Summarising current evidence-based strategies for recovery from injury, this article challenges mainstream views of risk/benefit in the pursuit of wellbeing through sport and exercise. Traditionally compartmentalised in (mainly physical, rehabilitative) specialities, the penny has dropped that contemporary holistic approaches to medical treatments for any adverse psychosocial life event may be selectively applied to sport and exercise injuries.
The frustration of setbacks through injury or disruption
Obstacles don’t have to stop you. If you run into a wall, don’t turn around and give up. Figure out how to climb it, go through it, or work around it.
Michael Jordan
From casual joggers through workout enthusiasts to elite athletes, most active people face detrimental setbacks that can negatively impact their psyche, and challenge their resilience.
The psychological impact of injury can be significant, and can include feelings of frustration, anger, anxiety, and depression. Additionally, those injured or otherwise prevented from pursuing their goals may struggle with a loss of identity, self-esteem, and social supports.
Both the magnitude of the stress response and sufferer’s appraisals of the situation may be influenced by the interplay between various psychosocial factors, which are divided into three broad categories: personality factors, history of stressors (including ‘daily hassles’), and coping resources(2.).
The work of coping
Undergirded by an honest self-inventory of one’s hardiness, sense of coherence, achievement motivation, sensation seeking, locus of control (internal vs. external motivation), and trait anxiety, many researchers highlight embracing setbacks as a major keystone for successful recovery.
On the other hand, denial and dogged perseverance- especially in overuse injuries (characterised by an often subtle, sporadic and gradual onset of symptoms)- can be counter-productive.
Self-help tips
Based on current theories (see appendix) and expert opinion, here are some important tips to help you deal with the mental struggle of getting back on your feet.
How’s your sleep?
Poor sleep has important implications including potentially impaired physiological and mental recovery, and an increased risk of complications.
Diarising frequency, duration and quality of sleep is a useful tool for monitoring your efforts to deal with setbacks and injury.
Name the feeling
The recovery process can be charged with emotional responses an athlete might not know how to manage. Research suggests that the simple act of labelling an emotion can discharge the potency of the feeling.
While there is a lack of agreement on predictable stages of emotional response to injury, there are many emotions that can be part of the recovery process including irritability, sadness, despair, frustration, powerlessness, anger, anxiety and even embarrassment.
Indeed, it may not be too far-fetched to keep in mind the five stages of grief (denial, anger, bargaining, depression, and acceptance). Recognising (some would say ‘honouring’) these feelings is the first step to managing them, owning them and moving through them.
Have a coping plan
Once named, develop strategies for coping with common negative feelings as they arise. This may involve identifying and addressing the ‘automatic’ thought patterns particular emotions trigger (more about ‘cognitive distortions’ later) or making a list of alternative tasks/goals to complete.
Thinking creatively, you can pursue new challenges to maintain a sense of purpose.
Importantly, make your plans specific (“implementation intentions”): instead of general intentions (“I intend to achieve Z”), step out your plan (“I intend to perform behaviour X when I encounter situation Y”).
Mental rehearsal, visualisation, and self-talk
When we imagine a past or future scenario, there is more going on than merely the visual component. There is a physiological component–we feel it in our body. Indeed, mental rehearsal has been found to activate the same neural networks as the action itself.
Ideally try to utilise multiple modes (visual, auditory, kinaesthetic (movement), and speech) in your rehearsals.
An accepted axiom of many self-care programs is that positive inner speech or dialogue (‘self-talk’) correlates with better outcomes. Preparing and repeating short word groups that act as positive cues (eg “tall and light”, “step by step” etc) features consistently in experts’ recommendations.
Focus on what you can rather than can’t do
A difficult part of dealing with a setback is staying focused. When you lose focus, don’t just give up!
Multitasking is seriously overrated. Try to do one task at a time and learn to do it with more purpose.
Gareth J. Mole, prominent sport & exercise psychologist
It’s all too easy to fall into a negative mind-set when you’re injured or your routine disrupted, however, it’s important to focus on what you can do rather than what you can’t. Depending on the nature of your injury, you may be able to maintain excellent cardiovascular fitness through low impact activities such as cycling, swimming and aqua jogging, or instead work on your core stability or flexibility.
Simple breathing techniques and various meditation practices can help you focus. Taking ten minutes out of your day to lay down and meditate can be extremely beneficial!
On the flipside, be aware of the strain of continual focussing. By allowing your attention to drift every now and then- notice sounds, smells, sensations, and objects in your peripheral vision- you can alleviate the pressure on your mind to maintain its focus on just one thing.
Work on your weaknesses
Periods of injury often present a fantastic opportunity to work on exercises that you tend to neglect. Again, just because you’re injured doesn’t mean that you can’t be active. Your workout simply needs to take other forms.
Look at the big picture
Although an injury or setback can seem like the end of the world, pause to remind yourself that in the grand scheme of things, this is rarely the case.
It’s not about reducing pressure it’s about building the capacity to embrace more.
Jonah Oliver, athlete
Keeping a gratitude journal provides an excellent way to widen your perspective by getting in touch with the many things you are grateful for on a daily basis.
