Approximately 500,000 athletes participate in National Collegiate Athletic Association (NCAA) sports in the United States annually (1). The benefits of participating in sport appear to outweigh the risks for most athletes. Participation in organized sport provides many benefits to the athlete aside from physical fitness, including access to social and cultural support, as well as psychosocial growth. However, there are potential negative aspects, including exposure to hazing, overtraining, pressure to perform, and career-ending and life-changing injuries (2). In some athletes for whom these negative consequences have a greater role, there may be lifelong effects on psychological well-being, including depression, anxiety, substance misuse, and disordered eating (2). Of particular interest to our group is the impact that involuntary retirement from sport due to injury or illness can have on mental health.
For the majority of student athletes, their careers end naturally when they graduate from college because less than 2% of all NCAA athletes advance to a career as a professional athlete (3). Athletes ending their careers naturally, or when retirement is considered voluntary, tend to cope better with the transition to life after their participation in collegiate sports have ended (4,5). This is likely because of having more opportunities to continue participating in recreational sports or continued physical activities throughout adulthood, although these athletes still have to cope with the change in social networks and support associated with retirement and change in identity. However, involuntary retirement due to injury or illness, or because of being cut from the team can significantly impact physical and psychological well-being for a substantial proportion of these athletes (6,7).
This review covers the current understanding of the long-term effects involuntary retirement has on psychological well-being in athletes. The primary focus will be professional, Olympic, and collegiate athletes, because the majority of research has focused on the impact of involuntary retirement at these levels. Summarizing these findings and likely best practices, an algorithm is proposed to provide guidance for clinicians facing these challenging discussions, particularly in college athletes who comprise the largest elite athlete population facing involuntary retirement. Recommendations include the provision of support programs and educational resources for athletes to reduce the potential long-term impacts of forced retirement. Overall, the goal is to limit the potential long-term implications of forced retirement on psychological well-being, but also to identify and predict those athletes at highest risk for experiencing psychological burden and most likely to benefit most from timely and comprehensive support.
Positive and Negative Impact of Sport Participation
Participation in sport, regardless of level of organization, is associated with musculoskeletal and cardiovascular development (8–10), and in long-term cardiovascular and cerebrovascular health, as well as lower overall mortality (11–13). Sport and physical activity also have positive benefits on mental health and cognitive functioning (6,14–18). As suggested in a recent commentary by Brian Hainline, MD (chief medical officer of the NCAA) and colleagues, being physically active is correlated with better overall health, while physical inactivity is associated with reduced neurologic health and cognitive development, and increased risk of obesity and substance misuse (19). Clearly, participation in physical activity, regardless of level of sport, can have lasting positive effects.
On the other hand, participation in sports is not without risk. Athletes often experience orthopedic injuries, fractures, muscle strains, tendon tears, sprains, tendinopathy, and concussions, as well as possible repetitive brain trauma (20–22). Injuries can result in long-term physical problems, such as chronic pain or osteoarthritis, which also can lead to prolonged use of analgesics which introduce risk of opioid seeking and dependence (23–26). With regard to the long-term effects of sports participation on cognitive, psychological, and neurological health, particular focus has regarded neurological injury following concussions among athletes involved in contact and collision sports (27–31). Concussion, and especially exposure to repetitive head trauma, have been associated with long-term impairments in cognitive and psychological functioning and neural alterations (see (27,29,32,33) for discussion of current literature). There also is emerging evidence to suggest that sports-related concussions (SRCs) and chronic exposure to repetitive head impacts can increase the risk for neurodegenerative diseases, such as chronic traumatic encephalopathy, Alzheimer's disease, and amyotrophic lateral sclerosis (34,35).
