Sport - recovering from long-term injury isn’t just about the body

While the majority of Premier League footballers are switching off on holidays that perhaps do not feel long enough given the fast approaching summer tours, for some the break seems to be interminable.

The long-term injured always seem to be in a different zone, operating in a different space, to the rest of the squad. Across the country others are in a similarly tough boat. The list of players trying to navigate their way back from a leg break, a cruciate tear or some such other nightmare includes Santi Cazorla at Arsenal, Callum Wilson at Bournemouth, Ilkay Gündogan at Manchester City, Érik Lamela at Tottenham and Mauro Zárate at Watford.

What do footballers do while recovering from long-term injuries?

For those whose contractual situations are up in the air there is added uncertainty as they try to regain full movement and confidence. Zlatan Ibrahimovic and Jack Wilshere have plenty of time to think as they recuperate.

All that thinking time is not necessarily beneficial to injured elite athletes. Far from it. The former Queens Park Rangers manager Chris Ramsey, who is technical director at the club’s academy overseeing all aspects of development, does not beat about the bush when he reflects on how he felt as a player who suffered injury after injury. “I had seven knee operations and three back operations and I was probably depressed for years,” he reflects. “People don’t realise with long‑term injuries you go into depression – no matter how mild it is.

“The cycle includes denial and anger before you can start recovering. Left to your own devices it can take a long time to accept what is happening. You think about where you are in your contract, where you are in your career, if a new manager might come in who doesn’t know you – will he buy someone to replace you? That’s the worst thing about it. There is so much time to think.”

Dr Misia Gervis is a leading sports psychologist who spent six years with England’s women’s team and works with Ramsey at QPR’s academy. As a senior lecturer in the field at Brunel University she recently led a study into the use – or lack – of psychological support for players with long-term injuries in football. With the help of the Professional Footballers’ Association, they gathered opinions at 75 professional clubs, and from around 50 players who had experienced long-term injury.

“We found that the majority had no psychological support at all,” she notes. “A tiny percentage might have spoken to someone. Yet we asked if they felt anxiety or isolation, and 99% reported experiencing some kind of psychological disruption. When you are in that rehab place and you can’t get on that pitch it seems like it’s forever. There is a wealth of evidence around the psychological challenges of long-term injury. If you are an elite athlete where it is your only identity, and suddenly that has been taken away from you, you are sitting there thinking: ‘Who am I now?’ It is a big sense of loss.”

At youth level, having some form of sports psychology is a requirement in order to have the highest category academy status. But at senior level, it is up to each club to offer whatever experts they want. Gervis is convinced that with long-term injuries it is hugely beneficial to recognise that the challenges are physical and mental. A player during months of rehabilitation will routinely see doctors, physios, strength and conditioning coaches. Sports psychology is not necessarily part of the package even though the evidence points to it being needed.

“We spoke to the PFA counsellors, as we wanted to find out if the things players were presenting with had injury as part of the story,” she says. “It was. For men in a football environment to go and seek help it has got to be quite tricky. They also reported an increase in gambling behaviour. Part of that is boredom when you are injured, difficulty to manage emotions, devalued behaviour. All those things are going on. It’s helpful to recognise that injury is a psychological trauma as well as a physical one. Routinely this is not being addressed.”

At QPR’s academy they aim to tackle the issues hand in hand. Gervis is essentially part of the backroom team and the progress of an injured player will be assessed by her in tandem with the physiological side. The example of a 12-year-old who was out with a cruciate injury shows exactly how the backroom team collaborate. The physios felt he was physically ready to return to training but Gervis did some tests that showed the boy was terrified of re-injury. The reintroduction to training was postponed to allow Gervis to encourage the boy to overcome his fears, and three weeks later he came back in good shape all round to return to football.

Ramsey wants to offer every possible support to the club’s young players, particularly in the case of a lengthy spell sidelined. “We’ve seen kids who are despairing,” he says. “Parents alert us to behavioural changes. They are linked to the way they are feeling about their injuries. Parents tell us: ‘When the football is good, their life is good.’ It is quite a taboo subject in football because people don’t like opening up. The most important part is to talk to someone who can give them strategies to feel better. We are trying to educate coaches to understand that psychology is the backdrop of everything we do.”

That education of coaches is a pertinent point. By Ramsey’s own admission it is not easy to find sports psychologists who are in it for all the right reasons and strike the right balance of adapting to the specialist demands in football and putting the needs of players and clubs first.

Gervis agrees that the best qualified people are needed to fill a role that is in some cases completely missing in football – particularly with injured players – and still very much misunderstood. “Look at the narrative that came out about Daniel Sturridge – it’s a narrative about psychological weakness,” she notes. “I just hope he has got someone to talk to. Pay attention to that everybody. The PFA counsellors are the ones dealing with you once you have fallen off a cliff, but my thought is: stop them getting to the edge of the cliff. They don’t need to be there. If you do your job properly you could have a successful rehab.

How football is trying to tackle the growing issue of players' mental health

“If you think of long-term injury as a journey, the challenges are different depending on where you are along that journey. The immediacy of taking in that your ACL [anterior cruciate ligament] is gone and you need an operation, coming out of that feeling helpless and dependent on people. Then you get to go into training and see everybody zooming past you and you are thinking: ‘They are all better than me.’ The next stage is coming back into training with the fear of re-injury and the uncertainty – people change their movement patterns, maybe carry a bit of tension and are not moving as freely. There are a whole range of things before a player is ready for competition. There are particular transitions and milestones we need to be aware of and support players through that.”