TOWARDS A HOLISTIC MANAGEMENT OF INJURED SOCCER PLAYERS: A PSYCHOSOCIAL RETURN-TO-PERFORMANCE PATHWAY
- Written by Dale Forsdyke, Adam Gledhill, Peter Schneider, Adam Weir, Andrew Mitchell
INTRODUCTION
Soccer has a large burden of injury with many players reporting poor outcomes following injury1,2. Returning players to their pre-injury level of performance or higher is complicated. While several important recovery pathways have been proposed3,4 most are one-dimensional and do not adequately address the complexity of return-to-performance. This can leave players without the necessary biological (e.g., tissue healing), physical-functional, and psychological readiness to successfully return.
One pathway guiding return-to-performance following injury was suggested by Mitchell and Gimpel5. This uses 11 phases from diagnosis and planning to pitch-based preparation. The previous pathway mainly focuses on physical function. It did recognise a psychological aspect to be considered and profiled but lacked specificity to empower practitioners to address psychosocial factors.
Psychosocial factors have important prognostic value in many sports injuries6,7. They are associated with failure to return to pre-injury competitive sport, reinjury and an inability to achieve full performance8-11. Despite this importance, many practitioners feel underprepared to address psychosocial factors12,13. Adding an explicit psychosocial framework into an existing pathway makes it more holistic. This would help develop biological, physical-functional and psychological readiness. Our article provides a psychosocial framework integrated within the pathway5.
Key Aspects of the Psychosocial Return-to-Performance Pathway
Research and applied practice were combined to develop the pathway with some important points in mind8,14-16. (Figure 1)
First, it is important to normalise considering psychosocial factors when helping injured players. Addressing psychosocial factors should form part of standard practice for mild, moderate and severe injuries, and not only be considered in challenging cases. Every phase now considers psychosocial factors (e.g., the typical characteristics of injured players and strategies that practitioners can integrate into their work). This content is intended to complement the original pathway's phases and profiling.
Second, in the early phases of the pathway it is likely practitioners will be addressing injury concerns in the presence of acute symptoms, load-vulnerable tissue, and loss of function (e.g., low movement efficacy). Performance concerns will likely be more evident later as players approach reintegration to training and matches, and want to positively contribute again (e.g., performing technical skills).
Third, we suggest profiling the psychosocial status throughout the pathway to inform shared decision-making on progression17,18. Profiling should include working knowledge of the player together with measures (e.g., inventories and scales), alongside biological and physical-function status19. Combining different measures is useful18,20-22 and may prevent socially desirable responses if the intention is to return to play prematurely (Table 2). Specific thresholds are suggested based on previous research, empirical evidence and applied practice23,24. Ideally, measures should be completed by practitioners, along with daily wellness monitoring measures (e.g., The Hooper Index; cortisol) and supported by referral processes aligned with the players setting25. Daily wellness monitoring examines the player’s relationship with stressors and their coping capacity to inform appropriate adjustments16.
Last, practitioners should be aware that psychosocial factors are individual and dynamic, and that physical and psychosocial recovery may have different timelines26. We advocate only progressing players when they are both physically and psychosocially ready11,25. Players may otherwise return to play with reduced performance and higher injury risk. (See supplementary files for the application of the psychosocial pathway to mild and severe injury examples.)
SPECIFIC ASPECTS OF THE PHASES
Diagnosis and Planning Phase “How quickly can I be back?”
This phase involves clinical assessments, treatment of acute symptoms, and diagnostic imaging. Players typically experience negative emotions due to physical signs and symptoms (e.g., pain, swelling, reduced mobility). The thoughts of missing opportunities and lacking competence to self-manage can lead to an exaggerated psychosocial impact (e.g., anxiety).
Practitioners should educate the player and manage expectations of the return-to-performance process. Not educating, or providing misinformation, increases fear, anxiety and helplessness. For example, practitioners often ask players “do you have any questions?”, without considering that they may not know the questions they should know the answers to. Providing players with a number of possible questions they can ask at appointments increases self-awareness27. This can be further enhanced by using clear non-inflammatory language that players can understand, is meaningful and reduces stress28. An interdisciplinary-team (IDT) meeting is essential to share diagnostic information, manage expectations, discuss contextual considerations, and clarify understanding.11 Making a social support plan so IDT members understand their roles ensures high-quality support throughout the process, avoiding fragmented or mixed communication29. Sharing return to running, training and playing criteria at this point is useful for long-term goal setting. It is important throughout the pathway that IDT meetings are psychologically safe environments with no fear of recriminations. Table 1 highlights how different IDT members can contribute throughout the pathway.
