During the 2021 Summer Olympics in Japan, gymnast Simone Biles brought the importance of an athlete’s mental health to the world stage when she chose not to compete in several gymnastics events. The same goes for tennis star Naomi Osaka, who elected to take time away from the court shortly after winning two of the sport’s four Grand Slam events. In the past, an athlete’s mindset was to ignore pain and injury that was affecting their performance; to go out and compete anyway. In recent years, that mindset has changed. Both the sports world and the medical profession now better understand how a person’s mental state can affect recovery from an injury.
Colin Looney, M.D., is a board-certified orthopaedic surgeon specializing in care of the knee, hip, shoulder and sports medicine. Since the start of his practice, he has been interested in the interrelation of the mind and body in healing. He takes a team approach when working with athletes who come under his care, offering them the assistance they need to heal and return to the level of performance they had before the injury or surgery.
Dr. Looney earned his medical degree and completed his orthopaedic surgery residency at Duke University Medical Center in Durham, N.C. He then completed a sports medicine fellowship at the Steadman Hawkins Clinic, now the Steadman Clinic, in Vail, Colo., receiving a certificate of qualification in sports medicine. Dr. Looney is a member of the American Orthopaedic Society for Sports Medicine, the American Academy of Orthopaedic Surgery, the Piedmont Orthopaedic Society, and the International Society of Hip Arthroscopy. He has written and presented a number of papers on surgical techniques and technologies, as well as being featured in a number of articles, including three consecutive years as one of Nashville’s Top Doctors in Nashville Lifestyles.
He serves as team physician for Battle Ground Academy and Centennial High School in Franklin, as well as working as an event physician at local sporting events such as the annual Iroquois Steeplechase in Nashville. He has previously worked with the Nashville Predators and various other athletic clubs. Here he discusses how he has seen an athlete’s mental health affect both recovery and performance.
Williamson Source: After what Simone Biles did at the Olympics last summer to bring the importance of mental health in athletes to the forefront, can you explain how an athlete’s mental health affects their recovery from injury?
Colin Looney, M.D.: After an injury or surgery, we must be cognizant of how our patients – whether they’re a competitive athlete or not – are impacted by depression and anxiety. This is just as true of the Olympian as it is the amateur athlete on the field at one of our local high schools. The most important piece to recovery after injury or surgery is the core of the whole patient; both the physical injury and their mental health during recovery as they get back to performance level.
I started early in my practice with a complete approach to treatment – mental and physical, bringing in the patient, their other doctors, physical therapists, athletic trainers, agents, coaches, parents and whoever else was needed to help the athlete recover and get back to their sport. Back in the day, we were not cognizant of how mental health really affected recovery from injury, but we began looking into it early.
Fifteen years ago, we became very interested in how mental health related to the recovery of athletes after hip surgery with labral repair or labral reconstruction. This is a major surgery that takes the athlete out of their sport for a year. I felt that how they coped psychologically was one of the key factors in their prognosis to recovery, but there was no research.
Then, 13 years ago a paper was published that looked at the prognosis of athletes and Army recruits after hip surgery. It looked at a range of bodily elements, whether the patient was male or female, and many other factors affecting recovery. The research showed that the number one factor in recovery was the patient’s ability to cope mentally with the surgery and how it affected them. Seeing that mental fitness and the ability to cope was the top factor in their recovery, it got me even more interested in mental health in relation to recovery from sports injuries and has been part of my practice ever since.
WS: What are some of the signs of potentially harmful psychological reactions to injury?
Dr. Looney: Mental health for sports medicine doctors – or any other doctor – is key in helping a patient recover from an injury, surgery or other major health event. We need to look at what the major mental health issues are present already in an athlete, including depression, anxiety, eating disorders, substance abuse, and overtraining and note those. They can display differently in each individual patient.
One important point is that depression is not just feeling sad. It can take many different forms: loss of interest and pleasure in past interests, fatigue, sleep disruption, irritability, restlessness, social isolation, lack of concentration, loss or gain of weight, and maybe a sense of hopelessness. It can also manifest physically as skeletal pain or headaches.
