VOLUME 68

Competitive Athletes: Preinjury and PostinjuryMood State and Self-Esteem

AYNSLEY M. SMITH, R.N., M.A., MICHAEL J. STUART, M.D., DIANE M. WIESE-BJORNSTAL, PH.D.,

ERIC K. MILLINER, M.D., W. MICHAEL O'FALLON, PH.D., AND CYNTIDA S. CROWSON, B.S.

OCTOBER 1993

In a prospective study, we determined whether preinjury and postinjury differences existed in themood state and self-esteem of competitive athletes. The influence of severity of injury, gender, level ofparticipation in sports, and type of sport on these dependeut variables was also measured. Amoug 238male and 38 female athletes from hockey, basketball, baseball, and volleyball teams, 36 sustained 43injuries. Significant postinjury increases were noted for depression (P<O.OOOl) and anger (P =0.0012),whereas vigor (P<O.OOOl) was significantly less after injury. When the 36 injuries were classified, 27were minor or moderate (nonparticipation in sports for only one or two weekly assessments), and 9were severe (nonparticipation for three or more weekly assessments). When a stepwise multipleregression equation was used to predict the scores for postinjury depression, the only significantpredictor was the severity of injury (F =8.48 [1, 34]; R2 =0.30; P =0.0063). Of the following physicaland psychosocial variables-level of participation, type of sport, age, previous injury, preinjury stress,gender, mood state scales, and self-esteem-only level of participation (P<O.OOOl) and type of sport(P =0.0004) were predictors of injury. The significant preinjury and postinjury differences in moodstate suggest that postinjury mood disturbances reported in previous studies are likely attributable tothe occurrence of injury, are related to the severity of injury, and do not merely reflect a disturbedpreinjury mood.

Three to 5 million sports-associated injuries were treated inthe United States in 1984,I and the National Athletic TrainersAssociation reported in 1989 that 1.3 million US high schoolathletes are injured annually.' Although most previous re-

From the Sports Medicine Center (A.M.S., MJ.S.), Department of Psy­chiatry and Psychology (E.K.M.), and Section of Biostatistics(W.M.O., C.S.c.), Mayo Clinic Rochester, Rochester, Minnesota; and Divi­sion of Kinesiology (D.M.W.-B.), University of Minnesota, Minneapolis,Minnesota.

This study was supported in part by Mayo Foundation.

Address reprint requests to Dr. M. J. Stuart, Sports Medicine Center, MayoClinic Rochester, 200 First Street SW, Rochester, MN 55905.

search has focused on the physical aspects of sports­related injuries.r" studies have also been conducted to de­termine whether psychosocial factors contribute to thefrequency of injury.":" To date, however, the postinjuryemotional responses of athletes have not been thoroughlyexamined. 17-21

Until 1988, researchers's:" suggested that athletes' emo­tional responses to injury were similar to the staged re­sponses of patients who have been told that they are termi­nally ill, as described by Kubler-Ross," This hypothesis wasoffered in the absence of empiric research, even though theKubler-Ross model was based on interviews with elderly,dying patients and children with leukemia during an era that

Mayo Clin Proc 1993; 68:939-947 939 © 1993 Mayo Foundation for Medical Education and Research

940 COMPETITIVE ATHLETES AND INJURY

preceded effective treatment." Although existing loss-of­health models-<" may be helpful, investigators should beaware that the emotional responses of young, healthy pa­tients with acute pain, such as injured athletes," may differconsiderably. Even though sports-related injuries are rarelyterminal, injured athletes often require prolonged rehabilita­tion. Consequently, understanding the potential effects ofsuch injuries" and determining whether postinjury depres­sion, if present, will impede the rehabilitation process areimportant." An enhanced understanding of what injured ath­letes experience psychologically will enable health-care pro­fessionals to choose appropriate therapeutic strategies.P"

To learn about the actual rather than the hypothesizedpostinjury emotional response,Weiss and Troxel" askedathletes directly how they felt about their injuries. In anotherstudy," significantly increased tension, depression, and con­fusion and decreased self-esteem were noted in 30 injuredrunners who were unable to run for 2 weeks in comparisonwith 30 healthy runners.

