the relationship between psychological factors and sports injuries

Leading Article

Sports Medicine 6: 127-134 (1988) 0112-1642/88/0009-0127/$04.00/0 © ADIS Press Limited All rights reserved.

The Relationship Between Psychological Factors and Sports Injuries

Gretchen Kerr and Barry Fowler School of Physical and Health Education, University of Toronto, Toronto, and Departments of Physical Education and Psychology, York University, Downsview, Ontario, Canada

Across a wide range of sports, at both profes-sional and amateur levels, injury rates have reached appalling proportions and are cause for grave con-cern. In a study of high school sports injuries, Gar-rick and Requa (1981) reported rates of 81 % in football, 75% in wrestling, 44% in softball, 40% in women's gymnastics, 30% in men's basketball and 28% in men's gymnastics. Although most of these injuries are strains and sprains, the severity of the injury problem is illustrated by Mueller and Blyth's (1986) findings that 33 fatalities and 44 permanent cervical cord injuries occurred between 1980 and 1985 inclusive, as a direct result of participation in high school football in the United States.

It has been assumed that injuries could be largely explained by external causes such as the environ-ment, equipment, and the degree of contact in-volved in the sport, although internal causes such as the physical state of the athlete have been re-cognised as contributing factors. Attempts to amel-iorate injury rates by addressing these variables have helped up to a point. However, it is becoming apparent that more complex injury models which consider other contributing variables are needed. The purpose of this paper is to discuss these new points of view which address the internal psycho-logical causes of injury.

1. The Simple Model of Sports Injuries The simple injury model assumes that external

factors can largely explain sports injuries. Such causes include the training environment, type of

activity and equipment. Brock and Striowski (1986), for example, reported that 14% of the injuries in-curred by elite figure skaters were attributed to the ice conditions and 18% of the injuries were related to the condition of the athletes' skates. Watson (1984) stated that inadequate equipment and fa-cilities were associated with 35% of major and mi-nor injuries incurred in school sports.

However, this simple model no longer appears adequate to explain the injury phenomenon. As Garrick and Requa (1981, pp. 115-116) stated, ' ... in spite of improvements in safety equipment, coaching and training practices, medical care and, in some cases, rules promoting safety, the number of injured participants has also risen.' Thus, the argument can be made that environmental and physical causes do not sufficiently explain the ath-letic injury phenomenon and therefore one must examine alternative contributors to the risk of sports injuries.

Recent studies of elite gymnasts (Kerr & Cairns 1988; Kerr & Minden 1988) revealed interesting findings regarding perceived causes of injury. 'Lack of concentration' or 'thinking of other things' was the most commonly reported cause of injury in the Kerr and Minden (1988) study and was second in frequency in the Kerr and Cairns (1988) study. These findings suggest that internal causes, which include not only the physical state, but also the psychological state of the athlete, are important. The proposition that psychological variables are

Psychological Factors and Injuries

worthy of consideration is supported by findings that indicate that personality and the psychological state of the individual are associated with the oc-currence of industrial and automobile accidents (Dunbar 1947; Stuart & Brown 1981) and accident proneness in children (Marcus et al. 1960; Plionis 1979). It seems reasonable to propose, therefore, that psychological variables may contribute to ac-cident occurrence in sports.

It was a result of the inability to control injuries simply in terms of external causes, coupled with the fact that there is a relationship between psy-chological variables and accidents that led to a new line of thinking. This new approach examines the psychological characteristics of the individual as contributing factors to injuries.

2. A More Complex Model 0/ Sports Injuries

The more complex model of sports injuries re-cognises the importance of external factors but as-sumes that internal factors, which include both the physical and psychological attributes of the athlete, also contribute significantly to injuries.

2.1 Physical Factors

As Todd (1982) stated, injuries may be caused when an athlete lacks sufficient strength, flexibility, agility, speed or the high level of endurance nec-essary to prevent physical fatigue. In Watson's (1984) study of school children's injuries, lack of fitness was identified as a contributing factor in 27% of the reported injuries. This finding is perhaps not surprising but even at the elite level, where pre-sumably fitness is higher, Kerr and Cairns (1988) found that competitive male gymnasts reported physical fatigue as the most common cause of in-jury. It appears that relatively little attention has been paid to this area, although it is obviously of crucial importance when making decisions about how soon an athlete can return to competition after sustaining an injury.

