I heard the snap in my Achilles, and I knew it was going to be a bad one. All I could think about was that I was going to miss the World Cup and that I probably would not be around for the next one. I was completely devastated.
Jane, international player
Kerr et al. (2008) defined an injury as an incident that occurs during a match or training that requires medical attention and stops you from playing rugby for at least one day after the injury occurs. Regardless of the level at which you play, you likely have already had an injury that has prevented you from playing rugby. Getting injured can be stressful, as revealed by the statement of a former British and Irish Lion international player:
Probably the most stressful times are when you are in the middle of a nip-and-tuck game and you get injured. There is that initial few minutes of wondering whether you can battle on with this, whether you can still do your job at 70 percent. When you realise that it is a no, you are walking off the pitch and you don’t want to look round at the boys because you feel you have let them down. You feel you have let everyone down so much. Injuries are unavoidable and they are just part of the game, but that is the hardest thing to deal with. A couple of years ago we were nip and tuck with the All Blacks, and I went off with about five or six minutes to go. We ended up losing by a point or two. I was captain at the time, and it was really disappointing. As a captain you want to lead from the front, and you almost take an injury as they have got one over on you, broken one of your players, which was pretty stressful.
Although you can make a full physical recovery in that the stability, strength, stamina, and flexibility of the injured area may be the same as they were before the injury, psychological barriers may prevent you from getting back to your best. Psychological barriers can occur because of an injury or because of poor psychological rehabilitation during an injury (Taylor & Taylor, 1997).
You might expect that physical factors such as overtraining, muscle imbalances, fatigue, and fitness are the main causes of injury. Research suggests, however, that psychological factors also play a role. For instance, stress levels have been identified as a major factor in causing injuries. That is, athletes who have the most stress in their lives experience more injuries (Williams & Andersen, 1998).
The relationship between stress and injury rates baffled sport psychologists for a number of years. Evidence suggests that athletes who have lots of stress in their life get injured more often, but what is the explanation for this relationship? Two theories have been presented to explain it:
1. Attentional disruption. When we experience stress our attention becomes hampered, as does our peripheral vision, which means that we can see less of what is happening in a rugby match. If you are experiencing stress in your life, your vision may be narrowed and you may fail to see a tackle coming. Therefore, you do not brace yourself for the tackle (Williams, Tonyman, & Andersen, 1991).
2. Increased muscle tension. When you experience stress your muscles are more tense, which interferes with coordination. Your tackling might not be as accurate, which can result in your getting injured (Smith, Ptacek, & Patterson 2000).
Injured athletes tend to go through three distinct phases in response to an injury. The speed and ease at which people go through the three phases can vary dramatically, depending on a number of factors such as personality, the injury sustained, and the rehabilitation process. The three phases are referred to as the injury information-processing phase, the emotional upheaval phase, and the positive outlook phase (Udry, 1997).
Injury Information Processing After the injury has occurred you focus on information such as how much pain the injury is causing you, how long the injury will keep you out of rugby, how the injury happened, and what you could have done differently to prevent the injury from occurring. You may also start to recognise the consequences of the injury, such as missing important matches or even missing the enjoyment of training and being around your teammates.
Emotional Upheaval After you have become aware of how long you will not be able to play, you may experience a range of negative emotions such as anger, agitation, and frustration. You may also be emotionally depleted, feel isolated from your teammates, have feelings of self-pity, or be in denial about the injury.
Positive Outlook You accept the injury and deal with it. Your mood becomes elevated and optimistic, and you are relieved as you see progressions in your rehabilitation.
Callard the COACH
When a player had an injury, especially a long-term injury, I would meet with him to discuss the injury, to let the player know that he was still in my thoughts despite his being out for eight or nine months. I would get the player involved in match analysis or coaching the junior rugby players. I wanted to get the player involved as much as possible and let him know that he was investing time in himself and for the good of club. It is a partnership! It is vital that players be involved whilst they are injured.
