Detailed appraisal of the literature on injury-proneness reveals that the syndrome has a multitude of possible causes which can also interact in complex ways. The concern here is primarily with those sports’ participants who are injury-prone partly or largely because of the effect of psychological influences. Even then this does not represent a homogeneous group, as the psychological variables operating are both numerous and complex, and can have many different repercussions.
Initially, the experimental evidence about the psychological antecedents of real injury will be discussed. In the second section the role of unconscious motives which can underlie real and imagined injury is examined.
EXPERIMENTAL APPROACHES TO INJURY-PRONENESS Experimental attempts to identify the correlates of injury-proneness did not begin until the 1960s. One of the earliest studies by Goven and Koppenhaver (1965) concentrated on psychological factors and found that neurotic college athletes were no more injury-prone than those without this tendency.
Kraus and Gullen (1969) conducted a large-scale epidemiological investigation of predictor variables associated with intramural touch football injuries. Age, kind of job (active or sedentary) and history of injury were identified as significant predictors but personality traits were not found to be related to injury susceptibility. Similarly, Brown (1971) was unable to discriminate between injured and non-injured athletes on the basis of trait scores on the California Personality Inventory.
More recent investigations however have suggested that personality factors may be related to injury-proneness. Jackson et al (1978), after finding no relationship between joint flexibility and joint injuries among various groups of athletes, examined the potential of the Cattell 16PF for predicting football injuries. Non-injured and injured players could be differentiated on Factor I, tender-minded players being more likely to be injured. These investigators acknowledged that frequency of play was not control- led in the non-injured group and that tender-minded players are intrinsically more likely to seek medical attention for injury. Reilly (1975) also used the Cattell 16PF but with professional soccer players, and found a relationship between Factor O (apprehensiveness) and the number of joint injuries sustained in a season. These findings seem to be complementary and post hoc explanations might well converge on the association of anxiety-based indecisiveness and injury susceptibility. Jackson et al (1978) also found that CattelPs Factor A was related to severity of injury, in that those players who were the most reserved and detached tended to have the most severe injury.
These trait investigations have been complemented by the study of Bramwell et al (1975) into the effect of psychological states on injury-proneness. Specifically, they examined the relationship between athletic injuries and experience of stressful life events as identified by the Social and Athletic Readjustment Rating Scale. A sample of 82 American football players indicated the incidence and kind of life events which demanded coping behaviour in the two-year period prior to the season under study. An individual accumulated Life Change Units (LCU) based on an estimate of how stressful were the events (death in the family, troubles with the head coach, etc) he had experienced. At the end of the playing season, players were divided into non-injured and injured groups.
It is clear that the injured players had accumulated significantly more LCU in both the one-year and two-year periods prior to the season. When the players were categorised into low, moderate and high-risk groups according to LCU magnitude, it was found that 30 per cent of low risk, 50 per cent of moderate risk, and 73 per cent of high risk players experienced significant time-loss through injury. As to why these relationships exist, Bramwell et al (1975) suggested that preoccupation with life change might affect concentration on the game and enhance the likelihood of injury. Also, they argued that life change stress could lead to a blocking of adaptive responses in potentially dangerous game situations.
It is generally accepted that many injuries could be avoided if participants werp more perceptually aware and able to recognise and negotiate these potentially dangerous situations. Presumably with this in mind, Pargman and his associates have examined the relationships between perceptual style and injury in groups of American football players. Pargman (1976), using the Group Hidden figures Test (GHFT), found that a non-injured group of players had a significantly greater visual disembedding ability than a group of injured players. Pargman et al (1976) however, found no relationship between incidence of injury in football and field dependence-independence as measured by the Rod and Frame Test. The fact that the GHFT and the Rod and Frame Test are measuring different aspects of perceptual style may account for the apparently contradictory results. It should also be noted that Parg-man’s (1976) results were obtained from a relatively small sample.
Several authors have offered reasons why the results of experimental investigations of injury-predictor variables have been equivocal. Haddon (1966) and Jackson et al (1978) noted that injury is a result of a complex interaction of many variables such as type of sport, level of competition, equipment used, experience, coaching technique, playing conditions, and the athlete’s physical and personality characteristics. Taerk (1977) also mentioned degree of ‘exposure’, characteristics of the opponent and psychosocial factors, as relevant parameters. Jackson et al (1978) suggested that ‘lack of awareness of surroundings’ and pain threshold/tolerance should be considered. No study to date has attempted to monitor all these variables, or to control them.
