Psychological Effect of Lower Limb Injuries among Football Players

Hani Hamed*, Hamdy El- Kalupy**, Tamer Hifnawy***

*Assist. Prof. of Psychiatry- Beni-Sueif University

**Lecturer of Sport Medicine- El-Mansoura University

*** Assist. Prof. of Public Health and Community Medicine- Beni-Sueif University

 


Abstract:

Objective: The influence of psychological factors on sports injuries has been demonstrated in numerous empirical studies. Athletes experience significant mood changes throughout rehabilitation, which may hinder rehabilitation early in the process. Method: Descriptive analytical case control study which includes fifty professional football players with lower limb injuries & another group of professional football players without any injury at all will be selected. All participants were subjected to Semi structured interview, Familial Sociodeconomic Status Scale, Semi-Structured Pain Questionnaire, Beck Depression Inventory, Beck Anxiety Inventory, Life Satisfaction Scale, and Facing Daily Stressful Live Events Scale. Results: The group of football players with lower limb injuries shows statistically significant higher depression (p<.001), and higher anxiety (p<.001) compared to the other group of players. There was highly statistical significant difference regarding Life Satisfaction Scale (p<.001), and Facing Daily Stressful Live Events Scale. (p<.001). Conclusion: Depressive and anxiety disorders were more prevalent among football players with lower limb injuries. Also, among the same group there was higher degree of life dissatisfaction, and more stress caused by life events.      

 


Introduction:

 

Football is one of the most popular sports worldwide. The frequency of football injuries is estimated to be approximately 10 to 35 per 1000 playing hours. The majority of injuries occur in the lower extremities, mainly in the knees and ankles [1].

 

Injury is one of the unfortunate risks that collegiate athletes are faced with today. Even worse, is the possibility that some athletes experience re-injury or multiples injuries during their athletic careers. Athletes who experience multiple injuries are often labeled as injury prone and are treated numerous times for their physical injuries, but are never examined or treated for possible neural, behavioral or psychological deficits. For standard orthopedic injuries, it is assumed that the athlete is healthy once motor performance has reached pre-injury levels. Additionally, if injured athletes harbor any of these deficits during return to play, they may become more susceptible to re-injury [2].

Injuries among can be classified according to Bakry (1997) [3] to:

-Minor injuries: injuries need treatment for days, about 10 to 15days like muscle spasm and sprains.

-Major injuries: need treatment for weeks or months like fractures, serious ligament tears and dislocations.  

The influence of psychological factors on sports injuries has been demonstrated in numerous empirical studies. Almost all investigations have been based on stress theory or a personality-profile approach. Although the majority of studies have employed different methods, the results are in general agreement that "life events" can influence the risk of injury in athletes. In this context, social support appears to have a buffering effect. The influence of stress-coping strategies is still somewhat questionable. From the numerous psychological attributes that have been investigated in relation to sports injuries, only competitive anxiety has been shown to be associated with injury occurrence [4].

Athletes experience significant mood changes throughout rehabilitation, which may hinder the process of rehabilitation [5].

Over the last two and a half decades, researchers have tried to determine if psychological variables predispose or buffer athletes from injury. They have found that sport participants who experience many recent stressors, and who do not have the resources and skills to cope with the stress, seem most at risk for injury [6].

Psychosocial factors increasingly are becoming recognized as significant factors in sports performance, injury prevention, rehabilitation, and management. Whether considering an individual or team sport, however, the contribution of focused attention, concentration, stress management, and cognitive strategies is important. In most sports, athletes and coaches alike commonly refer to the “mental game” as equally important as physical abilities and talent to overall performance. Indeed, for the elite and professional athlete, the mental game often provides the competitive edge necessary for winning [7].

 

Aim of the Work:

This research attempts to attack the issue of the psychological effect of lower limb injuries among football players.

 

 

Subjects and Methods:

A descriptive analytical case control study including fifty professional football players with lower limb injuries - “ cases” & another group of professional football players without any injury - “Controls”.

