By Margot Putukian

Injuries, while hopefully infrequent, are often an unavoidable part of sport participation. While most injuries can be managed with little to no disruption in sport participation and other activities of daily living, some impose a substantial physical and mental burden. For some student-athletes, the psychological response to injury can trigger or unmask serious mental health issues such as depression, anxiety, disordered eating, and substance use or abuse.

When a student-athlete is injured, there is a normal emotional reaction that includes processing the medical information about the injury provided by the medical team, as well as coping emotionally with the injury.  

Those emotional responses include:

• Sadness
• Isolation
• Irritation
• Lack of motivation
• Anger
• Frustration
• Changes in appetite
• Sleep disturbance
• Disengagement

How student-athletes respond to injury may differ, and there is no predictable sequence or reaction. The response to injury extends from the time immediately after injury through to the post-injury phase and then rehabilitation and ultimately with return to activity. For most injuries, the student-athlete is able to return to pre-injury levels of activity. In more serious cases, however, a student-athlete’s playing career may be at stake, and the health care provider should be prepared to address these issues. The team physician is ultimately responsible for the return-to-play decision, and addressing psychological issues is a significant component of this decision.

It’s important for athletic trainers and team physicians, as well as student-athletes, coaches and administrators, to understand that emotional reactions to injury are normal. However, problematic reactions are those that either do not resolve or worsen over time, or where the severity of symptoms seem excessive. Examples of problematic emotional reactions are in the accompanying table.

One problematic reaction is when injured student-athletes restrict their caloric intake because they feel that since they are injured, they “don’t deserve” to eat. Such a reaction can be a trigger for disordered eating. When a student-athlete is already at risk for disordered eating, this problematic reaction only heightens the likelihood these unhealthy behaviors will worsen.   

Another problematic response to injury is depression, which magnifies other responses and can also impact recovery. Depression in some student-athletes may also be related to performance failure. When student-athletes sustain significant injuries, such as knee injuries associated with time loss from sport, they can suffer both physically as well as emotionally with a decrease in their quality of life. When Olympic skier Picabo Street sustained significant leg and knee injuries in March 1998, she battled significant depression during her recovery. She stated: “I went all the way to rock bottom. I never thought I would ever experience anything like that in my life. It was a combination of the atrophying of my legs, the new scars, and feeling like a caged animal.” Street ultimately received treatment and returned to skiing before retiring.  

Kenny McKinley, a wide receiver for the Denver Broncos, was found dead of a self-inflicted gunshot wound in September 2010 after growing despondent following a knee injury. He had undergone surgery and was expected to be sidelined for the entire season. He had apparently made statements about being unsure what he’d do without football and began sharing thoughts of suicide.

These case examples demonstrate how injury can trigger significant depression and suicidal ideation.

Concussion is another injury that can be very challenging for student-athletes to handle emotionally. An injury like an ACL – while it poses a serious setback to the student-athlete – at least comes with a somewhat predictable timeline for rehabilitation and recovery. What makes concussion particularly difficult is that unlike most injuries, the timeline for recovery and return to play is unknown. With concussion, the initial period of treatment includes both cognitive and physical rest, which counters the rigorous exercise routine many student-athletes often depend on to handle stressors. Given the emotional and cognitive symptoms associated with concussion, student-athletes often struggle with their academic demands. In addition, compared with some injuries where a student-athlete is on crutches, in a sling, or obviously disabled in some way, with the concussed student-athlete, he or she “looks normal,” making it even more challenging to feel validated in being out of practice or play.

For the student-athlete with concussion, it is especially important – and difficult – to watch for problematic psychological responses to the injury. Some student-athletes experience emotional symptoms as a direct result of the brain trauma that can include feeling sad or irritable. If these symptoms don’t seem to be going away it is important to explore whether they might be related to a mental health issue such as depression and not directly to the injury itself. In some cases, the psychological reaction to the concussion – rather than the concussion itself – can be the trigger for the depression. When this is the case, simply waiting for the brain to recover isn’t enough: the depression also needs to be treated.