After your injury has been diagnosed you will start a phase of rehabilitation. The length of the rehabilitation depends on the injury and can vary from a week to several years in extreme cases. The purpose of rehabilitation is to enable you to repair the injured part of your body so that you can compete again. During your rehabilitation you may spend a long time working on restoring the injured parts of your body. Besides doing this physical rehabilitation, you need to engage in mental rehabilitation so that you experience emotional well-being during your time away from rugby and do not face psychological barriers on your return. Part of the mental rehabilitation involves understanding some of the negative feelings that you may have during rehabilitation and making an effort to overcome such negative emotions. According to Taylor and Taylor (1997) rehabilitation comprises four stages.
Stage 1: Range of Motion The primary goal of this stage of the rehabilitation process is to increase the range of motion of the injured area. In this stage of rehabilitation you are likely to experience pain because you will be performing movements that are unfamiliar and beyond your control. You therefore need to engage in pain management strategies. Advice on pain management is provided later in this chapter.
Stage 2: Strength After you have 80 percent range of motion in your injured body part, you are in stage 2 of the rehabilitation process. You will now begin to start testing the injured area for the first time since your injury. You may have some doubt about the ability of your injured area to manage the demands placed on it by testing it out. This apprehension can lead to cognitive anxiety (worry or nervousness) and somatic anxiety (muscle tension, breathing difficulties, or increased heart rate). Advice on managing anxiety during the rehabilitation process is offered later in this chapter.
Stage 3: Coordination After your strength has improved significantly, you enter what Taylor and Taylor (1997) referred to as stage 3. In stage 3 you continue strength training, but the training is more specific in that it includes movement patterns that build balance, agility, acceleration, and speed in the injured area. You need to maintain positive focus during this stage, because as the exercises that you do more closely simulate matches, you will inevitably make comparisons about how good you used to be. At this stage the comparisons will not be favourable, so you must maintain a positive focus.
Stage 4: Return to Sport The final phase that completes the rehabilitation phase occurs when you return to sport. At this stage the injured area will be at its preinjury level, so physically you are ready to start competing again.
The four stages outlined by Taylor and Taylor (1997) may give the impression that rehabilitation is a relatively straightforward process, whereby you go from one phase to the next with relative ease and make constant progress. This ideal progression will not always happen, and you may experience setbacks along the way. Most rugby players believe that rehabilitation is a steady process, but this does not always occur, as outlined in figure 11.1.
Recovering from injury is not a steady process, as highlighted in the actual recovery graph. Recovery is an unstable experience that includes ups and downs, setbacks, and plateaus when you do not see any improvements for some time. You need to understand that the recovery process and healing take time.
Experiencing a setback may elicit a range of feelings such as worry, frustration, anxiety, or even depression. But such setbacks can serve a specific function in the recovery phase. They provide you and your medical staff with information on the healing process and the speed of the rehabilitation program that you are undertaking. Accepting setbacks as part of the healing process is vital.
Injured athletes, especially those who are highly motivated and disciplined, may struggle to understand that rest is crucial in the rehabilitation process because it boosts recovery (Kindermann, 1988). If the medical professionals tell you to rest, you can do so without feeling guilty. Rest is just as important as the physical regime (Taylor & Taylor, 1997).
Callard the PLAYER
I was flying! Everything was going well. The training with the club, the personal training, and the matches were proving to be both enjoyable and successful. The team was gaining some identity for good rugby, and the part I was playing within it was very fulfilling. Then it struck, like a shot out of the blue—a pulled hamstring. The frustration and anger that I experienced were enormous. Everything was going so well, and then suddenly everything stopped.
I felt like this partly out of anguish, because I had worked hard to establish myself in the side and was contributing to it. Second, I was frustrated because I did not have the release of exercise that I had become used to. But this was only the beginning. I forced treatment and overdosed on inappropriate exercise that later caused problems. When I felt that the hamstring was responding well, I abused it and was set back, not only from playing but also from training, both club training and personal training. The downward spiral began again, and this time I was a little more angry and a little more frustrated.
Through time I got through it, purely through good fortune because there were natural breaks in the playing programme, which allowed me to relax in the sense that I was not in the side and not part of the team. Only when I looked back on the situation and the anguish that I had caused to those around me did I understand what I needed to do in the future.