It is important for a sports medicine doctor to also recognize anxiety. Symptoms are somewhat similar to depression, and anxiety can also manifest physically.
WS: What are some of the signs that a parent, coach, or other person interested in an athlete’s recovery can look for to know if the athlete – especially a young athlete – is dealing with depression or anxiety?
Dr. Looney: If the athlete finds no pleasure in things that were very important to them before the injury or surgery or if there is a change in overall behavior or their grades are dropping, then they may be dealing with depression or anxiety because their sport is part of their identity and it has been taken from them. Usually these behavioral changes don’t just take place on the field, but also become a part of their life off the field. Parents, physical therapists, athletic trainers, agents, coaches and sports medicine doctors can all be on the lookout for these factors and get help for the patient.
WS: How does severity of the injury or surgery affect mental health of the athlete patient?
Dr. Looney: Any long-term injury that removes an athlete from the field for an extended period of time is going to have an effect on their mental health. For example, an ACL injury will remove an athlete from their sport for a year before they will heal and be back to where they were prior to the surgery necessary to repair the injury. One study demonstrated that more than 40 percent of athletes recovering from ACL surgery report major depressive disorder.
Dislocations in football or any other contact sport can have the same effect. Once there is chronic instability, the injury must be repaired with surgery and it can take six to nine months to fully recover from the surgery, including time to get back to full performance. Up to 50 percent of athletes going through this type of surgery can suffer from depression.
Concussion brings with it a lot of depression and anxiety, and concussions are the most common injury happening on the field. Some who have had a concussion have lingering mental health issues.
It is the severity of the injury that is the major factor in the severity of mental health issues. An ankle sprain that takes three to four weeks to recover from is not necessarily the same as a severe injury that takes the athlete away from the sport they have dedicated their life to for an extended period, or may even end their career.
WS: How can those who care about the athlete help them recover?
Dr. Looney: Recognition. Communication. Being part of the healing team.
Communication is probably the most important piece here. Expression of feeling is very valuable. Although this is not specifically an adolescent, a more experienced athlete or pro athlete will be more open and public about their injury and recovery than an adolescent.
What makes adolescents most vulnerable is they have not fully developed their coping skills; they tend to be less communicative with adults who could help them, and this is a time when they are more likely to be introduced to substance abuse.
This is also a time to bring in a sports psychiatrist or psychologist. These mental health experts can recognize the level of impact of the injury on the athlete’s mental state, and their mental state on the healing process.
WS: How can athletes help themselves?
Dr. Looney: The most important thing they can do is be goal oriented, be objective in their recovery, and follow specific steps instead of giving into a sense of hopelessness. Next, communicate with the members of their recovery team and those they trust and care about. They need to be able to discuss their concerns and openly talk about their feelings.
Those who can turn a negative into a positive have the best outcomes. They celebrate the completion of their recovery goals instead of obsessing over what they have not accomplished. And some, like Biles, use what they have gone through to help others recover. She helped develop a mental health app for treatment of depression and anxiety called CEREBRAL.
WS: How are sports changing to take the athlete’s mental health into account?
Dr. Looney: The day of the coach that felt like he or she had complete ownership of his athletes and pushed them past their limits is fading. Coaches are realizing that, first, an injured athlete is not going to be able to play at the top of their ability and, second, an injured athlete playing at 50 percent is not good for the team.
Still, it is important for the athlete to communicate when they are hurt, and when there is persistent pain. Pushing through an injury at a poor level of performance hurts an athlete’s mental health and can have future physical and mental consequences.
We are getting better at recognizing injury, but now we need to improve implementation of care. We need to develop more facile systems for everyone as an avenue of healing.
There is no research for the mental impact on an athlete suffering a career-ending injury. What can be done to help them cope and move on in a healthy way? We have come a long way, but there are still many stones to turn over and new psychologies to explore. It is important and exciting.
To learn more about mental health’s effect on recovery from injury and surgery, contact Dr. Colin Looney at the Bone and Joint Institute of Tennessee. Dr. Looney can be reached at (615) 791-2630. Or schedule an appointment online.
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