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Injury Prevention

Are Your Stress Levels Causing Injury?

A new review shows a potential link between structural injuries and an athlete's personal attitudes, stressors, and relationships.

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Each month, Dr. Jeffrey Sankoff looks at a recent study or a body of research to talk to the researchers, explain the process behind it, and break down the findings.

This month: A recent review of research looking at the psychological and psychosocial factors that lead to injury—in other words, injuries are more than just physical.

After two years of pandemic related cancellations and postponements the Ironman World Championship is almost upon us, albeit at a different time of year than we are used to and on an altogether completely different and drastically more difficult course. Whatever your reaction to the change in venue, the fact that the race is happening is something that most everyone can agree is good news, and the building excitement is palpable. After almost three years we’ll get to see the best athletes in our sport toe the line together.

That excitement was definitely tempered somewhat though with the recent news that two of the favorites and arguably most popular athletes were going to miss the action because of injury. In rapid succession it was announced that first Lucy Charles-Barclay and then Jan Frodeno would have to skip the event. In the former case because of a stress fracture in the hip, and for the latter a partial tear of the Achilles tendon.

RELATED: A Running List of the Pros Not Starting St. George

Injury is very much a part of triathlon, and for professionals particularly, who are continuously pushing themselves to perform at a level that few of us mere mortals can fathom, it is a continuous, lurking hazard. In some cases, as was the case this spring for two-time world champion Patrick Lange, it may be the result of an acute traumatic injury. (Lange had bike crash and broke a shoulder, and is also unable to participate.) But for most professionals and high-performing age-group athletes, a far more likely cause of injury is overuse, where increasing load and inadequate recovery eventually cause damage to bones, tendons, or muscles and can result in the kinds of problems that Frodeno and Charles-Barclay and many others have to deal with.

However, the prevailing wisdom on overuse injuries—that they are simply a result of an imbalance of load and recovery—has recently come in to question with an additional factor now being raised as having an outsized and yet before unrecognized role.  

Researchers at the Swedish School of Sport and Health Sciences recently published a systematic review that summarized a body of research that posits that not only is there a physical component to the development of overuse injuries but that psychological and psychosocial factors may also have an impact on who is at risk for developing these injuries.

Dr. Ulrika Tranaeus and her team summarized the findings of nine quantitative studies and five qualitative studies, with a total of 1,061 competitive athletes evaluated for a total of 27 different psychosocial factors and their relation to overuse injuries.

Psychosocial factors were divided in to three different categories: intra-personal (e.g., exercise dependency, athletic identity, perfectionism, risk taking, etc.), inter-personal (e.g., coach-athlete relationship, inter-personal stressors), and sociocultural (e.g., perceived motivational climate).

While not all these risk factors could reliably be associated with an increased likelihood of overuse injuries, some were identified more frequently as issues and some did seem to be associated in this way.

For example, athletes who are more likely to report elevated perfectionist tendencies were much more likely to experience chronic psychosocial stress, and in turn showed higher rates of developing typical overuse injuries. Similarly, athletes who have a very high perception of themselves related to athletic identity or who tend to use goal-oriented motivation in their training and racing also had higher rates of overuse injuries.

With respect to inter-personal risk factors, athletes who have problematic relationships with coaches, specifically those who found communication difficult, report higher than expected overuse injuries. Finally, with regard to sociocultural risk factors, athletes who found themselves in environments that encourage “mentally tough” attitudes and behaviors are again more likely to experience overuse injuries.

Some of these findings may seem intuitive but others less so. How could it be that, with the same kinds of training and recovery, these psychosocial factors alone play into the development of physical ailments?

Tranaeus and her co-authors explain that because chronic, overuse injuries differ from acute injuries in terms of timing, psychosocial factors can have a real and important impact. For example, when an athlete suffers an acute injury like a sprain or broken bone, the time of injury is very well-defined and the process for recovery and rehabilitation is easy to prescribe. With overuse injuries there is no one point at which the injury happens. Rather, it is an ongoing process that develops over time. With such a gradual onset, there is more opportunity for psychophysiological stressors to play an important role. For example, psychosocial stress reduces effective recovery after training. In the presence of an underlying developing injury, this can worsen the problem.

Furthermore, psychosocial stressors are known to have an effect on the autonomic nervous system and hormonal responses, both of which can negatively impact behavior, influence recovery, and worsen injury. 

RELATED: How Do I Know If My Recovery Sucks?

Tranaeus is careful to point out that while her study suggests these links between psychosocial risk factors and overuse injuries, the evidence establishing causation is far from established. Most of the research included in her review were small studies and could be influenced by the biases of the authors that conducted them. Furthermore, none were experimental, a requirement to truly establish cause and effect.

Despite this, the authors do make suggestions for athletes and coaches to try and be more aware of the level of psychosocial stress in their lives in order to manage those issues and to be able to modify training and mitigate the likelihood of injury.

One such recommendation is to use assessment tools to monitor stress on a weekly basis. This could be done in order to know when an athlete is seeing an increase in stress that may put them at risk of worse recovery and therefore may need to decrease in training intensity and/or volume. The authors also point out that there is evidence that suggests that athletes experiencing increased stress are also at risk of experiencing acute traumatic injuries—likely because when stressed or time-crunched, people (not just athletes) tend to make mistakes or rush—all of which makes the monitoring of stress levels particularly important for athletes.

Other recommendations for athletes and coaches to come out of this study were to always strive for a positive and supportive training environment that emphasizes self-care and improvement over toughness. Open and honest communication between coach and athlete should be non-judgmental and allow for athletes to feel supported and heard at all times.

Overuse injuries are unlikely to ever be completely eliminated from sports like triathlon, but this early understanding of how psychosocial factors can play a role on top of the traditional view of this being a purely physical process can only help athletes assess and modify these factors. And, hopefully, high-performing athletes training for future events can be spared the kind of disappointment that Frodeno, Charles-Barclay, and Lange are facing this time around.