The Wrap Around with Dr Z: Issue XIII – Injury recovery

Posted on Dec 7 2019 - 1:50am by DV

Wrap Around with Dr. Dan Zimet, Sport Psychologist

Do you have a question about the greatest game played with a ball?  Send it to Dr. Zimet at MDHandball@hotmail.com.  For more articles (and additional mental strategies) go to www.WPHLive.tv, menu option ‘Wrap Around’.

Wrap Around 15:  Injury recovery

I’ve had to come back from many minor and a few serious injuries in my career.  I’ve even considered hanging up the gloves, since handball can be so tough on the body.  I know you need to do the right things physically, but is there a mental side to dealing with injuries?

Some clichés are annoyingly true.  Life isn’t fair.  You can’t always get what you want.  But somehow, when they apply directly to our own lives, they take on a new relevance.  This is specifically true for the saying, “You don’t know what you’ve got ‘til it’s gone,” a statement that is particularly relevant for our health. 

I vividly remember tearing my plantar facia.  Denial that the ‘pop’ I felt meant anything serious.  Confused that my entire foot, from toe to heel, looked like I had stepped in black ink.  But above all else, I was devastated.  No exercise?  No handball?  The physical pain was of minimal importance compared to the psychological impact.  I’d take ten-times the pain if I could have cut the recovery time or ensure a full recovery.

Getting hurt while competing is somewhat inevitable, although the less fortunate endure prolonged and even permanent injuries.  In addition to the inconvenience, pain, and cost (e.g., lost wages and medical care) any serious athlete suffers mentally.  You lose a source of self-esteem, a preferred method of managing stress, regular contact with friends, and now there’s a hole in your weekly calendar that used to say ‘handball’.  There are even larger implications, like the loss of identity, threats to independence, and feelings of physical vulnerability.  Dreams of court conquest are scrubbed from your dreams, and you are left wondering if your best days are in the past.

Thankfully, most athletes are able to make a complete or near complete recovery provided they work as hard off the court as they used to on the court.  In this issue of Wrap Around, we explore how to best cope with an injury with particular attention to the role of mental skills.

Do the Right Things:

Let’s start with the obvious.  The sooner you get an injury addressed, the less likely it will be that you make things worse.  Go to the doctor and get a full assessment.  Then do your homework.  Learn all that you can about your diagnosis and treatment options.  If you’re blessed to be working with someone you trust, communicate with your doctor and then do what you are told.  No more.  No less.  Athletes are extremely competitive, and often take an all-or-nothing approach to everything, even their treatment.  If you’re advised to do an exercise five times a day for three-minutes, don’t think that your doc will be impressed when you do it ten times a day for eight-minutes.  Be patient!  Healing takes time, and it’s better to take a little longer and come back completely than to rush back and risk re-injury.

Although many injuries can be considered ‘fluke accidents’ or a ‘part of the game’, there might be an explanation for why you were vulnerable.  Was your conditioning insufficient to cope with your on-court expectations?  Were you overaggressive in trying to retrieve a ball?  Were you wearing appropriate shoes?  Did you warm up properly?  Particularly as we get older it’s important to take care of the details if you expect a long career as an athlete.  These details can include a longer warm-up, more cautious retrieving, and increased or changing off-court conditioning.  For example, many older athletes use yoga for muscle flexibility and joint support.  Getting hurt is an opportunity to evaluate how well you take care of yourself on and off the court.

Mental healing:

Now that you’re addressing the physical side, let’s consider the mental piece.  Getting injured is traumatic, and athletes often experience the range of emotions common to significant losses, including denial, anger, sadness, and fear.  It’s normal to have these kinds of feelings.  They accurately reflect a difficult situation.  But allowing yourself to sink deeply into these feelings will compound your problems and complicate your recovery.

In many circumstances, feelings of depression and anxiety contribute to withdrawing from people and previously enjoyable activities.  Pain can impact sleep quality and make it challenging to perform normal life routines such as taking a shower or getting dressed.  This further contributes to a negative state of mind and creates a cascading pattern of deeper emotional distress.  In addition to prolonging your physical recovery, the rest of your life can spiral downward.

You’re going to need to address the new reality head on by working with it and becoming positively engaged in your recovery.  Thankfully, research shows that certain factors lead to a more rapid rehabilitation.  When Levleva and Orlick (1999) compared slow and fast healers, they found that the fast healers…

  • took personal responsibility for healing
  • had high desire and determination
  • had more social support
  • maintained a positive attitude
  • used creative visualization
  • were less fearful of re-injury upon return to full participation

More recently, Arvinen-Barrow et al (2019) reported that of the 27% of NCAA athletes who used mental skills in their injury recovery, 72% said that it helped them heal faster.  The top three skills these athletes used were goal setting, positive self-talk/positive thoughts, and imagery.