Significant mood disturbance on the Profile of MoodStates" was reported in five seriously injured intercollegiateathletes.'? Our previous study in 1990,18 which involved 72injured recreational athletes, identified more tension; depres­sion, and anger and less vigor in the 23 most seriouslyinjured athletes who were unable to participate in sportsactivities from 6 weeks to 5 months. The two groups ofathletes with minor injuries had less mood disturbance thancollege norms, and the severity of injury was the most sig­nificant determinant of mood disturbance. More recently,British investigators studied 61 injured (41 male and 20female) and 61 noninjured sportspersons with use of newsubscales of the Profile of Mood States." When the scores ofthe injured group were compared with both those of thenoninjured sportspersons and the college norms, the injuredgroup was significantly more disturbed on every negativemood subscale.

Increased tension, depression, and anger and decreasedvigor have now been substantiated in injured runners," seri­ously injured recreational athletes," intercollegiate ath­letes,'? and other injured sportspersons." These emotionaldisturbances can persist and parallel the athletes' rating ofperceived physical recovery.18,19

One limitation of these prior studies was that they lackedpreinjury emotional profiles. Preinjury and postinjury moodstates were not directly compared; therefore, postinjurymood disturbance could not be attributed directly to theeffect of injury. In fact, one study described a subgroup ofathletes who had not only high preinjury stress but also poorcoping skills and who sustained a high incidence of injury .16

These factors raise the possibility that preexisting mood dis­turbance may have predisposed the athletes to injury, ratherthan the occurrence of injury causing a mood disturbance.

Mayo Clin Proc, October 1993, Vol 68

In the current study, we attempted to answer the follow­ing questions: (1) Were differences evident betweenpreinjury and postinjury mood state and self-esteem? (2)Did the severity of injury influence the mood state or self­esteem of competitive athletes? (3) Did mood state and self­esteem differ at various levels of participation within thesame sport? and (4) Did mood state and self-esteem differbetween genders or between athletes in different sports? Byanswering these questions, we hoped that the emotionalresponses of competitive athletes to injury would be betterunderstood.

METHODSDefinition of Terms.-For this study, a competitive athletewas defined as one who was on (1) a high school varsity orjunior varsity team, (2) a US Hockey League junior hockeyteam (seeking a scholarship), (3) a division I college team(most had received scholarships), or (4) a National HockeyLeague minor league team (players were dependent onthis sport for their livelihood). An injured athlete was de­fined as an athlete who had sustained an injury as a conse­quence of participating in sports, exercise, or a game. Forinclusion in this study, a sports-related injury must haverestricted activity for at least 1 day after the injury (a defini­tion from the American Medical Association) and promptedthe athlete to seek medical attention. Severity of injury wasdefined as the duration of nonparticipation in sports activi­ties, a definition used in our previous study of injured recre­ational athletes."

Study Participants.-The preinjury subjects, 238 maleand 38 female athletes from hockey, basketball, volleyball,and baseball teams, were invited to participate in a studyto determine how athletes feel before and after injury.The distribution of athletes by sport and gender is shown inTable 1.

Questionnaires.-The following instruments were usedto determine the athletes' preinjury and postinjury emotionalstate, mood, and self-esteem.

The Emotional Responses of Athletes to Injury Question­nairel8,32 was modified for use in this study: Form A was thepreinjury assessment tool, Form B was used immediatelyafter injury, and Form C was administered weekly afterinjury until the athlete resumed sports activities. Form Aassessed the athletes' perceived athleticism, sports prefer­ences, motives for participation, and sources of life stressand asked about previous injuries. Form B, which wasadministered only to those who sustained injuries, assessedeach athlete's perception of the injury, rating of perceivedrecovery, volunteered emotional responses to injury, and aranking of a list of emotional responses. Form C, an abbre­viation of Form B, was completed by injured athletes eachweek until they returned to full participation in sports.

