Mindset around performance, sport injury and recovery in female athletes.

Dr. Arianna Gianakos’s comments, an orthopaedic surgeon who specializes in sport-related injuries of the foot and ankle, about the role of mindset in women sport.

May 20, 2024

Mostafa Sarabzadeh [WomenSportPress] Although the term of "psychology" may initially be considered as a major deal with mental disorder, the term actually encompasses a set of traits and behaviors that may significantly contribute to an individual's athletic success.

In fact, the mental level of a male or female athlete is as important in determining that individual's ability to endure and perform as other physical assessments such as height or fast-twitch muscle fibers. So that most of the time this factor determines the result of the match as the main director.

Much numbers of research has been done in this regard, but the research study recently conducted by Dr. Arianna Gianakos and her team from Department of Orthopaedics & Rehabilitation based in Yale School of Medicine, USA, presented many up-to-date valid points in the injury prevention and rehabilitation of female athletes.

Arianna was All-American Athlete, former collegiate basketball player, and track and field athlete, and is currently an orthopedic surgeon and specialist in lower limb sports injuries, which a part of her talk with AfraSport on the psychology of women's sports injuries is as follows:

Mental endurance (resilience)

Psychological resilience has been defined as “the role of mental processes and behavior in promoting personal assets and protecting an individual from the potential negative effect of stressors.” In fact, these individuals are able to continue to grow and perform in the face of hardship despite experiencing adversity.

It has been reported that the greater the mental endurance of a female athlete, the less likely she is to give up, get bored, get injured and drop out. This factor is even more important when we are working with young and female athletes than when our target population is male athletes.

So the question is, Arianna, have you ever struck by seeing a patient's recovery went beyond your expectations with no medical explanations but her / his incredible resilience ? I'd like to get some firsthand information of the amazing comeback stories you may have come across to?

Arianna Gianakos: such experience was usually a lot, but I don't remember a specific case as an example to state now. You know, resilience and grit are two factors that can play a role in an athlete's return to sport.

While healing must occur physically, this must be accompanied by psychological healing as well. It can be difficult for an athlete to return to the activity that caused the injury in the first place. Rehabilitation protocols must focus on this resilience and grit aspect of returning to sport so that athletes can feel comfortable and confident returning to play. Mental toughness can help an athlete recover more efficiently and with overall better mental health and wellness. That is why resilient individuals seem to employ more problem-focused coping skills such as seeking information and/or assistance with handling a stressful situation, removing the source of the stress and/or removing oneself from the stressful situation.

On the contrary, non-resilient athletes are more likely to manage stressful situations with emotion-focused coping behaviors. Therefore, understanding this skill is very important for women coaches to differentiate athletes with a high risk of negative emotions from other athletes to consider specific stress-relief practices for this group.

Do you think it has its own impact on recovery as well? And how do you think women athletes with negative emotions should be identified during recovery to have a better comeback to sport?

Arianna Gianakos: Yes, it is definitely true that emotions should always be controlled for success. To do so, questionnaires can be useful in evaluating people with mental abnormalities or In other way, in mentally returning to sports. We typically use a modified version of the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) Questionnaire which addresses the emotional component. As long as the results are not ideal, the person cannot be allowed to return to the main routine exercises.

I think further research is necessary to better understand the right questions to ask so we can better help our athletes mentally return to play.

Looking back at the stories of female athletes, they have had more experiences of being the victims of bullying behavior, arrogance, suffering from eating disorders and sustaining sports-related injuries. Arinna, with keeping all these in mind, do you think we should prescribe different rehabilitation protocols for women to transform these women athlete-specific obstacles into tools for personal and professional growth ? Have you ever noticed how this factor affects recovery or comeback process of female athletes?

Arianna Gianakos: I think you raise such a critical point. Rehabilitation protocols need to be holistic and need to not focus just on the physical injury alone.

Talking about an ideal approach, a multi-disciplinary approach can be utilized including surgeons, primary care physicians, physical therapists, trainers, nutritionists, gynecologists, and psychologists (and others) to work together to provide our athletes, particularly our female athletes with the right tools to overcome all the various obstacles they face during the post-injury and rehabilitation period.

Another area unrelated that we need to improve is the way we portray our athletes in social media. Social media creates unattainable standards and a false reality which contributes to lower self-esteem and negatively impacts mental health, specifically in women athletes who, according to research, are even more susceptible to such injuries than men athletes by two times.