Goal setting:

Focus on what you can do, rather than what you can’t do.  You’ll want to set goals for the healing process, as well as using the recovery period productively. 

Setting goals starts with forming a specific and clear recovery protocol with your treatment team.  Be prepared to ask a lot of questions, including benchmarks for when you can return to activity, what movements will help or hinder your progress, and what needs to be done to avoid future problems.  Use resources on the Internet to develop a base of knowledge, and then confirm or disconfirm your online research with your doctor.  I would also encourage you to consider different options for healing, including but not limited to physical therapy, acupuncture, use of a chiropractor and massage therapist.

Your objective is to create goals that position you effectively once you’re ready to return to the court.  See if there are creative ways to stay in shape despite your injury, for example swimming or selective weight lifting.  Be extremely mindful not to gain weight.  Poor conditioning and additional weight increase your likelihood of getting reinjured, and also prolongs your return to pre-injury form.

You’ll want to use your time well by getting engaged in something that gives you purpose while you’re unable to compete. Consider working on your game off-court, like watching film or discussing areas for development with fellow competitors.  Unfortunately, your injury may end up causing permanent limitations to your game.  What alternatives can you develop or rely upon now?  For example, if a shoulder problem makes it impossible to hit an overhand ceiling shot, you’ll need to develop your punch shots.

Stay involved by supporting handball as a volunteer.  Giving back to the game is a great way to keep you connected with the community, and having a supportive social system really helps. In addition, it helps maintain that handball segment of your schedule. Determine if low-level handball activities can be used as part of your physical therapy. In addition to the support, interacting with other handball players that have come back from injury can provide information about prevention and recovery techniques.

You can also direct your energy towards something outside of sport.  Perhaps another hobby or special interest, like music or art, or a project you’ve been procrastinating.   This can be particularly hard if your identity is deeply tied to athletics, or if the injury causes you to miss an event that’s very important to you.  Diversifying your interests acts as an emotional buffer and distraction.  The more you like to do, the more opportunities you’ll have to find something interesting to occupy your time.  You may find that the hobby you picked up while injured becomes a regular part of your life even after you’re healthy.

Stay positive:

To state the obvious, everything is better when you keep a positive mindset.  When it comes to an injury, have confidence in your body’s ability to heal.  Believe that you can bounce back.  Medical care has come a long way, and it’s amazing how effectively our bodies recover under healthy conditions.  Granted, it may take a long time and you may need to deal with an unfortunate reality that you may not be the same as you were before the injury.  But staying positive means keeping the focus on the half-full side of things.    

It can be hard to avoid negative ‘what if’ scenarios.  Recognize them for what they are; predictions of a future that may have no resemblance to the truth.  Mentally strong athletes find opportunities to grow and learn from adverse conditions, including injury.  For example, athletes who suffer serious injuries often report a renewed perspective on sport, increased motivation, and an improved ability to cope with frustrations (Podlog & Eklund, 2006).  I worked with a young man who, after a knee injury forced him out of collegiate wrestling, changed his major and became a physical therapist specializing in sport rehabilitation.  He now works at the same college where he competed and supports the wrestling team as an assistant coach in his spare time. 

Staying positive gets back to another one of those cliché’s I mentioned earlier.  It’s not what happens to you that matters.  It’s what meaning you make of those events.  Take a moment to think about what your injury means to you.  Staying positive means developing a greater appreciation for life and your ability to compete and perform physically.  It means not taking for granted how fragile our health can be.  That opportunities to compete won’t last forever, and we need to value each and every match, game and point.  Getting injured reminds us that life is precious.  These lessons have been brought home to me time and time again, and not always because I get injured.  When one of my competitors is hurt, the game as a whole suffers.  Shifting gears to recover from an injury increases our flexibility in coping with life’s challenges and seeking new opportunities.

Visualization

If you’ve read previous issues of Wrap, you’ll know that visualization (e.g., mental imagery) is a powerful tool for motivation and skill development or maintenance.  For healing, it helps create positive expectations.  Here is an example I recently used with an athlete who presented with nerve damage from knee to ankle, causing partial paralysis.  First, we did a breathing exercise for relaxation, and then I guided him through a visualization exercise that included movement, strength, healing, flexibility, and durability.  I had him visualize his foot pressing against the floor, lifting his heels smoothly off the ground.  I asked him to him to feel his calf flex, the muscles taut and hard, his toes gripping the carpet for purchase.  Then I had him visualize bouncing up and down as though jumping rope, the foot flexing and relaxing in perfect timing.  During the exercise I slowed the experience down, encouraging him to feel the leg relaxing in the air, then strengthening to accept his weight, flexing and then firing to lift him slightly off the ground again so the imaginary rope could clear his foot.