I needed to apportion blame, even just for self -gratitude. I blamed myself or other players, but I eventually accepted that the injury was in the past. The only thing that I could control, which is what I subsequently did with later injuries, was to accept that I was injured and that my participation levels would be lowered. Thus, I needed to concentrate on what was required for the future and the role I had to play in that from a physical and mental perspective.
A detailed plan was drawn up that noted frequency of treatments, frequency of tests, and a progressive monitoring system that allowed me to progress from one stage of rehabilitation to the next. An example of this was a simple uphill walking session on the treadmill for 20 minutes. If I completed this session pain free with full range of movement, I could move to the next stage, which was to do some straight-line running over various distances without sudden stopping. Physically, I had satisfied myself, but more important, I felt good psychologically knowing that I had completed the programme correctly and that I was making progress.
Also important in my process of dealing with the injury was understanding what the injury was, how it happened, and what was needed to correct it. This was fascinating, because it was almost a picture in my head of where I needed to go—what the three-centimetre tear actually looked like, how it repairs itself, and what it looked like when it was in a semirepaired state. I could better understand the consequences of my actions if I chose not to follow the prescribed rehabilitation course.
You can use a range of strategies to manage the feelings that you are likely to encounter during rehabilitation. Strategies such as goal setting, rehabilitation profiling, mental imagery, and coping that have been discussed in detail in other chapters can be used to deal with injuries in much the same way that you would use them to improve your game.
Setting goals is crucial to enhancing your motivation and adherence, and it is vital when you are injured. The staircase method is an example of how you can set a range of progressive goals. You may want to complete this exercise with your physiotherapist or doctor. Figure 11.2 is an example of a goal staircase.
After the injury happened, this player first intends to walk, jog, run at half pace, sprint, and then return to rugby.
When setting your goals, make sure that they adhere to the SMARTER goals principles outlined in chapter 1. Complete the goal-setting staircase in figure 11.3.
Rugby players often just set the goal of returning to their sport injury free. This simple approach is fine, but if you adopt it you might be missing the chance to improve areas of your game that you normally don’t have time to work on. For example, if you know that you will be unable to play for several months because of a knee injury, you have the opportunity to work on other aspects of your physicality, such as your upper-body strength. You could therefore set yourself a goal of returning to rugby stronger and faster than you were before the injury. Table 11.1 can help you identify your weaknesses before you were injured and then set goals for when you return to rugby.
Complete table 11.2 to identify your weaknesses before you were injured and the areas that you would like to improve when you make your return to rugby. If you are unsure about your weaknesses or the parts of your game that you should work on, talk with your coach. In addition, always speak to your medical professional to ensure that you can safely work on the areas that you have chosen.
This strategy uses the same premise as the performance profile does, but it is aimed toward the rehabilitation process. As such, rehabilitation profiling focuses on the physical and psychological factors that are crucial throughout the rehabilitation process. Table 11.3 is an example of a completed rehabilitation profile.
Phase 1: Identifying Physical and Psychological Qualities Write down the qualities that you believe are crucial to recovering from your injury in table 11.4. Consider both physical and psychological qualities. These represent a range of likely contributory factors to success in your rehabilitation. Try to generate as many qualities as you can.
Phase 2: Selecting the Most Important Qualities and Defining Their Meaning After you have listed the most important physical and psychological factors, you should define what each quality means to you. Phase 2 of the performance profile involves your listing the most important qualities from phase 1 and then writing down what each quality means to you. An example generated from table 11.3 is presented in table 11.5.
Review the qualities that you listed in table 11.4 relating to physical and psychological qualities that are important in the rehabilitation process. Write them down in table 11.6 and describe what they mean to you.
Phase 3: Plotting the Rehabilitation Profile During this phase you list the qualities and then rate yourself on a scale of 1 to 10 by colouring the appropriate boxes. An important point to consider is what a score of 10 actually means. Assume that 10 is your maximum potential score. After you have completed the performance profile, prioritise what you are going to improve in the action point box. In addition, state in specific terms how you will be able make improvements. See figure 11.4 on page 146 for an example of a completed profile. Then complete your own rehabilitation profile in figure 11.5 on page 147.