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Table l.-8tudy Subjects and Injuries, Stratified by Sport and Gender,at Various Levelsof Participation

Levelof

No. of Injuries participation*

Sport Gender participants (no.) 2 3 4

Hockey M 127 25 21 23 24 59F 0

Basketball M 37 4 15 22F 24 3 II 13

Baseball M 74 2 74F 0

Volleyball M 0F 14 2 14

Total 276 36 21 63 24 168

*I =minor league hockey (National Hockey League); 2 =National CollegiateAthletic Association division I team; 3 =juniorlevelUSHockey League; 4 =highschool.

The Profile of Mood States" includes scales for tension,depression, anger, vigor, fatigue, and confusion and asks thesubject, "How have you been feeling during the past week,including today?" It can be completed in 3 to 6 minutes andhas been used previously for assessment of injured ath­letes.17~20 It was administered in conjunction with Forms A,B, and C of the Emotional Responses of Athletes to InjuryQuestionnaire.

The Rosenberg Self-Esteem Inventory" uses a 4-pointscale to measure 10 items that reflect global self-esteem. Itwas administered together with Forms A, B, and C of theEmotional Responses of Athletes to Injury Questionnaireand the Profile of Mood States. It also has been usedpreviously for study of injured athletes. L7

Procedures.-The current study was introduced at a pre­season team meeting, and the principal investigator orientedathletic trainers and team managers to the study. Participa­tion was voluntary; players signed consent forms, and thoseyounger than 18 years of age had to obtain their parents'signatures as well.

Athletes provided preinjury data (Form A packet) at theteam meetings, which were held within I week of the start ofthe competitive season. A code letter was assigned to eachathlete to ensure confidentiality. When injuries occurredduring the same season, the athletic trainers or team manag­ers (high school only) asked the athletes to complete theForm B packet. If athletes were still unable to participate intheir sports activities 1 week later, they completed the FormC packet, and this abbreviated questionnaire was completedweekly until they resumed full participation. The formswere placed in sealed envelopes and given to an impartialresearch assistant, who scored and entered the data into thecomputer.

Statistical Analysis.-Descriptive statistics were used toassess preinjury data, such as perceived athleticism and mo­tives for participation in sports, from the Emotional Re­sponses of Athletes to Injury Questionnaire. Boxplots andscattergrams provided a visual display of the data. Student ttests were used to determine differences in the pre­injury (Form A packet) and postinjury (Form B packet)mood scales and self-esteem; the scales of tension, depres­sion, anger, vigor, fatigue, and confusion were each exam­ined separately. Repeated measures were not done becausenot all subjects were in the study for the same period; con­sequently, the sample size differed on each measurementoccasion. Analysis of variance was used to test differencesamong various levels of participation in sports. When mul­tiple comparisons were done, the Bonferroni correction wasused to adjust for the increased likelihood of a type I error."

Logistic regression was used to predict injury on the basisof variables such as level of participation, type of sport, age,previous injury, history of stress, gender, self-esteem, andthe six separate Profile of Mood States scales. Multipleregression was used to predict postinjury emotional responseand self-esteem on the basis of such preinjury variables asself-esteem, mood state scales, level of participation, type ofsport, age, history of stress, severity of injury, gender, andprevious injuries. In both instances, stepwise procedureswere used to develop the final regression equations, andinteractions and higher order terms were evaluated.

RESULTSBecause of a collection error, postinjury data were unavail­able from the National Hockey League minor league team.Therefore, the professional team data (N = 21) were used forpreinjury analyses only and were excluded from preinjury-

942 COMPETITIVE ATHLETES AND INJURY

to-postinjury comparisons and from the multiple regressionequations.

