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174 REVIEW Psychological responses to injury in competitive sport
Psychological responses to injury in
competitive sport: a critical review
Authors
Natalie Walker, PhD,
University of Northampton,
Boughton Green Road,
Northampton, N7 8AL, UK
Tel: +44 (0)1604 892490
Email: natalie.walker@
northampton.ac.uk
Joanne Thatcher, PhD,
CPsychol, Department of
Sport and Exercise Science,
Carwyn James Building,
The University of Wales,
Aberystwyth, Penglais
Campus, Aberystwyth,
Ceredigion, SY23 3FD, UK
Tel: +44 (0)1970 621545
Fax: +44 (0)1970 628557
Email: jet@aber.ac.uk
David Lavallee, PhD,
CPsychol, School of
Sport & Exercise Sciences,
Loughborough University,
Ashby Road,
Loughborough,
Leicestershire, LE11
3TU, UK
Tel: +44 (0)1509 226302
Fax: +44 (0)1509 226301
Email: d.e.Lavallee@
lboro.ac.uk
Corresponding author:
Natalie Walker, as above
Key words
athletic injury; behavioural
response; cognitive
appraisal; emotional
response; grief
JRSH Copyright © 2007 The Journal of The Royal Society for the Promotion of Health
ISSN 1466-4240 DOI: 10.1177/1466424007079494
Page 174
JRSH 2007;127(4):174-180
Abstract
Research has attempted to examine the psychological impact of athletic injury to assist
rehabilitation personnel when treating injured athletes. Sports trainers, sports therapists,
physiotherapists, medical staff and sports psychologists should be aware of psychological
factors impacting on the injury experience when involved in an athlete’s rehabilitation. A number
of models have been proposed as useful frameworks for investigating and describing the
psychological response to athletic injury. Many researchers have relied upon applying or
adapting grief and cognitive appraisal models originally derived from the clinical and stress
related psychology literature in an attempt to describe the psychological response to athletic
injury. This article provides an overview of these models and offers a critical appraisal of this
research, specifically focusing on the grief response models and the integrated model of
response to sport injury and rehabilitation. Criticisms focus on the lack of research supporting a
uniformed sequence of stages as a feature of response to athletic injury. Further grief criticisms
centre on the absence of denial in much of the research to date. The article then focuses on
the dynamic core of the integrated response to sport injury and rehabilitation model. It is
argued that the interrelationships between emotional responses, behavioural responses,
cognitive appraisals and recovery outcomes are not as simple as suggested in the model.
INTRODUCTION performance on the athlete’s return to training and
Injury is an unfortunate consequence of competition.1
Grief and cognitive appraisal models have been
participation in athletic activity. The physical
aspects of athletic injury that influence injury onset proposed as useful frameworks for investigating and
and recovery have been, and continue to be, the describing the psychological response to athletic
primary focus of athletic injury research (e.g. injury.2–8 It is the intention of this article to outline
aetiology, epidemiology, outcome measures, some of this research to date. Some sports
prevention, diagnosis, treatment). However, research psychology research has highlighted that the grief
has also explored psychological factors (e.g. process observed in those suffering bereavement,
personality variables, life events, daily hassles) that illness and disability is similar to that of individuals
are suggested to predispose athletes to injury. suffering from athletic injury.9–11 The grief
However, less attention has been directed to the response has been typically viewed as a response to
the loss of a significant other or object.12,13
psychological consequences of athletic injury.
There is a need to examine the psychological The stage approach to grief management has
impact of athletic injury. An understanding of been most frequently adopted within the
how athletes respond to injury and rehabilitation sports psychology literature when describing
would assist rehabilitation personnel when treating responses to athletic injury. Kübler-Ross’14
injured athletes. Rehabilitation personnel should be stage theory has influenced the majority of
aware of psychological factors impacting on the this research. She suggested that the grieving
injury experience if complete holistic recovery is individual passes through the following five
to occur. By raising the awareness of the sequential stages:
psychological response to athletic injury they
could empathise and assist athletes to cope (1) denial
effectively and attempt to prevent adverse (2) anger
responses to injury disrupting rehabilitation and (3) bargaining
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(4) depression
(5) acceptance
Sports psychologists in the 1980s and early
1990s appear, almost without exception, to
have based their research into responses to
athletic injury on this five-stage model of
grief.
The body of opinion for and against the
application of grief models to athletic injury
appears equivocal. Many offer partial
support for its application to athletic
injury.15,16 Heil stated that the extent10 to
which the grief-like response is
characteristic of all injuries is unknown,
suggesting that this response might only be
limited to severe or psychologically
traumatic injuries. Similarly, Udry et al.16
stated that they could only provide minimal
support for the stage of denial and no
support for the bargaining stage as a
response to athletic injury. They stated that
denial has been mislabelled in previous
research and stressed that it should be
reserved for non-compliant athletes who,
despite education about the nature and
extent of their injury, refuse to accept it. It
has been proposed that athletes do not deny
the existence of an injury but are more likely