Chapter 6 outlined how you can use mental imagery to develop strategies for playing at your best. Research suggests that mental imagery can not only improve performance but also aid recovery (Durso-Cupal, 1996). It is thought that imagery promotes healing of the injury by increasing blood flow and warmth to the injured area (Blakeslee, 1980). Imagery can serve a number of other purposes when you are injured such as replacing the physical practice that you are no longer able to do with mental practice, allowing you to see yourself recovering, mentally practicing skills that you learned before your injury, and controlling negative disturbances that can be associated with being injured.
To promote healing, you can imagine images associated with the healing process such as
• blood flowing to the injured area,
• ice on the injured area blocking out all pain,
• the injured body part performing movements, and
• the injured body part feeling strong.
You can use imagery during actual rehabilitation sessions or in the privacy of your home. Spend at least 10 minutes per day doing healing imagery. With regard to the performance-orientated mental imagery that you can do whilst injured, see the imagery script in chapter 6 (page 84) and use it to create your own imagery script. You could adapt the instructions to imagine yourself recovering from the injury or controlling the negative emotions that you might be experiencing whilst injured.
Like goal setting, profiling, and mental imagery, coping was discussed earlier in the book. Being injured and going through rehabilitation can be stressful, so you have to cope with the stress that you experience. Recent research with a sample of professional rugby union players suggested that avoidance is an effective coping strategy when dealing with a long-term injury, such an anterior cruciate ligament injury (Carson & Polman, 2010). The two types of avoidance coping are behavioural avoidance and cognitive avoidance.
• Behavioural avoidance. Coping strategies classified as behavioural avoidance involve you physically removing yourself from a stressful situation, such as by walking away from a coach who is shouting at you.
• Cognitive avoidance. Coping strategies classed as cognitive avoidance involve attempts to disengage mentally from thoughts surrounding a stressor, such as blocking out the pain of an injury.
The research by Carson and Polman (2010) reported that several behavioural avoidance (see table 11.7) and cognitive avoidance strategies (see table 11.8) were effective. When you are injured try using these coping strategies to manage any stress that you may encounter during your time away from rugby.
Rehabilitation sessions can be extremely painful, so you must use a range of strategies to manage the pain that you encounter. Two of the most popular techniques to manage pain nonpharmacologically are abdominal breathing and dissociation.
According to Taylor and Taylor (1997) this method is the simplest and one of the most neglected ways of reducing pain. To heal more effectively and reduce pain, the body needs a greater amount of oxygen than normal, which can be gained through long, slow inhalations associated with abdominal breathing. To do this type of breathing,
1. lie on a cushioned floor or on your bed with your hands clasped on your lower abdomen,
2. inhale through your nose to the count of 4, and
3. exhale slowly to the count of 5.
Dissociation involves directing your attention away from the pain that you are experiencing. You can distract yourself internally by counting, by imagining yourself being on your favourite beach, by humming a song, or externally by listening to music, by watching television, or by reading a book.
You can use abdominal breathing or dissociation during rehabilitation sessions or when you are at home and need some pain relief. Try the various methods and see which works for you the best.
To help you maintain a positive attitude during your injury period, you can focus on the four Ps (Taylor and Taylor, 1997):
• Positive. Think about the positive features of your rehabilitation.
• Present. Think about the present and don’t look too far ahead or dwell on the past.
• Process. Think about what you need to do daily to enhance your recovery.
• Progress. Think about the gains that you have made.
After you have completed your physical recovery you will be ready to resume playing rugby, which can be both physically and emotionally demanding. The challenge will be in proportion to the length of time that you were injured and the severity of your injury. On your return to competitive action, you may have doubts that you will ever be able to return to the level at which you were playing before your injury, which is normal. Taylor and Taylor (1997) stated that when you return to competitive rugby you will go through five stages: (1) initial return, (2) recovery confirmation, (3) return of physical and technical abilities, (4) high-intensity training, and (5) return to competition. Having an understanding of these phases will ease the transition to full competition.