Taerk (1977) and Jackson et al (1978) observed that groups of athletes being investigated are of necessity biased samples in that many injury-prone individuals have already been selected out. This restriction in range can cause radical reductions in the correlations between injury and the predictor variables.
Realistically, it must be acknowledged that if progress is to be made, then the research methodology employed must be considerably refined. Taerk (1977) concluded that maximum control can be exerted over extraneous variables only if a captive (college student) sample, involved in a non-contact indoor sport, for example, volleyball or swimming, is monitored on a wide range of variables over a period of years. The implication is that most of the previous data, usually gained from American football squads, is seriously contaminated by nuisance variables such as weather conditions and differential exposure to situations in which injury could occur. Consequently, many findings may be spurious or, even if legitimate, are not able to be reliably generalised. Further, the element of chance will always figure prominently in injury statistics which means that the most sophisticated battery of predictive indices will never account for anywhere near the total amount of variance. Individuals with low risk quotients will continue to be injured and many with high risk quotients will remain injury free. This fact alone caused Bramwell et al (1975) to have ethical reservations about the identification of predictor variables in the sense that ‘high risk’ athletes might be needlessly screened out of participation. This is a particular problem when prediction is based on global analysis of groups rather than a consideration of the unique circumstances of the individual. It is likely that advances in understanding of the psychologically injury-prone can be made in the context of the effect of unconscious motives and forces on the behaviour of the individual.
DYNAMIC APPROACHES TO THE SYNDROME OF INJURY-PRONENESS
Dynamic theories of personality are often used, in a case-study context, to explain the maladaptive behaviour of individuals with psychological problems. A recurring tenet of these theories is that abnormal behaviour results from the individual’s unconscious attempts to cope with anxiety reactions.
In Freudian terms, an important cause of anxiety is the subject’s ambivalence about the commission of aggression. It is instinctual and yet the process of social and moral education determines that by adulthood, we are conditioned to channel our aggressive impulses into generally acceptable avenues – what Moore (1967) described as a useful assertiveness in life. The ambivalence is generated by the existence in society of two areas of conduct in which direct physical aggression is encouraged – war and competitive sports. This, for many, will induce a classic conflict situation of the ‘approach-avoidance’ type (Dollard and Miller, 1950). On the one hand the athlete wishes to approach the contest because there are rewards, such as victory and prestige to be had. On the other hand, however, he wishes to avoid the game as it offers repulsive aggression and punishment, maybe in the form of injury. The anxiety and tension which is associated with such conflict can seriously affect performance and increase the likelihood of real or imagined injury, as an unconscious means of reducing tension.
Anxiety reactions are universal, and to counteract their effect, to reduce tension and maintain psychological equilibrium, the individual usually has recourse to quite effective coping mechanisms. These serve to reduce transient tension and the individual is more or less aware of their value in this respect. On the other hand there are defence mechanisms which, although reducing psychological tension, usually involve some distortion of reality. An example of a defence mechanism in operation would be the manifestly anxious athlete at physiological boiling point who sincerely believes that he is not anxious. This reaction represents denial in psychoanalytic terms. The anxiety-prone athlete is more likely to employ defence mechanisms to maintain equilibrium. He is further identified by his emotional vulnerability, easy loss of composure, negative thinking, underlain by various kinds of exaggerated fears or phobias. Such individuals often display a recurring sense of guilt which they attempt to reduce by self-imposed suffering and punishment (Alexander, 1949). Their self-destructive tendencies include the elements of aggression, punition and propitiation (Menninger, 1936). The previously discussed evidence of Reilly (1975) and Jackson et al (1978) suggests that the anxiety-prone athlete is also a loser in the sense of being more injury-prone. Their results can be tentatively interpreted as evidence of the desirability of decisiveness and commitment in the sports arena rather than the hesitancy and half-heartedness to be expected from an anxiety-prone athlete. However, further evidence is necessary before firm conclusions can be drawn.
Although anxiety can be seen as the main psychological factor underlying psychological injury-proneness, the associated explanations of behaviour can vary markedly. Various types of injury-prone athlete can be delineated. Recognition of them in the clinical situation may well influence the kind of treatment administered.