Inclusion criteria:

Exclusion criteria:

Methods:

  Both groups were subjected to the following:

Players were interviewed guided by a psychiatric history taking sheet designed at the Department of Psychiatry, Cairo University. It includes detailed developmental, family, educational and past history. Also it includes a mental state examination.

 

II - Beck Depression Inventory (BDI) [8]: 

 

         This inventory for measuring depression is a self-report scale designed to assess DSM-IV defined symptoms of depression such as sadness, guilt, loss of interest, social withdrawal, increase and decrease in appetite or sleep, suicidal ideation and other behavioral manifestations of depression over the previous 2 weeks. It can be used also over time to monitor symptoms and to assess response to therapeutic interventions.

 

         The inventory is composed of 21 groups of statements on a 4-point scale with the subject selecting the one that best matches his or her current state. Each statement group corresponds to a specific behavioral manifestation responses are scored 0-3, corresponding to no, mild, moderate or severe depressive symptomatology in the response. The score range varies from 0 to 63 where higher score indicate greater depression severity. According to (Beck et al., 1988) [8] score in range of:  (0 – 13) indicate no or minimal depression; (14 – 19) mild depression; (20 – 28) moderate depression; (29 – 63) severe depression.

 

III- Beck Anxiety Inventory (BAI) [9]:

 

         This inventory for measuring anxiety is a self-report scale designed to assess severity of anxiety symptoms over the past two week. Each item describes a common symptom of anxiety such as inability to relax and dizziness. The scale is designed to discriminate depression from anxiety and emphasizes the more somatic and panic-type symptoms of anxiety rather than symptoms of generalized anxiety such as worry, sleep disturbance and poor concentration. The BAI is a reliable and widely used screen for somatic anxiety symptoms that is sensitive to treatment response.

 

         The inventory is composed of 21 item and the items are scored on a 0 to 3 corresponding to no, mild, moderate or severe Anxiety symptomatology. The score range varies from 0 to 63 where higher score indicate greater anxiety severity. According to (Beck et al., 1988) [9] score in range of: (0 – 7) indicate no or minimal anxiety; (8 – 15) mild anxiety; (16 – 25) moderate anxiety; (26 – 63) severe anxiety.

 

IV-Life Satisfaction Scale [10]:

It is a 30-statements scale that includes 6 subscales to which the subject agrees disagrees or is equivocal. These subscales are the happiness, sociability, self assurance, stability, sociable acceptance, and satisfaction. It was designed to assess the level of satisfaction about life. The higher score indicates higher level of satisfaction and comfort about life.

 

 

 

V- Facing Daily Stressful Live Events Scale [11]:

It is a 30-statements scale that includes 3 subscales to which the subject agrees disagrees or is equivocal. It was designed to give an idea about different strategies can be used by the person to face and adapt different daily stressful life events (different coping skills). These subscales are the positive reaction (approach), negative reaction (avoidance), behavioral reaction. It was designed to assess the level of satisfaction about life. The higher score indicates higher level of satisfaction and comfort about life.

 

 

   All scales were applied in Arabic language after being back translated to English language and reviewed by the research team to ensure accuracy of the Arabic version.

Statistical Analysis:

data were collected coded and analyzed using SPSS software version 16 under Windows XP, The chi-square “X2” test was used for the analysis of categorical data. The Pearson product moment correlation coefficients “r” were calculated between the different investigated parameters. [12].

The level of significance was set at p <0.05.

 

 

Results:

 

I- Sociodemographic and clinical Data:

 

 

Table 1: The age and Years of Experience

 

Cases

Controls

P

Age

Mean

22.12

22.22

.825

Std. Deviation

2.31

2.17

Years of Experiences in Years

Mean

7.34

7.30

.932

Std. Deviation

2.33

2.36

 

 

Table 2: Socio-demographic characteristics of the studied groups:

 

 

Cases

Controls

P

No.

Percent

No.

