Point of No Return

When an athlete suffers a career-ending injury, the rehab process takes on a different meaning. At Cal State Fullerton, a team approach guides athletes both physically and psychologically.

By Laura Smith

Laura Smith is an Assistant Editor at Training & Conditioning. She can be reached at: lsmith@MomentumMedia.com.

Training & Conditioning, 15.6, September 2005, http://www.momentummedia.com/articles/tc/tc1506/noreturn.htm

For some athletes, it happens in an instant—one misstep, one quick twist, one bad break. For others, it’s the end of a long, hard road—multiple injuries, a series of surgeries, months spent working and waiting. Either way the final diagnosis is hard to take: “Career-ending injury.”

Injuries that take away an athlete’s ability to play his or her sport are statistically rare. But sooner or later, most athletic trainers encounter one, and it turns the rehab process on its head. The usual driving force behind an athlete’s rehab—returning them to the sport they love—doesn’t exist. Returning the athlete to functionality and a good quality of life becomes the goal, and the focus shifts to helping him or her cope, not only with the injury, but also with the grief of a huge loss, a life change, and a reorganization of identity, goals, and dreams.

Perhaps more than in any other situation, helping an athlete navigate a career-ending injury means treating the whole individual. At California State University-Fullerton, that challenge is taken on by a seasoned team. Julie Max, MEd, ATC, Head Athletic Trainer, contributes 20 years of experience and a holistic approach to physical and psychological treatment. Ken Ravizza, PhD, Professor of Sports Psychology and a mental skills training consultant, lends his deep knowledge of athletes’ inner experiences. And Amanda Rice, ATC, a graduate assistant in Sports Psychology, draws on perspectives from both fields. From making the determination that an injury is “career ending,” through the process of physical and psychological rehab, we’ll take a close look at how these three experts collaborate to help athletes who won’t be coming back.

MAKING THE CALL
Whether an athlete has a sudden, severe injury or a series of injuries that resist treatment, recommending the end of a competitive career is a step that Max takes with extreme caution. It’s also a decision she never makes alone.

“Before we label an injury career-ending, we make sure we’re very, very certain,” Max says. “‘Career-ending’ means that even if the athlete leaves this institution, they can no longer compete in their sport. It’s over. This is a very big decision to make, and we believe the only safe way to make it is with a team approach.”

In addition to Max, the Cal State Fullerton decision-making team involves the student-athlete, the attending physician, the coach, and often the student-athlete’s parents. As the head athletic trainer, Max is usually the group’s leader.

“I spearhead the decision-making process because I’m the one who sees the athlete on a daily basis, and I’m closest to the situation,” she says. “Coordinating collaborative efforts is part of my daily job description, so I know how to do it effectively. And the athletic training office is a natural nucleus where information can be centralized because I’m in touch with our team physician and coaches daily.”

As the hub of the decision-making team, Max attends doctor’s appointments with the athlete or calls the doctor afterward so information doesn’t get misinterpreted or lost. She also makes sure that multiple medical professionals—team doctor, orthopedic surgeon, neurologist, and general practitioner—are able to share information easily. She facilitates conversations between the athlete and the coach, explains to the athlete in lay terms what is going on with their body, takes calls from parents, and makes sure everybody’s questions get answered.

Rice says it’s especially important to involve the coach in the decision to end an athlete’s career. “A coach who isn’t fully aware of what is happening medically can negatively influence the athlete,” she says. “For some athletes, the opinion of the coach can be intimidating. It’s imperative that the coach completely understands the athlete’s injury and that he or she is not pushing the athlete in an inappropriate direction.”

The challenges behind the decision can vary depending on whether an athlete’s career ends suddenly with a single injury or gradually with multiple events or an unsuccessful rehab. “I have an example of each scenario on my desk right now,” Max says. “We have a female tennis player who sustained damage to three disc levels in her back at once. It was immediately obvious to us that her competitive tennis career was over.

“Then we have a wrestler whose career has ended in a very different way,” Max continues. “He underwent three different shoulder surgeries and has been attempting to rehab over a series of months. When he injured himself the last time, it became clear that it was not appropriate for him to continue to wrestle.”

For Max, the decision to recommend the wrestler end his career was easier to make. “There was a lot of data adding up over a long period of time, all pointing to the fact that this was the right decision, and that makes it easier for the athlete to accept,” she says. “With a sudden injury, it’s harder for the athlete to believe that one event has ended their career. They want to believe they’ll be the one case that actually comes back. These are harder to deal with in the decision phase, and fortunately, they’re much more rare. The key is to rely even more heavily on the team approach and take extreme caution.”