Set realistic goals for your comeback
List realistic and achievable goals. Your target should really excite you and should be something that makes you want to come back stronger and fitter. To keep progress achievable, set SMART goals – an acronym for Specific, Measurable, Attainable, Relevant, and Time-Bound.
To keep progress achievable, set SMART goals – an acronym for Specific, Measurable, Attainable, Relevant, and Time-Bound.
Whilst some need to be major long-term targets, others might be short-term goals like the progress you want to see each week. Record it all in a diary to help keep you motivated.
Recognise that the comeback phase requires increased patience; the potential risk of recurrence can be as emotionally charged an event as the trauma of initial disruption itself and may be identified as a potential limiting factor for rehabilitation and successful re-entry.
Evaluate and reflect
Be proactive about discovering what contributed to your injury and how you can prevent it in the future. Perhaps you need to change or take better care of your equipment or accessories (eg shoes) more regularly, or perhaps not always push yourself to the limit.
Although it may not feel like it at the time, setbacks can often be blessings in disguise. An enforced rest can help you to physically and mentally recharge, which can leave you ready for bigger challenges ahead.
Check your attitude
One of the most important things in the process of overcoming a setback is to stay positive. It makes the journey more enjoyable and creates a better atmosphere for you. It’s hard to stay positive when you’re limited to an injury or have self-defeating feelings, but it has to be done.
Research has found that “smiling makes people feel happier, scowling makes them feel angrier, and frowning makes them feel sadder.” It makes the challenge easier and reduces intrusive negative thoughts.
Stay connected
Relationships are important in all healing and coping processes. To counterbalance isolation in the wake of injury, recognise the isolation trap, assert yourself, and actively look to connect with people in other ways or simply ‘show up’ to maintain the connections you have established previously.
How can a psychologist help?
I think that everything is possible as long as you put your mind to it and you put the work and time into it. I think your mind really controls everything.
Michael Jordan
It has been reported(4.) that significant psychological factors capable of predicting the occurrence of sport or exercise injuries include the following: trait (as opposed to ‘state’) anxiety, mistrust, negative life-event stress and poor or maladaptive coping abilities.
The “warrior mentality” so prevalent in competitive sport has served to stigmatise seeking help for mental health and psychological concerns:
“You need to show the world that you are strong, so if you were to say, ‘oh, I have mental issues,’ that just cracks the facade of trying to show the world that you’re impervious.”
Olympic medalist Sasha Cohen, rep. 2020
Perfectionism and other personality traits affecting patterns of thinking
Sport and exercise psychologists regularly address the fallout from perfectionism. Other maladaptive coping strategies may be rooted in dichotomous or rigid (all/nothing, black/white) thinking and other cognitive distortions including catastrophising, and may be addressed by cognitive behaviour therapy-based strategies and other therapeutic approaches.
Interoceptive awareness
Interoception refers to self-reported detection of internal bodily sensations and includes emotional awareness and attention regulation.
For those prone to feeling emotional distress or worry in response to negative body sensations, psychologists may apply techniques to foster positive tendencies including boosting “attending to others’ emotions”, or work toward extinguishing fear-conditioned responses to physical discomfort or distress.
The psychological fallout from disruption and recovery
For some individuals, the emergence or exacerbation of symptoms of anxiety, depression, eating, or substance use disorders may indicate a need to seek professional help.
Persistent problems returning after injury
Based on expanding research into the relationship between fear and pain, fear avoidance modelling explains why some injuries transform from acute to chronic while others heal in normal time frames. Less well-known is the aetiology (origin & causes) of kinesiophobia (an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury). Overlapping the psychological treatment of chronic pain , professional help is best sought in addressing this condition.
Psychological interventions
It’s what you learn after you think you know it all that really counts.
John Wodden, pioneer sport & exercise psychologist
There are three relatively commonly employed and evidence-based psychological interventions that have not only demonstrated effectiveness in positively impacting the injury rehabilitation process but are used across a wide-array of mental and behavioural health concerns. These include Mindfulness- Based Stress Reduction Training (MBSR), Acceptance and Commitment Training (ACT), and Motivational Enhancement Training (MET). Each is a manualised treatment that can also be adapted in various ways as applied interventions.
Tools including imagery, relaxation, goal setting, positive self-talk, coping skills, modelling, psychoeducation, biofeedback, and social support-building may be utilised to produce positive mood changes, improved self-efficacy, reduced stress and anxiety, improved motivation and satisfaction, healthier self-image, and, where necessary, more effective pain management.
More specific to sport and exercise in its orientation, psychological skills training (PST) refers to the systematic and consistent practice of mental or psychological skills for the purpose of enhancing performance, increasing enjoyment, or achieving greater sport and physical activity self-satisfaction(5.).
Dysregulated arousal is another systemic inhibitor of success in coping with sport and exercise setbacks. Crucial in this context is the presence of fear of failure, which can trigger a self-reinforcing increase in muscle tension/tone and loss of co-ordination.
