This story is part of Peak, The Athletic’s desk covering the mental side of sports. Sign up for Peak’s newsletter here.
Ian McMahan is a San Francisco-based writer and certified athletic trainer. He has worked as an athletic trainer for Major League Soccer, the women’s World Cup and the San Francisco 49ers.
Helping hundreds of athletes through the ordeal of injury and surgery has led me to one absolute: rehab and recovery are hard. From pro athletes to those in high school, the challenge is as much mental as physical.
As sports medicine professionals, we often focus on the physical recovery because that’s what we can evaluate, measure and improve. What can’t be easily seen or measured but can impact recovery as much as a weak muscle or stiff joint are the psychological aspects.
Because adolescents face injury rates nearly triple those of adults, that’s especially true.
“I think, unfortunately, from a clinical aspect, we’re a little bit behind in understanding the role psychology plays in the recovery from injury,” said Ryan Zarzycki, a physical therapist and associate professor in the department of physical therapy at Arcadia University. “A lot of the research over the past three decades has been focused more on the physical parts of rehabilitation after a big sports injury.”
The last 10 to 15 years, Zarzycki said, have produced a lot of evidence that psychological factors matter for anyone recovering from significant injury, but especially athletes.
Here are three important aspects of psychological recovery:
Mental health influences injury risk
While we often focus on strength, fitness, and technique to keep young athletes safe, a player’s psychological state is just as critical to injury prevention as their physical strength. A recent clinical review characterized this relationship as a “vicious cycle” in which poor mental health raises the risk of sports injury and injury exacerbates the risk of poor mental health.
In one study cited in the review, adolescent athletes with poor mental health and well-being were one-and-a-half times more likely to sustain an injury compared with their peers without mental health problems.
“Stress, anxiety and low mood can influence sleep, focus, decision making and physical healing,” said Emily Pluhar, director of the sports medicine behavioral health team at Boston Children’s Hospital, “Elevated psychological distress has also been linked to injury and increased reinjury risk in young athletes.”
Injuries affect mental health
Beyond the physical pain of a torn ligament or a broken bone, a sports injury often strips a young athlete of a big part of their identity.
“For many adolescents, sport shapes daily structure, sense of belonging and self-confidence,” Pluhar said. “When injury forces time away, athletes may experience shifts in how they see themselves and their role within their sport or peers, even when their physical recovery is going well.”
Adolescents and young adults are especially at risk for these challenges to mental health, Pluhar said, because their identities and sense of self are still developing.
This forced transition from the center of the action to the sidelines can trigger a variety of strong emotions.
According to Pluhar, Parents and coaches should understand:
- Early recognition of injury-related depression and anxiety is important as unaddressed distress can affect rehab adherence and lengthen recovery.
Supporting strengths beyond performance and maintaining a meaningful connection to the team/sport can help with confidence and continuity of that identity during recovery. - Although injury recovery is challenging, many young athletes develop greater resilience, patience, emotional awareness and body awareness through rehabilitation.
- When psychological care is integrated alongside medical and physical treatment, athletes are often better prepared not only to return to sport, but to prevent and manage future setbacks more effectively.
The confidence to return
Beyond the emotions of injury and recovery, how an athlete feels about the function and capability of their injured area — the knee after an ACL injury, for example — can affect the return to sports. In this area, because of the high numbers of young athletes with the injury, much of the focus has been on the return to sports after an ACL surgery.
“Those psychological factors — confidence and fear of reinjury — also seem to be really tied to how an athlete feels about their knee function and the likelihood of ACL reinjury,” said Zarzycki. “There are associations with just how you move, which then have implications for returning to sport and reinjury.”
According to research, a recovering athlete is more likely to sustain another ACL injury if they are fearful of returning to sports or lack confidence in their physical ability to move. Those athletes, likely at least in part sensing a physical vulnerability, such as a lack of strength, coordination or control, tend to move differently, even with simple tasks like walking or running.
More than just making an athlete less safe, the fear of reinjury can prevent an athlete from returning to their sport.
“Psychological factors heavily influence the return to sports,” said Kate Webster, director of the sport, exercise and rehabilitation research at La Trobe University in Melbourne, Australia. “Fear of reinjury, often manifesting as reinjury anxiety, is one of the most common reasons athletes cite for delaying, not returning at all, or returning at reduced levels.”
The fear, Webster said, can make young athletes avoid sport-specific movements like cutting or jumping even after physical clearance.
But there’s the other side: overconfidence.
“Many younger athletes exhibit the opposite, a strong desire to rush back, driven by impatience, fear of losing their spot or overconfidence,” Webster said. “This premature return is concerning because young athletes already have disproportionately high reinjury rates, often linked to returning before they are mentally and physically ready.”
Similarly, because overconfidence leads them to return too soon, these athletes are at higher risk of injury.
“So on one side, it’s really bad to really have a negative outlook about returning to your sport,” Zarzycki said. “But on the flip side, you should have some anxiety about returning to sport after a big injury like an ACL, especially when you’re probably still in that four to seven month range when the reconstructed knee isn’t ready for the stress of playing a game.”
Balancing these two extremes, fear that delays and haste that risks reinjury, is key, Webster said.
Parents and coaches should understand:
- Regular assessments of mental state can identify problems with psychological readiness and mental state before they can significantly affect recovery/rehabilitation and return to sport.
- Assessments and check-ins by parents and coaches can destigmatize the normal psychological difficulties that a recovering athlete might feel after a significant injury.
- Mental readiness (often called psychological readiness as well) often lags behind physical healing.
- Athletes might be medically cleared yet still feel hesitant, avoid specific movements or ruminate about reinjury. These reactions are common and typically reflect difficulty trusting the body rather than a lack of motivation or effort.
- Psychological readiness is an important factor in safe return to play and reinjury risk, making gradual exposure through both imagery and real-world practice, along with open discussion and validation of fear, essential parts of recovery.