Emotional Responses of Athletes to Injury Question­naire. Perceived Athleticism.-In an attempt to clarify theimportance of sports to the athletes, subjects were asked torate themselves on a Likert scale-from 1 (low) to 5(high)-for perceived athleticism. Overall, 92.6% of theathletes perceived themselves to be "extremely athletic" or"very athletic."

Motivation.-In an effort to determine the magnitudeand source of the subjective loss experienced when an injuryoccurred, athletes were asked to rank various preinjury rea­sons for participating in sports-from 1 (low) to 10 (high).Athletes at all levels of participation assigned a "10" mostoften to fun (38.4%), pursuit of excellence (17.4%), compe­tition (16.0%), goal achievement (12.9%), fitness (5.5%),self-discipline (2.7%), socialization (2.4%), outlet of aggres­sion (1.7%), weight management (1.0%), and stress manage­ment (0.7%). Items suchas "it was expected" and "I wanteda scholarship" were rarely chosen as explanations.

Preinjury Stress.-When 235 athletes responded towhether they had experienced stress in their lives during thecurrent season, 54 (23%) said yes and 181 (77%) said no.Stress was attributed (in decreasing order of frequency) tothe following factors: (1) sports-related concerns such as adifferent coach, a new team, and performance demands; (2)personal or family problems; (3) life changes, such as leav­ing home or starting college; and (4) previous injuries. Of

Mayo Clio Proc, October 1993, Vol 68

the 21 players on the National Hockey League minor leagueteam, 14 (67%) reported stress, 4 (19%) reported no stress,and 3 (14%) failed to respond. A major source of stress forthese players was having just been "cut" from the NationalHockey League team.

Previous Injury.-Of the 249 study participants whoresponded to the question of prior injury, 155 (62.2%) hadexperienced no previous injury during the past year, al­though 94 (37.8%) had had injuries during other years beforethe preceding year.

Were Differences Evident Between Preinjury andPostinjury Mood State and Self-Esteem?-The meanscores for all six mood scales and the Rosenberg Self-Es­teem Inventory are shown in Table 2 for all study subjects aswell as preinjury and postinjury values by gender. Preinjuryand postinjury Profile of Mood States and self-esteem scoresfor all injured athletes were assessed by using paired, depen­dent t tests. With use of the Bonferroni correction, P valuesof less than 0.0083 (0.05 divided by 6) were consideredsignificant. Although total mood disturbance scores arecustomarily reported, our clinical interest prompted us toexamine the subscales separately to minimize the risk ofoverlooking postinjury depression. Even when this adjust­ment was made to control for the possibility of type I errorinflation, postinjury depression (P<O.OOOl), anger (P =0.0012), and decreased vigor (P<O.OOOl) were still signifi­cant. Decreased fatigue (P = 0.0241) was not significant atthe corrected level of significance.

Table 2.-Preinjury and Postinjury Mood State and Self-Esteem Mean Scores (±SD)for Noninjured and Injured Athletes, Stratified by Gender

Overall Preinjury Postinjury

M F M F Total M F Total SignificantFactor (N =238) (N =38) (N =31) (N =5) (N =36) (N =31) (N =5) (N =36) difference*

Tension 11.9 13.0 11.1 14.6 11.6 11.8 17.8 12.6 NS±3.6 ±9.0 ±5.8 ±8.3

Depression 10.1 9.0 7.5 7.2 7.5 15.1 2604 16.7 <0.0001±7.5 ±8.9 ± 12.7 ±21.4

Anger 12.8 8.7 10.6 10.2 10.5 15.0 20.6 15.9 0.0012±7.2 ±8.5 ± 10.8 ± 16.9

Vigor 20.1 19.2 20.4 20.8 2004 16.1 14.8 15.9 <0.0001± 5.3 ±4.7 ±6.2 ±7.2

Fatigue 804 9.3 8.6 6.2 8.3 5.7 9.2 6.2 0.0241±6.3 ±5.5 ±4.1 ±7.1

Confusion 7.5 8.5 6.6 9.8 7.0 8.0 11.8 8.5 0.Q7±3.7 ±6.5 ±4.9 ± 5.1

Self-esteemt 34.7 34.0 34.8 32.6 34.6 34.5 32.9 34.3 NS± 3.3 ±5.1 ±3.6 ±5.2

*Between preinjury and postinjury scores. NS =not significant.tRosenberg Self-Esteem Inventory.

