Many orthopaedic surgeons have routines to prepare for surgery—a certain playlist; a favorite snack; a cadence to how they scrub, prep, and drape; or for some, meditation or prayer. In this way, surgeons are not so different from the athletes they treat. Whether it is a strategic choice to reach a focused mindset or more of a compulsion, surgeons and athletes share many practices to perform at a high level. They all seek approaches to optimize their performance, enhance their focus, and elevate their outcomes.
The COVID-19 pandemic has dramatically impacted the sports landscape, upending many of these routines and highlighting the importance of maintaining a healthy mindset as athletes navigate a “new normal” in their sports. Athletes are uncertain about when and how to return to play. All levels of sports have shown successful ways to return to sports safely; however, in addition to updated medical screening algorithms, concerns for players’ mental well-being exist and unfortunately are often overlooked.
The rising prevalence of mental health disorders is a challenging topic that profoundly impacts athletes of all ages. Prior to the pandemic, mental health disorders were on the rise, especially among youth and adolescents. The World Health Organization (WHO) reported that 32 percent of teens have experienced an anxiety disorder and 13 percent have been diagnosed with major depressive disorder. In the midst of the COVID-19 pandemic, those statistics were on the rise.
Deviation from an individual’s normal routine, as has been necessitated during the COVID-19 pandemic, can cause internal disruption. The new reality created by the pandemic has driven more and more athletes to cope with the pains of doubt and anxiety by seeking feasible ways to train, improve, and stay ready. In a survey of more than 37,000 NCAA student-athletes, more than one-third of respondents reported sleep difficulties since sports ended abruptly in March 2020. More than one-quarter reported feeling sadness and a sense of loss, and one in 10 reported feeling so depressed it was difficult to function “constantly” or “most every day.”
Athletes are dealing with uncertainty regarding return to sport, concerns about the medical implications of the coronavirus, and, due to social distancing and quarantine requirements, likely fewer outlets for their stress and anxiety. These challenges are the reality of today’s landscape, from amateur to professional sports, but orthopaedic surgeons receive little to no training in managing the mental health of athlete patients. This article aims to provide physicians with tools to acknowledge, discuss, and cultivate mental well-being among their athletes.
Following Theodore Roosevelt’s adage, “People don’t care how much you know until they know how much you care,” empathy must radiate throughout a physician’s work with an athlete. There is no one-size-fits-all approach to understanding the gravity of an athlete’s need for help. Nevertheless, the goal is always to create a safe haven for athletes to sustain their mental well-being.
Most of an athlete’s challenges are invisible to the naked eye. Signs of anxiety, apathy, and energy loss are much harder to notice than a torn ACL. An individual’s psychological architecture could be built up or worn down, but outsiders can never fully see its condition. Even when asked, a doubtful athlete may momentarily mask his or her struggle through overcompensating excitement. External strength may hide internal weakness. So, how can orthopaedic surgeons identify psychological decline and strategically solve seemingly esoteric concerns? The answer comes in three simple steps:
- Maintain a heightened sense of awareness.
- Ask empathetic questions to initiate compassionate conversations.
- Provide qualified contacts and resources.
To identify apparent or even latent concerns for an athlete’s mental well-being, a physician should initiate and maintain dialogue to discover variances in routine. Trust developed through effective communication is key. Before or during diagnosis, prognosis, and treatment for a physical or psychological injury, a physician can embody empathy by showing interest in an athlete’s daily life. Here are a few great questions to consider asking an athlete:
- “How are you feeling about the upcoming season?”
- “What are some of your goals for this year?”
- “How is your training coming along?”
- “Do you feel like you are finding a good balance between working hard and recovering?”
- “Are there any strengths or weaknesses you are particularly focusing on throughout your training?”
- “When does your season start, and what does your schedule or routine look like leading up to it?”
The magnitude and number of deviations from routine matter. For example, an athlete who has recently started having difficulty sleeping, drastically changed nutrition and lifestyle, started spending more time alone, or significantly altered the training regimen requires more urgent help than an athlete who simply modified his or her workout plan leading up to the start of a season. Instead of relying on written pre-participation questionnaires, use direct, empathetic communication to realize the holistic health of an athlete.
Cristina Versari, PhD, chief executive officer and director of the Sport Psychology Program and former program administrator of the National Basketball Association/National Basketball Players Association Education and Career Development Program, suggests, “To assist professional athletes who are experiencing signs and symptoms of psychological illnesses, members of the team must first earn the players’ trust. You can build trust by asking questions, active listening, being supportive and empathetic.”
After identifying a potential concern, physicians can provide contacts and resources, such as a list of nearby clinics, facilities, and therapists. The National Suicide Prevention Lifeline is 800.273.8255, which provides 24/7 service to more than 160 crisis centers nationwide.
Although the goal of supporting athletes’ mental health seems basic, implementing these recommendations may be challenging. Key barriers to discussing mental wellness include negative attitudes toward players who seek assistance, which often create fear of the consequences of seeking help. Conversely, support and acknowledgment from those who surround athletes enable an environment with reduced stigma and normalization of the desire for enhanced mental well-being.
An athlete’s mental health is not a stigma to avoid but a priority to discuss.
Catherine A. Logan, MD, MBA, MSPT, is a sports medicine orthopaedic surgeon at Colorado Sports Medicine and Orthopaedics in Denver, Colo. She is the head league physician for the Premier Lacrosse League and a team physician for U.S. Ski and Snowboard.
Mark Glicini, BA, is a five-year professional lacrosse player and the founder of Mark Glicini Peak Performance. He was a Division I All-American at Yale University. Currently, he is a captain of the Chaos Lacrosse Club in the Premier Lacrosse League, a defenseman on the San Diego Seals in the National Lacrosse League, a member of the U.S. Men’s National Training Team, and a certified mental performance coach.
Patrick S. Buckley, MD, is a sports medicine orthopaedic surgeon at University Orthopaedic Associates in Wall Township, N.J. He is a board-certified, fellowship-trained physician and is a team physician for U.S. Ski and Snowboard teams and Neptune High School in New Jersey.