Four-time Olympic gold medalist Simone Biles, 24, experienced the “twisties” while competing at the 2020 Olympics. The dangerous condition is when gymnasts “lose their sense of space and dimension in midair.” In addition, Biles was also grieving the unexpected loss of her aunt, who passed away during the Olympics. As a result, she pulled out of several events to focus on her mental health. Before the conclusion of the Olympics, she competed in the balance beam and won a bronze medal.
Courtesy of Loic Venance


Published 8/24/2021
James S. Lin, MD; Julie Balch Samora, MD, PhD, MPH, FAAOS, FAOA

MSK Injury versus Mental Health Disorder: A Very Different Perception

Why is there a stigma around athletes’ prioritizing their mental health?

In June, tennis player Naomi Osaka pulled out of the Wimbledon Championships, citing concerns about her mental well-being. A month later, at the Tokyo 2020 Olympic Games, gymnast Simone Biles withdrew from team and individual competitions to focus on her mental health. Had either athlete cited musculoskeletal injury as a reason for withdrawal, they would not have been met with the tidal wave of press and criticism they are now facing.

Pundit Piers Morgan, for one, asked, “Are ‘mental health issues’ now the go-to excuse for any poor performance in elite sport?” An observation from sports surgeon and U.S. Ski and Snowboard team physician Catherine Logan, MD, MBA, MSPT, may be an apt response: “Most of an athlete’s challenges are invisible to the naked eye.” Although a torn anterior cruciate ligament is far easier to recognize than psychological decline, the latter should be regarded with comparable gravity by an orthopaedic surgeon providing care for athletes.

Although COVID-19 has presented competitors with a plethora of new challenges, mental health disorders have had pandemic-level effects on athletes for years. According to a 2018 meta-analysis, 34 percent of current elite athletes have had anxiety or depression. Comparatively, 20 percent of the general U.S. population reported experiencing mental health problems in 2019, according to the Centers for Disease Control and Prevention. A partial explanation for the high incidence of anxiety and depression among athletes is the “overwhelming weight on one’s shoulders” that has been described by decorated athletes such as swimmer Michael Phelps and golfer Rory McIlroy. Speaking in support of Biles, McIlroy described the “weight” he has experienced as a representative of the 6 million people of Ireland, speculating that the pressure of representing 300 million Americans must be massive.

Not all athletes represent an entire nation, but the pressure to perform affects athletes at all levels and ages. Ten years ago, 50 percent of NCAA student-athletes reported feeling overwhelming anxiety. Another survey in 2013 found that NCAA student-athletes had double the rate of depression of retired college athletes. Since then, stressors have only been amplified by increased competitiveness in youth sports and the growth of social media, where young adults feel pressured to perpetually portray an image of happiness and success.

The prevalence of mental health disorders among adolescents is on the rise. Student-athletes often glean their personal identities from their sport, and quitting may never seem like an option. They must contend with the demands of education and other stressors of college while performing at the elite level expected of them. The NCAA lifted restrictions on athlete endorsements for this new academic year, meaning student-athletes will now grapple with a new set of unprecedented stressors. Some student-athletes will certainly enter this season with the expectation and added pressure to garner endorsements and financial compensation. Many universities are already scrambling to partner with companies that will teach students how to manage their personal brands.

Raising awareness is the first step in tackling the challenges of supporting student-athletes’ mental well-being. Orthopaedic surgeons are authority figures for athletes rehabilitating from musculoskeletal ailments, but they must also be cognizant that one in three patients may be suffering from a mental health ailment, as well. Sports-related injury itself is a risk factor for mental health problems in athletes, as are overtraining and participation in individual sports (rather than team sports). The signs of psychological decline may not be immediately apparent, but they could include increased anxiety, eating disorders, and substance abuse.

The next step to combatting this problem is destigmatizing it. One-third of all college students experience depression, anxiety, or some other mental health condition. Among those students, just 30 percent seek support. Of college athletes with mental health issues, only 10 percent seek help. To compete at the collegiate level, student athletes tend to be goal-oriented, highly motivated individuals who face severe time constraints. Athletes are taught to be mentally tough; failure to seek help may stem from fear of being perceived as weak by their coaches and peers. Orthopaedic surgeons are in a unique position to discuss mental health with athletes and connect them with the proper resources. Dr. Logan’s June 2021 AAOS Now article, “COVID-19 Pandemic Causes Unique Stressors Among Athletes,” provides many good examples of how healthcare providers can initiate compassionate conversations through empathetic questions, such as asking athletes about their goals for the upcoming season or how they are managing to strike a balance between work and rest.

Several initiatives are positively addressing this issue. In 2013, the NCAA declared mental health its No. 1 health and safety concern. Three years later, the NCAA published mental health “best practices” online as a resource for athletes, coaches, and institutions. In 2019, the Power Five athletic conferences voted unanimously to require schools to provide mental health services for athletes. That same year, former Division I volleyball player Victoria Garrick founded The Hidden Opponent, an organization dedicated to destigmatizing mental health issues in student-athletes. The group has amplified the voices of many athletes sharing their mental health experiences and seeks to support those who are currently experiencing challenges.

Despite the actions taken on the collegiate level, the highly visible vitriol directed at professional athletes shows that significant progress remains to be made. After withdrawing from the French Open due to mental well-being concerns, Osaka was labeled as a “diva,” “brat,” and “narcissist.” It is encouraging that many elite athletes have since rallied behind their peers who have prioritized mental health, and it is time for physicians to do the same.

The orthopaedic surgeon’s role in addressing these challenges has never been well defined. Nevertheless, it is time to recognize that we do have a role.

For some athletes, a relationship with an orthopaedic surgeon may be the most meaningful relationship they have with a doctor. Therefore, orthopaedic surgeons have a critical opportunity to prioritize mental health in athletes. We have the opportunity to support the notion that it’s okay to show weakness, it’s okay to be injured internally, and, as Osaka has eloquently asserted, “it’s okay to not be okay.”

James S. Lin, MD, is an orthopaedic surgery resident at The Ohio State University. He has a particular interest in upper-extremity surgery and providing care for the competitive athlete.

Julie Balch Samora, MD, PhD, MPH, FAAOS, FAOA, is a pediatric hand surgeon at Nationwide Children’s Hospital in Columbus, Ohio, where she serves as associate medical director of quality for the hospital. She is also the deputy editor of AAOS Now. Dr. Samora can be reached at


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