to be attempting to make sense of it and
determine its severity.16,17
In general, the emotions consistent with
the various stage models have been
observed in athletic injury research (e.g.
depression, anger, frustration) but a
common sequence of discrete responses to
athletic injury has not been documented.
Responses to injury in fact would appear to
be more global and varied across individuals
than stage models would predict.18 Overall,
the injury-grief literature has many
limitations. The literature has primarily
been descriptive in nature and lacks
empirical rigour. Describing anecdotal
evidence of how the response to athletic
injury is similar to that of the stages of grief
is flawed considering that the Kübler-Ross14
model was originally derived from patients
with terminal illness and was not intended
to be representative of athletes’ experiences
of athletic injury.
Recognizing the limitations of grief
response models and their lack of account
for individual differences, a number of
researchers have adopted cognitive appraisal
models as a framework for understanding
July 2007 Vol 127 No 4
Page 175
Psychological responses to injury in competitive sport REVIEW 175
and examining the psychological response
to athletic injury.18,19 The roots of cognitive
appraisal models are found in various
theories of stress and coping.
Cognitive appraisals are processes
through which a potentially stressful
situation is assessed as being stressful and
the individual’s evaluation of the extent of
that stress. Appraisals influence the way in
which an individual copes with a stressful
situation. Coping is defined as an
individual’s ever-changing efforts to manage
circumstances that are appraised as
stressful.20 This is a transactional process
between individuals and their environment.
Hence, coping varies within individuals,
depending upon the circumstances,
individual differences and upon the
individual’s cognitive appraisals. Cognitive
appraisals are said to occur in two forms,
primary and secondary appraisals.20
Primary appraisals involve an assessment of
what is at stake taking into account
challenge, benefit, threat, and harm/loss.20
Secondary appraisals mirror primary
appraisals and involve an assessment of the
coping options available to manage the
demand. The appraisal process shapes the
degree of perceived stress and the content
and strength of the emotional and
behavioural responses.20 Typical cognitive
appraisal models suggest that personal (e.g.
dispositional or historical attributes of the
individual) and situational (e.g. injury-
related characteristics, variable aspects of
the social and physical environment) factors
are proposed to mediate how an athlete
appraises their injury.18 The appraisals then
subsequently affect emotional responses
(e.g. anger, depression) and further
influence behavioural responses (e.g.
adherence to rehabilitation).
Wiese-Bjornstal et al.8 proposed that
cognitive appraisal and grief process models
are not mutually exclusive. They stated that
the sense of loss identified in response to
athletic injury is a process that occurs
following an appraisal and leads to
emotions commonly associated with grief
(e.g. depression, anger). They therefore
proposed a broader integrated stress process
model, which subsumes grief as an
emotional response (see Figure 1). It is
beyond the scope of this article to outline all
cognitive appraisal models that feature
within athletic injury research. The
The Journal of The Royal Society for the Promotion of Health JRSH
integrated model of psychological response
to the sport injury and rehabilitation
process has been proposed as being the
most accepted, well developed model,
offering a good basis for further
research.21–23
Wiese-Bjornstal et al.8 proposed the
model as depicted in Figure 1 with the first
section of the model reflecting the impact of
psychological variables on the likelihood of
injury onset as suggested by Andersen and
Williams.24 The remaining sections of the
model extend the theme of the stress
response to the post injury phase, where the
injury itself is considered the stressor and
the extent of the stress is determined by the
athlete’s cognitive appraisals.
Key aspects of the model relate to the
mediating role of the characteristics of the
injury, the sport specific situational factors,
interactions with the sports medicine team,
individual differences, and the resultant
cognitive appraisals. These appraisals
subsequently affect emotional responses
(e.g. fear, tension, anger) and behavioural
responses (e.g. adherence to rehabilitation,
use of psychological skills strategies). This
aspect of the model is known as the
dynamic core and should be viewed as a
three-dimensional spiral that heads in an
upward direction towards full recovery, or
in a downward direction away from full
recovery if the recovery outcomes are
negative. The reader must be aware that not
all recovery outcomes are positive. The
recovery outcomes are centred between the
athlete’s cognitive appraisal, emotional and
behavioural responses, implying that all can
directly impact on recovery outcomes. The
dynamic core highlights a reciprocal
relationship between cognitive appraisals,
and emotional and behavioural responses.
The proposed predominant path (as
indicated by the larger arrows) is that
cognitive appraisals affect emotions, which
subsequently affect behaviours.
Describing the emotional response to
athletic injury Wiese-Bjornstal et al.8
summarised 19 studies from 1985 until
1997, stating that it was difficult to
consolidate findings across studies as there
is tremendous variation in the populations
studied, research designs employed, and
measures used. The next section will outline
the research reviewed by Wiese-Bjornstal
et al.8
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176 REVIEW Psychological responses to injury in competitive sport