This was a deeply emotional exercise, and the first few times we did it he was overcome.  We were then able to talk about his fears of never recovering, what it would mean to his future if he lost his scholarship, and how it would impact his identity and life if he never walked again without a cane.  Coming to terms with those anxieties was an important part of his recovery, and visualizing doing what he wanted with his leg helped create positive expectancy.

Visualization can also help overcome fears that arise after you return to play.  Getting injured effects an athlete’s self-confidence which, when combined with a reduction in performance following time away from sport, causes stress and anxiety.  Visualization helps build motivation and reminds an athlete of their abilities.  It’s worth noting that you also need realistic expectations.  It takes time to rebuild after a layoff.

Stay active.  No matter what.

You want to be active for the rest of your life.  The fact is, handball can be a brutal game on the body.  Its challenge is why we love it, but it can also be a curse.  Playing to your level helps, although it’s mentally challenging if an injury causes a permanent drop in skill.  While handball hates to lose members, you may need to consider another option that causes less stress to your specific injury.  For example, pickleball is gaining popularity because it’s easy to learn, combines a number of elements that make games like tennis and badminton enjoyable, and it’s softer on the body than either of those sports.

Whatever your injury, know that the pathway to recovery is a both physical and mental journey.  Take good care of your mind and body, and I look forward to seeing you on the court soon!

Musings from the Masters

Vern Roberts Jr., Tucson, AZ.  b 1954.  Handball Hall of Fame, induction 2002.  Preferred to play outside (prior to replacement parts)

There’s a mental side to everything related to our handball game(s).   Early on, I was told: “Everyone who has a great off-hand had to use it during an injury to their strong hand.”   While there are certainly some injuries that mandate time off the court, some are conducive to working on a particular aspect of your game.   One of those is an injured strong hand/arm.   Playing with a minor injury gives you the opportunity to not worry about the win or loss or score.

Having a goal for the time on (or off) the court during the injury is also important for the mental aspect of dealing with the injury.  Shooting for a tournament at some point after the projected “heal” date is also a good plan.

 Of course, keep in mind that some injuries are better left to heal while resting.  And, you can still have the goal of a tournament in the future during this recovery/rehab period.

LeaAnn Martin, Bellingham, WA., b. 1956, Handball Hall of Fame (2010), 20+ National and World titles in singles and doubles, played 4 wall.

There is absolutely a mental aspect to dealing with injuries! Of course, it makes a difference if the injury is short-term (a broken bone takes only 6 weeks to heal) or a career-ending injury. In my handball career, I have suffered a ruptured Achilles, two broken fingers, two broken ribs, a broken wrist, and a myriad of pulled or strained muscles. Each injury was different in terms of length of recovery and adjustment back into competition. I also had a total ankle replacement several years ago that has ceased my handball playing.

The first thing I would do after my injury was to assess the cause. Was there something in my training or conditioning I could have done to prevent it? Is there something I now need to change? Was I training too little? Too much? I’d also ask how the injury might impact my handball in the short or long term?

For shorter term and localized injuries (e.g., broken fingers), I was able to continue training during recovery. For example, with a broken wrist on my dominant (right) arm, I could still get in the court and practice like crazy with my left arm. I think that injuries to my dominant side improved my game in that my non-dominant strokes would progress with focused practice. Some would call it a benefit of being injured, and I certainly approached it that way. I even played in a local tournament left-handed only, wearing a cast on my right arm. I don’t recommend that because it most likely increased my chance for other kinds of injuries and could have contributed to a re-injury. But, as Pete Tyson often told me, the IQ drops significantly once the gloves go on the hands. There are still mental aspects involved such as wondering when I would get to play again, if there would be effects on my game, etc. The key is to remain positive, do what you can, and see it as a temporary setback.

For longer term injuries (e.g., ruptured Achilles) or conditions, the recovery and rehabilitation are much more significant. Some of these injuries can be career-ending. Immediately after rupturing my Achilles, I was ready to abandon handball, but that was somewhat short-lived. Just weeks after my surgery to repair the tendon, I was thinking of when I could get in the court again. I found a “support group” in a handball friend who had also ruptured his Achilles (thanks, Joe Thomas!). Reality set in that while I could play again, it would be a long road to recovery. The physical recovery was tough – lots of time in a cast, wearing heel lifts, lots of walking, and nothing in the court. As my flexibility, strength, and cardiovascular conditioning increased after the removal of the cast, I was able to get in the court to just hit the ball around. Once in the court, it was clear that my physical recovery surpassed my mental recovery. Being confident playing with a previously significantly injured leg was difficult. In fact, I joked with people after I started playing again that I was “fine from the neck down.” However, my success in the court was greater after the ruptured Achilles. Thus, while I originally viewed it as career-ending, it was far from it. And I attribute that to the fact that throughout I visualized good shots and did my best to think positively. When I couldn’t get in the court, I saw myself hitting good shots and mentally practiced all the time. I was always committed to physical training and practice, but not having the ability to do that meant my mental practice took on added importance. I also knew that in the grand scheme, losing the ability to play and compete for 8-12 months was minor.