Injury resulting from counter-phobia
Most sportsmen become injured at some stage in their careers and as a result they become a little wiser and are able to avoid situations in which injury is likely. Some, however, never learn from mistakes and this does not appear to be a function of intelligence (Ogilvie and Tutko, 1971). Typical of this type is the individual who finds the aggressive atmosphere of competitive sport very anxiety-inducing and he attempts to counteract the anxiety by meeting it head-on, by being overtly aggressive and fearless. It involves what Horney (1937) has described as the ‘process of ruthlessly marching over an anxiety’. He repeatedly tempts fate by testing his indestructibility, a course of action which markedly increases the likelihood of injury. Moore (1960) maintained that this kind of individual is attracted to high risk sports such as downhill skiing, boxing, rugby or motor racing.
Moore (1967) reported the case of an ice hockey goalkeeper who had the puck smashed into his face many times. Yet in hospital for minor surgery after a car crash, he was terrified of allowing the surgeons to touch him. His counter-phobia was geared to the planned danger of ice hockey but his real fear of injury was revealed in the unplanned situation of the hospital ward.
Injury as a sign of masculinity
A type who may have counter-phobic tendencies is the athlete who uses injuries as a mark of his courage and masculinity. He lacks real confidence, needing the visible scars of battle to confirm his manhood. An indication of the pervasiveness of this feeling of enhanced masculinity can be gained by most sportsmen simply by reference to their own history of injury. Who at some stage has not felt a certain pride and satisfaction when carrying the visible scars of contest – the marks of distinction and toughness?
Expression of masculinity is one of the motivating forces which produce the injury-prone hero. He takes a martyr’s role by continuing to play despite his illness or injury. His sacrifice is accompanied by obvious signs of distress and pain. This serves the dual function of securing admiration for his courage and also giving himself a ready-made excuse in case he performs badly.
Injury resulting from masochism
The risk-taker may be what Menninger has termed ‘chronically suicidal’. He is possessed of masochistic tendencies as a result of inward-directed hostility and he achieves satisfaction in injury. The hostility may be the result of obsessively seeking after athletic standards which he sets unrealistically high. The pain and injury are the punishment which relieves the feelings of guilt over his inevitable inability to meet the standards. The inwardly directed hostility may alternatively be
the athlete’s atonement for the injury he has caused another. The fact that he has injured another, or even contemplated it, indicates his aggressiveness, a picture of himself which he finds unacceptable.
Injury as a weapon
Conversely, there is another kind of athlete who uses injury as a means of punishing another or others in an indirect way. Ogilvie and Tutko (1971) gave the example of the reluctant athlete forced to play because of an athletically-frustrated father. By being injured, he can accomplish several objectives: he can make his father feel guilty for pressurising him; he can frustrate his father’s displaced aspirations; and he can avoid the undesired competition.
Injury as an escape
There is the athlete who fears competition so much that he virtually needs to be injured. An example is the ‘training-room athlete’ who gets injured in practice, thereby avoiding competition (Ogilvie and Tutko, 1971). He has strong feelings of inferiority but cannot straightforwardly opt out because of his fear of isolation and rejection. With injury, whether real or imagined, he can avoid the feared competition, remain a member of the squad, and keep his ego intact because he can always tell himself that had he not suffered so much injury, he would have been an outstanding athlete. His disability can be used by his team mates as a rationalisation of their failure. A related type is the compulsive failure-seeker who sees an injury-full life as the best means of maintaining the illusion of his great potential had he not suffered so much injury.
Ryde (1965) described the case of a top female athlete who had a leg injury which did not respond to treatment over a period of months. It transpired that the injury represented a form of escapism. It enabled her to avoid her dominant father-figure coach who, she felt, would strongly disapprove of her impending engagement.
Unconscious psychological forces can be so great as to precipitate psychosomatic injury. The athlete frequently complains of injury and yet no organic reasons can be obtained to substantiate the claim. A coach faced with this situation may feel that the complaint has been assessed incorrectly as his attempts to help are frustrated. The athlete does not respond to conventional treatment. This athlete is also likely to be unreliable in that injury is possible at any time. He might be dismissed as not too much of a problem if his ability is low but it is extremely frustrating to all concerned if he is a talented sportsman. If he is the latter, then a build-up of resentment in the team will enlarge his psychological problems.