Acute Phase – Acute Management and Modified Conditioning “I feel useless just sitting here receiving treatment and no help to my team”
This phase focuses on continued treatment, carefully reintroducing movement to aid healing and maintain physical capacity in injured and contralateral limbs. Players may experience fear and low movement efficacy because of symptoms. Treatment and modified conditioning will likely be done away from teammates and coaches. This means players can feel isolated; adding stress and decreasing motivation30.
If there are injury concerns then education, stress management strategies, and ensuring social support are important considerations. Education may centre around lifestyle factors to facilitate healing (e.g., diet adjustments, sleep quality), the healing process, and intended action of treatment modalities31. Giving players stress-management resources (e.g., mindfulness) improves their ability to cope with potentially high-intensity, unfamiliar stressors16. Although practitioners are key social support providers during this time, regular interactions with teammates and coaches are also important30,32. Avoid scheduling treatments during important social times (e.g., arrival or lunch).
Gym Phase 1 – Early Loading and Normal Movement “I need to start trusting my injury”
This phase involves reintroducing load to restore functional movement. Players tend to realise the magnitude of the journey ahead and progress can appear slow, which can cause frustration. High-intensity symptoms should be resolved, so practitioners should be aware of players exhibiting lingering fear of movement (e.g., reluctance to complete exercise or compensate). Conversely, players with little or no pain and good range of motion may try to progress too quickly for load-compromised tissue. Early gym-based loading is often carried out at quiet times (e.g., non-injured players are pitch-based training) and this may make players feel isolated30. Understanding the player’s preference is key, as some players prefer to do their gym-based phases away from the team to avoid being viewed as weak.
Players need autonomy and agency, which can be improved by involving the player in decision-making31. Managing expectations around the experience of exercise (e.g., pain-threshold vs pain-free), the need to focus on motor control, and function of loading may help limit over-or-under motivation. Setting shared goals including phase-focussed and lifestyle-focussed goals improves adherence and gym-phase outcomes33. Opportunities for engaging with teammates should continue to be promoted. This might include taking on additional tasks, involvement in game analysis, and exercising alongside other injured players16. For some players, a rehabilitation residential, creating a change of scene can be beneficial34. In preparation for increasing load demands in Gym Phase 2, an IDT meeting (Table 1), ideally led by the player, should take place reflecting on progress, re-evaluating timeframes, evaluating readiness to progress, and addressing ambiguity35.
Gym Phase 2 – Reconditioning Pathways “Why is my injured leg so much worse than my non-injured leg?”
This phase involves prescribing specific and controlled loads to restore muscle capacity, strength, and power. Despite growing movement efficacy, players maybe fearful of increasing loads and velocities of movement in this phase36. This can lead to avoidant behaviours or compensatory movement patterns15. Adaptation to reconditioning loads takes time (e.g., addressing between-limb difference) and players may feel frustrated at their progress, with some trying to quicken their return to training or playing by being over-adherent (e.g., loading too much or too frequently)37. If scheduled away from teammates and coaches, players may feel growing isolation and not professionally valued.
Managing expectations is an important consideration in this phase. Some examples might be around timeframes for tissue adaption, the importance of recovery, likely muscle soreness, and maintaining movement quality with increasing heavy loads or velocities of movement. This phase is ideal for multifaceted goal setting, with lifestyle goals supporting recovery and adaption (e.g., protein intake)5. Reintegration into team-based strength and conditioning (S&C) sessions alongside their peers should be allowed, while considering injury limitations.
Gym Phase 3 – Return to Running “What happens if I do it again?”
This phase involves profiling the player's readiness to resume running and sport-specific actions in Grass Phase 1. Injured players should have growing optimism and psychological readiness about a near return to the pitch-based activities. There are risks for a player engaging with running too early without meeting necessary criteria to progress38. Anxiety can be expected about ability to progress and risk of reinjury, as everything the player has been exposed to has been highly prescribed. While this is not always detrimental, anxiety may manifest as under-adherence and over-concern about minor issues.
Reinforcing the achievement of criteria at this phase (e.g., via hop battery, isokinetic profiling) is important to develop psychological readiness39. Managing player expectations may regulate motivation as they are not quite ready for “normal” running, albeit they may be engaging in running preparation activities and anti-gravity treadmill running40. Sharing and using the return-to-running criteria as phase-based goals may boost motivation and self-awareness (e.g., achieve the movement retraining sessions, >80% performance symmetry index on plyometric and strength qualities)5. Players should feel empowered to “chair” IDT meetings to evaluate their progress, discuss concerns, and generate shared decisions35. Additional members of the IDT may provide further insight from performance-focused data to inform the player about progress and boost psychological readiness (e.g., sports scientists, performance analyst). Presenting data on effective movement kinetics and kinematics can reinforce movement efficacy. Here, the purpose of profiling is to inform the decision to progress to running. Using several measures is recommended to examine levels of psychological readiness and anxiety25. However, research suggests this is something rarely done at this phase41.
