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REVIEW ARTICLE
Year : 2021  |  Volume : 21  |  Issue : 3  |  Page : 75-80

Incidence of Sports Injury and its relationship with psychological factors: A qualitative review


1 Sports High Performance Centre, Tata Steel, Jamshedpur, Jharkhand, India
2 Department of Sports Science, Faculty of Medicine, Punjabi University, Patiala, Punjab, India

Date of Submission16-Sep-2021
Date of Acceptance03-Nov-2021
Date of Web Publication13-Dec-2021

Correspondence Address:
Paramvir Singh
Department of Sports Science, Punjabi University, Patiala, Punjab
India
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DOI: 10.4103/sjsm.sjsm_25_21

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  Abstract 


Sports injury is prevalent, extensive, expensive, and to an extent a preventive problem. This review paper aims at identifying the psychological and psychosocial factors predicting injury occurrence. Qualitative and mixed methods studies were reviewed indicating psychological predictors of injury. In the discussion, the current qualitative research is critiqued and evaluated on psychological predictors. It has even concluded that history of stressors, personality traits (aggression, perfectionism, hardiness, etc.), daily hassles, previous injury, coping strategies, negative life events, and anxiety are psychological factors predicting injury risk.

Keywords: Personality, psychological factors, sports injury


How to cite this article:
Singh K, Singh P. Incidence of Sports Injury and its relationship with psychological factors: A qualitative review. Saudi J Sports Med 2021;21:75-80

How to cite this URL:
Singh K, Singh P. Incidence of Sports Injury and its relationship with psychological factors: A qualitative review. Saudi J Sports Med [serial online] 2021 [cited 2022 Jan 21];21:75-80. Available from: https://www.sjosm.org/text.asp?2021/21/3/75/332393






  Introduction Top


Sports injuries are common issue faced by most athletes during their sports. Approximately 8.6 million sports and recreation-related injuries have been reported annually. Thus, it is a growing concern for many. Moreover, sports injuries result in breaks from sports, causing a threat to the athlete's sports career and success consequently becoming a bigger concern for themselves and the coaches. Not all athletes return to sports after recovery, rather injuries have been one of the most recurrent reasons for termination from sports (8.4% dropout rate). Sports injuries can be extremely stressful and emotionally disruptive for athletes, especially when the injuries are severe. Along with physical stress, an athlete must cope with psychosocial stresses such as threats to self-esteem and termination from sport. In addition, with physical and psychosocial burdens, injuries can be an economic problem, considering the high cost of health care and the psychological aid during and postrehabilitation. Thus, it is vital to be aware of the risk and cope efficiently and effectively with injuries.

Sports injury

In the field of psychology, significant variability exists among the definitions used for analyzing sports injury, among that the common factors are that (a) the injury was incurred or experienced during training for or competing in sports, (b) medical care was required, and (c) time loss from training and/or competing in sports.[1] Noyes et al. defined injury as the inability of an athlete to return to the field of play on either the same day or the following days of injury. The severity of the injury can be measured by the actual number of days until return to play. The same injury could have a different result on different athletes: either can lead to termination from sports or would not cause any impairment in performance.[2] Ristolainen et al. suggested that an increased understanding of the injury occurrence mechanisms would aid in the prevention of injury along with rehabilitation programs to meet the needs of the injured athletes. In addition to the various definitions, it is vital to acknowledge all the variations in definition while evaluating the sport injury studies and comparing those studies.[3]

Models

The theoretical frameworks regarding the antecedents of injuries often cited include the stress and athletic injury model, Williams and Anderse. The theoretical model “stress and athletic injury” suggested a framework for the prediction and prevention of stress-related injuries considering variables such as cognitive, physiological, attentional, intrapersonal, behavioral, social, and stress-history whilst addressing various mechanisms behind the stress-injury relationship. The model suggested that in a stressful situation, an athlete with a lot of stress in their lives, having personality traits that tend to aggravate the stress response and have few or ineffective coping resources, will be more likely to evaluate the situation as stressful, exhibiting greater muscle tension and attentional changes, consequently being at a greater risk of injury compared to athletes of the opposite profile.[4]