Involuntary retirement from sport can be particularly detrimental psychologically and is associated with adverse long-term mental health outcomes (2,6,7,36–43). Athletes forced to retire are more likely to report symptoms of distress, depression, sleep disturbances, adverse nutritional behavior, have worse quality of life, and lower life satisfaction compared with athletes retiring on their own volition (6,7,37,41). In the clinical setting, patients report a sense of loss, unfinished business, physical complications of injury impairing exercise and lifestyle, and social displacement. Involuntary retirement is likely difficult because of the sudden change in athletic identity, which encompasses loss of personal and public identity, and social support networks (18,40,41,44,45). This can result in feelings of worthlessness, depression, anxiety, hostility, anger, and maladaptive coping strategies, such as substance abuse (7,42,46,47). Furthermore, a lack of planning for the transition to life after sport, which is often the case when athletes are involuntarily retired, can significantly affect psychological well-being (4,7,48). The high degree of mental health symptoms in former elite athletes compared with the general population may be related to sport-specific retirement stressors, such as athletic identity, involuntary retirement, lack of retirement planning, low educational attainment, and chronic pain (7). Together, these factors increase the risk of postcareer mental health symptoms and disorders (7).
Although injury severity can be sufficient to warrant retirement, many of the cases of retirement from sport do not cause a noticeable, outward disability. There is often a discrepancy between ability to accomplish activities of daily living and a major injury precluding participation in elite sport. Despite the ability to maintain normal activities and schedules, these high-performing athletes perceive a major functional and life-changing disability. For example, an athlete that has had a multiple ligament injury of the knee may not be willing to participate in recreational fitness activities due to fear of recurrence. Patients with persistent postconcussion symptoms might fear sustaining further head injury (49) and feel they cannot engage in potentially risky activities, even potentially low impact recreational sports. These patients can constantly reevaluate the safety of activities that others would not question. In addition to fear regarding further injury, a transition to recreational fitness or sport may feel unnatural to a former competitive athlete involuntarily retired due to injury, because of fear or even more insidiously, the disappointment of not participating at a satisfactory level compared with their preinjury status.
While an athlete that follows a natural course to retirement may have a gradual decline in participation and reduced access to social networks, this will be compounded following unexpected displacement due to involuntary retirement because an athlete may have to seek individual outlets for exercise and competition without the supportive network of a team, coach, and support staff. This sudden change also can leave individuals without a peer group who would ordinarily provide support and keep them active. Additionally, athletes may not fully understand the importance of continued engagement in cardiovascular and fitness training after retirement from their sport for long-term health (12,19). For instance, one study found that former soccer players had an increased risk of weight gain, and thus cardiovascular disease, as well as decreased bone mineral density, if they assumed a sedentary lifestyle after sport compared with their physically active peers (12).
As the majority of authors on this article are clinicians who work with active athletes, as well as those transitioning to retirement, we see a need for: 1) a structured, evidence-based approach to inform clinical decision making with regard to how and when to retire an athlete; 2) strategies to help athletes transition to their new identity postretirement; 3) methods to identify those who may struggle with this transition; and 4) determining who will benefit from interventions, such as psychological support, career transition planning, and goal setting. We have thus developed such an algorithm to aid in this clinical decision-making process, steps that should be taken to ensure the successful transition to life after sports, and resources to provide continued support after retirement.
Clinical Recommendations and Avenues for Future Research
Factors informing an algorithm on when to retire the athlete
Factors leading to retirement decisions following any injury vary player to player, and include sport-specific factors (inherent risks of reinjury in ordinary participation), severity of current injury, as well as other contextual factors learned through conversations between the player, health professionals, coaches, and other stakeholders. As noted in the 2019 American Medical Society for Sports Medicine position statement, “There are no evidence-based guidelines for disqualifying or retiring an athlete from sport after concussion; therefore, each athlete should be carefully and individually assessed to determine the safety and potential long-term health consequences for continued participation” (50). However, as Schmidt and colleagues (51) have highlighted, “These recommendations have been based predominantly on clinical opinion without any quantification of relevant factors”. The lack of objective data makes the recommendation to retire/medically disqualify more challenging for the provider and more difficult for the athlete to accept.
