THE PSYCHOLOGY OF AN INJURY

Injuries are the plague of all athletes, and this includes all weight-training athletes from recreational trainee to bodybuilders, powerlifters and Olympic weightlifters. They can range from minor nuisances to devastating, career-ending muscle tears or ruptures.
A severe injury generally requires a prolonged and specific period of planned rehabilitation, during which time the recuperative ability of the injured area is taxed and what was once easy to perform seems completely out of reach. This taxes the athlete’s patience and creates a variety of psychological responses. Some of these are expected and normal and will resolve in a healthy manner. Others, unfortunately, are inappropriate and should be of concern to the injured trainee’s physician, family and friends.
Physical rehabilitation requires a variety of therapy methods to address the specific diagnosis and all the relevant factors, including the skills and demands of the patient’s particular sport. The goal in sportsmedicine is to return an injured athlete to competition as soon as it is safely possible, which is not as simple as it sounds. The athlete must be as active as possible while still being clinically safe. Too much too soon or too little too late will set him or her back in recovery.
Every health care provider has to deal with the frustration and despair of the injured trainee. This month I asked sports psychologist Michael Brannon, Psy.D., to help explain this complex subject. In addition to his knowledge of psychology, Brannon was a powerlifter for 15 years, an amateur wrestler for 12 years and a professional wrestler for 10 years. He is currently in practice in Plantation, Florida.
“There are common patterns of reactions to injuries,” Brannon began. “Athletes react to losing their sport as if they were reacting to death and dying. It is not quite that extreme, but it is analogous. There are stages of denial, anger, bargaining, depression and acceptance. The emotional intensity of the reaction to the injury is proportional to the self-identity with sports. If they identify strongly with the sport, the reaction is usually severe.
“The loss is the biggest factor if the athlete is not able to train. The support group of friends and training partners provides a positive reinforcement. The injured bodybuilder who is unable to train does not receive reinforcement of the pump, growth or training pain. The bodybuilder has a great deal of control and independence in his or her life. The control is demonstrated in the diet, training and sleep, [and it] is a powerful factor. Once the severe injury occurs, the physician or physical therapist is telling the bodybuilder what to do.”
At the Soft Tissue Center we see trainees who have what appear to be normal reactions and others who seem very hard to reach. Those who are hard to reach and behave inappropriately seem to have a slower recovery.
As Brannon explained, “The healthy reaction is usually a lack of compliance due to the denial stage. “No pain, no gain’ and ‘It will go away’ are the prevailing attitudes in the early stage of denial. Acknowledgement of the injury means time off from training. This is difficult because the bodybuilder’s self-esteem is wrapped around the perception of body size. This is known as an athletic body image disorder comparable to anorexia nervosa. The mirror is distorted in the mind. This creates real problems. One week off equates [in the mind of the injured bodybuilder] to seeing drastic changes in the mirror.
“A big factor in the psychological response to an injury is the athlete’s health prior to the injury,” Brannon added. “The age of the patient is a key factor. The same injury may be seen as severe in a young athlete, but in an athlete who is older it may be definitely career ending. There may simply be different responses to the same injury in similar patients. One athlete may perceive the injury as career ending, while another may perceive it as a normal course in [his or her] career.”
The question is, then, What is a normal reaction vs. an abnormal reaction? “There is behavioral, emotional or cognitive [thinking] reactions, Brannon said. “Normal reaction to an abnormal situation, of a behavioral type, may include isolation, increase of bad habits [like the use of drugs and alcohol], forgetfulness, argumentative tendencies and a loss of interest in other areas of life. The normal emotional reaction will lead to moodiness, distractibility, guilt---ie., ‘Should I have warmed up?’ or ‘Why did I do that exercise?’---depression, anger, nightmares and sleep disturbance. The cognitive normal reaction is the negative mind-set---ie., ‘I’ll never be the same again,’ ‘Why me?,’ ‘Is the pain ever going to stop?’ and ‘I’ll never be where I was.’”
Health care providers in sportsmedicine deal with these patient emotions on a regular basis. Their symptoms are still considered to be normal reactions to an abnormal situation. The abnormal reactions are another story.