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Did the Severity of Injury Influence the Mood State orSelf-Esteem of Competitive Athletes?-Among the 36 ath­letes who sustained 43 injuries, 61 postinjury assessmentswere done. Only the first injury for each athlete, however,was included in this analysis (Table 1).

When the 36 injuries were initially classified by severity(on the basis of duration of nonparticipation in sports activi­ties), 23 were minor (group I-not participating in sportsduring one postinjury assessment), 4 were moderate (group2-not participating during two weekly assessments), and9 were severe (group 3-not participating during three ormore postinjury weekly assessments). Because no signifi­cant differences were found between groups 1 and 2 andgroup 2 consisted of only four subjects, these groups werecombined for further analysis and compared with group 3(Table 3).

When a stepwise multiple regression equation was usedto predict the scores for postinjury depression, the onlysignificant predictor was the severity of injury (F = 8.48[I, 34]; R2 = 0.30; P =0.0063). The most severely injuredathletes (group 3) experienced more postinjury depressionthan did groups 1 and 2. Gender, age, type of sport, level ofparticipation, previous injuries, preinjury stress, preinjurymood scales (on the Profile of Mood States), and preinjuryself-esteem were examined for inclusion in the multipleregression model but were not significant.

Did Mood State and Self-Esteem Differ at Various Lev­els of Participation Within the Same Sport?-Separateanalysis of variance studies were done with use of each of themood scales on the Profile of Mood States and theRosenberg Self-Esteem Inventory as dependent variables todetermine whether significant differences in these scoreswould be noted on the basis of level of participation inhockey. No significant differences were found between thelevels of participation on preinjury or postinjury mood scalesor self-esteem scores for hockey players.

In cases in which only two levels of participation wererepresented, such as in men's and women's basketball, inde­pendent t tests were used for the same purpose. In basket­ball, preinjury self-esteem scores for division I players(mean =35.80; SD =3.43) were higher than the self-esteemscores for high school players (mean = 32.57; SD = 4.20), adifference that was significant (P = 0.0016). After injury, nosignificant differences were noted in the mood state or self­esteem of basketball players at various levels of participa­tion. Furthermore, when multiple regression was used todetermine which variables predicted the postinjury scoresfor mood state and self-esteem, neither age nor level ofparticipation was significant.

Did Mood State and Self-Esteem Differ Between Gen­ders or Between Athletes in Different Sports?-Genderdifferences were examined only in basketball, which had

COMPETITIVE ATHLETES AND INJURY 943

Table3.-Comparison of PerceivedInjuries AmongAthletes,Categorized by Severity of Injury*

Groups I and 2 (N = 27) Group 3 (N = 9)No. of No. of

Injury athletes Injury athletes

Bruise 8 Sprained kneeStrained muscle 4 ligament 3Sprained knee Fracture

ligament 4 Stress 2Separated shoulder 4 Hand IGroinpull 2 Foot 1Ruleout fracture Dislocated ankle 1

of knee I Sprained or tomSprained ankle I elbow ligamentRuleout fracture

of foot IOther 2

*Severity was based on duration of nonparticipation in sports ac­tivities (longest for group 3-at least 3 weeks). See text forfurther details. Diagnoses listed are what the athletes believedmightbe wrong.

male and female study participants at both division I andhigh school levels.

No preinjury gender differences were noted for depres­sion, vigor, fatigue, and confusion. Significant preinjurydifferences were noted for anger (P = 0.0011); male athletes(N = 236) had a mean score of 12.8, and female athletes hada mean score of 8.7. When differences in level of participa­tion were examined by gender, division I male basketballplayers (mean =36.40; SD =3.18) had higher self-esteem(P = 0.0047) than did their high school male counterparts(mean = 32.60; SD = 4.24). Division I and high schoolfemale basketball players, however, did not demonstratethese differences.