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2.2 Psychological Factors

The psychological factors researched to date as potential correlates of injury may be classified as personality variables or psychosocial variables. The former refers to fairly stable, enduring qualities of an individual, whereas the latter considers the in-dividual within a changing social environment.

2.2.1 Personality Factors Much of the impetus for the study of psycho-

logical correlates of injuries came from research on industrial and automobile accidents and accident proneness in children. Dunbar (1947) claimed that in at least 80% of all industrial accidents, the cause was related to one's personality rather than a func-tion of chance, other people, machinery or job training.

A variety of personality variables have been ex-amined in sport, including the general personality make up of the individual, trait anxiety, locus of control and self-concept.

Attempts to establish relationships between the general personality make-up of the athlete and in-juries have failed (Brown 1971a; Govern & Kop-penhaver 1965; Jackson et al. 1978; Valliant 1980, 1981). Despite the varied use of personality inven-tories and athletic samples, the findings are con-tradictory and inconclusive.

One trait that Dunbar included in her profile of the accident-prone person was the individual's be-lief in the external control of his or her environ-ment by factors such as fate, luck or chance. This trait was later defined by Rotter (1972) as an ex-ternal locus of control. At the other end of the lo-cus of control continuum is an internal locus, which refers to a belief in personal control and respon-sibility. Dahlhauser and Thomas (1979) claimed that fewer injuries were incurred by players with an internal locus of control, suggesting that those who accept personal responsibility for their per-formance and safety sustain fewer injuries than those athletes who place responsibility on the coach, environment, fate or chance. However, 2 other studies (Kerr & Minden 1988; Passer & Seese 1983)


failed to show significant relationships between lo-cus of control and athletic injuries.

Another personality variable investigated in the sport literature is trait anxiety, which has been de-scribed as a general disposition or tendency to per-ceive certain situations as threatening and to react with an anxiety response (Spielberger 1966). De-spite the established relationships between trait an-xiety and accidents, an examination of trait anxiety within the sport environment has failed to show any significant relationships with injury incidence or injury severity (Kerr & Cairns 1988; Kerr & Minden 1988; Passer & Seese 1983).

The accident literature clearly indicates that in-dividuals with low self-concept tend to incur more accidents than individuals who maintain a more positive perception of themselves (Marcus et al. 1960). Although Young and Cohen (1981) claimed that female high school basketball players with high self-concept incurred more injuries than players with low self-concept, a closer examination of their data indicates that only a trend exists (p < 0.10). The authors concluded that high self-concept ath-letes were more apt to take additional risks in game play and subsequently found themselves in situa-tions which resulted in injury. This trend was sup-ported by Kerr and Minden's (1988) research, where a significant positive relationship was found be-tween self-concept and the number of gymnastic injuries incurred, but no relationship existed be-tween self-concept and injury severity. As only trends have been found, and because these trends from the sport literature contradict the results of the accident research, the relationship between self-concept and athletic injury occurrence requires fur-ther clarification.

In summary, attempts to identify personality correlates of sports injuries have resulted in incon-clusive findings. With methodological improve-ments such as greater consistency in the use of measures, these relationships may be clarified; however, at this stage it appears unlikely that the study of personality traits will produce much in-formation about the aetiology of injuries. As En-dler's Interactionist Model (1981) states, person-ality accounts for only 5% of the variance in human

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behaviour, and to begin to predict behaviour or outcome measures such as injuries, we must con-sider the interactions between the personality, the situation and the person's typical mode of re-sponse. Research that has shown more promising results is the study of psychosocial correlates of in-juries, which attempts to take into account the interactionist model.

2.2.2 Psychosocial Factors The psychosocial area of study considers the in-

teractions between the individual and the individ-ual's social environment. Research in this area be-gan with an interest in the relationships between stressful life events and the onset of illnesses. Stressful life events are positive or negative events which usually evoke some adaptive or coping be-haviour or a significant change in the ongoing life pattern of the individual (Holmes & Rahe 1967). Some examples of stressful life events include death of a loved one, move to a new residence, marriage and change of job or school. Research consistently indicates that a clustering of life events requiring change usually precipitate such physical, mental and behavioural outcomes as myocardial infarction (Theorell 1974), anxiety and depression (Paykel 1978; Vinokur & Selzer 1975), accident occurrence (Dunbar 1947; Levenson et al. 1983) and lowered academic performance (Johnson & Sarason 1979). These findings led researchers to ask whether the experience of stressful life events was also associ-ated with the incidence of athletic injuries.