“The abnormal reaction to an abnormal situation will demonstrate exaggerated and severe moodiness, fistfights, life being perceived as worthless, lack of socialization, continual angry outbursts with family and friends and the exhibition of psychological signs of no adjustment to the injury,” Brannon said. “No progress is fast enough for this person. Isolation may dominate. Alcohol usually becomes a bigger part of the picture. Other signs include hyperactivity, progressive loss of sexual activity, lack of compliance with the rehab schedule and even behavior that is counterproductive to rehab. The patient may change to another doctor for ‘the right answer.’ There is a cognitive breakdown.”
As there is rarely one simple answer with such patients, other issues must be examined. For example, if patients don’t recover, they may use the injury to escape doing things that they don’t want to do. The injury may even be used as a weapon against a spouse or family members. Both adults and children can get caught up in this; some are aware of what they’re doing, while for others it is subconscious behavior.
I must emphasize at this point that these symptoms are not for the pop psychologist or person who studied “psych 101” in college to attempt to deal with. This is a clinical problem, and it must be handled by a clinical professional, either a psychologist, a psychiatrist or a marriage and family counselor.
There is another issue that we touched on previously -- exercise addiction. Bannon described this behavior as a negative reinforcement model; that is, the behavior, in this case the exercise, is increased to avoid something that is perceived as negative. The exercise controls the person; the person does not control the exercise.
“These people tend to be more restless, anxious and depressed,” he continued. The [person feels] euphoric [during the exercise], and after it the person feels drained and more relaxed, and the metabolism and the psychological arousal state decrease. They will experience withdrawal symptoms if they are not able to work out. The moodiness and nervousness increases, and they ‘can’t live without it.’ This is dangerous when they are injured. There is no motive for health, well-being or appearance. The factors outside of exercise must be addressed. This group has the lowest compliance of all. If you have a patient who is running with stress fractures, you must question if this is exercise addiction.”
If you’ve been around the gym long enough, you’ve probably heard every type of rationalization in these situations. I have heard from injured patients that so-and-so or Mr. Whatever said that you must “work through the pain” — “no pain, no gain” — and other such trivial trash. Some trainees are not capable of distinguishing between what we call normal muscle burn and abnormal joint and tendon pain, and there are a variety of overuse symptoms that they also fail to recognize.
“Unfortunately, many champions display mild exercise addiction,” Brannon said. “They may also be unhealthy both physically and psychologically. They must retire sometime. If they have not balanced their lives, their lives may become closed books upon retirement.”
I suspect that none of you wants your training efforts to end in such a tragic situation. Very few trainees ever compete in anything, and of those who do, few are of state or national caliber. Literally a handful are elite, world-class athletes, and of that handful there is usually only one champion per year in any sport. It is unrealistic for the majority of us to copy the workout schedules of professional athletes. It’s not the workout that makes an athlete an elite champion; that person had the necessary qualities, and he or she trained hard as well. Training in itself does not produce the prerequisite characteristics.
Please don’t misunderstand these last comments. Weight training is a tremendous form of exercise. Olympic weightlifting, powerlifting and bodybuilding are great sports as well, but remember that less that 1/100 of 1 percent of weight trainees compete.
Don’t arrange your life around an unrealistic schedule. Structure intelligently planned workouts and, most of all, enjoy them and the rewards they bring. If you find yourself becoming obsessive about your training, step back and ask yourself why you’re doing it in the first place and whether you’re taking the appropriate steps to fulfill your goals. Do you have goals? Are you treating recreational training as if it were an Olympic regimen? Are your job and family suffering because of your workouts? Maybe you should ask the people around you how they feel about your attitude toward your workouts. As with anything else your training may require a little juggling of time to fit it in, but it should not control your life.
Exercise addiction is a major issue in sportsmedicine. If your attitude toward your training has remained healthy, then you’ll continue to derive the benefits of a terrific form of exercise. If you’ve lost your way and this type of destructive behavior is controlling your life, please seek professional help. If you have friends or family members who fall into this category, approach the situation with tact and concern. You may need the assistance of your family doctor, minister, school counselor or a respected family member. Even so, the most important factor is that people who need such help must decide for themselves that they want it.
Until next time train hard — and above all train smart.
Author:
Joseph Horrigan, DC, DACBSP, CSCS
Originally published in IRONMAN Magazine December 1992
Updated by author February 2004

:)