In either case, the attending physician ultimately has the final say on ending an athlete’s career. However, at Cal State Fullerton, more often than not, it’s the athlete who decides it’s time to stop. That’s an important step, according to Rice.

“All their lives, athletes have been in control of their athletic success,” she says. “They’ve fixed problems by training harder, eating better, practicing more, or working hard at rehab. With a career-ending injury, they’re faced with a situation where none of those things is going to help, and they suddenly feel very out of control. We give them as much power as we can in the decision-making process to help ease that feeling.

“Of course, we don’t hesitate to offer our opinion when we believe returning to play is not the best thing,” she adds. “But we’re patient, and whenever possible, we allow the athlete to reach the decision on their own.”

PSYCHOLOGICAL CHALLENGES
Once the decision has been made that a Cal State Fullerton athlete’s career is over, Max relies on a collaboration between her staff and Ravizza to help an athlete deal with both the physical and emotional trauma. However Ravizza stresses that, although he is the sports psychologist, Max is really the one who takes the lead in helping the athlete heal psychologically as well as physically.

“Julie’s role on the mental side is crucial because athletes know her and trust her, and she is the one who sees them day in and day out,” he says. “When I see her working with these athletes, the empathy she shows is amazing and that is what’s needed the most.”

Max is careful to watch for times when an athlete needs more psychological expertise than she can offer. “I understand my boundaries, and when I see that an athlete is struggling, becoming depressed, or in any way needs more help than I can offer, I go straight to our experts, Ken and Amanda.”

Every athlete who endures a career-ending injury has a unique experience and reaction, but there are several common threads that most face in dealing with the psychological aftermath. These are the issues that Ravizza, Rice, and Max see arising most often, along with some solutions that have worked for them.

Grief and loss. “We see the same stages of grief among most athletes: disbelief, denial, anger, bargaining, depression, and acceptance,” says Ravizza. “We used to believe that the stages occurred in that order, but we’ve found that athletes actually bounce around. One day they’re angry, one day they’re in denial, the next day they seem to have accepted it, and the day after that, they’re angry again. But these distinct emotions are all there at some point.”

“When I first came to this profession and heard about the stages, I was skeptical, but they really happen,” Max agrees. “As athletic trainers, we put a lot of effort into learning to recognize the stages of grief and being sensitive to what an athlete is feeling on a given day. We also talk with the athlete about these common emotional reactions so they understand that their feelings are normal, and we’re not afraid to address the athlete’s feelings directly. If an athlete comes in and seems very angry, for example, we’ll ask them about their anger.”

Educating the athlete about the stages has an added benefit. “Even if they can’t process what you’re saying right away, they’ll recall it later when they run into one of the stages, and that will help them,” Ravizza says.

Identity crisis. When an athlete’s career ends, his or her sense of self is almost always thrown into chaos. “During their identity-forming years, they were probably deeply immersed in the athletic world,” Ravizza says. “Their sport is deeply woven into their sense of self. Being very competent in this one area is what has supplied them with a lot of their confidence and self-esteem. When that gets ripped away, it’s very traumatic.”

Again, acknowledging what is happening and why is the first step to helping the athlete deal with his or her feelings. “I sit down with them and explain how identity gets formed and why they suddenly feel so lost,” Ravizza says.

His next step is to help the athlete understand that the parts of their personality that made them so successful at their sport are still there, even though they aren’t using them to compete. “They are still the same person with the same drive, dedication, competitiveness, and competence,” Ravizza says. “My job is getting them to see that they don’t have to lose those things—they can apply them to other areas of their lives. I’ve seen many athletes, once they can no longer play, focus their energy on their academics and discover that they can achieve things they never thought possible.”

Also, Ravizza and Max pay special attention to keeping the athlete as active and fit as possible. “Much of an athlete’s identity comes from their physicality: ‘I am a strong person. I am a fit person,’” Max says. “We work within the specifics of their injury to find an exercise routine they can do. They need to sweat and put in the effort they are used to, and doing that will connect them back to their body’s competence and help them feel like themselves.”

Loss of social supports. “When an athlete’s career ends, all their major relationships shift,” Rice says. “Their teammates were their closest friends. Now they’re not a member of the team in the same way, and they often feel like they’ve been cast out of the group just when they need support the most.”

Disconnection from the coach can be the most painful relationship shift. “We see the gamut of responses from coaches when an athlete’s playing career ends,” Max says. “Some are very supportive and stay involved, and others treat the athlete as if they no longer exist.”