With this kind of athlete it is possible that a Freudian defence mechanism entitled somatisation is involved. Somatisation is occurring when emotional disturbance is reflected in physical symptoms. Freud referred to this syndrome as conversion hysteria and specifically investigated several cases of blindness and paralysis of limbs which were primarily emotional in origin. These are extreme examples, but it is not uncommon for individuals, including sportsmen under stress, to develop physical symptoms which at once protect them from anxiety and provide them with an excuse for withdrawing from the stressful situation. The physical symptoms may well disappear when the emotional problem is solved.
Injury as a concoction
Another type of athlete whose injuries cannot be substantiated physically is the malingerer, I.e. the athlete who concocts injuries for his own ends (Ogilvie and Tutko, 1971). He is given to ostentatious demonstrations of pain and injury, and displays a large discrepancy between his stated intentions and his actual performance. The reasons underlying this behaviour vary both between and within individuals: 1. He may seek to avoid training, which is seen as irksome and not strictly necessary. 2. He fears actual injury if he participates. 3. He wishes to cause difficulties for the team and/or the coach because of real or imagined grievances-a particularly effective technique when the player is valuable. He lacks courage for a confrontation, so he reacts in this indirect but effective way. 4. He wants to avoid unfavourable comparison with others, which might occur if he practises and competes. 5. He may not even like the sport, having been coerced into it because of his physical talents or he may have been attracted by the financial prospects.
As for recognising and treating the various kinds of injury-prone athlete it is important that all personnel concerned with ensuring the athlete’s complete recovery should have access to as much information about the individual as possible. Ideally, medical, physical and psychological records should be available to be used by, say, the physiotherapist, to enrich his interaction with the athlete during the treatment phase. If he can establish that he is dealing with a particular kind of injury-prone athlete, then there will be much he can do in terms of lessening the likelihood of future injuries, by encouraging caution, instilling confidence, recommending psychotherapy or advising the athlete’s doctor of his suspicions. The causes of the underlying anxiety would have to be identified to enhance the prospects of complete recovery.
Several authors have emphasised the need for cooperation among players, coaches, physical educators, trainers, physiotherapists, psychologists and physicians (e.g. Ryde, 1971; Godshall, 1975; Jackson et al, 1978). Vulnerability profiles could be established on the basis of epidemiological data. Any athlete could then he checked to assess his degree of vulnerability to injury or illness, thus allowing the possibility of positive injury prevention. Moore (1967) listed several conditions which might identify the psychologically vulnerable athlete: 1. Discrepancy between ability and aggressiveness. 2. Discrepancy between father and son in ability/aggressiveness. 3. Uninhibited aggressiveness and/or feelings of invulnerability. 4. Excessive fear of injury. 5. Extensive history of injuries. 6. Concealment or exaggeration of injuries. 7. Success phobia.
What is certain is that there is no one way of handling injury-prone athletes and even sympathy would not be recommended universally. With the malingerer or some of the psychologically injured athletes, sympathy would tend to reinforce the undesirable behaviour patterns. Concern for an athlete’s well-being can lead to anxiety in the coach and anxious coaches tend to produce anxious athletes.
For progress to be made in the investigation of the phenomenon of injury occurrence and its prevention, systematic research is needed. It should embrace a wide variety of hypothetically important factors in a well-controlled context. However, much useful information could be gained without sophisticated experimental techniques. For example, the perceptive coach with comprehensive records of the athlete under his control could produce evidence meriting more detailed investigation. He may find that the lack of confidence displayed by a particular injury-prone athlete is a product of nothing more complex than a lack of fitness, induced by inadequate training per se, or by training constraints imposed by previous injury. It is obvious that any individual competing in sports where physical demands are high and injuries are common should be exceptionally fit. It is equally obvious that the physiotherapist and trainer have an essential role to play in preparing the injured athlete’s path to maximum fitness. Confidence, one of the keys to success, can only be enhanced by supreme fitness.
The highly motivated athlete presents a special problem in that complete physical fitness is essential if he is to avoid injuries. Any lack of fitness and his high competitiveness will lead him to push beyond a safety margin, and as a result incur injury. Such athletes are prone to becoming permanently weakened, both physically and psychologically.
Physical fitness together with psychological fitness has a liberating effect on the athlete. One often hears the remark that an athlete should know his limitations. It is suggested that the greatest athletes are those who do not know their limitations, but who have the confidence to explore their potential and push back the limits, a confidence born of supreme physical and psychological fitness.
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