Figure 1 feelings.27 Emotions however have a

short-term effect and are relatively easy to
Integrated model of psychological response to the sport injury and identify the source of the affective state.28
rehabilitation process (Wiese-Bjornstal et al.8) Wiese-Bjornstal et al.8 themselves use
mood, emotions, and affect interchangeably
Stress when discussing the emotional response
Response to athletic injury without clearly
distinguishing between each.
Personality

History of
Stressors

Intervention
Wiese-Bjornstal et al.8 also reported

Resources
Coping
SPORT evidence of some extreme emotional
INJURY
responses to athletic injury. Some athletes
have reportedly expressed relief from
external pressures when injured (e.g.
RESPONSE TO SPORT INJURY AND REHABILITATION PROCESS parents, coaches, teammates, perfectionism
PERSONAL SITUATIONAL and commitment). Some athletes also
INJURY FACTORS FACTORS report an immense sense of loss when
-History
-Severity SPORT injured. Studies have revealed that a
-Type -Type number of injured athletes, approximately
-Perceived cause -Level of competition
-Recovery status -Time in season
10% to 20%, experience extreme responses
INDIVIDUAL DIFFERENCES -Playing status to injury, particularly depression, which
Psychological -Practice vs game surpass levels usually recommended for
COGNITIVE APPRAISAL
-Personality -Scholarship status
-Self-perceptions
-Goal adjustment clinical referral.29–31 Suicidal tendencies are
-Rate of perceived recovery SOCIAL an area of concern for those athletes.8
-Motivational orientation
-Self-perceptions -Teammate influences
-Pain tolerance When emotions are appropriately
-Beliefs & attributions -Coach influences
-Athletic identity
-Coping skills
-Sense of loss or relief -Family dynamics controlled and focused Wiese-Bjornstal
-Cognitive coping -Sports medicine team
-Psychological skills et al.8 propose that the emotion itself might
-History of stressors influences
-Social support provision actually have a positive effect on coping.
-Mood states
Demographic -Sport ethic/philosophy However, this remains unexplored at
-Gender ENVIRONMENTAL present. In addition to some extreme
-Age -Rehabilitation environment
-Ethnicity
emotional responses to athletic injury,
-Accessibility to
-Socioeconomic status
RECOVERY
rehabilitation Wiese-Bjornstal et al.8 suggested that
OUTCOMES
-Prior sport experience some athletes may recover beyond their
-Psychosocial
Physical
-Use of ergogenic aids
-Physical pre-injury status either physically,
-Physical health status psychologically, or both. After enduring the
-Disordered eating challenge of a long rehabilitation period,
BEHAVIOURAL RESPONSE EMOTIONAL RESPONSE athletes may be more dedicated, focused,
-Adherence to rehabilitation -Fear of unknown mentally tough and may also be physically
-Use of PST strategies -Tension, anger, depression
-Use/Disuse of social support -Frustration, boredom stronger than they were pre-injury via the
-Risk taking behaviour -Positive attitude/outlook intensive strengthening activities required in
-Effort & intensity -Grief rehabilitation.
-Malingering -Emotional coping
-Behavioural coping Despite the integrated model of response
to sport injury and rehabilitation
highlighting a number of emotional
responses to athletic injury, this is clearly not
an exhaustive list. For example, the emotion
EMOTIONAL RESPONSE response to athletic injury.11 As a of fear (e.g. fear of losing team place, fear of
RESEARCH consequence mood and emotion are terms re-injury) is not a feature within the model,
Typical emotional responses to athletic that are often used interchangeably. with the exception of fear of the unknown.3
injury have included tension, anger, However, mood and emotion are not one
depression, frustration and boredom.11,17,19 and the same constructs. Despite both
Frustration and boredom are reportedly the mood and emotions having cognitive BEHAVIOURAL RESPONSE
primary responses when athletes are asked origins,25 mood is generally assumed to have RESEARCH
to select, volunteer, or rank post injury a longer span and is a general stimulus. Behavioural responses to athletic injury
emotional responses.17 Moods lack a relationship with an object26 include adherence to rehabilitation,31,32
Mood states have often been reported and often the individual experiencing the the use of psychological skills,7,33 the
when aiming to explain the emotional mood does not know the causes of the use of social networks17 and risk taking.6