The stress-based model of prediction of injury implicated that personality traits (e.g., hardiness, locus of control and competitive trait anxiety), history of stressors (e.g., major life events, daily hassles, and previous injuries) and coping resources (e.g., social support, psychological skills, and coping strategies) accord to the prediction of sports injury either in isolation or interactivity. Thus, athletes with undesirable personality traits, history of stressors, and unsatisfactory coping resources are more susceptible to appraise a potentially demanding athletic situation as stressful and exhibit greater attentional and/or physiological responses (e.g., increased muscle tension) than athletes with an opposite profile.[4] A research has suggested that personality traits (e.g., sensation seeking and dispositional optimism) and coping resources (e.g., psychological skills and social support) correlate with major life events subsequently, influencing one's vulnerability or resiliency to injury.[5]

For many years, the sciences of sports injuries were discerned entirely through the lenses of physiological and medical research and aspects, substantially neglecting the obligatory role of psychological factors and aspects. However, now many studies have supported the hypothesis that psychological factors are strongly related to sports injuries. In conclusion, psychological factors and aspects play a chief role in a comprehensive understanding of sports injuries. The foundation of a theoretical approach is proposed by Williams and Andersen's “stress-injury model” (revised by Williams and Andersen), which consist of three main aspects: personality traits, history of stressors, and coping resources.[4]

Personality traits are defined as context-dependent, psychological attributes distinguishing the athlete. The personality type can conclusively effect if an athlete assesses satiation as stressful or not. For instance, athletes high on anxiety may frequently appraise situations as stressful and intensify their response to the situation, resulting in an increased risk of injury. Hardiness is a subtype of personality trait and was conceptualized as resilience. It was observed that individuals who experienced adversities without any negative health-related implication were identified by hardiness and had three resilient attitudes: commitment, control, and challenge (i.e., 3Cs of hardiness). In other words, individuals high on hardiness feel profoundly involved in or committed to activities in their lives, believe that they can moderately control events they encounter, and consider change as a challenge and opportunity to grow and develop rather than scrutiny. Researchers investigating hardiness have found hardiness to negatively speculate sports injury, positively moderate the destructive effects of major life events on injury occurrence, and a beneficial effect on athlete's postinjury psychological responses.[6]

Perfectionism can be defined as a personality disposition designated by straining for flawlessness and serving exceedingly high standards of performance accompanied by tendencies for excessive critical evolution of one's behavior.[7] The diathesis–stress model of perfectionism by Hewitt and Flett hypothesized that perfectionism is a vulnerability factor putting people at risk of chronic stress.[8] A research suggests that an athlete high in perfectionism concerns trains harder and longer than an athlete low in perfectionism concerns.[9] In other words, the athletes can feel the internal pressure to meet their high expectations regarding their sports performance, and due to their personality traits, they could predispose themselves to injury. In addition, it has also been suggested that personality traits such as aggression and anger have a positive relation with injury risk, and indicated that high anger directed outward increased injury risk.[10]

The overtraining risk and outcome model by Richardson et al. discussed that stress load over time is a risk factor for overuse injury and that overuse injury can be an outcome of overtraining. An athlete could hide the physical pain caused by the injury due to the fear of being replaced in the team and losing their athletic identity or end up overtraining themselves due to staleness and showing carelessness toward their body, predisposing themselves to injury. Alternatively, personality traits such as Type-A behavior (e.g., high motivation and competitiveness) tend to overuse and train harder than usual, subsequently heightening the risk of injury. Athletes who are face pressure (external/internal) of performing well end up overtraining and overuse the injury to meet their expectations, putting themselves high at risk of injury.[11]


  Methods Top


Literature search

We searched the electronic database of Science Direct, PubMed, PsycINFO, and SPORTDiscus, these were selected to give a sizeable range for capture across contexts and are acknowledged as the top research databases. A combination of the following keywords was used: “Sports injury,” “psychological influence,” “psychological predictors” “personality,” “perfectionism,” “burnout,” and “stress or anxiety.” These terms encompassed a broad array of subjective experiences that would indicate a heightened risk for injury in one of the contexts of interest because of psychological factors. Reference lists were searched for any additional research that would be eligible for inclusion.

