ACL injury in elite female footballers: Psychological risks successful transition1 Opinion
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Tags:ACLCopingFA WSLFemalesFootballInjuryprofessionalPsychological effects of injuryPsychology of SportSelf-Determination TheorySport Psychologywomen's football
About Chris Lynch
I hold an MSc in Sports Psychology from LJMU. Using the principles of Sport Psychology I am currently supporting people in sport to unlock their potential. I am a former inter-county Gaelic footballer now giving back through coaching.
Research within sport psychology highlights and emphasises the potentially stressful nature of sports participation (e.g., Fletcher, Hanton & Mellalieu, 2006; Fletcher, Hanton Mellalieu & Neil, 2012; Giacobbi, Foore, & Weinberg, 2004). Stress can significantly influence both an athletes’ well-being (DiBartolo & Shaffer, 2002; Tabei, Fletcher, & Goodger, 2012), competitive performance (Humphrey, Yow, & Bowden, 2000) and mental health (Brennan, 2001). One major stressor of note that has come around in the media of late in relation to Women’s professional football (in particular the FA WSL) has been the risk of injury, where many players and media outlets have raised a generalised view around the issue of ACL (Anterior Cruciate Ligament) injury risk and a general fear around ACL injury within the world of female sports participation. This fear was highlighted most recently within my own M.Sc research study regarding organisational stress in WSL footballers and also by recent media stories and debates regarding the use of artificial surfaces at the 2015 Womens World Cup in Canada.
One reason for this generalisation around ACL injury may originate from the participation of some WSL fixtures and training sessions on artificial surfaces. In addition, research around the link between artificial surfaces and risk of ACL injury has espoused that a greater risk of injury from playing on artificial surfaces than that of natural turf surface (Dragoo, Braun, & Harris, 2013; Dragoo, Braun, Durham, Chen & Harris, 2012). Physiological research also suggests that female athletes are more susceptible to ACL injury in particular when compared to their male counterparts (Waldén, Hägglund, Werner, & Ekstrand, 2011). However, what these recent highlighting reports in the media have not alluded to is the additional psychological risks that stem from the ACL injury lay-off itself and the length of recovery for many athletes. ACL Injury has the capability of producing various negative and dysfunctional psychological effects, in particular, and not limited to an athlete’s self-confidence and athletic identity, and may also result in symptoms of anxiety, negative emotional response, depression and even eating disorders or self-harm.
Professional/elite-level athletes who financially benefit from their involvement in sport may feel additional pressures to return to their sport. Previous research (Bianco, 2001; Crossman, 1997) reported athletes feeling pressure in wanting to regain their position on the team, fear of letting team-mates or coaches down by not returning as they predicted, and concerns about an inability to perform at their pre-injury levels upon return. Long term injury lay-offs in professional athletes in addition to media portrayals and stereotypes of female athletes can also lead to self-objectification behaviours (Harrison, K., & Fredrickson, B. L. 2003). These perceived stresses may lead to premature return to participation before they are psychologically ready to do so, which has subsequently been found to increase the likelihood of re-injury and illness risk. In addition, many WSL footballers also undertake part-time/full-time study, employment or a combination of both to cope with external demands and also in preparation for the eventual transition out of elite level sports participation. However, for many players, football is still considered to be the number one priority with the expectation placed upon total commitment to their football club. This in itself can bring about organisational stressors and forces compromise in order to cope with such demands (Miller & Kerr, 2002).
Self-determination theory (Deci & Ryan, 2000) provides an appropriate framework to which sports psychologists, physiotherapists and other members of the support team around the footballers may specifically focus on when returning the athlete into sport. It also enables the team to account for individual differences in psychological responses, to assist those key stakeholders around the athlete to identify and subsequently address dysfunctional psychological behaviours that may provide risks to the athletes mental health and well-being. If these dysfunctional responses are not regulated, it may eventually result in dropout from the sport. The key factors to consider, informed by self-determination theory include:
- The athletes perception of their own control in their transition back in to the sport (Autonomy);
- Their personal and honest feelings about their own readiness for returning to sport (Competence); and additionally,
- How they perceive the available support from coaches, team-mates and other key stakeholders in their return to sport (Relatedness).
By increasing the athletes’ positive perceptions of returning to sport this increases the potential for a successful transition back into participation following injury (Ardern et al., 2012; Ardern et al., 2013). Furthermore, by involving the athlete in the process of identifying a realistic potential time of return to training, contact and game time, this will promote a sense of autonomy. Competence can be promoted by the use of goal setting with key stake holders in the rehabilitation process and also the use of imagery throughout the rehabilitation period to target a positive increase in self-confidence and self-esteem. Improvements in confidence may also be achieved via congruence from key stakeholders and social support network (e.g. coaches, parents, spouse, physiotherapist, and academic/vocational stakeholders) which will contribute to reducing potential conflicts, will aid in setting realistic performance expectations and also in recognising advancements and/or setbacks in the process (Bianco, 2001; Johnston, 1998). Consequently, when negative perceptions appear post-injury/surgery, the potential of non-return and negative psychological risk increases (Johnston, 1997).
A further component to a successful transition back into sport following injury and improved mental health and well-being provision in sport is the use of athlete psychological screening post injury, post-surgery and additionally, further along the rehabilitation phase. This enables the support team to identify potentially dysfunctional psychological responses to injury. Furthermore, by identifying potentially dysfunctional responses to injury, the ability to implement strategies to address and combat such responses increases. Any such screening may include psychological factors such as, measures of motivation (autonomy), confidence and fear (competence) and perceptions of identity within the sport/organisation (Relatedness) should be considered. The ACL-RSI is an applicable example of psychological screening for patients returning to sport after ACL injury.