It is also important to be aware that with increasing media attention being paid to neurodegenerative diseases such as chronic traumatic encephalopathy (CTE) among professional athletes, some student-athletes might fear that even the mildest concussive injury will make them susceptible to these highly distressing outcomes. Though there is very little known about what causes CTE or what the true incidence of CTE is, the concern for possibly developing permanent neurodegenerative disease can be paralyzing. Athletic trainers and team physicians can help educate injured student-athletes about the known risks associated with concussions and can help them focus on managing the injury in the present. They should also be aware that student-athletes who are expressing a high level of anxiety could be experiencing a mental health condition that requires treatment by a mental health professional.

Seeking treatment

Injured student-athletes who are having a problematic psychological response to injury may be reticent to seek treatment. They may be afraid to reveal their symptoms, may see seeking counseling as a sign of weakness, may be accustomed to working through pain, may have a sense of entitlement and never had to struggle, and may not have developed healthy coping mechanisms to deal with failure. In addition, many student-athletes have not developed their identity outside of that as an athlete. Thus, if this role is threatened by injury or illness, they may experience a significant “loss.” Getting a student-athlete to consider treatment can be challenging (and it is complicated by privacy issues), so coaches, athletic trainers and team physicians as the support network for the student-athlete should work together to provide quality care.

As an athletic trainer or team physician, it’s important to be aware of common signs and symptoms for various mental health issues and understand the resources available to treat them. Those personnel also must do everything possible to “demystify” mental health issues and allow student-athletes to understand that symptoms of mental health issues are as important to recognize and treat as symptoms for other medical issues and musculoskeletal issues. Underscoring the availability of sports medicine staffs to provide for early referral and management of mental health issues is essential.

It’s also important for coaches, athletic trainers and team physicians to support injured student-athletes and do what they can to keep athletes involved and part of the team. This might include keeping student-athletes engaged, and at the same time encouraging them to seek help and not try to “tough their way through” situations that include mental health factors.

For coaches, one of the most powerful actions is to “give the student-athlete permission“ to seek treatment (see Mark Potter’s article in Chapter 1 emphasizing this notion). This is often incredibly helpful in encouraging student-athletes to seek care. Having programs available to educate student-athletes as well as sports medicine and administrative staffs regarding the resources available and the importance of collaborative programming helps provide appropriate care.

It is important to understand the mental health resources available on each campus and consider both early referral as well as establishing multidisciplinary teams that include athletic trainers, team physicians, psychologists, psychiatrists and other health care providers to provide care for mental health issues in student-athletes. If this can be incorporated into the overall goal of optimizing performance, along with nutrition and strength and conditioning, it may be better received by student-athletes and coaches, thereby increasing the compliance with management and treatment.

Given all that is known about mental health issues in athletes – and the role of injury and the barriers to treatment – the bar is raised in terms of what athletic trainers and team physicians can do in the future. Having a comprehensive plan in place to screen for, detect and manage student-athletes with problematic response to injury is an important first step.

Margot Putukian is the director of athletic medicine and head team physician at Princeton University, where she is also an assistant director of medical services at University Health Services. She has an academic appointment as an associate clinical professor at Rutgers Robert Wood Johnson Medical School. Putukian has a B.S. in biology from Yale University, where she participated in soccer and lacrosse, and an M.D. from Boston University. She completed her internship and residency in primary care internal medicine at Strong Memorial Hospital in Rochester, New York, and her fellowship in sports medicine at Michigan State University. Putukian is a past president of the American Medical Society for Sports Medicine. She currently works with US Soccer and US Lacrosse as a team physician, and several organizations advocating for health and safety issues, including the NCAA, the NFL, USA Football, the American College of Sports Medicine, US Soccer and US Lacrosse. She can be reached at putukian@princeton.edu.