Percent

Education

School students

2

4

3

6

 

 

 

.370

School Graduate

19

38

24

48

University Students

14

28

7

14

University Graduate

15

30

16

32

Total

50

100

50

100

Occupation

Not Working

7

14

6

12

 

 

 

.886

Skilled Worker

1

2

2

4

Semi- Professional

31

62

29

58

Professional

11

22

13

26

Total

50

100

50

100

Marital Status

Single

40

80

42

84

 

 

.741

Married

6

12

6

12

Divorced

3

6

2

0

Widow

1

2

4

0

Total

50

100

50

100

 


 

Table 3: Team Position in both Groups

 

Cases (No= 50)

Controls    (No= 50)

P

Attacker

No.

9

9

 

 

 

 

 

.972

%

18

18

Middle

No.

19

18

%

38

36

Defender

No.

12

14

%

24

28

Goal keeper

No.

10

9

%

20

18

Total

No.

50

50

%

100

100

 

 

     Table 4: Description of Injury

 

Min.

Max.

Mean

Std. Deviation

Number of Injuries

1.00

5.00

2.44

1.40

Periods of Rest in Weeks

2.00

23.00

4.98

4.87

 

 

Table 5: Type and Site of Injury

Type of Injury

Frequancy

Percent

Muscle Spasm

4

8

Ligament Tear

16

32

Sprain

9

18

Fracture

7

14

Multiple Injuries

14

28

Total

50

100

Site of Injury

 

Frequancy

Percent

Thigh Muscles

4

8

Knee Joint

16

32

Ankle Joint

30

60

Total

50

100

 

 

Table 6: Severity of Injury

 

No. of Players

Percent

Mild

5

10

Moderate

19

38

Severe

26

52

Total

50

100

 

 

 

 

 

 

1 - Beck Depression Inventory:

 

Table 7: Beck Depression Inventory in both Groups

 

Cases (No= 50)

Controls    (No= 50)

P

No.

%

No.

%

No Depression

12

24

50

100.0

 

 

 

<.001

 

 

Mild Depression

21

42.0

0

0.0

Moderate Depression

15

30.0

0

0.0

Severe Depression

2

4.0

0

0.0

Total

50

100

50

    100

 

 

 


 

Table 8: Beck Anxiety Inventory in both Groups

 

Cases (No= 50)

Controls    (No= 50)

P

No.

%

No.

%

No Anxiety

6

12.0

46

92.0

 

 

<.001

 

 

Mild Anxiety

11

22.0

4

8.0

Moderate Anxiety

23

46.0

0

4.0

Severe Anxiety

10

20.0

0

0.0

Total

50

100

50

    100

 

 

 

 

Table 9: Life Satisfaction Scale

Life Satisfaction Scale

Cases

Controls

P

Life Satisfaction Total

Mean

57.90

77.46

<.001

Std. Deviation

7.35

8.52

Happiness

Mean

14.52

19.02

<.001

Std. Deviation

1.96

2.22

Sociability

Mean

11.34

12.34

.004

Std. Deviation

1.98

1.38

Self Assurance

Mean

10.58

14.60

<.001

Std. Deviation

2.26

2.0

Stability

Mean

7.22

8.64

<.001

Std. Deviation

.76

.65

Social Acceptance

Mean

7.80

14.42

<.001

Std. Deviation

2.07

2.86

Satisfaction

Mean

6.66

8.66

<.001

Std. Deviation

1.15

.75

 

 

Table 10: Facing Stressful Life Event Scale

Facing Stressful Life Event Scales

Cases

Controls

P

Positive Reaction

Mean

22.26

9.16

<.001

Std. Deviation

6.27

2.11

Negative Reaction

Mean

21.82

4.12

<.001

Std. Deviation

6.48

2.66

Behavioral Reaction

Mean

16.24

5.32

<.001

Std. Deviation

9.31

2.42

 

 

1- Correlation between Type of Injuries and Beck Anxiety Inventory:

Table 11: Correlation between Type of Injuries and Beck Anxiety Inventory

 

No Anxiety

Mild Anxiety

Moderate Anxiety

Severe Anxiety

P

Muscle Spasm

 

No.

1

1

1

1

 

 

 

 

 

.010

%

16.7

9.1

4.3

10

Ligament Tear

 

No.