The initial study with athletes was conducted by Bramwell et al. (1975) who examined the relation-ship between the amount oflife change over 1- and 2-year intervals and athletic injury occurrence in college football players. Their Social and Athletic Readjustment Rating Scale contains a list of sig-nificant and important life events which influence personal and athletic performance and which ne-cessitate adjustment on the part of the-athlete. Re-sults indicated that injured players experienced sig-nificantly more life changes than the non-injured players over both 1- and 2-year periods prior to testing. On the basis of their scores on the stressful life event questionnaire, the players were divided


into low, moderate and high risk groups for the purpose of injury prediction. It was found that 30% of the low risk players sustained an injury com-pared with 50% of the athletes in the moderate risk group and 73% of players in the high risk group. It was concluded that the risk of injury to football players increased in direct relationship to the ac-cumulation of the perceived stressful life events.

A study by Coddington and Troxell (1980) ex-amined the relationship between life events and in-juries in high school football players. The instru-ment used was similar to that employed by Bramwell et al. (1975) but modified for use with children and adolescents. It was found that the risk of injury was 5 times greater for a boy who had experienced the loss of a parent by death, or sep-aration from 1 parent through divorce (high object loss), than for players experiencing no such loss. Furthermore, there was a low but significant cor-relation between severity of injury and severity of parental loss.

Passer and Seese (1983) examined the stress-in-jury relationship with college football players from 2 teams, but distinguished between positive and negative life changes. Although there were no sig-nificant differences between injured and non-in-jured players on one team, the findings from the other team revealed that those players who were unable to participate for more than 7 days due to injury had experienced a greater number of nega-tive but not positive life changes over the previous year. Similar to the findings of Coddington and Troxell (1980), Passer and Seese (1983) noted that a greater percentage of injured players experienced high object loss, such as the death of a parent.

Again using college football players, Cryan and Alles (1983) found that injured players had expe-rienced significantly more life events than non-in-jured players. Athletes with several life changes ran a greater risk of receiving multiple injuries during the season although severity of injury was not re-lated to a player's life event score. The authors sug-gested that future research must investigate whether these findings could be replicated for non-contact sports.

Consequently, Williams et al. (1986) examined

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whether male and female intercollegiate volleyball players with high life stress would be at greater risk of injury. The results indicated that no significant relationships existed between life stress and injury, suggesting that the American football studies did not generalise to the sport of volleyball. The re-searchers speculated that the life stress-injury re-lationship may vary with contact versus non-con-tact sports.

However, studies in gymnastics (Kerr & Cairns 1988; Kerr & Minden 1988), a non-contact sport, support the findings from the football studies. Us-ing both female and male national calibre gym-nasts, significant relationships were found between reported stressful life events and the number and severity of injuries incurred, such that the gymnast who had experienced many stressful life events in-curred more injuries and more severe injuries. Fur-thermore, reanalysis of the Kerr and Minden (1988) data indicates that those gymnasts with the highest life event scores had 4 times as many injuries and the severity of these injuries was 4.5 times greater than the gymnasts with the lowest life event scores. Severity of injuries was measured by assigning 1 point to every week of training compromised due to the injury.

Although the research findings from the above review of literature are not unanimous, there is a predominance of results which support a relation-ship between stressful life changes and the expe-rience of athletic injuries. This raises the question of what mechanisms mediate this association. This is not only of theoretical interest but is of vital im-portance from an applied point of view. If the pro-cesses by which stress leads to injury can be iden-tified then a target for remedial action or injury prevention becomes possible.

3. Hypotheses for the Stress - Injury Relationship and Implications for Remedial Action

Two hypotheses have been proposed for the re-lationship between stressful life events and injury occurrence, each with different implications for re-medial action.


