an athlete successfully completes a critical step in their physical recovery, they may draw motivation from a psychological perspective, owing to their prior achievements. The connection between success and goals is fundamental in sustaining individuals' motivation levels.[factual?]

## Guidelines for Returning to Sport

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### Physical return

When returning to play (RTP), it is crucial to adopt a gradual approach, encompassing both a thorough physical and psychological RTP. On the physical side, athletes should engage in consultations with professionals. Even after an injury has healed, there might still be a risk of reinjury or other related issues. Once full medical clearance is granted, athletes should also undergo a psychological evaluation.[factual?]
Figure 6 demonstrates the recommended course of action following injury. From the time of the injury until receiving full medical and psychological clearance for RTP (Denegar, & Flanagan, 2009).
It is importance that athletes trust professionals, as this facilitates a smoother recovery process. This increases the likelihood that the athlete will listen to advice from the professionals and apply it to their RTP. During the recovery phase, athletes should maintain patience and understand that the RTP may require an extended period and may involve setbacks. Recognising that rest and recovery days are as essential as training days in preserving long-term health.[factual?]

### Psychological return

When athletes aim to return after recovering from an injury, the psychological aspect often becomes a challenge. Focusing on psychological readiness is critical because athletes may encounter numerous hurdles if they are not mentally prepared. These challenges may include motivation issues, self-doubt, quitting the sport, fear of re-injury (Ardern et al., 2014), concerns about future performance, anxiety, or even depression. Additionally, inadequate psychological readiness can increase the risk of further injury.
* To assess an athlete's psychological state for a successful return to play, two valuable tools are available:
* Re-injury Anxiety Inventory (RIA): This comprehensive assessment includes 28 items designed to gauge re-injury anxiety. It comprises two factors:
* Re-injury Anxieties Regarding Rehabilitation (RIA-R): This subset (15 items) assesses anxiety related to the rehabilitation process.
* Re-injury Anxieties Regarding Returning to Training/Competition (RIA-RE): The remaining 13 items focus on anxieties associated with returning to training and competitive play (Walker, Thatcher, & Lavallee, 2010).
* Injury-Psychological Readiness to Return to Sport Scale (IPRRS): This concise questionnaire consists of six items and uses a 100-point rating scale. Athletes rate their readiness to return to sport, with responses ranging from 0 (little to no confidence) to 100 (utmost confidence) (Scott, 2019).
Both of these assessment tools are useful for evaluating an athlete's psychological readiness to return to sport. They help identify and address anxieties or confidence issues that may affect the athlete's ability RTP

## Conclusion

It's essential to recognise that each individual athlete follows a unique path when recovering from a long-term injury. Transitioning away from sports for a professional athlete can be likened to leaving any job, career, or passion. There is a significant impact that an extended absence from sports can have, including isolation and social consequences, depression, loss of identity, fear, anxiety, motivation issues, and potential post-traumatic growth. These emotions that athletes experience after an injury can greatly affect their daily lives.
Adapting the motivational approach to align with the athlete's specific traits and situation is important. The integration of various psychological theories and methods, such as the Kubler-Ross model, Self-Determination Theory, Social Identity Theory, Attribution Theory, and Achievement Goal Theory, can influence the overall success of an athlete's return to play. Developing a personalised strategy can harvest optimal results.
The involvement of sports psychologists can play a pivotal role in providing guidance and support throughout the recovery process. This becomes especially crucial when an athlete is preparing to RTP after an extended absence. The athlete must be both mentally and physically prepared to ensure the best possible outcome.