1. Initial Return Stage 1 of this five-stage process involves your initial return to training with your teammates. This process can be demanding psychologically because you will find out how successful your rehabilitation was. You may also be excited because you will be playing rugby again after what may have been a long time away from the game. But people tend to develop unrealistic expectations, which may lead to disappointment. You may expect in your return to rugby that your rehabilitated injury will be free of pain and that you will be able to perform as you did before the injury. If you have some pain and decreased performance you could become worried and down. Finally, some rugby players may be concerned about the rate of their progression and push themselves faster than it is safe to do. Be realistic in your expectations and discuss any concerns that you have with your physiotherapist or doctor.
2. Recovery Confirmation During this stage you receive confirmation either that your injury has healed or that there may be complications. A successful initial return to training will provide you with evidence that your rehabilitation was effective, which will have a positive effect on your confidence and motivation. But if your return to training is not successful you may experience physical difficulties such as unexpected pain, swelling, decreased strength, and compensation injuries to other parts of your body. You may also experience a range of psychological difficulties because you may start thinking that all your rehabilitation efforts were wasted.
3. Return of Physical and Technical Abilities During this stage you start to increase the intensity of your training to improve your conditioning, and you can spend time practicing the technical skills associated with your position that you have not been able to practice whilst you have been injured (e.g., passing, kicking, catching, and so on).
4. High-Intensity Training You can now take part in high-intensity training to improve your conditioning, and you can do contact work so that you become used to physical contact again. All aspects of your injured area should be better or the same as they were before you sustained your injury.
5. Return to Competition After you have improved your physical conditioning you will be ready to return to competitive action. You may feel excited at being able to play rugby again because all your hard work during rehabilitation is going to be rewarded, but you may also feel nervous. If you feel nervous, use the coping strategies outlined in chapter 5.
Although you have healed physically, you may experience psychological stress from the injury on your return to competitive play (Taylor & Taylor, 1997). The fear of being reinjured may cause the most stress (Heil, 1993). A fear of being reinjured can cause psychological difficulties such as reduced focus and decreased confidence, as well as physical difficulties such as muscle tension. These complications increase the likelihood that you will become injured again.
Fear of injury can occur from spending time away from your sport and being isolated whilst being injured. If you spend a long time away from the rugby environment, you will lose contact with the sport and thus have less familiarity and control on your return. Therefore, you should try to maintain involvement in some way during the time when you are injured. You could do match analysis, scout opponents, or even run some coaching sessions. This additional education might be beneficial when you return to rugby (Taylor & Taylor, 1997).
Despite your efforts to stay involved with your team, you may still have concerns about getting injured again. This fear may arise when you are about to resume training or about to make your return to competitive rugby. If this occurs, you should recognize that being apprehensive is normal. These fears will likely pass with time.
To accelerate the rate at which your fear of reinjury disappears, you should establish the cause of your fear. Any number of circumstances could prompt your fear, such as being in a situation in which your injury occurred (e.g., being tackled), returning to the same venue, or even not wanting to go through a bout of rehabilitation again. After you have established the cause or causes of your fear, you should challenge your fear of injury. You can do this by testing your injured body part and measuring how strong it is. When tests confirm that this part of your body is strong enough, you know that you are ready for the rigors of rugby. Take confidence and trust from this finding and let the fear go.
• Psychological factors such as stress in your life can increase the likelihood that you will get injured.
• When you get injured you go through three phases: the information-processing phase, the emotional upheaval phase, and the positive outlook phase.
• When you get injured identify the areas that you would like to make stronger than they were before your injury.
• Besides doing physical rehabilitation for your injury, you can use a range of psychological skills to help ease the rehabilitation process, such as rehabilitation profiling, goal setting, and coping.
• Don’t be too concerned by setbacks that occur during rehabilitation. Accept that this is part of being injured.
• Stay involved whilst you are injured by scouting opponents, doing match analysis, or running some coaching sessions.