Previously, members of our group proposed an algorithm now in practice, which provides guidance for key decision points when considering retirement after SRC (52). The algorithm draws on key signs of complications from the current specific injury, athletic exposures, number, type and duration of prior head injuries, level of sport, current neurological impairment, future risk of premature neurologic decline, as well as potential for alternative style of play, position, or sport. Built on a model of shared decision making, the algorithm primarily focuses on three principal components: a) absolute clinical or biomarker-based evidence of permanent neurological injury, b) relative contextual factors about the injury and sport, and c) patient-centered decision points including perceived risk of recurrent injury and personal valuation of participation in sport. It draws on clinical evidence of lasting complications from the current injury; athletic exposure history; the number, type, and duration of prior head injuries to inform a cumulative burden exposure to head injury; sport-specific factors including level of sport; presumed or perceived future risk of premature neurologic adverse outcomes; as well as potential for the athlete to adapt an alternative style of play, position, or sport. Clear criteria also exist for determining whether an athlete should be retired from collision sport following a cervical spine injury including neurologic symptoms and radiographic parameters (53–55). Since the time of the Torg ratio regarding cervical spinal stenosis after injury, restrictions regarding participation in collision sport have been refined (56). There also are published guidelines regarding the need for sport modification or restriction based on medical conditions and cardiac concerns (57–60).
Although algorithms for other types of athletic injuries, such as recurrent knee or shoulder instability, are not as clearly outlined, concussion retirement algorithms exist that may be informative and potentially adaptable to other injuries resulting in medical retirement. Specifically, regardless of the type of injury, the physician making the retirement decision is tasked with determining: a) the safety of an athlete returning to the same activity that led to the injury they are being treated for and b) the individual risk-benefit including whether the short-term and long-term associated outcomes (e.g., psychological burden, loss of identity) do not outweigh the risks of returning to sport.
As detailed above, and in contrast to neurologically focused decisions, decisions to retire following orthopedic injuries are specific to one or several joints or musculoskeletal groups which may impair elite sports performance but not necessarily impact normal functional abilities. Broadly, factors informing retirement include: a) signs of persistent musculoskeletal limitation likely to make an athlete unable to perform at an adequate level, b) a high likelihood of worsening injury with repeated exposure, and/or c) potential introduction of a sport-specific or general disability at an early age due to the demands of the sport on the injured area.
Use of a retirement tool has improved engagement of patients in the process and helps to insure key features of the discussion occur in a methodical fashion (5). Each of the above guidelines stress the magnitude of a decision to retire from sport and hint at the potential stress of retirement, yet none of these guidelines offer solutions or strategies to approach the stress of retirement. Further, once the decision has been made, a clear transition plan can help predict and avoid potential negative consequences. However, currently, no standardized transition process exists for clinicians to support the process of retiring athletes.
Algorithm on transitioning to retirement
Past research has highlighted potential problems that athletes face during retirement (Table). Athletes struggle with psychological distress and report mental health concerns both during their career and after it has ended (7,41,47,61). After retirement, athletes also struggle with coping with changes in, or loss of, athlete identity, and feelings of lack of control over retirement choice (18,40,41,44,45). Further, athletes often report problems with the transition to retirement when they do not feel prepared for life after retirement (e.g., career development, financial adjustment, and emotional support) (45,48,62). Moreover, athletes also report using maladaptive coping strategies after retirement, such as disordered eating, substance abuse, as well as sleep disturbances which may be due to dealing with chronic mental health problems (e.g., depression and anxiety) and physical conditions (e.g., chronic pain), all of which may exacerbate these conditions (7,47,63,64). As such, providing strategies and retirement plans as part of the exit interview may reduce the presence or severity of these problems, as well as help identify individuals who may benefit from early intervention methods (e.g., counseling services; see Figure; recommended interventions for each is provided in the Table).