Grass Phase 1 – Re-loading and Technical Reintroduction “Running feels different than it used to”
This phase involves returning to the pitch to resume “controlled” running and low-intensity sports-specific skills before Grass Phase 2. As this is the first phase back on the pitch, there is likely excitement and optimism as activities look and feel more like soccer. The demands of running, together with many injuries occurring during a running-based situation, may mean some players experience reinjury anxiety42. This phase should see growing confidence in performance of drills and skills.
Practitioners should reinforce the player’s functional and performance achievements to continue the development of psychological readiness39. Education on how running will be progressed and how return to running may feel should provide reassurance and facilitate compliance33. Use of session and phase-based goal setting around running duration, volume, intensity, and frequency to help adherence20. Doing gym-based injury prevention and S&C sessions with non-injured peers can help reintegration, boosting feelings of support.
Grass Phase 2 – High-speed Running and Agility Drills “When will I get fast again?”
This phase involves increasing the volume and intensity of running, with planned and unplanned changes of direction. The introduction of “chaos” may mean players experience anxieties over reinjury and performance. For example, it is common for high-speed running to be a mechanism of non-contact soft tissue injury43. This may manifest as mentioning a loss of “sharpness” or inefficient movement strategies during high-intensity efforts (e.g., accelerating, decelerating, cutting). By the end of this phase psychological readiness to perform planned and reactive high-intensity drills should be improving.
Good coaching skills together with augmented feedback from video analysis and global positioning system (GPS) metrics will reinforce functional and performance achievements, reducing anxieties and improving psychological readiness39. Educating the player about intended load metrics on intensive and extensive days, progressive passing distances, and recovery from load should boost self-awareness and empowerment31. There should be an increasing amount of activities that can be completed with teammates and increased contact with coaches to foster a feeling of support and mitigate anxieties44. Contact with coaches is important to maintain the player-coach relationship, preventing potential unrest during the subsequent phases45.
Grass Phase 3 – Maximum Speed and Positional Drills “I feel rusty, and my touch is awful”
This phase is increasingly “chaotic,” restoring the ability to repeatedly sprint at maximum speed using position-specific drills. It is normal for players to experience performance-related anxiety as physical and cognitive loads begin to reflect match-play and coaches help co-construct and observe sessions46. It is important players demonstrate good psychological readiness in their performance of drills and skills during maximum-intensity drills whereby physical contact occurs with other ‘rehabbing’ players. Being psychologically underprepared is associated with increased reinjury risk and reduced performance10,47.
Feedback on functional and performance achievements from different members of the IDT (e.g., coaches, sports scientists) should boost psychological readiness39. One strategy is to repeatedly expose the player to the inciting incident to build confidence of a successful outcome should they be exposed to the same event (e.g., landing, cutting, withstanding contact)20. Carefully managed, introducing supra-optimal loads may also enhance confidence and decrease anxieties. As team training is the next step, players should be well-informed by medical and performance staff about the nature of this, and who to contact with concerns16. For example, explaining that team training will be “conditioned” may alleviate reinjury or performance concerns (e.g., moderating high-intensity loads, non-contact). In some instances, players will also want to over-train to return expediently; it is important that these same explanations are shared by the IDT to minimise any risk of injury or impeded progress. Readiness for training includes tolerating a high percentage of match load (>85%) and attainment of physical function criteria (e.g., completion of contact drills)5. Achieving these can also be indicative of being psychologically ready (e.g., not holding back).
Grass Phase 4 – Return to Training “I’m excited to be back but I feel like I’m holding back and have lost my power”
This phase involves being reintegrated back into team training. For moderate to severe injuries this should be “conditioned” to allow for incremental exposure to the “chaos” of match loads. At this point, emotions are likely to be positively toned, whereby the player will be naturally optimistic and excited from completion of previous phases25,36. However, a multitude of anxieties may present as the player nears playing, with most being performance-related15. This may be amplified with perceived pressure to play, comparison to their previously non-injured state or with non-injured peers. Players and coaches can become frustrated at not meeting the physical, technical or cognitive objectives of regular team training as both parties learn to “trust” each other again.