When a coach drops contact with an athlete, Max believes it’s her job to intervene. “It’s a delicate balance, but I will speak discretely to the coach and bring his or her attention to the fact that the athlete is having difficulty with how they are being treated,” she says. “I’ll point out that the athlete is going through a crisis and let the coach know that his or her behavior is counter-productive to the healing process. Sometimes the coach isn’t aware of what they’re doing and appreciates the heads-up.”

Ravizza also addresses the issue with coaches. “I encourage them to make sure they are at least touching base with this athlete,” he says. “I know they have tight schedules, so I’ll ask them to schedule one day a week where they are going to make contact with two athletes on their roster who are not playing, and the athlete whose career has ended is definitely on that list.”

Max also works to find a role the athlete can still fill on the team. “They can be a team manager, an academic mentor, or a psychological support person,” she says. “We’ve had athletes who contributed by keeping stats, stuffing envelopes, and doing PR for events. We try really hard to get our coaches to include them.

“For many athletes, still being able to contribute helps the healing process, but for others, being around the sport is too difficult,” Max adds. “Someone who was a point guard may not want to play the role of the video manager. We encourage them to do whatever is going to be best for them.”

In some instances, Max and Rice become the center of the athlete’s suddenly smaller social network. “Sometimes, we’re the only people who understand what they’re going through,” Rice says. “So we make sure we always listen deeply and never turn them away.”

MAINTAINING MOTIVATION
After the decision has been made that an athlete will not return to play, the physical rehab continues nearly unchanged. “We don’t alter much,” Max says. “Our goal is still to get the athlete back to full functionality. I take just as much pride in restoring them to a good quality of life as returning them to play.”

On the positive side, one thing that usually does change is the pace of rehab. “Once the decision has been made to end their career, the pressure is off for my staff to get them better as quickly as possible,” Max says. “For the athlete, the pressure is off to drive themselves in rehab. We can allow the body to heal on its own timetable, and that can be a relief and an advantage.”

A less positive change in rehab, however, can be a drop in motivation on the athlete’s part. This is particularly true when the athlete has been dealing with injury and rehab for a long time prior to the decision to end his or her career. “Once an athlete no longer has the goal of playing again, a drop in motivation is common and understandable,” says Ravizza. “But it’s important to eventually find a way to motivate them again so they can rehab as best they can for the rest of their activities.”

Rice, Max, and Ravizza all believe setting goals is the key to motivation, and when competing is no longer the objective, they help the athlete set new goals that are specific, measurable, and meaningful to the athlete. “Goal setting is another opportunity to put the athlete back in control of what’s happening to him or her,” Rice says. “We have them sit down and write out their goals, focusing on things that are important to them. When motivation drops, we revisit those goals. We’ll say to an athlete, ‘You said you wanted to be running by week eight, and it’s week six. You have two more weeks to reach your goal, and here is what you need to do.’”

Motivation comes from seeing results, so Ravizza also focuses on helping the athlete assess progress realistically. “One of the biggest problems is that athletes are often comparing themselves to where they were before the injury,” he says. “If an athlete is spending all their time thinking, ‘I used to be able to slam dunk a basketball and look at me now,’ they’re not going to be able to see that being able to walk to and from class without pain is progress. So I keep reminding them to compare how they are doing today to how they were doing the day after their injury, not the day before.”

Because these athletes are vulnerable and dealing with a huge loss, it’s important to know when to push and when to back off. “We keep in close contact with the athlete and watch their mood,” Rice says. “Sometimes they simply need a vacation. Coming in to the athletic training room day after day, seeing athletes who are still playing, is wearing. When we sense they need it, we tell them, ‘Take three days off and go do whatever you want. But don’t forget to come back.’”

SILVER LINING
When an athlete whose career has ended has had some time to adjust and is ready to hear it, Ravizza presents another message: Depending on how you handle it, this event can be a wonderful opportunity. Hard to believe? Maybe, but Ravizza has proof to back up his claim. He himself played college football, until a knee injury ended his career during his sophomore year.

“My identity was obliterated, and my future was gone,” he says. “But after a little time, I was able to redirect my energy into academics, and I went after a PhD the way I had been going after a football career. Out of that devastating experience came the career I have today.

“So I tell our athletes, ‘This crisis gives you a once-in-a-lifetime chance to get a whole new perspective on who you are and what you want,’” he continues. “‘You may have thought your sport was the sum total of your identity, but that was never true. Who are you? What do you want to do now with the time and energy you have?’ If we can help the athlete eventually see this event in their lives that way, we’ll have a very successful outcome.”