The type of sport failed to predict changes in eitherpostinjury mood state or self-esteem.

In addition to the research questions addressed, a logisticregression equation was designed to predict injury as a de­pendent variable, on the basis of the following physical andpsychosocial factors: level of participation, type of sport,age, previous injury, preinjury stress, gender, all mood statescales, and self-esteem. Level of participation (P<O.OOOl)and type of sport (P = 0.0004) were the strongest predictorsof injury.

DISCUSSIONSignificant differences were found in certain preinjury andpostinjury mood states of competitive athletes-specifically,for the mood scales of depression, anger, and vigor, evenwhen the Bonferroni correction was used to adjust for mul­tiple comparisons. Furthermore, slight mean differences(Table 2) between all male study participants and the male

944 COMPETITIVE ATHLETES AND INJURY

athletes who became injured showed less preinjury depres­sion and anger for those who later sustained an injury. Thefive female athletes who became injured had profiles similarto those who did not become injured (Table 2). Thesefindings suggest that preexisting (preinjury) mood distur­bance was unlikely to have contributed to either the occur­rence of injury or the postinjury mood disturbance. Onmultiple regression, all six preinjury mood scales, theRosenberg Self-Esteem Inventory, and the presence of stressfailed to predict the occurrence of injury in these competitiveathletes.

Therefore, the significant postinjury increases in depres­sion and anger and decrease in vigor are most likely attribut­able to the injuries sustained. The results of these preinjuryand postinjury comparisons fortify earlier studies that usedthe Profile of Mood States'"" and concluded that postinjurymood disturbance was attributable to injury.

For the total group of injured athletes, the meanpostinjury fatigue score was lower than the preinjury value.When examined by gender, the preinjury-to-postinjury de­creases in mean fatigue scores occurred for male athletesonly. Preinjury fatigue may have been due to the stress ofpreseason tryouts, "dryland" training, weight training, andpractices deliberately designed to stress players to forceadaptation and a beneficial conditioning response. The de­crease in energy expenditure and the rest necessitated byoccurrence of an injury are possible explanations for thedecreased fatigue after injury.

In previous studies.Y" competitive swimmers showedmood states that increased in response to increases in. theinterval training workload and decreased in response to ta­pering of the schedule. These findings support the concept

Mayo Clio Proc, October 1993, Vol 68

that decreases in fatigue after injury might be attributed tothe imposed need for rest. Nevertheless, elite athletes in thecombative sport of judo failed to demonstrate increases innegative mood states in association with an increased train­ing volume." Furthermore, no significant changes werefound in the judo players when they were asked weeklywhether they experienced fatigue or how bothered they wereby injuries for the 2-, 4-, 8-, and 10-week intervals of incre­mental training activities. Although this research is impor­tant and relevant to conditioning of athletes, its relationshipto the prediction of or response to injuries for competitiveathletes in team sports has yet to be established.

In our current study, severity of injury was the variablemost predictive of postinjury depression (P =0.0063). Themost seriously injured athletes (group 3 in Table 3) wererestricted from and deprived of the benefits of participationin sports longer than athletes in groups I and 2. Thesefindings in competitive athletes support a previous study ofinjured recreational athletes," in which severity of injurywas the best determinant of postinjury depression. For com­petitive athletes, missing training, fun, competition, goalachievement, and opportunities for scholarships or beingreplaced on the team and facing a loss of livelihood areall consequences of injury that may affect the postinjuryresponse.