Studies were considered for inclusion if they were (1) published in peer-review journals; (2) published between 2010 and 2020; (3) written in English; (4) investigated psychological predictors of sports injury; and (5) the population sample was athletes/competitors/sports players. A review of titles identified 60 studies that failed to meet the inclusion criteria, leaving 45 unique records. A review of the abstract identified an additional study that failed to meet the inclusion criteria, leaving 32 studies. These studies were read, and 17 were excluded for not meeting one or more of the inclusion criteria. The following 15 papers were used for this review [Table 1].
Table 1: Qualitative and mixed methods of studies

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  Review Top


In their study, Johnson and Ivarsson reported that athletes experiencing high levels of somatic trait anxiety and low level of mistrust are more susceptible to injuries. However, their findings suggested that negative life event stress is the strongest predictor for injury occurrence. The possible reason could be that high-stress levels can probably lead to difficulty in focusing on relevant and vital cues while participating in sports. As a result, the athlete would end up in a problematic situation, such as injuries (influencing other predictors). In other words, the study provided evidence those predictors: negative life event stress, somatic trait anxiety, negative coping, stress sensitivity, and mistrust could explain 22% of that total variance of injury occurrence. In addition, no significant relationship was found between athletes portraying aggressive behavior and injury occurrence.[12] Contradicting, opposite results were found by Keller et al., which suggested that aggressive athletes have higher livability to expose themselves more, leading them to higher injury susceptibility.[13]

In addition, another research, Devantier, provided evidence that coping with adversity, and previous injuries were best predictors for injury occurrence. However, coping with adversity and previous injuries were significant predictors, elucidating approximately 11% variance of the number of days lost due to injuries. The impact of the previous injury is predicted to increase successive injury span with approximately 49% for each previous injury. Thus, previous injuries cannot be ignored as a predictor of injury and should be recognized as a vital confounding variable of injury prediction. On the other hand, competitive trait anxiety was not found predictive of injury occurrence or injury duration.[14] Deroche et al., found similar results: direct contribution of previous injuries, perceived similarity, and perceived control to the perceived risk of injury. The study suggested that previous injuries would increase the perceived risk of further injury because people perceive themselves as a typical injury's individual.[15]

A research investigating the factors of the model of stress and athletic injury to predict injury, Ivarsson, et al., has suggested that personality trait would directly increase injury risk. However, trait anxiety was secondarily related to injury risk through negative life event stress and daily hassles. The lack of direct interconnection between trait anxiety and injury occurrence is because personality traits may be inadequate for directly increasing one's injury proneness. In addition, negative life event stress had an indirect effect on injury frequency through the daily hassle. Whereas daily hassle stresses had a moderate, direct positive relationship with injury occurrence resulting from the sudden change, an athlete would be exposed to due to the injury risk. Furthermore, maladaptive coping strategies were found to have a negative relationship with injury probability.[16] A meta-analysis on injury prediction variables based on the model reported that history of stresses and stress response variables has the strongest relationships with injury rates, Ivarsson et al. The study results suggested that the stress associated with negative events (i.e., daily hassles, previous injuries, and negative life events) has the strongest association with injury rates as compared to more positively valenced events (i.e., positive life event stress, total life event stress). The stress response was found to be an evident mediator for the relationship between psychological variables (i.e., history of stressors, personality traits) and injury rates, thus suggesting that the stress response mediated the relationship between psychosocial variables and injury occurrence.[17]

Supporting the current findings, the study of Singh and Conroy showed that major life events and daily stressors exhibited a positive association between stress and injury. Thus, the increase in major life events stressed and daily stressor would consequently increase the risk of injury occurrence. Furthermore, anxiety was reported to have a positive association with stress and injury. It is likely that when an athlete feels anxious, they tend to stress up even more, subsequently tensing their muscles which could lead to injury occurrence. Finally, the study statistically showed that stressor exposure and stress response in the athletic context has a positive association with injury (77.2%) and that mere exposure to a stressor, irrespective of the magnitude of responses, could elevate the risk of injury. Therefore, stress is associated with increased injury risk.[18] In addition, a research, Tranaeus, et al., has shown that stressors are potential risk factors for overuse injuries. The study suggested that athletes with strong athletic identity accepted pain and continued training, showing carelessness toward their bodies, consequently leading to an increase in injury occurrence. It was also stated that athletes with futile and/or restricted coping resources for managing such stressors might heighten the risk of sustaining overuse injuries.[19] Timpka et al., reported in their study that maladaptive coping behavior, self-blame, was a strong predictor of overuse of injuries among track and field athletes as compared to self-reported training behaviors. Overuse injuries were found to be partly the repercussion of inadequate self-perception among athletes.[20]

