Lucas André Borato*

borato.la@gmail.com

Cristiane Rodrigues Pedroni**

cristiane.pedroni@unesp.br

*Programa de Pós-graduação em Ciências da Atividade Física (USP)

Fisioterapeuta pela Universidade Estadual Paulista (UNESP)

Mestre em Ciências da Atividade Física

pela Universidade de São Paulo (EACH - USP)

Membro do grupo Pesquisa e Aplicação Tecnológica

em Reabilitação (PATER) (EACH - USP)

Colaborador do Laboratório de Pesquisa

em Ortopedia e Recursos Terapêuticos - LAPORT.

**Departamento de Fisioterapia e Terapia Ocupacional (UNESP)

Fisioterapeuta, PhD, Docente do Curso de Graduação em Fisioterapia

e Pós-Graduação em Desenvolvimento Humano e Tecnologias

da Universidade Estadual Paulista - UNESP

Coordenadora do Laboratório de Pesquisa

em Ortopedia e Recursos Terapêuticos - LAPORT.

Estudo conduzido na Universidade Estadual Paulista, Departamento de Fisioterapia

e Terapia Ocupacional, Marília - São Paulo

(Brasil)

Reception: 08/25/2021 - Acceptance: 11/30/2021

1st Review: 11/06/2021 - 2nd Review: 11/26/2021

Accessible document. Law N° 26.653. WCAG 2.0

Suggested reference: Borato, L.A., & Pedroni, C.R. (2022). The Relationship between Psychological Stress and Injury Risk in Young Soccer Players. A Systematic Review. Lecturas: Educación Física y Deportes, 26(285), 161-173. https://doi.org/10.46642/efd.v26i285.3175

 

Abstract

    Within soccer, a number of both intrinsic and extrinsic factors may expose athletes to injury. Recent studies have shown that among these conditions, psychological stressors can lead to several complications. No review articles were found that analyzed the relationship between psychological stress and risk of injury in soccer athletes of this age group. The objective of this systematic review is to identify and discuss studies that relate psychological stressors to the risk of injury in young soccer athletes and the main stressors related to this risk. A computerized search of the entire PubMed, Cochrane and Virtual Health Library (VHL) Libraries was conducted to identify relevant articles. Only four studies were included, their analysis demonstrates that four main stressors would explain 23% of injuries. Regarding the occurrence of injuries, it is associated with the high level of daily boredom and lower decreases of daily boredom. Moreover, implementation of psychosocial programs may be effective in reducing injuries of young soccer athletes. Psychological stress can play a role in the presence of disease in athletes. The present study demonstrates that injuries in young soccer athletes have a strong relationship with psychological factors and are associated with other illnesses.

    Keywords: Athletic injury. Psychological stress. Soccer.

 

Resumo

    No futebol, vários fatores intrínsecos e extrínsecos podem expor os atletas a lesões. Estudos recentes mostraram que, entre essas condições, os estressores psicológicos podem levar a uma série de complicações. Não foram encontrados artigos de revisão que analisassem a relação entre estresse psicológico e risco de lesões em atletas de futebol dessa faixa etária. Assim, O objetivo desta revisão sistemática é identificar e discutir estudos que relacionem os estressores psicológicos ao risco de lesões em jovens atletas de futebol e os principais estressores relacionados a esse risco. Uma busca computadorizada de todas as Bibliotecas PubMed, Cochrane e Biblioteca Virtual em Saúde (BVS) foi realizada para identificar artigos relevantes.Apenas quatro estudos foram incluídos, eles demonstram que quatro estressores principais explicariam 23% das lesões. Por sua vez, à ocorrência de lesões está associada ao alto nível de tédio diário e menores diminuições do tédio diário. Além disso, a implementação de programas psicossociais pode ser eficaz na redução de lesões em jovens atletas de futebol. O estresse psicológico pode desempenhar um papel na presença de doenças em atletas. Esse estudo demonstra que as lesões em jovens atletas de futebol têm forte relação com fatores psicológicos e estão associadas a outras doenças.

    Unitermos: Traumatismos em atletas. Estresse psicológico. Futebol.

