Psychological effects of training and injuries on female athletes

Danielle R. Steilen-Matias, MMS, PA-C

In both male and female athletes, injury or the desire to push the limits of one’s abilities can lead not only physical injury, but to changes in body physiology and mental state. In this article we will explore the psychological impact of training and recovering from a sports injury in the female athlete.

No gender differences were found between male and female athletes in the emotional responses of athletes to injury

In 1990, a landmark study from the Mayo Clinic reported:(1)

“This study (of 72 patients – men and women) was conducted to identify the emotional responses of athletes to injury and to determine which (of these emotional) responses might interfere with rehabilitation and necessitate psychologic or psychiatric intervention. A follow-up surveillance was continued from the time of injury until resumption of sports activity.

Patients completed the Emotional Responses of Athletes to Injury Questionnaire and the Profile of Mood States (POMS) test, and significant differences were found when the Profile of Mood States scales of depression and anger were compared with college norms.

Average Profile of Mood States scores were compared by sex, age, and severity of injury. No gender differences were found, and only for anger were age groups significantly different (younger athletes were most angered). Three severity-of-injury groups (based on the duration of time the athlete was unable to participate in sports) were also compared.

The most seriously injured group experienced significantly more tension, depression, and anger and less vigor than college norms, a mood disturbance that lasted one month. Emotional disturbance can occur after a sports-related injury, and its prompt recognition may facilitate the athlete’s optimal rehabilitation and a safe return to participation in sports.”

The learning points were:

There were no differences between the way a male athlete responded and how a female athlete responded.
Younger athletes suffered more anger over their injury than an older athlete.
The more severe the injury the more tension, depression, and anger.

One more item of note, there was no real significance between male and female athletes. Now let’s see how this research has sustained its significance more than three decades later.

The more competitive the athlete the worse the possible emotional and mood swings could be.

In 1999, nine years later, the Sports Medicine Center at the Mayo Clinic in Rochester. Minnesota referred to this research in a study published in the Clinical journal of sport medicine. (2) The purpose of this study was to look at male and female athletes who required longer rehabilitation, such as those recovering from ACL reconstruction surgery.

Twenty-seven athletes (15 men and 12 women) who required anterior cruciate ligament (ACL) reconstruction surgery.
Monitored for psychosocial and physical changes 6 months after ACL surgery. Included: Emotional (mood) and cognitive (coping) functions and physical recovery (range of motion, physician-rated level of recovery, and physician permission to return to sport).

Results: There was a significant time-effect difference in mood, with a greater mood disturbance and recovery rate for competitive athletes than recreational athletes. Differences in mood and pain coping were significant at 2 weeks and 2 months after surgery. “Athletes experience significant mood changes throughout rehabilitation, which may hinder rehabilitation early in the process. Longer-term rehabilitation was not impacted by mood or pain coping.”

The learning points here:

The more competitive the athlete the worse the possible emotional and mood swings could be.
Overtime, rehabilitation was not impacted by mood or pain coping.
- There could be many reasons as we have seen in our patients for this. For one, the time frame to return to competitive sport has now passed and the athlete chose not to return to sport. We cover this subject and other aspects in ACL reconstruction surgery alternatives and regenerative treatment options.

Knee injuries can negatively impact emotional health-related quality of life in the female athlete

In regard to the female athlete, knee injuries and their psychological effects have been of great focus. Researchers writing in the Clinical Journal of Sports Medicine (4) suggest that knee injuries can negatively impact emotional health-related quality of life in the female athlete.

The researchers looked at 255 women who injured their knee participating in sport or recreational activities. Injuries were categorized as anterior cruciate ligament (ACL) tears, anterior knee pain, patellar instability, meniscus tear, collateral ligament sprain, and other.

Use a scoring system they measured physical functioning, bodily pain, general health, vitality, social function, and emotional and mental health.

They noted:

“In addition to negatively affecting knee function, sport medicine providers should be aware that knee injuries can negatively impact the health-related quality of life in these athletes immediately after injury.”

In other words, knee injuries go beyond a pain and dysfunction. Emotional quality of life is at stake, placing an even greater emphasis on sports injury healing.

2022: Recovery has an important psychological component that has only recently been addressed in the literature

Let’s look at a 2022 paper Current reviews in musculoskeletal medicine (3) thirty-two years after the 1990 study suggested a psychological component to rehabilitation. The researchers here write: “Return to sport is a particularly important factor for many Anterior cruciate ligament reconstruction patients, and recovery has an important psychological component that has only recently been addressed in the literature, with positive preliminary findings.”

Psychological effects and Eating disorders

An April 2022 study from Japanese, Italian and New Zealand university researchers examined the problems of eating disorders in elite female athletes. The study appeared in the journal Frontiers in Nutrition. (5) The researchers here examined and assessed female participants at the 2021 Tokyo Olympics. The study wrote: “In the 2021 Tokyo Olympics, female athletes reached a record high of 48.8% of all athletes, and women competed in various events. Underneath the success of women in sports, reproductive dysfunction and impaired bone health associated with female relativey (lack of caloric intake or eating disorders) in sports are considered problematic . . . Long-distance female runners aim to maintain low body weight or tend to lose weight prior to competition to optimize their time-based performance. Consequently, some long-distance runners experience eating disorders in the effort to obtain desired low body weights; about half (46%) were classified as “at risk” for developing an eating disorders in a study of collegiate endurance runners from seven US universities.”

Eating disorders

In a July 2021 study published in the International journal of sport nutrition and exercise metabolism (6), doctors at California State University Long Beach, University of California Davis, San Diego State University, and the University of California San Diego evaluated the three-year change in menstrual function and bone mass among 40 female adolescent endurance runners according to baseline disordered eating status. Three years after initial data collection, runners underwent follow-up.

Diagnosed with eating disorders were runners who were concerned about their weight, body shape, and/or had previous episode of pathologic behavior in the previous 28 days up to evaluation.
Runners diagnosed with eating disorders reported to the researchers fewer menstrual cycles over the course of a year, more years of amenorrhea, and a higher proportion of menstrual irregularity.
Runners diagnosed with eating disorders did not see bone increase in lumbar spine or total hip bone mineral density at the 3-year follow-up.

Addressing the psychological concerns after injury during the period of rehabilitation is important to better facilitate return to sport in female athletes

A January 2022 paper lead by researchers at Harvard-Massachusetts General Hospital, Amsterdam University Medical Center, the Royal College of Surgeons in Ireland and Tulane University School of Medicine published in the journal Arthroscopy, sports medicine, and rehabilitation (7) reported on their outcomes and that of previous research. They noted “Psychological factors including (the ability to self-manage to a successful outcome), identity, and fear of reinjury may all play a role in an athlete’s ability to return to sport. (Previous studies have reported that) female athletes recovering from injury are often self-directed and exhibit greater levels of anxiety concerning an injury’s impact on their lives and a loss of physical self-worth with injury when compared with their male counterparts. (Other research evaluating outcomes) after psychosocial interventions to help facilitate recovery after musculoskeletal sports injuries and showed positive mood changes, improved pain management, and better exercise compliance and rehabilitation adherence when the following interventions were incorporated during rehabilitation: relaxation and/or guided imagery, positive self-talk, goal setting, counseling, emotional and/or written disclosure, and modeling videos. Therefore, addressing the psychological concerns after injury during the period of rehabilitation is important to better facilitate return to sport in female athletes.”

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This article was updated July 23, 2022