A research, Wadey, et al., has shown that negative major life events (elaborate) increased the likelihood of injury occurrence, therefore a positive relation. Whereas as hardiness, commitment, control, and challenge increased, the likelihood of injury decreased, therefore a negative relation. Athletes high on hardiness might experience a potentially demanding situation in the same manner as athletes low on hardiness. However, the athletes high on hardiness demonstrated to appraise or reappraise the associated demands of the situation in less stressful terms. As a result, they could potentially decrease the severity of the stress response after the risk of injury. The study reported that hardiness was positively correlated with reorganization, problem-focused and emotion-focused coping, and devastation and dispirited. Therefore, such athletes have adequate and efficient coping resources and strategies when faced with adversities and thus are less likely to get injured and affected because of negative major life events.[21] A research on perfectionism, Madigan, et al., suggested a positive relation with injury prediction. Although only perfectionistic concerns entered to be a significant positive predictor, perfectionistic striving did not have a significant relationship with injury occurrence. Thus, the athletes with deeper perfectionistic concerns would be at higher risk of injury than the athletes with lower perfectionistic concerns. Perfectionism was associated with maladaptive coping strategies for coping with stress. Therefore, perfectionism is a factor predisposing athletes to injury.[22]

Li et al. suggested in their research that athletes, irrespective of gender, who experienced anxiety symptoms at the preseason were at a higher risk of getting injured during the prospective season than those without. In contrast, only male athletes with co-occurring symptoms of anxiety and depression were more likely to experience injury when compared to male athletes with no symptom co-occurrence. Regarding depressive symptoms, a study found that only female athletes were more likely to report symptoms preseason although did not demonstrate an increased risk of injury during the prospective season compared to male athletes. Furthermore, the results were consistent with other studies, indicating that trait anxiety, stress from negative life events, and daily hassles were significant predictors of injury among professional and junior soccer players.[23] In addition, a research on combat sports injury, Hammami, et al., did not find a significant difference between male and female fighters in injuries reported, although the injury locations were considerably different. The study suggested that the sports skill level and competition ranking are significant aspects that increased the risk of injury, the higher the level of completion, the higher the level of anxiety and psychological stress caused. Therefore, injuries were proved to be related to the level of skill and experience.[24]

Furthermore, a study on wrestlers, Kalkhoran, et al., suggested a significant negative relationship between emotional intelligence (EI) and the probability of injury among wrestlers, thus, EI increased, the probability of injury occurrence decreases. The study showed that wrestlers with a high ability to regulate their emotions will suffer from fewer injuries. Such athletes having a lower ability to regulate their EI may impose lower control over muscles tension and neuromuscular interaction, consequently being high at risk of injury occurrence.[25] Another study conducted on wrestlers, Pedro and Martins, suggested that the injury rates increase with the practice time in sports and competition stress. When the wrestlers get used to being injured, they tend to value less the stressful period or events and more on managing and dealing with the stressful period. The study even suggested a negative correlation between confidence level and injury occurrence during the weight-loss period. This could be led due to the deprivation encountered by the wrestlers during the weight-loss period and their effect on the psychological state of mind.[26]


  Conclusion Top


Sports injuries are relatively common among athletes and are one of the prime reasons for the termination of sports. However, as a research field, they have received comparatively little attention especially considering the psychological factors leading to injury occurrence. The present review article identified several psychological factors that have influenced injury occurrence or were present before the injury.

The factors in the model of stress and athletic injury to predict injury have been statically proven to influence injury occurrence. Therefore, factors such as history of stressors, personality traits, negative life events, daily hassles, coping resources, and somatic trait anxiety influence injuries over time. In addition, aggressive behavior has been proven to heighten the risk of injury. Personality traits such as perfectionism are significantly proved to be a predictor of overuse injury. On the other hand, athletes high on hardiness are less susceptible to injury. Furthermore, symptoms of anxiety and depression preseason increased the risk of injury during the prospective season. It can be concluded that psychological factors and psychosocial factors play a vital role in injury predicting and injury occurrence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Deroche T, Stephan Y, Woodman T, Le Scanff C. Psychological mediators of the sport injury – Perceived risk relationship. Risk Anal 2012;32:113-21.  Back to cited text no. 15
    
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Ivarsson A, Johnson U, Podlog L. Psychological predictors of injury occurrence: A prospective investigation of professional Swedish soccer players. J Sport Rehabil 2013;22:19-26.  Back to cited text no. 16
    
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