 

Resumen

    En el fútbol, ​​diversos factores intrínsecos y extrínsecos pueden exponer a los atletas a lesiones. Estudios recientes han demostrado que, entre estas condiciones, los factores de estrés psicológico pueden provocar una serie de complicaciones. No se encontraron artículos de revisión que analizaran la relación entre el estrés psicológico y el riesgo de lesión en jugadores de fútbol en este grupo etario. Así, el objetivo de esta revisión sistemática es identificar y discutir estudios que relacionen los estresores psicológicos con el riesgo de lesiones en jóvenes futbolistas y los principales estresores relacionados con este riesgo. Se realizó una búsqueda computarizada de todas las bibliotecas PubMed, Cochrane y Virtual Health Library (BVS) para identificar artículos relevantes. Solo se incluyeron cuatro estudios que demuestran que cuatro factores estresantes principales explicarían el 23% de las lesiones. A su vez, la ocurrencia de lesiones se asocia con un alto nivel de aburrimiento diario y menores disminuciones en el aburrimiento diario. Además, la implementación de programas psicosociales puede ser eficaz para reducir las lesiones en jugadores jóvenes de fútbol. El estrés psicológico puede desempeñar un papel en la presencia de enfermedades en los deportistas. Este estudio demuestra que las lesiones en jugadores jóvenes de fútbol están fuertemente relacionadas con factores psicológicos y están asociadas a otras enfermedades.

    Palabras clave: Lesiones en deportistas. Estrés psicológico. Fútbol.

 

Lecturas: Educación Física y Deportes, Vol. 26, Núm. 285, Feb. (2022)

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Introduction 

 

    Soccer is the most common sport in the world and has high physical and mental demands. As a result, as the level of competition increases, it is common for some soccer teams to play one or two matches during the week and participate in international tournaments such as world championships and the Olympic Games. (Slimani, & Nikolaidis, 2017)

 

    The rates of matches, training and muscle injuries of professional male soccer athletes have hardly changed since the 2000s, suggesting that preventive practices in this sport have not been significant in decreasing injury rates. (Ekstrand, Hägglund, Kristenson, Magnusson, & Waldén, 2013; Ekstrand, Waldén, & Hägglund, 2016; Ekstrand, 2016)

 

    In total, 8029 injuries were documented during 2001 and 2012, with 4546 (57%) occurring during games and 3483 (43%) during training. On average, players suffered two injuries per season, which is equivalent to 50 injuries per season for a team of 25 players. The total injury rate based on all teams and all seasons was 7.6 injuries per 1000 hours. The injury rate in the game was almost seven times higher than the injury rate in training. (Ekstrand et al., 2013)

 

    Within soccer, several factors, both intrinsic and extrinsic, can expose athletes to injuries, recent studies show that among these conditions, psychological stressors can lead to various complications such as burnout syndrome and overtraining (Gustafsson, Hassmén, Kenttä, & Johansson, 2008), thus leading athletes to injuries, difficulty recovering from injuries and decreased performance of athletes. The stress factors that predispose to injury range from perceived pain, sadness, anger, and fear (Ivarsson et al., 2017) to the coach's leadership style. (Ekstrand et al., 2017)

 

    Therefore, we must also pay attention to the juvenile athletes, since young athletes who seek to reach the highest levels within the sport, in order to achieve their goals must dedicate significant physical resources to the practice and maintain this level of dedication throughout several years (Ward, Hodges, Starkes, & Williams, 2007). Thus, all this effort and athletes' experiences can vary considerably, and it can be psychologically rewarding for some young athletes and put them on the path of long-term participation in the sport. While for others, the psychological and physical demands may be excessive, fostering an experience fraught with frustration and self-confidence leading to extreme discouragement (Jowett, Hill, Hall, & Curran, 2016). The objective of this systematic review is to identify and discuss studies that relate psychological stressors to the risk of injury in young soccer athletes and the main stressors related to this risk.