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Wiese-Bjornstal et al.34 stated that generally
the research indicates that athletes who
adhere to rehabilitation, use psychological
skills, effectively use available social support,
reduce risk taking, and pursue rehabilitation
goals with maximum effort and intensity
are more likely to recover from injury and
return to previous athletic levels than those
who do not engage in these
behaviours.7,17,32,33
Brewer18 stated that adherence to sports
injury rehabilitation programmes has
emerged as a prime area of interest in the
behavioural responses to athletic injury
research. Wiese-Bjornstal et al.8 specifically
identified personal and situational factors
that have been suggested to be associated
with adherence to rehabilitation. The
personal factor most consistently linked to
adherence is self-motivation, where all
studies have identified a positive correlation
between self-motivation and rehabilitation
adherence.31,32 Single case studies have also
identified some personal factors that relate
to rehabilitation adherence. These include:

attribution of recovery to personally
controllable factors35

attribution of recovery to stable factors35

cognitive appraisal of ability to cope
with injury36

importance or value of rehabilitation to
the athlete37

instrumental coping38

emotional adjustment36

perceived susceptibility to further
complications without rehabilitation

rehabilitation self-efficacy.37
Situational factors can also mediate
adherence to rehabilitation following
cognitive appraisals. The situational factors
that have been positively related with
adherence include:

a belief in the efficacy of the treatment31

comfort of the clinical environment32

convenience of the rehabilitation
scheduling32

perceived exertion during rehabilitation32

social support for rehabilitation.31,32
Single case studies have also identified some
situational factors that are positively
correlated with rehabilitation compliance.
These factors include academic class
July 2007 Vol 127 No 4
Page 177
Psychological responses to injury in competitive sport REVIEW 177
status,18 injury duration18 and perceived
injury severity.37
RESEARCH EXPLORING THE
PROPOSALS OF THE INTEGRATED
MODEL OF PSYCHOLOGICAL
RESPONSE TO THE SPORT INJURY
AND REHABILITATION PROCESS
Following the development of the model
there have been relatively few attempts to
explore its proposals. This is despite the
model lacking empirical rigour and the
suggestion that it is a useful foundation
on which to base further research.21–23
Of the research that has attempted to
explore the model, or some aspect of it,
there are many limitations. These
limitations include retrospective designs,39
lack of exploration of credibility and
trustworthiness,40 response biasing,39
failure to explore the full injury experience40
and responses to a hypothetical injury
scenario.41
Walker, Thatcher and Lavallee42 explored
the longitudinal responses to athletic injury
in three case participants. Utilizing
existential interviews to explore the
meaning of the experience of athletic injury,
the research offered further insight into the
dynamic core of the Wiese-Bjornstal et al.8
model. Walker et al.42 offered support for
some of the proposed mediators of
responses to athletic injury. Of the personal
mediators suggested by Wiese-Bjornstal
et al.8 support was offered for injury history,
severity, type, perceived cause, recovery
status, personality, pain tolerance, athletic
identity, coping skills, history of stressors
and socio-economic status. However, other
mediators such as surgery, visibility and
mobility of the injury – which have been
identified in previous research3 – are not
included in the model. Walker et al.42 also
offered support for sport type, level of
competition, time in the season, playing
status, practice versus game, teammate
influences, coach influences, family
dynamics, sports medicine team influences,
and social support provision as situational
mediators of the response to athletic injury.
These personal and situational factors
mediate the appraisals of athletic injury. For
example, Walker et al.42 stated that an
athlete who had sustained a career-ending
injury described pain as a mediator of his
The Journal of The Royal Society for the Promotion of Health JRSH
recovery status appraisals. Walker et al.42
stated that appraisals appeared to be
related to the rate of perceived recovery,
self-perceptions, beliefs, attributions, and a
sense of loss, as suggested by Wiese-
Bjornstal et al.8 A multitude of appraisals
occurred during the rehabilitation and
return to training/competition in the case
participants investigated by Walker et al.42
Appraisals were made of the severity of the
injury, the functional limits the injury
imposed, levels of social support received,
medical team usefulness, information
provision about the injury, and the length of
time each case perceived that they would be
unable to engage in physical activity.
Walker et al.42 identified that cognitive
appraisal influences subsequent emotional
and behavioural responses, as suggested by
Wiese-Bjornstal et al.8 A wealth of
emotional and behavioural responses were
experienced by the case participants
explored by Walker et al.42 Many of these
responses however do not feature within the
integrated model proposed by Wiese-
Bjornstal et al.8 (e.g. use of alcohol and
re-injury anxiety). However, support was
offered for adherence to rehabilitation, the
use of psychological skills, the use of social
support, risk taking, and behavioural coping
(e.g. avoidance strategies) as behavioural
responses to athletic injury. They also
offered support for fear of the unknown,
tension, anger, depression, frustration,
boredom, positive attitude, grief and
emotional coping (e.g. crying) as emotional
responses experienced by case participants.
Walker et al.42 offered support for the
proposal that the appraisal of an injury
influences the athlete’s subsequent
emotional responses. Furthermore, the
authors stated that the emotional response
influences the subsequent behavioural
response. With respect to the proposed bi-
directional relationship between cognitive
appraisals, behavioural responses, and
emotional responses, Walker et al.42
suggested that cognitive appraisals can
influence behavioural responses without the
influence of emotions. For example, when a
case participant perceived that his injury
could be controlled he subsequently
adopted goal-setting strategies without a
preceding emotion. However, behavioural
responses appear only to affect subsequent
emotions following a reappraisal. For
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178 REVIEW Psychological responses to injury in competitive sport
example, the behavioural response of goal
setting was appraised by a case participant
as beneficial to the rate of perceived
recovery and subsequently the athlete
became more optimistic.42
There is no available supporting evidence
demonstrating that behaviours directly
affect emotional responses without a further
reappraisal. Research evidence appears to
demonstrate that behavioural responses
(e.g. increased effort and intensity in
rehabilitation) cause a reappraisal of the