Potential effects of retirement and recommendations for intervention.
||Recommendations for Interventions
|Psychological distress including symptoms of anxiety and depression
||The exit examination after retirement from sport should involve screening for mental health conditions. The visit should normalize psychological distress after retirement, provide resources for distress, teach healthy coping strategies, and educate the athlete about warning signs for mental distress. Athletes at higher risk: chronic injuries, multiple concussions, or with nonvoluntary retirement from sport also should be screened periodically after retirement as issues may arise after the immediate retirement interval.
|Physical fitness can wane after retirement
||A formal discussion of the athlete’s relationship with fitness outside of competitive goals can identify barriers to continued exercise such as chronic injury. The health benefits of exercise may not be self-evident to athletes, and engagement with routine training may require motivational strategies that stress the benefits of consistent cardiovascular and strength training.
|Coping with the loss of athletic identity
||During and at the end of athletic careers, athletes should consider therapy with a sports psychologist to address how the loss of their identity as an athlete after retirement may impact their broader identity and future goals outside of sport.
|Potential for substance misuse
||The exit examination should include education for healthy alcohol use practices. Identifying smoking and drug use as possible detrimental coping strategies is important to deter use, while offering healthier tools to manage stress. Athletes should be counseled as to warning signs for substance misuse and provided resources for anonymous help.
|Academic and long-term goals may not be well defined outside of sport
||Engagement with academic advisors is important to address goals outside of athletic aspirations. Academic goals may not be well-defined, and it is possible student-athletes, especially those early in their pursuit (i.e., freshman) may not have a well thought out plan for the future. Loss of structure around sport also may derail academic goals. Opportunities, organizations, and connections to former athletes should be provided to players for mentorship to help guide the transition.
|Disordered eating behaviors
||Athletes should have an exit examination with a nutritionist or team doctor to discuss the large shift in caloric need that will follow cessation of high metabolic demand sports. Athletes should be counseled regarding the changes their body may undergo after retirement.
||Sleep hygiene should be taught to athletes during their exit examination. Athletes should be educated regarding sleep disturbance as a warning sign for psychological distress.
In the following section, we provide an algorithm that can be used across sports to help athletes develop a plan for the transition to life after sport, while also intervening to reduce the potential problems that can arise during the retirement process. We suggest the use of a multifaceted postretirement interview following the steps outlined in the Figure, which may help to elucidate an individual's concerns and provide guidance for treatment or engagement with appropriate support staff. Factors influencing a positive adjustment to retirement, such as individual demographics (e.g., socioeconomic status, physical health, age), psychosocial (e.g., planning for retirement, personal control over retirement), organizational (e.g., prepared for retirement), and social group support (e.g., continued group membership and positive change in identity), are well defined in existing models and frameworks (65–68). As such, in addition to past research and our group's clinical experience working with collegiate athletes, we incorporated information from models of retirement from the general population to inform our retirement algorithm in collegiate athletes.
The first component of our athlete retirement algorithm is to determine if the retiring athlete has a plan for life after sport. If the athlete does have a plan, the goal is to determine how realistic their goals are, determine if their goals are feasible, and refine the plan to make sure they feel a sense of control over the retirement transition. There are a number of questions that should be reviewed with the athlete's academic advisor. Should he/she review their coursework and options for graduating with their current major or consider a new major? Given the demands of their sport, the athlete may not have previously sought out internships, work-study programs, or other opportunities for experience in the chosen field and may need support doing so. Can the athlete afford to continue his/her studies without athletic scholarships or stipends? Is graduation a goal of the student? Is postgraduate study something the athlete should consider?
Many athletes will feel a sense of loss upon retirement, providing them with control and support in determining their plan will reduce this burden. In this step, one must also consider how much support the athlete currently has (e.g., financial, emotional) and whether this will benefit them, or hold them back, moving forward.
If the athlete does not have a plan, the main component is to determine why they have not planned for life after sport. Obviously, this will be affected by how far along the student is within their academic pursuits (e.g., freshman vs senior), but with the exception of the small percentage of collegiate athletes who continue sport on the professional level, all athletes know their career as a student athlete will end. However, young athletes may live in the moment without a plan for the future. Thus, it is important to determine why the athlete does not have a plan for life after sport as this will impact their retirement plan and transition. Reasons for lack of a plan include: a) denial that a career will end (as part of a grieving process relating to unrealized life goals), b) fear of the future or the change in identity and status, and c) weak connection or perception of complementary or alternative skill sets. The goal in this step is to determine what the athlete is interested in, the skills they have, and the relationships they have fostered that can help them move to the next steps in their career.