‘Psych-up/psych-down’ techniques involving self-talk, imagery, physical activity, short or cued relaxation; pre-performance and performance routines; mental rehearsal strategies; stress management and mood enhancement strategies can reduce anxiety or reduce the interpretation of symptoms of performance anxiety as debilitating.
In general sports psychology literature, relaxation techniques are highlighted as being helpful to hasten the recovery processes after training or competition. Psychologists are adept at assessing which relaxation techniques (e.g., progressive muscle relaxation, autogenic training, self-hypnosis etc) are best suited to a particular scenario.
If you or someone you know may benefit from seeing a sport and exercise psychologist, please feel free to contact us for more information.
Appendix: current theoretical concepts
1. Integrated sport injury (ISI) model
The foundation of ISI is assessment of thinking patterns that drive emotional and behavioural responses to setbacks. If appraisals are adaptive in nature, the sufferer is more likely to head toward full recovery, but if they are maladaptive, then a downward spiral away from full recovery could occur.
| Considerations | Examples |
| Pre-injury factors | goal orientation, motivation, trait anxiety, history of stressors, coping skills |
| Personal and situational factors | pain tolerance, athletic identity, injury severity, participation level, social support, mental status |
| Cognitive, emotional, and behavioural response | self-esteem, rate of perceived recovery, grief, fear of the unknown, avoidance behaviour |
2. Dimensions of sports injury related growth (SIRG) model.
In brief, SIRG suggests that we are more likely to experience positive adaptations and growth post-injury if we possess certain characteristics (eg an optimistic outlook, an emotion- and problem-focused coping style), actively draw upon previous experiences of adversity, and are willing to seek help and social support (eg physical/mental advice/therapy).
| Outcome dimension | Examples |
| Personal strength | Increased empathy, mental toughness,self-reflection, hardiness, optimism, and resilience. |
| Improved social life | Improved appreciation for and fostering of relationships and being a member of a group. |
| Health-related benefits | Enhanced pain management, awareness of injury prevention, commitment to maintaining health. |
| Social support and recognition | Valued by others beyond performance and readily supported for needs and responsibilities. |
3. Self-determination theory (SDT)
SDT is a useful conceptual framework from which to study exercise and sport persistence and dropout. The theory has been widely utilised in understanding motivational outcomes in other achievement contexts such as educational and work settings, and has proven particularly effective in ‘return to play’ (RTP) programs.
| Type | Exemplars |
| Intrinsic motivation (engagement in specific activities for their own sake, pleasure, fun, and satisfaction) | Individuals consider their actions to be self-determined and volitional (willed from within), gravitating toward novelty, knowledge acquisition, and accomplishment. |
| Extrinsic motivation (rewards, and public recognition and praise) | Promotes negative feelings (failure, guilt, anxiety) and self-talk (“must” or “have to”). |
| Amotivation (lacking a sense of efficacy, control, or self regulation in attaining a desired; outcome). | External locus of control- expectations (‘pressure’), fear-punishment cycles, low autonomy, and low sense of community involvement (isolation). |
References
1. Iona,T., Raimo, S. et al. (2022). Specialization and Injury Risk in Different Youth Sports: A Bio-Emotional Social Approach. Front. Psychol. 13:818739.
2. Slimani, M., Bragazzi, N.L. et al. (2018). Psychosocial predictors and psychological prevention of soccer injuries: A systematic review and meta-analysis of the literature. Physical Therapy in Sport Volume 32, July 2018, Pages 293-300.
3. Gouveia, M. J., Vieira, A. L., et al. (2021). Resistance exercise and musculoskeletal injuries: A systematic review and meta-analysis. Journal of Sports Sciences, 39(8), 821-832.
4. Brooks, T.J., Bradstreet, T.C. and Partridge, J.A. (2022) Current concepts and practical applications for recovery,growth, and peak performance following significant athletic injury. Front. Psychol. 13:929487.
5. Birrer, D., Morgan, G. (2010). Psychological skills training as a way to enhance an athlete’s performance in high-intensity sports. Scand J Med Sci Sports 2010: 20 (Suppl. 2): 78–87.
6. Martin, S., Johnson, U., McCall, A., & Ivarsson, A. (2021). Psychological risk profile for overuse injuries in sport: An exploratory study. Journal of Sports Sciences, 1-10.
7. Liu H., Huang, L., et al. (2021). Fear of Movement/(Re)Injury: An Update to Descriptive Review of the Related Measures. Front. Psychol. 12:696762.
8. American College of Sports Medicine. (2019). ACSM’s guidelines for exercise testing and prescription. Philadelphia: Wolters Kluwer.
9. Nery, M., et al. (2023). Editorial: Safeguarding in sports. Front. Psychol. 13:1096118.
10. Anzalone, A., Albano, D. L., & Spada, M. M. (2021). The association between exercise and anxiety in the time of COVID-19: A cross-sectional survey. Journal of Affective Disorders, 279, 31-36.
11. Gomez-Espejo, V., Olmedilla A., et al. (2022). Psychological readiness to return to sports practice and risk of recurrence: Case studies. Front. Psychol. 13:905816.