 

Methods 

 

    A computerized search of all PubMed, Cochrane Libraries and the Virtual Health Library (VHL) was performed to identify relevant articles. All the search was performed without delimitation of publication date due to the low number of studies found during the process of determining the best search strategy. The search terms were mapped to MeSH Terms, being searched under three concepts: (1) Athletic Injuries, (2) Psychological Stress, and (3) Soccer. The research was limited to clinical trials in English. The search strategy was performed by combining the keywords of each concept with the word AND, the search for relevant articles was done manually. The papers were selected, first, by analyzing the publication titles, and finally, by reading the abstracts of the studies.

 

Results and discussion 

 

    After the search (Figure 1) was found, totaling the three virtual libraries, twenty-six articles of which there were four duplicate studies and also sixteen articles excluded due to the title and two by reading the abstract, in the end, four studies were included.

 

Source: The authors

 

    Johnson, & Ivarsson (2011) in a study with 108 young male and female soccer players in school years applied five questionnaires, as well as collected data on athletes' injuries directly with their coaches for eight months. The authors demonstrated that four main stressors would explain 23% of injuries. These factors would be stress-causing events, somatic trait anxiety, fear and ineffective coping. They also state that athletes with high-stress levels are likely to have difficulty focusing during important moments in the match that would increase their chance of injury while athletes with high levels of somatic trait anxiety have decreased attention; athletes with low fear of threatening stimuli tend to put themselves in situations beyond their ability to control. Moreover, players with a low level of coping resources are related to a higher frequency of injury illustrating that there are well-defined stress factors that would generate injuries.

 

    Through a ten-week study, Ivarsson, Johnson, Lindwall, Gustafsson, & Altemyr (2014) showed that the occurrence of injuries was significantly associated with the high level of daily boredom and with lower decreases of daily boredom. Specifically, they showed that both the initial levels of daily boredom and the fewer positive changes in daily problems were positively related to injury risk. In addition, a sharp drop in high mood was positively related to the risk of injury. They also highlight the importance of monitoring changes in these stress variables overtime to advance the understanding of the complex and dynamic relationships between factors that influence the risk of injury among athletes, as stress has been identified as one of the major risk factors for sports injuries. Changes in stress can also lead to the assumption that an athlete's risk of injury can change rapidly.

 

    Complementarily, the Olmedilla-Zafra, Rubio, Ortega, & García-Mas (2017) study demonstrated that the implementation of a psychosocial program was effective in reducing sports injuries of young soccer athletes, with good acceptance by coaches who stated that this does not interfere with the common training routine and reported that athletes were more focused and less anxious. The authors also stated that they had a high level of satisfaction and commitment from the studied athletes who reported particularly enjoying progressive muscle relaxation and self-instructional modules. The results demonstrated that a program consisting of muscle relaxation, respiratory reeducation and self-instruction stress inoculation was able to reduce the frequency of injuries in junior soccer players both for comparing the mean pre and post-treatment injuries and for comparison between treatment and non-treatment groups after the program administration. Thus, it was concluded that a psychological intervention aiming at enhancing stress management skills, reducing muscle tension, and attentional distractibility often caused by stressful conditions was effective, making players less vulnerable to sports injuries.

 

    In contrast, a study of Brink et al. (2010) after applying a questionnaire to 53 elite players between 15 and 18 years, despite no clear relationship between injury occurrence and psychological stress was shown, a relationship between injury and diseases with physical stress was present. Then, psychological stress seems to be important when considered the presence of disease in athletes. The authors state that physical stress was related to traumatic injuries, as weekly training and game duration, training load, monotony, and tension in the previous week were significantly higher for players with traumatic injury compared to healthy players. The analysis of the applied questionnaire showed no clear relationship between specific stress components and recovery with the occurrence of injuries.

 

    The fitness/injury subscale was significantly higher for players with traumatic injury as well as for players with overuse injury when compared to healthy players. Sick athletes reported significantly more stress than healthy in six of the seven subscales evaluated. In addition, they reported a social recovery, overall well-being and significantly lower sleep quality. While in the sport-specific components of the questionnaire, sick players reported more disturbed breaks and emotional exhaustion as well as feeling less fit and fitness. Finally, the authors state that individual monitoring of stress and recovery can yield important information for the prevention of injuries and illnesses in soccer players once factors as training monotony and load, and the duration of trainings and matches can help trainers and coaches to follow and identify players at injury risk. (Brink et al., 2010)

