More Than a Physical Injury — Why Sports Medicine Prioritizes Mental Health

Whether a football player misses several games after a knee injury or a volleyball player tears her ACL and won't get to play her senior season, the Sports Medicine staff is a dedicated support system. Cody Walker, supervisor of Sports Medicine at Arkansas Children's Hospital in Little Rock, has been an athletic trainer for eight years, the last five at ACH. Many athletes have a stigma that they have to be tough and unbothered by an injury. But it's common for those facing months of healing to struggle mentally.

"I think one of the things that I try my hardest to remind my team of is providing holistic care. Let's not just forget about a kid's mental or emotional state," Walker said of his team of athletic trainers and some part-time PRNs. "That's just as important as making sure that their ankle or their knee or shoulder is fine."

How is an athlete's mental health assessed?

Arkansas Children's Sports Medicine, both at ACH and Arkansas Children's Northwest in Springdale, is dedicated to treating and preventing injuries. In 2021, there were 6,399 visits to Sports Medicine in Little Rock and 654 in Springdale.

Most ACH Sports Medicine patients are 11 to 21 years old, the most active years for sports and the possibility of a sports injury. Many children, teens and young adults base their identity around their favorite sport, wearing athletic apparel or sharing their highlight reels on social media. When it's taken away from them because of an injury, it's mentally jarring.

"They kind of forget that they're more than just an athlete. Our job is to take care of the physical side of injuries, but there is this emotional side they have to cope with," Walker said. "And so just helping them through that, that their identity isn't solely on the sport that they play, or what they do on the athletic field. It's also what they do in the classroom, what they do at home, what they do when they're with their friends. All that plays into who they are, not if they're on a certain position on a team."

The ACH clinic treats each patient uniquely. When an injury requires a lot of rehab and follow-up appointments, they assess mental health organically, said Dr. Michael Israel, director of Sports Medicine at Arkansas Children's Hospital in Little Rock and associate professor of Orthopedics at UAMS. Instead of bombarding patients with a bunch of questions on a sheet of paper, Israel said it's better to get children and teens talking. Some general life questions can include:

• How is school going?
• What do you like to do for fun?
• Are you sleeping at night?
• What are your concerns?
• What are your favorite sports?

"So we look for kind of the soft signs that there might be some underlying mental health issues that need to be addressed. Sleep is a big one. If kids are having problems sleeping, sometimes it's just being a normal teenager, but sometimes it is due to anxiety issues, depression issues, things like that. And you add on top a significant injury, it can definitely cascade pretty quickly," Israel said.

It boils down to establishing trust and giving honest answers to patients needing long-term rehabilitation.

The mental hurdles patients experience often depend on the healing time and the situation surrounding an injury. For example, a return to play for a torn ACL is typically nine to 10 months. Some athletes shrug off the news, while others might cry.

"Some people don't hit that wall until three months post-op when they realize they're not even halfway to the finish line," Israel said. "At some point, almost every kid hits that wall where they sort of shut down and get frustrated. Those are the ones that up front, we keep a closer eye on and start asking them again, 'How's school going? How's your sleep? How're your friends?' That kind of stuff to keep them more engaged."

Athletes are more prone to struggle if they miss their senior or junior season when college recruitment ramps up than an athlete who might miss a season in eighth grade.

Supporting athletes’ mental well-being

Through educational competencies classes, athletic trainers are educated in psychosocial interventions in sports psychology to help players cope with an injury to get through rehabilitation and back in the game.

There are signs an athletic trainer looks for to determine the mental health of their patient:

• Sadness, depressed state
• Athletes who are not as excited to go to practice or physical therapy visits
• Missing practice or rehab
• Negative self-talk, like "I'm never going to get better" or "I'm never going to play like I used to."

Walker explained that parents can also watch if their usually happy child suddenly becomes withdrawn and it appears something is "off" with their personality. It's important for patients, parents/guardians, coaches and the medical team to have open communication about these issues.

Walker said there are several techniques for helping injured athletes overcome fears, including:

• Imagery; A physically-healed athlete may be worried about reinjury and hesitant to play. Trainers will encourage them to visualize being back in the game, catching a pass, dunking a basketball or being able to cut and tackle. It takes them out of the present and helps them focus on the future. It can also include showing them previous video reels from games or practices of how they performed.
• Keeping the athlete near the game; using a U.S. Army concept of keeping injured soldiers close to the battlefield, athletic trainers make their rehab mobile, working with athletes on the sideline of their field or court so they can be close to the action while healing.
• Positive self-talk; Instead of saying, "I'm never going to get back to this," athletic trainers will encourage athletes to say things like, "OK, I may be hurt now, but I'm going to come back stronger and better able to do these things than before."
• Showing physical proof of healing; Athletes who struggle with trusting their body after an injury can benefit from seeing new X-rays or tests that confirm they are physically healthy.

The Sports Medicine staff continues to walk with patients even after rehab. Surgeons will often see their athlete patients back one to two years post-surgery to assess their physical health and how they are performing in their sport. Athletic trainers will also meet with them to re-tape injury spots or adjust braces. They stay in touch with the school and coaches on how student-athletes are doing.

If an athlete's injury is catastrophic and they cannot return to their sport or if they will miss their final season of a sport, the staff approaches those conversations carefully, confidently and with compassion.

"One of my ways is trying to get the kid to see the bigger picture. So, let's think about a season-ending knee injury. If we don't take care of that, then that kid is going to be more susceptible to arthritis or further issues down the road when they get to be 30 or 40 or 50," Walker said. "It's hard for kids to see 20, 30 years down the road. It's hard for adults to see 20, 30 years down the road. And so, just trying to help them understand these things happen sometimes. We've got to try to see the bigger picture here and explain to them why. I think a lot of kids have questions. And so being able to articulate answer and those questions in a confident manner that they understand, not using big fancy doctor lingo, but things they understand, I think that helps too."