3.1 Attention

The first hypothesis involves the intervening variable of attention (Lysens et al. 1986). Bramwell et al. (1975) suggested that life events may act to hinder concentration on crucial environmental cues such as detecting the blind side block in football. Modern theories of attention provide some guid-ance as to how performance may be disrupted by inattention. Schneider and Fisk (1983) have sug-gested that skilled athletes rely on 2 information processing systems. One is fast and allows actions to be run off automatically without attention being paid to them - the seemingly effortless perform-ance of the elite athlete. The second system is slower and effortful, it requires conscious attention. The latter is used to monitor overall strategies, thereby enabling sets of automatic actions to be run off as required. Schneider and Fisk (1983) emphasise that an athlete must 'let go', not attempt to direct au-tomatic actions consciously if skilled performance is to be successful. We suggest 2 possibilities. It could be that a high incidence of stressful life events leads to worry about performance which prevents the athlete 'letting go', or it could be that the in-trusion of inappropriate thoughts prevents the sec-ond system from monitoring performance in an ef-ficient manner.

The attention hypothesis receives some indirect support from the Kerr and Minden (1988) study in which the majority of gymnasts reported 'lack of concentration' or 'thinking of other things' as the major cause of their injuries. Some elaborated to say 'I was thinking of all the homework I had to do after training', 'thinking about something that happened at school that day', or 'thinking about an argument I had with my mother this morning'.

3.2 Fatigue

A second hypothesis that has been proposed by Kerr and colleagues for the correlation between life events and injuries is fatigue, because Kerr & Cairns (1988) found that a majority of gymnasts reported this as a contributing factor. It could be that life stressors exhaust the athlete's energy resources (Se-

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lye 1979), producing fatigue and increasing suscep-tibility to injury. In this context, fatigue is not nec-essarily just physical but can also be mental. The latter refers to a complex syndrome characterised by subjective feelings of lassitude and disinclina-tion towards activity that has long been of concern in industry and aviation for safety reasons (Cam-eron 1974). Both physical and mental fatigue can lead to decrements in performance although the problem of measurement has not been entirely re-solved (Holding 1983). It should be noted that fa-tigue could play a double role as a precursor of injuries; firstly, in the direct manner discussed in section 2.1 and, secondly, indirectly as proposed in this section. Moreover, the attention and fatigue hypotheses are not mutually exclusive. It could be that the symptoms offatigue contribute to inatten-tion which in turn leads to injuries.

3.3 Remedial Action

The attention and fatigue hypotheses are ad-mittedly highly speculative but this question is an important one for future research because the re-medial action required to ameliorate injuries will vary depending upon the causal mechanism.

The attentional hypothesis implies that athletes should be provided with an intervention pro-gramme of attentional training (Nideffer 1976; Or-lick (986), to enable them to focus on the appro-priate task or to shift their focus from one task to another. If the intervening process is fatigue, it would be important for the athlete and coach to recognise the vulnerability to injury associated with periods of mounting life change and modify train-ing accordingly. Perhaps the athlete could reduce training intensity, emphasise conditioning or per-fect basic skills, rather than learn new and risky skills during times of change.

4. Some Future Methodological and Theoretical Considerations

Future research must not only attempt to an-swer the questions raised above, but also to ad-dress criticisms directed at the life event field of research.


Although no hard data exist, our best estimate from the literature suggests that the variance ac-counted for by stressful life events in explaining injuries is 10 to 20%. Furthermore, this variance may be underestimated because of moderating variables, which are defined as factors that play a role in determining the stressful life event-injury relationship.

StUdying moderating variables amount to in-quiring about the mediating factors that affect the way one appraises stressors and reacts to stress. Life stress does not have uniform effects on people. Ex-posure to the same stressful life event will leave some suffering physically and psychologically, while others display remarkable resistance.. Some me-diating factors found to influence the impact of stressful life events on illness outcomes include the controllability (Suls & Mullen 1981) and predict-ability (Matheny & Cupp 1983) of the life event, and the 'psychological hardiness' or stress resist-ance (Kobasa et al. 1979, 1981) of the individual. To date, these variables have not been explored as mediators of the stress-injury relationship; how-ever, it is proposed that their inclusion might assist in the understanding of this association. Social support has also been found to mediate the rela-tionship between stress and several physical and psychological outcomes (Cobb 1976; Thoits 1983; Williams et al. 1981) although preliminary data (Kerr & Cairns 1988) suggest that social support does not act as a mediator of the stress-injury as-sociation. However, further research is needed in this area.