4

4

8

0

%

66.7

36.4

34.8

0.0

Sprain

No.

0

4

4

1

%

0.0

36.4

17.4

10

Fracture

No.

1

2

4

0

%

16.7

18.2

17.4

0.0

Multiple

No.

0

0

6

8

%

0.0

0.0

26.1

80

 

 

2- Correlation between Type of Injuries and Life Satisfaction Scale, Total:

 

Table 12: Correlation between Type of Injuries and Life Satisfaction Scale

 

Mean

Std. Deviation

P

Muscle Spasm

64.75

2.06

 

 

.015

Ligament Tear

57.75

7.01

Sprain

62.44

6.77

Fracture

56.71

6.44

Multiple

53.78

7.12

 

 

3- Correlation between Severity of Injuries and Beck Anxiety Inventory:

 

Table 13: Correlation between Severity of Injuries and Beck Anxiety Inventory

 

No Anxiety

Mild Anxiety

Moderate Anxiety

Severe Anxiety

P

Mild

 

No.

0

3

1

1

 

 

.036

%

0.0

27.3

4.3

10

       Moderate

No.

5

4

9

1

%

83.3

36.4

39.1

10

Severe

No.

1

4

13

8

%

    16.7

36.4

56.5

80

 

 

 

 

 

 

4- Correlation between Severity of Injuries and Life Satisfaction Scale:

 

Table 14: Correlation between Severity of Injuries and Pain Questionnaire & Life Satisfaction Scale

 

Life Satisfaction Scale, Total

 

Happiness

 

Sociability

Self Assurance

 

Stability

Social Acceptance

Satisfaction

Severity of Injuries

 

R

-.502

-.383

-.346

-.461

-.336

-.327

-.447

P

<.001

.006

0.014

.001

.017

.021

.001

N

50

50

50

50

50

50

50

 

5- Correlation between Beck Depression Inventory and Facing Stressful Life Event Sub-Scales:

 

Table 15: Correlation between Beck Depression Inventory and Facing Stressful Life Event Sub-Scales

 

Mean

Std. Deviation

P

Negative Reaction

 

No Depression

21.42

6.97

 

 

 

 

    .022

Mild Depression

21.90

6.72

Moderate Depression

20.27

3.67

Severe Depression

35.00

7.07

Behavioral Reaction

 

No Depression

15.50

8.06

 

 

 

     .010

Mild Depression

 

15.90

9.01

Moderate Depression

14.53

8.37

Severe Depression

37.00

4.24

 

 

 

 

 

6-Correlation between Life Satisfaction Scale & it’s subscales and Facing Stressful Life Event Scale:

 

Table 16: Correlation between Life Satisfaction Scale and Facing Stressful Life Event Scale

 

Positive Reaction

Negative  Reaction

Behavioral

Reaction

Life Satisfaction Total

 

R

.329

.140

.152

P

.02

.332

.291

N

50

50

50

Happiness

 

R

.394

.227

.176

P

.005

.112

.221

N

50

50

50

 

Sociability

 

R

.329

-.008

.061

P

.020

.957

.674

N

50

50

50

Self Assurance

 

R

.326

.073

.086

P

.021

.616

.551

N

50

50

50

Stability

 

R

-.004

.033

.067

P

.980

.980

.644

N

50

50

50

 

Social Acceptance

 

R

-.079

.087

.095

P

.584

.548

.513

N

50

50

50

Satisfaction

R

.334

.177

.163

P

.018

.218

.257

N

50

50

50

 

Discussion:

Players among both groups were nearly from the same age group (the mean was 22.12 ± 2.31, 22.22 ± 2.17 for cases and controls respectively). Also, there was no statistical significant difference between players among the two groups regarding the years of experience (the mean was 7.34 ± 2.33, 7.30 ± 2.36 for cases and controls respectively) (table 1). There was no statistical significant difference between players in both groups regarding education, occupation, marital status, and team position (P= .370, P= .886, P=.741, P= .972 respectively) (table 2, 3). This highlight that  the two groups were cross matched.