Next, the aim is to provide goal management and structure. Goal management and structure include potentially restructuring the athletes' academic and career goals because these may not have been their focus during their athletic career. Further, these goals may change depending on the reason for retirement (e.g., no longer interested in sport, no longer able to participate in sport as they once did). Development of career transition plans and long-term career goals should be completed. Athletics provides a tight and structured schedule with tangible strides toward athletic and academic goals; keeping a routine without the structure of athletics is initially difficult. Thus, having a structured plan for obtaining these goals will provide the athlete with a sense of agency and power over the transition.
Mental health planning would benefit from continued meetings with coaches and athletic personnel during the transition process. Because coaches and athletic personnel often serve as mentors to athletes, they should be involved in their planning and goals for life after retirement. However, inclusion of coaches and athletic personnel in retirement planning should ultimately be the athlete's decision and is dependent on how they perceive that relationship. Once the retirement decision occurs, meetings with coaches can help athletes cope with the emotional reaction to the loss of sport, gain a sense of closure, and in some cases, even find a new role within the team while maintaining a relationship with their coach-mentor. Meetings with coaches can maintain a sense of connection to the team because many athletes might feel that their usefulness to the team is over when their participation ends. Again, this will ultimately be the athletes' decision, depending on their relationship with coaching staff and athletic personnel at the time of retirement. Although former athletes can take up alternate roles, such as coaching, they may be resistant to these roles as the rewards do not align with their prior goals. Continued sport engagement in a new role, such as student coach or initiation of another sport that avoids the risks that caused the injury or illness requiring retirement, may be suggested to help develop a new role and identity.
Additionally, throughout the retirement process, it is strongly recommended that athletes schedule appointments with the school's wellness and counseling center; meetings with a counselor or behavioral therapist as a planned part of the retirement process may improve compliance with this intervention and help add structure to their life. Schools with limited resources may not have on-campus access, but the advent of telehealth appointments and virtual resources can help eliminate this barrier for underresourced schools. This is particularly important because many athletes may not request treatment or actively pursue treatment even if it is suggested to them or they are having a difficult time (47). In addition to this algorithm and meetings with coaches, access to psychological counseling for those at risk for experiencing psychological distress should be planned. The provision of counseling services in anticipation of the grief reaction that is expected after retirement also is recommended.
Physical health planning should include access to ongoing fitness training to maintain healthy exercise. Athletes may feel a loss of having a competitive outlet after retirement. Providing them with options for other outlets, such as recreational sports or coaching, can keep them active in sport, physically fit, and socially engaged in their peer group. Furthermore, continued access to fitness facilities, such as gyms and pools, or sports medicine personnel, such as athletic trainers, when coping with injury will help the transition to retirement. Similarly, nutrition counseling to understand healthy calorie consumption now that they are no longer participating in competitive sport and potential psychological and physical challenges with changes in body composition would be beneficial during this transition. Finally, counseling for potential substance use issues after retirement, as well as adding structure to their lives, may limit the possibility of future substance abuse. We further suggest that these physical and mental health support programs be in place for athletes in the long term to help manage life stressors and problems that may arise after retirement.
Finally, based on how the athlete has managed the plans and structure presented in the algorithm, coupled with their mental (history of self or family substance use) and physical health history (e.g., career ending injury), it should be determined if they will have problems coping with the transition to retirement and if there is a need for early intervention. Having a sport psychologist involved in the postretirement process can be part and parcel in protocol with a mandatory interview to identify risk factors and assist with transition process engagement of each athlete. If a sports psychologist is not part of the college athletic medical team and an individual is not able to engage with planning and execution of a successful academic and fitness plan, referral to psychology or psychiatry for further evaluation and treatment of occult psychological illness is recommended.