Most of my injuries were just “bumps in the road,” However, I had a ankle replacement three years ago and based on my surgeon’s instructions, have quit competing in handball. The need for a replacement was decades in the making. It was most likely due to a broken ankle or two prior to my being introduced to handball and many, many years of sports and conditioning after the original injury. While not able to play was and is devastating, I continue to stay involved in the sport I love in many other ways. As well, I have altered my physical conditioning to cardio and strength training that doesn’t involved impact.

In sum, I think there are several keys to dealing with injuries. First, focus on prevention whether it be through conditioning, practice, or the way you play. Secondly, focus on the positive by considering what you can do if that is through mental practice of good shots or limited practice. Thirdly, keep things in perspective. We all love handball, but there are times when playing is no longer an option. There are other ways to be involved and interact. And, while it is hard for me to say, handball is not your life.

Albert Apuzzi, Brooklyn NY.  B. 1955.  Handball Hall of Fame, Twenty National Open 1-wall titles, 32-time Open finalist.  Prefers 1-wall small ball

When I was playing tournament ball I always had the date of the Nationals programmed into my mind. That was my deadline & somehow I would be healthy by then.

As I grew older I realized that it took longer to heal & that if I waited until I was 100% healed I would become too deconditioned. I learned to try to keep moving & playing. Only as hard as sensible in order not to get injured.

Cesar Sala, Bronx NY.  b 1977.  Six National Open 1-wall titles (2 singles & 4 doubles), 1 Worlds Singles small ball.  Prefers 1-wall small ball.

Anyone who’s played ball competitively knows the importance of the mental aspect. Injuries can be one of the biggest mental hurdles to get over. There are stages a person has to go through in order to come out successfully on the other side. I have dealt with my share of injuries both relatively minor and severe. The hardest part for me has been knowing when to quit. I’ve had a habit of pushing through when I should’ve eased up. Over time I learned more about my body and how to navigate through injuries and get back on the court.

   When I was young, I had the mentality that I just had to fight through the pain and keep pushing forward. That worked fine for me as far as the minor stuff went like bone bruises, sprained wrists & ankles, jammed fingers etc. My first real injury was a back injury. That was a real problem for me when I was about 19 years old. That was tough on me. Up until that point, pushing through things worked but this injury would teach me a different lesson.

   I never went to the doctor to find out what was wrong because I didn’t have insurance at the time and I couldn’t afford to pay for it in cash. So I just tried to do things that I had heard or read would help. At first, I had trouble getting out of bed without feeling sharp pains in my back and it would really stiffen up on me. Swinging and twisting was completely out of the question. So I’d stretch and run as much as I could as well as practice whenever possible. I struggled with it for about 3 years and I can’t say I’ve ever really felt the same after. I just learned how to work with it. Over that time I tried to play and compete dealing with it and I had some success but it always came at a price. After a tournament I’d have trouble walking around then over time I’d slowly feel good enough to play and I’d go back out and do it again. At some point I realized that practicing and doing drills where I focused on my form help strengthen the right areas of my body but playing hard was A bad idea. The sudden movements, changing direction along with over swinging would really set me back. One of my favorite shots at that point was hitting the ball sidearm lefty into the right corner as hard as I could. Mainly because I enjoyed the oohs and aahs of the crowd. I eventually realized that had to take that out of my game and I began to work on hitting the ball with less pace, using the spin of the ball to get a bigger angle. I developed a sweeping motion that was a lot easier on my body and it took a lot less strength. That was one of a bunch of things that helped to shape my game. The back issues forced me to explore other ways to win volleys and expand my game.

   Later I dealt with the aging process. My shoulders have been tough to deal with due to arthritis and a number of other ailments that have developed over time. One of which led me to having surgery on my right shoulder. For the most part I’ve had a full recovery and I get to play and compete at a relatively high level. The bottom line for me was accepting that there are limitations but that doesn’t mean you can’t continue to improve. You just need to figure out what you can improve on and follow through on that. When my back hurt, I worked on my legs & abs. I also worked on my form and control along with the basics.  It was a blessing in disguise because it opened my mind to learning how to deal with adversity while still driving forward eventually getting to my ultimate goal of winning the nationals.

   Joe Kaplan & I won our first nationals doubles when I was 22 and I won my first singles nationals when I was 23. Overcoming that injury was one of the biggest mental hurdles I’ve had to face as a player. And it was totally worth it!

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