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After the initial shock is over, many athletes tend to play down the significance of the injury. However, as the injury becomes more apparent, shock is often replaced by anger directed internally toward themselves or externally towards other people. The responses can vary in intensity depending on situational and personal factors but can be especially strong in individuals whose self-concept and personal identity are based on being ‘an athlete’. The loss of identity due to an inability to perform can cause much distress.

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This article aims to present an overview of research findings from studies of the psychological impact of injuries. These might be useful for those working with injured athletes and potentially draw attention to issues of service delivery.

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It is necessary to be particularly aware of athletes who almost obsessively ask about returning to their sport. Having a desire to recover is healthy but some athletes over-estimate their capabilities and risk re-injury by over-stretching themselves. During attendance at knee clinics I came across a good example of this – a skier who had suffered an ACL injury and had undergone a reconstruction. Having reached the stage of being able to cycle for the first time in the presence of a physiotherapist, this athlete over-estimated her recovery progress. The first cycling session lasted just 10 minutes and was apparently taken as the green light for resuming more intense training. Without consulting her physiotherapist, the skier completed a 20-mile outdoor cycle ride (in her own time) only a few days after the initial cycling session. The predictable result of skipping the steady progressions caused increased swelling and a loss of range of motion at the joint, and rehabilitation was inevitably prolonged.

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Over the last decade, researchers have become increasingly interested in the psychological impact of injury and how athletes react to being hurt. This has spawned an advancement of knowledge about the psychological adjustments made by athletes during times of injury, and the subsequent impact of these on mental state and adherence to rehabilitation programmes. Although ideally the psychological support of injured athletes should be provided by psychology professionals, in practice it is very often administered informally by physiotherapists. Although physiotherapists generally consider psychological components of injury as important, recent research suggests that most feel limited in their abilities to deal with these concepts and consider additional training as necessary (2). Further, a related study of patient perspectives indicated that injured athletes felt that physiotherapists and other members of the healthcare team had not consciously considered the emotional impact of their injuries (3).

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In reality, although some athletes experience negative emotions during the adjustment process, most cope without great difficulty (6). Positive adaptation can be helped by reducing the uncertainty surrounding rehabilitation and the recovery process. Psychologists recognise uncertainty as one of the major triggers for anxiety, but by educating the patient about the injury and what to expect during the rehabilitation phase this uncertainty can be reduced. Although individuals differ in the way they cope with injury and how much information they require, it is probably best to prepare the athlete for the difficulties of the process. Other applied sport psychologists take a similar approach to athletic counselling and suggest that by acknowledging the difficulties, the athlete is less likely to be deterred by unforeseen occurrences.

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Sport and exercise psychologists Robert Weinberg and Daniel Gould suggest that providing the injured athlete with an approximate timescale for achieving certain goals during rehabilitation is important. For example, knowing that if things go well and compliance with the rehabilitation programme is maintained, that by week 4 (as appropriate) exercise cycling could be possible, to help to maintain a patient’s motivation. During my own rehabilitation a number of clear targets helped me keep positively striving for progress. These included regaining full range of motion at the joint, walking without a leg-brace, swimming, cycling, running on a trampette, running on grass and returning to competitive action (the dream goal). These markers are good examples of what psychologists call intermediate goals – the stepping stones that pave the way to achieving the dream goal. This approach can help combat any feelings of self-doubt that can arise from only focusing on the long journey towards a dream goal. Intermediate goals provide direction for the day-to-day efforts of the injured athlete. Physiotherapists can also help to provide short-term goals in the form of daily exercises that should be performed by the athlete. Goal achievement is especially good for increasing an athlete’s self-confidence.