Recommendations have also been made to move away from the preoccupation with stressful life events or major 'ephemeral, once-in-a-lifetime episodes .. .' (Pearlin 1983, p. 5). Instead, several authors advocate the study of day-to-day, repeated and more common stressors. Kanner et al. (1981) term these daily stressors 'hassles', while Pearlin (1983) uses the term 'role strains' to describe those daily stressors associated with our social roles. The implications of such suggestions are that research which addresses the influence of psychosocial fac-tors on athletic injuries must include an examin-ation of both types of stressors, episodic life events

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common to most people as well as the stressors specific to individuals in athletic roles.

Traditional life events research has also come under scrutiny as a result of its retrospective de-signs, a point that also applies to the studies cited in this paper. The inventories usually ask the sub-jects to check those life events which they have experienced during the previous 6 months or year. Problems of memory recall or biased recall are as-sociated with this format. A risk of retrospective contamination (Rabkin & Struening 1976) or 'ef-fort after meaning' (Brown 1974) exists in which past events are exaggerated in order to justify sub-sequent or more recent illnesses or injuries. Sub-jects may therefore report more life events in at-tempt to explain their difficulties. In response to the retrospective design criticisms, recommenda-tions for prospective studies have been made (Ko-basa 1981; Taerk 1977). A prospective design im-plies a longitudinal study in which both stressful life event and injury data are collected as they oc-cur in time, thus circumventing the problems of memory recall and retrospective contamination.

And, finally, in order to isolate psychosocial contributors to the injury process, a variety of other factors need to be controlled. Athletes should be chosen from sports where the environment is con-stant and therefore all subjects are exposed to the same athletic stressors. Medical histories should eliminate those athletes with susceptibilities to spe-cific injuries. Monitoring of training variables, namely frequency, intensity and type, would ad-dress the alternative hypothesis that the injuries are due to increasing training demands.

5. Conclusions and Implications for Future Research

Data regarding the prevalence of injuries in sport suggest that further understanding of the injury process and injury prevention is warranted. In or-der to maximise the benefits attainable from sport participation, we must minimise the chance of in-curring injuries. A search for causes has revealed that the training environment and physical quali-ties of athletes cannot account for all sport injuries,


and thus researchers have begun to examine the psychological correlates of injuries.

Attempts to identify personality factors related to injury incidence have failed to produce clear and conclusive findings. Research of the psychosocial characteristics of the athlete, however, has elicited more encouraging results. The majority of studies suggest that an athlete who experiences several re-cent stressful life events tends to incur more in-juries. In other words, the athlete who is required to adjust to many changes in his or her life within a relatively short period of time increases his or her chances of becoming injured. It is suggested that stress may lead to injury by interfering with one's ability to focus attention or by producing fa-tigue.

The practical implications of these findings are that an athlete's health and performance are influ-enced not only by events occurring within the sport environment but also by his or her life outside of the participation in sport. For the coach, this means having an awareness of other aspects of the ath-lete's life. It also suggests the importance of pro-moting skills to assist the athletes to compartmen-talise their attention and energy, thus minimising the spill-over effect of problems in one area of life to the others. Attentional skills, designed to in-crease one's ability to focus attention have been recommended as one potential strategy for reme-dial action. Furthermore, recognising that an ath-lete is undergoing many life changes and therefore many adjustments should be an indicator for the coach to modify training by reducing levels of in-tensity and risk. All of these implications are fa-cilitated by a one-to-one relationship and open, 2-way communication between each athlete and coach.

Theoretically, in order to further understand the process between the experience of stress and in-juries, we need more elegant research which is pro-spective in design and which considers mediating variables. Presumably, information from experi-mental designs that implement remedial strategies such as attentional training will facilitate our understanding of the aetiology and thus the pre-vention of sports injuries.

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Author's address: Gretchen Kerr. University of Toronto, School of Physical and Health Education. 320 Huron Street. Toronto, Ontario M5S IAI (Canada).

the relationship between psychological factors and sports injuries

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