As your recent study and other studies in the field have reported, common injuries affecting female athletes---even more than men---include overuse, anterior cruciate ligament (ACL) rupture, ankle sprain and instability, and shoulder instability. Do you think, generally speaking, this vulnerability of women to such injuries are more results of hormonal, biomechanical and neuromuscular, or psychological differences between women and men?

Arianna Gianakos: I guess to answer this kind of question, much research needs to be done. I believe though these differences are a result of all those factors - hormonal, biomechanical, neuromuscular, and psychological. Our research says women tend to have increased ligamentous laxity which has contributed to higher rates of ACL injury and ankle sprains. In addition, studies have demonstrated differences in basic walking gait as well as running gait patterns between men and women. In order to better manage our athletes, we need to focus on these differences and understand how the rehabilitation process can be tailored to the individual. This case can also be an answer to an earlier question we talked about differences in training programming based on gender, and it reminds us that especially in training programming for female athletes due to the higher level of their vulnerability and longer recovery, neuromuscular and strength exercises should be used in a monthly training model.

The role of psychological interventions, mindfulness and mental relaxation, should be taught to female athletes at a young age (adolescence).

The basic and inherent or acquired mental relaxation ability through exercise can have significant positive effects on the performance and health of athletes.

The courses of the meditation training program for female athletes have always brought significant results and in many sports teams, and it has caused a change in the athlete's behavior or a different relationship with sport-specific emotional tensions. This shows how mindfulness exercises can complement resilience as a potential positive stress coping behavior to help our athletes in facing adversity.

Mindfulness can shape how athletes process and react to physical feelings as well as emotions. Research even has shown how mindfulness can mediate the relationship between mental toughness and pain catastrophizing for injured cyclists. These practices enabled these athletes to moderate their reactions to their surroundings, adapt to the challenge faced and ultimately persevere.

As mentioned earlier, we have innate quality of mindfulness as well, other than learned or practiced mindfulness, which its negative association with pain catastrophizing, stress hormone (salivary cortisol), muscle spasm, anger, rage, and its positive correlation with mental toughness, attention control and admitting failure, has been reported.

So talking about the role of psychosocial interventions on return-to-sport / re-injury in female athletes, do you think the age is matter? I mean the more younger, the more benefits come out of these practices?

Arianna Gianakos: To answer this question, it is better to take a look at the research of Webster et al., which was published in AJSM in 2018. They reported that being male and being younger were contributing factors in improving psychological return to sport. You know, It is really hard to draw conclusions as to why age may be a factor, although depending on the age group, younger athletes may feel that have a lot more athletic career ahead of them. With that psychological perspective, this may allow them to approach their rehab with a more positive outlook and attitude which translates into success. I think that regardless of age, individualizing rehabilitation and taking into consideration the various psychosocial aspects of return to sport and using various strategies and techniques to aid in return will ultimately be the most critical factor to allow athletes to get back into their game.

Sleep habits

Another important factor that affects not only the physical performance of a female athlete, but also her mental state is sleep. In fact, sleep has been reported to both enhance athletic performance and protect athletes from sports injuries.

In recent years, a study conducted on the sleep habits of 26 professional female gymnasts, showed that there are significant relationships between the reduction of the total sleep time, the increase in the training load, and finally poor sports performance. These findings support the principle that adequate sleep during recovery is critical to maximizing an athlete's ability to compete. On the other hand, limited sleep can be a risk factor for musculoskeletal injury, and this has been proven in numerous studies.

Moreover, sleeping for six to eight hours, with at least two hours being before midnight, reduces the possibility of sports-related injuries by 61%. Therefore, sleep hygiene should be included in an athlete's recovery and rehabilitation program to help prevent or recover from injury.

It is not easy for the coaches of women's sports teams to recognize these cases, but apart from the things that Dear Arianna mentioned, such as questionnaires and clinical interviews, I guess observational skills of high-experienced coaches can also be helpful to identify high-risk athletes and to plan specific training to deal with it. I mean when you notice an athlete who is strangely constantly complaining about everything and showing unstable mental states, this athlete will clearly not be ready to go under heavy training loads, and this is where you have to know that the potential for injury is extremely high.