Among our study participants, mood state and self-es­teem differed only slightly with level of participation withinthe same sport. Preinjury data for four levels of participationin hockey are compared in Table 4. Although no largedifferences were noted, anger and fatigue were somewhathigher in the division I (level 2) athletes. This finding forfatigue may reflect the overtraining or conditioning differ-

Table4.-Comparison of Preinjury Mood State and Self-EsteemMean Scores for Four Levels of Participation in Hockey

and for Marathon Runners

Hockey-level of participation*

Factor

TensionDepressionAngerVigorFatigueConfusionSelf-esteemt

1:NHL

(N = 21)

14.012.412.520.67.48.1

34.2±3.9

2: 3:division I USHL(N = 23) (N = 24)

13.6 13.512.0 11.617.0 14.018.9 18.112.8 9.99.1 8.2

34.7 33.3±3.l ± 3.7

4:high school

(N =59)

12.710.813.620.9

7.57.8

33.1±4.1

Marathonrunners](N = 27)

10.56.87.9

21.16.97.4

*NHL=National Hockey Leagueminor league team; divisionI =National CoLle­giateAthletic Association; USHL= US HockeyLeague,junior level,

tThese data wereobtained by the first authorwithuse of the Profileof MoodStates.tMean scores(±SD)on the Rosenberg Self-Esteem Inventory.

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ences necessary during preseason to achieve the desiredaerobic and anaerobic fitness appropriate to each level ofparticipation. The reasons for increased mean anger scoresare unknown but may reflect the physiologic and sociologicconditioning of players in a rough contact sport. Similarfindings have been reported in wrestlers; the explanationoffered was that anger might represent an adaptive mentalset. Further research with athletes in contact sports is neces­sary to determine whether the increased anger reflects thecombined effect of physiologic and psychosocial factors."

The appropriateness of using the Profile of Mood Statesfor athletes in contact sports might also be questioned. Forexample, items such as "ready to fight" offered as an indexof anger may be rated positively by players in sports such ashockey, in which a willingness to fight is considered toconfer an adaptive advantage. The influence of this itemmay also have contributed to the mean preinjury genderdifferences noted on the anger subscale (Table 2).

In basketball, the higher self-esteem found in male ath­letes in division I in comparison with that in the high schoolplayers may reflect a college player's perceived status andcompetence. Considerable attention is paid to division Icollegiate basketball players; at the beginning of the seasonwhen these data were collected, expectations may have beenhigh. This finding may also reflect ethnic, social, or culturaldifferences because substantial racial diversity was notedonly in this sport. In our study, the high school players werewhite and from a midwestern, professional community,whereas most division I athletes were black and primarilyfrom other geographic areas. No differences in self-esteemwere noted for "level of participation" comparisons in fe­male basketball players, although the racial representa­tion was almost identical to that among the male basketballplayers.

No significant preinjury-to-postinjury differences werefound on the Rosenberg Self-Esteem Inventory; this resultdiffers from that reported by Chan and Grossman," whofound that injured runners experienced a decrease in self­esteem. Differences in personality, a recreational versuscompetitive athlete orientation, the motivation for partici­pation in sports, or a variability or vulnerability in theself-esteem of runners may have caused these divergentfindings.

Neither gender nor type of sport was a significant pre­dictor of postinjury mood state and self-esteem in our study,although level of participation and type of sport were thestrongest predictors of injury. Studies in hockey'v" (StuartMJ, Smith AM. Unpublished data) have found that theinjury rate per player per year increases dramatically fromyouth leagues to high school, college, and professionalteams, a phenomenon believed to be a function of playersize, speed, lack of protective equipment, collision forces,

COMPETITIVE ATHLETES AND INJURY 945

and tolerance of illegal physical activities, which increasewith level of participation. These factors and the increasednumber of games and practices collectively amplify the riskof exposure and explain why injuries occur more frequentlyat higher levels of competition than at lower levels. Thefailure of mood state, self-esteem, preinjury stress, age, andgender to predict injury in this study suggests that, in hockey(the sport in which most injuries occurred), the causes ofinjury were primarily biomechanical.