Important avenues for future research
Extrapolating the professional athlete's experience as reference, and clinical experience in our own practices with retired athletes, the need for further research is apparent to determine the impact forced retirement can have on collegiate student-athletes, as well as potential treatments and support systems to structure transition. Verifying our suspicion that involuntary retirement can lead to negative outcomes also would open pathways for prospective studies to determine whether specific programs reduce risk of psychological burden. Models used to examine whether there are personality factors that impact the psychological burden in the long term should be studied as well. These models could inform early intervention to mitigate these risk factors. Future studies should prospectively examine factors increasing the risk for problematic substance use in involuntarily retired athletes to better inform early intervention models. Further, methods for identifying and predicting who may be at risk (e.g., career ending or life-altering injuries, lack of career planning) for substance misuse when leaving athletic programs are needed. Development of a patient reported outcomes survey to measure immediate and late responses to retirement could offer insight into if and when intervention is needed and useful.
In addition, our understanding of the impact of retirement specifically in female athletes is significantly lacking. Although female athletes often report similar difficulties with retiring from sport as those reported in male athletes, such as involuntary retirement, with loss of athletic identity, or when they have not planned for life after retirement (38), female athletes also are faced with other reasons underlying, and struggles with, retiring from sport. Female athletes may have fewer options for continued participation in sport after college, such as limited opportunities to play professionally and access to recreational leagues. Female athletes, who are able to continue their sport professionally or at an elite level often make lower salaries compared with male athletes, report having to get part-time work, or a secondary income, to support themselves (62). Furthermore, women also experience injuries that result in significant career disruption or retirement, such as anterior cruciate ligament injuries or the female athlete triad (69). Female athletes have to make the planned and/or unplanned choice to retire because of having children/pregnancy or childcare responsibilities (70); however, these are often viewed as positive outcomes postretirement (38). Although there are a number of cases of women returning to professional sport or national teams after having children, pregnancy may introduce unique considerations in collegiate athletes.
Unique collegiate opportunities for planning before injury
Retirement after an injury of any kind often comes as a shock to student athletes, particularly those in elite programs who through both internal and external reinforcement have been focused on professional career goals. In our experience, through the course of medical retirement discussions, it is often revealed that many of these individuals may have no backup plan. Through these discussions, it is clear that sports career expectation setting is one critical matter in the scope of retirement, which is a more systemic issue and likely warrants greater attention as part of a cohesive athletic and training program, and need not start only after an injury leads to a focused physician evaluation. Expectation setting may be increasingly important as athletes escalate through more elite levels of play. Discussing disqualification following an injury, before any injury occurs, may not be useful when entering a program, and some athletes may not listen or think that this information does not apply to them. However, advance care planning is best practiced when started well before critical illnesses occur and emergent life-changing decisions are necessary, and discussions of realistic expectations of career trajectories should likely occur early and often in the course of athletic careers.
Collegiate athletic programs are uniquely positioned to be a part of a formative conversation about how one's sports experience will be a part of a bigger personal and professional life course. The beginning of collegiate careers, when many athletes are first in contact with comprehensive coaching and care teams may be the first opportunity for such a discussion in a well-supported environment with appropriate support, counseling, and expertise. While no athlete wants to hear that their competitive career likely ends after their senior year, and such a message could have negative psychological impacts in competitive play or more broadly, the reality is that organized sports end after college for the vast majority of competitive collegiate athletes. Perceptions of future professional opportunities may vary by conference and may be more realistic among those schools which infrequently develop future professional athletes.
Athletic participation confers many immediate and life-long benefits related to uniquely personal and intertwined physical fitness, social engagement, and leadership experiences. In clinical practice, athletes who are forced into retirement may face a sudden psychological burden, including sense of loss or unfinished business. When effectively approached, such as through steps suggested in the plan detailed herein, transition from sport can be an opportunity to identify skills gained from sports which are applicable and useful throughout the athlete retiree’s life. Retirement is an opportunity to frame career goals, skills and interests, as well as establish new structured routines, goals for continued physical fitness, and establishing personal resilience to change. Without guidance, athletes dealing with forced involuntary retirement may face a slower process of personal definition outside of the sport with the potential of losing the benefits gained and having to start from the ground level. A planned support program for an athlete going through retirement transitions can amplify the positive social and individual benefits of sports participation. Involuntary athlete retirement encompasses different risks than planned retirement or following graduation and is a specific area in need of outcomes-based research to further inform current practice.
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