injury (e.g. perception of being active in
the recovery process and reducing the
recovery time) which then produces an
emotional response (e.g. improved mood
and optimism) and a subsequent
behavioural response (e.g. adherence to
rehabilitation).7 It is unlikely that not
adhering to rehabilitation, for example, will
directly cause an emotion, such as anger, in
the absence of appraising the consequences
of that behaviour. Where an individual
appraises their behaviour as hampering
recovery then it is likely that the athlete will
respond with an emotion such as anger.
However, it is feasible that behaviours may
impact on physiological responses, as
opposed to emotions, in a reflex type
response. For example, where an athlete
does not follow rehabilitation advice, such
as icing the injury, pain may be experienced
and healing and recovery may be delayed.
Walker et al.42 results also offer support
for the proposal that emotional responses
influence reappraisals. For example, where
boredom and frustration were evident the
perception of a sense of loss was increased.
Emotions are said to impact on cognitions
due to changes in arousal that accompany
some emotions.42 Increased arousal may
impair working memory, have detrimental
effects on recall of information, alter
attentional focus, reduce the cognitive
resources available for the task and therefore
reduce the likelihood of relevant
information being processed.43–45
When considering the effect of cognitive
appraisals and behavioural responses on the
athlete’s physical and psychosocial recovery
outcomes Walker et al.42 did not offer full
support for the proposals of Wiese-Bjornstal
et al.’s8 dynamic core. Physical and
psychosocial recoveries do not occur
simultaneously nor are they always complete.
Behavioural responses appear to affect both
JRSH The Journal of The Royal Society for the Promotion of Health
Page 178
physical and psychosocial recovery outcomes.
Where behaviours reflected adherence to
rehabilitation it is clear that there can be
physical recovery gains achieved (e.g.
improved strength, reduced pain). In
addition, when positive self-talk behaviours
were adopted by case participants in the
research conducted by Walker et al.42
psychosocial recovery outcomes appeared
also to be enhanced. Exercise has also been
associated with positive mental health.46
Therefore, as athletes begin to engage in
physical activities in rehabilitation there
could be a decrease in negative emotional
responses, and hence an increase in
psychosocial recovery outcomes. Research
also highlights that as goals are attained
negative mood states reduce. Therefore, the
adoption of goal setting in the case sample of
Walker et al.42 could not only influence
physical recovery outcomes but also
psychosocial recovery outcomes through
goal attainment. Where behaviours have
positive effects on physical recovery
outcomes the athlete will also see that they
have some control over their recovery, hence
this could also influence their psychosocial
recovery outcomes. An injured athlete’s
appraisals are also likely to influence recovery
outcomes. An appraisal that the injury is
healing, and return to competition is near, is
also likely to affect psychosocial recovery.
Emotional responses themselves
appear to only affect psychosocial recovery
Figure 2
Relationships between appraisals, emotions, behaviours and recovery
outcomes (adapted from the dynamic core of Wiese-Bjornstal et al.9
integrated model)
Cognitive appraisal
Recovery outcomes
-Physical
Behavioural
responses
Bi-directional relationship, but this direction is not as strong
outcomes following a cognitive appraisal
and have no direct impact on physical
recovery. It is difficult to assume that an
emotion could directly enhance physical
recovery outcomes. For example, re-injury
anxiety will not influence strength or
range of movement directly. However, the
cognitive appraisal of these anxieties
could affect behaviour, which could then
affect physical recovery (e.g. where an
athlete is anxious about re-injury occurring
during a rehabilitation activity such as work
on a proprioception board he may avoid
this activity and hence proprioception may
not improve). Physical and psychosocial
recovery outcomes themselves also appear
to impact subsequent cognitive appraisals.
For example, where psychosocial recovery
outcomes are attained Walker et al.42
reported that case participants
appraised the injury to be less stressful
and they perceived they were more able
to cope. Where physical recovery
outcomes were attained case participants
appraised the length of time until the
return to training and competition to
be short and hence perceived they
could cope.42
Given the findings of Walker et al.42
perhaps a more suitable representation of
the relationships between cognitive
appraisals, emotional and behavioural
responses, and recovery outcomes should be
depicted as in Figure 2.
Recovery outcomes
-Psychosocial
Emotional
responses
July 2007 Vol 127 No 4
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THE FUTURE
At present the psychological process an
injured athlete goes through is unclear.
Wiese-Bjornstal et al.8 concluded that there
has been a lack of rigorously controlled
investigations and advocate that future
research adopts a prospective, longitudinal
design through the full recovery process and
into the return to competition to further
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Psychological responses to injury in competitive sport REVIEW 179
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