Anger and depression

When we talk about anger and depression, not only in athletes, but also in society, women suffer from these disorders more than men. A recent study has shown that women athletes suffer from depression and anxiety almost twice as much as men athletes. The reasons seem to be high performance expectations, overtraining, unwanted injury, or even leaving a sports contract undesirably.

Even at the early age of entering professional sports, this vulnerability to psychological tension has been reported to be high in our girls, with the greatest risk for single-sport athletes. Many studies have suggested that team component is protective against such development of anxiety and depression. It appeared that working with a team gives an athlete a constantly present support system during training and in competition, which may be therapeutic in overcoming obstacles and processing adversity in sports.

This means that even in individual sports, there are many ways to work as a team, so that the athlete can feel that supportive social network constantly during the training and recovery season. There are also defensible literature in this respect that have even reported that the recovery time from the injury in female athletes who had symptoms of aggression and depression, was twice as long as their teammates, Dr Arianna Gianakos said. Coaches have to understand the importance of this fact that how badly a double time in professional sports’ recovery---where seconds can dictate result of the match---affects several games or an entire season for an individual or an entire team.

Fear of reinjury and return to sports

It is unlikely to talk about the appropriate recovery program in general, because the influencing variables differ from person to person and depend on several factors, including the personality of the athlete, the type of injury, the emotional and physical trauma caused by injury, and the length of time the athlete has been away.

However, for some endurance athletes, returning to exercise can cause severe anxiety. It is worth mentioning that when we are uncertain about the future, we can feel anxious. This may happens in post-recovery time because of the doubts about whether the injured body part would be strong enough after rehabilitation.

You know Arianna, experiencing anxiety is unpleasant and may lead our athletes to focus on negative thoughts. I mean things like negative ifs: What if I get hurt again? What if I can't get back to my routine level? What if I expose compensation for secondary damage? As my last question, let's talk a little about the solutions to overcome these post-injury negativities?

Arianna Gianakos: Yes, this is normal to some degrees that some athletes, especially women, may get completely caught up in negative thoughts upon their return to training and competition.

To help overcome these negative thoughts, in addition to the mental exercises supported by the new research, there are some practices that these athletes and coaches can benefit from in post-recovery time. In general, full-control pain-free exercises should be done under the supervision as start, and then if we saw no discomfort and acute pain of the athlete’s body, low-intensity activities such as swimming, cycling, rowing could be freely done, depending on the type of injury. Equipments such as exercise simulators, balance makers, jump makers, steppers and cross trainers as well as cold water therapies could also be considered as supplementary post-injury rehabilitation to prepare our athletes mentally and physically better for a successful return to sport.

Considering all these, along with psychological therapies mentioned earlier, our female athlete can successfully complete the last phase of the recovery period, which is very important in reducing the athlete's fear and worries of re-injury in returning to sports.We all know, the increase in women's sports participation, accompanied by other women sport-specific factors we talked about earlier, has led to an increase in the numbers of specific injuries in female athletes, with higher rates than men.

For example, overuse injuries are more common in female athletes than the other injuries, and than in similarly aged male athletes. Other common injuries affecting female athletes, as reported by research, include anterior cruciate ligament (ACL) rupture, patellofemoral pathology, ankle sprain and instability, and shoulder instability.

The ACL tears are also 2 to 8 times more common in female athletes than in their male counterparts, showing our sport professionals should act accordingly by adding individualized compensatory strategies to avoid such common injuries in women sport.

When we talk about invasive treatments, female athletes need surgical interventions more than their male counterparts, the reasons could be attributed to hormonal and anatomical, biomechanical and neuromuscular differences, in addition to what was said about the psychological pressures specific to women.

Therefore, I would say the anatomical and biomechanical evaluations of women's bodies, which have many differences in the joint angles and muscle structures, should be an integral part of pre-season’s athlete women preparation, to schedule as much tailored and efficient as protective training programs every women athlete need.

At the end, I would recommend you all to keep in mind that rehabilitation in sport, specifically with women as our target population, should be multidisciplinary, and psychologically speaking, may include, but not limited to, relaxation and/or guided imagery, positive self-talk, goal setting, counseling, emotional and/or written disclosure, and modeling videos.

Thank you so much Arinna for accepting my invite for this interview and I wish you all the bests.

Arianna Gianakos: it’s great to see you and be part of your wonderful works—best wishes