 

    The studies presented demonstrate a relationship between psychological factors and the physical health of young athletes. Other studies not included in the review also demonstrated this relationship between psychological stressors and injury (Gustafsson et al., 2008; Gouttebarge, Aoki, Ekstrand, Verhagen, & Kerkhoffs, 2016; Olmedilla, Ortega, & Gómez, 2014). In a study with volleyball players, Gómez, & Pérez-Farinós (2020) demonstrated that the injury risk is higher when the perceived stress levels or the competition levels are higher. On the other hand, Garit, Surita, Zafra, & Gómez-Espejo (2021) showed that between baseball athletes the perceived relationship between stress and injury by athletes are low and that athletes with previous injuries have a different perception from psychological variables than non-injured athletes such as self-confidence and negative coping control. In the study of Akamine, Passos, Pizzo, & Costa (2016), team sports athletes reported discomfort in situations of pressure, fear of injury, anxiety and concerns about returning to competition, while in the study by Farias, & da Silva (2021), psychological stress seems to be correlated with training load or competitions.

 

    Specifically, Gustafsson et al. (2008) related stress with Overtraining and Burnout syndromes, and the author states that Burnout of athletes seems to be a complex interaction of multiple stressors, inadequate recovery, and frustration of unmet expectations, partly explained by perfectionist characteristics and goals since this process is fueled by impulses to assert self-esteem, sometimes in conjunction with feelings of imprisonment. In addition, Figueroa Solórzano. & Patiño Bautista (2021), in their evaluation of the relationship between Burnout syndrome and sports injury in soccer players, recommended that the athletes should be assessed integrally to avoid burnout complications. Hence, the importance of psychological counseling and the role of sports psychology in sports injuries. (Reynaga-Estrada, & Aguirre-Olivas, 2019)

 

    Moreover, musculoskeletal injuries and surgeries during the career of European soccer players are related to symptoms of common mental disorders such as stress, anxiety and sleep problems (Gouttebarge et al., 2016). The study by Costa, Souza, & Vargas (2019) demonstrated that injured athletes perceived more debilitating situations of physical and psychological demand, disturbance, physical risk, criticism and reprimand. These athletes also evaluated situations of training and inadequate preparation negatively. The authors also reported that for coping strategies, injured athletes had greater use of motivational strategies and uninjured athletes had greater use of a rational, methodical strategy in coping with the problem. Additionally, before an injury, athletes show higher levels of stress and self-confidence and, after injury, athletes demonstrate higher levels of depression and somatic and cognitive anxiety. (Olmedilla et al., 2014)

 

    In the interesting study of Aroni, Bagni, Bocchio, & Machado (2019), it is shown that a number of different psychological factors influence athletes from sports initiation to professionalization. The authors pointed out that for the young soccer players some stressors as schooling, economical issues, parents and family, biological maturation, physical injuries were causes for concern and that the fear of injury by itself could end a player`s career as it would impact in tests and opportunities. Even in senior soccer athletes, psychological stress may also increase the risk of injury; findings indicate that somatic trait anxiety, psychic trait anxiety, stress susceptibility, and irritability traits appear as significant predictors of injury risk (Ivarsson, & Johnson, 2010). Moreover, Olmedilla, García-Alarcón, & Ortega (2018) showed that women soccer and futsal players’ stress levels increase as the injury sustained has a higher severity.

 

    In addition, other factors may influence the occurrence of injuries in soccer players as an adequate nutritional intake, as, for instance, calcium and vitamin D once that these nutrients play a role in bone health (Dobrowolski, Karczemna, & Włodarek, 2020), another factor would be sleep deprivation due to congested schedule, in which players may experience acute and chronic fatigue that can lead to injury. (Nédélec et al., 2015)

 

    Finally, the study of Brink et al. (2010) has shown that the injuries were mainly located in the lower limbs and the most frequent injuries would be muscle strain, rupture, tear or cramps, while Costa, Souza, & Vargas (2019), in their study with 81 soccer athletes, found that right- and left-backs and forwards had higher injury rates while goalkeepers were not injured in the season, and also that the thigh, knee and ankle were the most affected areas. Furthermore, in the study by Olmedilla, García-Alarcón, & Ortega (2018) in which 102 female soccer and futsal players were analyzed, more than 55% of the athletes suffered at least one injury during the season and most of these injuries were considered moderate to severe. However, no study was found that correlates specific injuries and psychological stressors.