   Among the group of injured players, the mean of number of injuries was 2.44 ± 1.40, and the mean of period of rest in weeks was 4.98 ± 4.87 (table 4).  The majority of players (32%) were with ligament tears and (28%) were with mixed injuries. Most of injuries were in the ankle joint (60%) and knee joint (32%) (table 5). The majority of injuries were of severe (52%) and moderate degree (38%) (table 6). Bailey et al., (2009) [13] found that most injuries were minor (class 1 severity), and none exceeded class 3 severity.  Knee and ankle injuries were the most common (27% and 47%, respectively), consisting mainly of sprains.

There was statistical significant difference between players in both groups regarding Beck Depression Inventory (P <.001) (table 7). Also, injured players showed higher degree of anxiety. There was statistical significant difference between players in both groups regarding Beck Anxiety Inventory (P <.001) (table 8). This was consistent with (Nor, 2006) [14] who stated that injuries may lead to emotional problems such as anxiety and depression. These negative moods and behaviours place the athlete at risk for prolonged rehabilitation and further behavioural problems.  Injury is often a traumatic event where emotional and psychological reactions are produced. Typically, these reactions are based on the individual’s perceptions of loss (e.g., mobility, playing time, career). Although this loss is perceived differently by different individuals, injuries can often prevent athletes from pursuing a self-defining activity. As a result, they are particularly vulnerable to psychological reactions such as anxiety, depression, fear, and loss of self-esteem [15]. Leddy, (1994) [16] found that injured athletes exhibited greater depression and anxiety and lower self-esteem than control groups immediately following physical injury and at follow-up sessions.

Players among the control group showed higher degree of satisfaction. They showed higher levels of happiness, sociability, self assurance, stability and social acceptance. There was statistical significant difference between players in both groups regarding Life Satisfaction Scale (P <.001) (table 9). The occurrence of injury among athletes may disrupt the emotional and psychological reactions, which are typically negative and affect the different aspects of their lives [17]. Again, dissatisfaction in different aspects of life among injured football athletes could be explained physiologically and psychologically by once an athlete becomes injured, both physiologic and psychological processes occur. Physiologically, a vicious pain-spasm-pain cycle will continue, causing further damage, if appropriate care is not provided. Furthermore, many physiologic changes that occur during psychological stress may impair recovery. Increased muscle tension, heart rate, bloodpressure, and skin conductance, all indicative of autonomic nervous system (ANS) activity, are present after injury. Also, attentional changes (ie, worry about self) that occur after athletic injury may cause further generalized muscle tension, which in turn may result in further musculoskeletal injuries from disturbances in fine motor coordination and reduced joint flexibility. Prolonged distress accompanying an injury may also lead to continual ANS arousal (eg, epinephrine, norepinephrine, and cortisol release) that may prolong recovery by impairing immune functioning and skeletal muscle repair [18].

    There was highly statistical significant difference between players in both groups regarding Facing Stressful Life Event Scale (P <.001) (table 10). This statistical significant difference included not only the negative reaction but also, the positive and behavioral reactions. Smith et al., (2001) [19] stated that athletes have difficulty coping with the changes that accompany injury, activity restriction, long rehabilitation, and feelings of being externally controlled by their injury. Also, (Newcomer, 2000) [20] found that physically recovered athletes with a recent injury history experience greater frequency and intensity of intrusive thoughts and avoidance behaviors when compared to athletes without a recent injury history. Injured athletes had higher scores on Impact of Event Scale which donate that they experienced a variety of stressful events.  Andersen & Williams, (1999) [21] stated that personality characteristics that tend to exacerbate the stress response, with a history of many stressors, and with few coping resources will be more likely, when placed in a stressful situation, to appraise the situation as stressful and thus exhibit greater physiological activation and attentional disruption. The muscle tension, distractibility, and perceptual narrowing that occur during the stress response appear to be the mechanisms behind increased injury risk.