Although this study was not designed to test the Andersonand Williams model? or the Wiese-Bjornstal and Smithmodel," psychosocial predictors in the logistic regressionequation failed to predict injury. Only severity of injurypredicted the emotional response. Because of the timingbetween mood assessment and injury, the influence of mood(for example, fatigue from overtraining) and otherpsychosocial factors on occurrence of injury is unclear andwarrants further investigation.

In our current study, preinjury and postinjury differencesin competitive athletes were found, which addressed a limi­tation of our previously reported analysis of recreationalathletes. 18 Furthermore, other studies to date that have re­ported the emotional responses of athletes to injury lackedpreinjury information for comparison. The severity of theinjury (perceived by the athlete and related to the duration ofnonparticipation in sports activities) was the best predictor ofpostinjury depression, a result that replicated our findings ininjured recreational athletes.

Health-care professionals must be aware that athletes canhave profound responses to injury (as evidenced by the largestandard deviations for depression and anger found in ourcurrent investigation). The suicide attempts of severalyoung athletes after serious injuries have reinforced ourbeliefs that prompt detection of depression is important andthat psychiatric referral is sometimes necessary."

The potential influence of injuries on athletes must beunderstood to help athletes to overcome depression andprogress to an optimal rehabilitation program.28.29.31,32 Inas­much as severe depression is often associated with decreasedenergy, seriously injured depressed athletes may lack moti­vation for what is often an arduous rehabilitation program.Once mood state improves, athletes may be receptive tolearning about setting goals, positive reinforcement, andhealing imagery, factors that may facilitate healing.v-" Be­cause of the current cost of health care, methods to acceleratethe healing process and help athletes make wise decisionsabout returning to school, college, professional sports, andwork must be viewed as having both economic andpsychosocial benefits.

One limitation of this study was that, even with 13 athleticteams involved, the number of injuries was insufficient inbasketball, volleyball, and baseball to allow statistically

946 COMPETITIVE ATHLETES AND INJURY

meaningful comparisons of levels of participation and be­tween-sport differences. Multicenter prospective researchtrials with a focus on sports with both male and femaleparticipants and high injury rates, such as football, hockey,gymnastics, soccer, and cheerleading, might address thislimitation. Factors indicative of psychosocial stress shouldbe measured at specified intervals throughout the season todetermine whether sports-related stress (overtraining) orother stressors contribute to occurrence of injuries. Morefrequent assessments would allow mood states to be moni­tored throughout training and would provide a model bettersuited for distinguishing between the emotional responses toacute and to overuse injuries.

CONCLUSIONThe current study incorporated several important features inits design. It was the first report of preinjury and postinjuryemotional profiles of athletes determined with use of thesame psychometric instrument. This multidisciplinary studywas blinded to the primary investigator to eliminate bias indata measurement. Because team athletic trainers collect­ed the data, athletes had no motivation to report responses ina manner pleasing or socially acceptable to the primaryinvestigator.

Injured competitive athletes demonstrated significantlyincreased depression and anger and decreased vigor in com­parison with their preinjury profiles, a finding related pri­marily to the severity of the injury. The findings in this studyare consistent with our earlier work on injured recreationalathletes, a result that suggests that injured competitive ath­letes experience an individualized, integrated emotional re­sponse that is generally proportionate to the severity of theirinjury.

ACKNOWLEDGMENTWe thank Dr. Bernard F. Morrey, Dr. Thomas D. Rizzo, Jr.,Dr. Gerard A. Malanga, and Dr. Hugh C. Smith and theathletic directors, coaches, and athletes who participated inthis project. Athletic trainers Leah Wollenburg, RobertBroxterman, Roger Schipper, Kathy Czeh, Sally Shuster­Shoff, Lisa Cook, Hope Holly, and Will Fish also providedassistance. Michael Morrey and Linda S. Gentling assistedwith data collection and data entry, and Connie Bruce orga­nized the data.

REFERENCES1. KrausJF, Conroy C. Mortalityand morbidityfrom injuries in

sports and recreation. Annu Rev Public Health 1984;5:163­192

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