 

Author	Participants	Data collected	Intervention	Outcomes	Results
Johnson, & Ivarsson (2011)	85 male and 23 female soccer players (n=108), between 17 and 19 years old.	Injury report; State-Trait Anxiety Inventory (STAI); Sport Anxiety Scale (SAS);Athletic Coping Skills Inventory-28 (ACSI-28); Life Events Survey For Collegiate Athletes (LESCA); Swedish universities Scales of Personality (SSP).	None.	Life event stress, somatic trait anxiety, mistrust and ineffective coping could explain 23% of injury	Negative life event stress (p=0.047); Somatic trait anxiety (p=0.020); Negative coping (p = 0.019); Mistrust (p = 0.008); Stress sensitivity (p = 0.104).
Ivarsson, Johnson, Lindwall, Gustafsson, & Altemyr (2014)	67 males and 34 females soccer players (n=101), between 15 and 19 years old.	Injury report; Hassles and Uplifts Scale (HUS).	None.	Injury occurrence is associated with high initial levels of and negative changes in daily hassle Injury occurrence was significantly associated with greater decreases in daily uplift.	Injury prediction by the initial level of hassle (p< 0.01)as well as change in daily hassle (p<0.01); Injury prediction by the change in daily uplift p<0.01.
Olmedilla, Ortega, Gómez, & (2014)	74 male soccer players (n=74), between 17 and 19 years old.	Injury report; Self-monitoring cards; Athletes’ satisfaction, improvement and commitment survey; Coaches’ satisfaction interview.	Program based on Stress Inoculation Therapy - One hour, once a week for three months (Linking thoughts and emotions; Progressive muscle relaxation, breathing, imagery, passive and differential muscle relaxation; Self-instructional and attention-focus training; and Stress inoculation training.	A psychosocial program can reduce the incidence of sports injuries in young athletes	Larger average number of injuries in non-treatment group (p=0.005); Significant decrease in the average number of injuries in the treatment group (p<0.001).
Brink, Visscher, Arends, Zwerver, Post, & Lemmink, (2010)	53 male soccer players (n=53), between 15 and 18 years old.	Injury and illness report; Physical stress (Duration of training sessions and matches in minutes; and Rate of Perceived Exertion (RPE); Psychosocial stress and recovery (Recovery Stress Questionnaire for Athletes (RESTQ-Sport).	None.	There is a relationship between injuries and physical stress; Physical and psychosocial stress and recovery are important regarding illness.	Physical stress was related to both injury and illness (range OR 1.01 to 2.59); Psychosocial stress and recovery were related to the occurrence of illness (range OR 0.56 to 2.27).

Source: The authors

 

Conclusions 

 

    This study illustrates that physical injuries in young soccer athletes are strongly related to psychological factors and are associated with other illnesses. Exposure to stress factors would explain a large amount of these physical injuries in young athletes. Furthermore, the implementation of psychosocial programs would have a positive impact on reducing injuries suffered by players and it is a good option due to the good acceptance by the coaching staff and players.

 

    Finally, the scarcity of existing studies shows little depth in the subject. Studies about the influence of psychological stressors on sports injuries are highly indicated to better delineate what these stressors are, as well as the incidence and prevalence of these stress-associated injuries. Moreover, it is recommended that studies identifying if specific psychological stressors have a direct impact in the injuries type should be performed to help clarify the role of these stressors in sports injury.

 

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Aroni, A., Bagni, G., Bocchio, G.L., & Machado, A.A. (2019). Estresse da iniciação esportiva até profissionalização: uma análise exploratória da trajetória de atletas profissionais de Futebol. RBFF-Revista Brasileira de Futsal e Futebol, 11(43), 263-272. http://www.rbff.com.br/index.php/rbff/article/view/773

 

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Lecturas: Educación Física y Deportes, Vol. 26, Núm. 285, Feb. (2022)