There was statistical significant difference between type of injury and Beck Anxiety Inventory (P= .010) (table 11). Injured players with tear ligament showed lower degree of anxiety (66.7% no anxiety and 36.4% with mild anxiety). While the majority of players with multiple injuries showed higher degree of anxiety (80% with severe anxiety and 26.1% with moderate anxiety). This might be explained by Shuer (1997) [22] who stated that fear is another emotion prevalent among athletes with multiple injury. Athletes are fearful about re-injury and because of this fear, they may be reluctant to train with full intensity. Some athletes may be reluctant to return to training at all as a result of the fear. Wasley and Lox (1993) [23] suggested that the type of injury may determine differences in self-esteem and coping behavior.

Also, there was statistical significant difference between type of injury and Life Satisfaction Scale (P= .015) (table 12). Injured players with muscle spasm (64.75%) showed more satisfaction with life. While players with multiple injuries (53.78%) showed lower degree of life satisfaction. This was in line with Patterson et al., (1998) [24] who found a relationship of life stress, which affect the quality of life, to athletic injury. They found a positive relationship between injury and high life stress (daily hassles, and life changes). These findings suggest that preoccupation with life change may affect concentration on training and competition and increase the likelihood of further injury. Williams and Andersen (1998) [25] have proposed that physiologic (eg, increased muscle tension and narrowing of visual field) and attentional (eg, increased distractibility) aspects of the stress response are possible underlying manifestations of stress that increase susceptibility to injury.

Players with severe injuries showed higher degree of anxiety (80.% with severe anxiety and 56.5% with moderate anxiety). While the majority of players with mild injuries showed lower degree of anxiety (27.3% with mild anxiety). This difference reached statistical significant difference (P= .036) (table 13). The present study corroborates findings with Lavallee & Flint, (1996) [26] and Kolt & Roberts, (1998) [27] who revealed that such relationships are often found between injury outcome and risk factors such as competitive trait anxiety, low self-esteem and low mood state early in the season.

There was a highly significant negative correlation between severity of injury and Life Satisfaction Scale and it’s sub-tests (table 14). This means that the higher severity of injury is associated with less satisfaction of life and lower degree of happiness, sociability, self assurance, stability and social acceptance. This could be explained by Smith et al., (1990) [28] who found a relationship between negative life events and injury outcome among athletes, and such negative life events definitely affect different aspects of life satisfaction.

Regarding the correlation between Facing Stressful Life Event Scale and Beck Depression Inventory, there was statistical significant difference between severity of depression and negative & behavioral reactions (P= .022, P=.010 respectively). The negative and behavioral reactions were associated with higher means of severe depression (mean=35 ± 7.07, mean=37 ± 4.24) (table 15). Damage to self-esteem is a potential consequence of injury that has been neglected by researchers in favor of the closer examination of emotional reactions following injury. Certain components of self-esteem, physical self-efficacy, perceived physical competence, and higher are likely to be affected by the occurrence of injury. Some empirical evidence does exist that suggests that injury can lead to changes in how a person views him or herself which make them more vulnerable to psychological reactions such as anxiety, depression (Smith, 1996) [29].

There was a highly significant positive correlation between positive reaction in Facing Stressful Life Event Scale and Life satisfaction Scale total, Happiness Sub-scale, Sociability Sub-scale, Self Assurance Sub-scale & Satisfaction Sub-scale (P= .02, P=.005, P=.020, P=.021, P=.018 respectively) (table 16). Ford et al., (2000) [30] stated that injured athletes with more optimism, hardiness, global self-esteem or better coping strategies may adapt more effectively with life change stress, resulting in reduced injury vulnerability and recovery rates which is associated with higher satisfaction.

 

Overall, besides the improvement of physical performance, technical and tactical skills and injury prevention, psychological state of the players in a team will be essential for team success and should be addressed. Beyond the physical pain of the injury, it also contributes to exclusion from team activities, stresses about losing abilities, and considerations of surgery, prolonged recovery and rehabilitation. Also, fears about regaining previous functioning are also present. These stressors can cause a great deal of psychological angst and disturbance, and produce symptoms of depression, anxiety, and low self-esteem

 

 

Conclusion:

 

Recommendations:

     injuries among football  players.

  

 

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