At this point, the expectations of the players, medical team and coaches need to align29. The shared focus should be on safeguarding readiness versus a “rushed” mentality16. For example, allowing engagement in training to take precedence above performance levels. Goals at this stage may be driven by achieving load and performance metrics from GPS or key performance indicators (KPI) in small or large-sided games. Psychological readiness will be enhanced by positive feedback from teammates and performance staff39. This is important as often psychological readiness scores stay lower even after several months of playing47. An IDT meeting is important to evaluate progress, consider benefits and risks of progression, and discuss contextual information around playing11. Medical staff still have an important role at IDT meetings when their contact time with the player is diminishing by challenging perceptions of others to gain well-informed and balanced impressions on readiness to progress (e.g., discussing further injury-specific work, playing “devil’s advocate”). Combining psychosocial profiling from several measures should be advocated to compliment technical and tactical impressions for well-rounded decisions (Table 2).
Grass Phase 5 – Return to Playing “I feel useful again, but I’m concerned about letting everybody down”
This phase involves gradual exposure to competitive match play. For mild injuries this can be expedited, but for moderate and severe injury this may take several weeks. As such, it is common for players to experience frustration with limited game time and the extent they can contribute to team performance. While injury-related anxiety should be minimal, some performance-related anxieties are likely. For example, reaction of fans, media criticism, letting teammates down, and restoring the coach’s “trust”. At this point players should be psychologically ready to play, otherwise they do so risking underperformance and reinjury10.
Managing everyone’s expectations at the point of returning to play is crucial as different IDT members may interpret differently what successful playing looks like11. Through an IDT meeting, the process of returning to play should be agreed with contingency options as the nature of competition is dynamic (e.g., event of limited first-team opportunities). IDT members should appreciate the contextual factors around playing, as these may amplify frustration and anxiety at this stage (e.g., coaching team change, contractual situation, value of competition). Performance-related goal setting is likely to manage expectations, maintain motivation, and further develop confidence16. For example, when it is realistic to regain pre-injury status and attaining specific KPI’s during reduced match play. One option to boost confidence and reduce anxiety is to integrate players in constrained competition (e.g., reserve/youth squads) where successes are more likely. Ongoing monitoring of psychosocial status is advocated for at least 2-months as psychological readiness has been found to be depressed several months after return to play5,44. Low scores may predispose players to reinjury and explain underperformance at this point10,49.
Grass Phase 6 – Return to Performance “I’m back in the starting line-up, and my metrics are higher than ever”
This phase is often a marker of success involving the player performing at or above pre-injury performance levels. Although return-to-performance is a primary goal for players and IDT members, it is not always easily achieved50. Pragmatically, some players may never reattain previous performance levels or it may take several months or years. At this phase, the player should have high psychological readiness and minimal performance or injury-related anxieties. By successfully navigating the pathway, the player should have increased body awareness and coping skills should they sustain further injury. This may improve adherence in strength and conditioning sessions and reduce risk-taking behaviours. Players who have sustained injury and successfully returned to performance could be used as role-models for teammates. For example, such players are likely to model adaptive behaviours such as adherence to injury risk reduction strategies51.
Even here, it is important to monitor the psychosocial status of the player. This will most likely be in the form of how non-injured players are routinely monitored (e.g., wellness, GPS metrics, KPI’s). Depressed performance metrics may be indicative of latent performance or injury-related concerns resurfacing, which can be further explored.
SUMMARY
Despite over 50 years of research on psychology of sports injury, the extent of which this has been implemented into practice is questionable16,41. It is often done implicitly; we attempt to make this more explicit and structured. Evidence shows that psychosocial factors are key to successfully returning to performance though little formal attention is given to them. By not considering psychosocial factors in our practice, we are missing an important piece of the return-to-performance jigsaw. Our proposed pathway includes both physical-functional and psychosocial perspectives. This should allow practitioners, who often feel underprepared, to more adequately recognise and address psychosocial factors. Outlining typical characteristics, practitioner considerations, and profiling throughout the pathway should make your management of injuries more holistic and facilitate better outcomes for players.
Dale Forsdyke1
Adam Gledhill PhD, CPsychol, FCASES2
Peter Schneider3
Dr Adam Weir MD4,5
Andrew Mitchell3
1 School of Science, Health and Technology
York St John University
York, United Kingdom
2 School of Sport, Exercise and Health Sciences
Loughborough University
Loughborough, UK
3 Medical Department
RasenBallsport Leipzig
Leipzig, Germany
4 Department of Orthopaedics and Sports Medicine
Erasmus MC
University Medical Centre
Rotterdam, The Netherlands
5 Sport Medicine and Exercise Clinic Haarlem (SBK)
Haarlem, The Netherlands
Contact: andrew.mitchell.gb@gmail.com
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