Association between musculoskeletal injuries and depressive symptoms among athletes: a systematic review

Ci a ion: Ma concin, P.; Sil a, A.L.; Flô es, F.; Nunes, A.; Lou enço, J.F.; Pe al a, M.; Minghelli, B. Associa ion be ween Musculoskele al Inju ies and Dep essi e Symp oms among A hle es: A Sys ema ic Re iew. In . J. En i on. Res. Public Heal h 2023,20, 6130. h ps://doi.o g/10.3390/ ije ph20126130 Academic Edi o s: Daniel Boullosa and Han C. G. Kempe Recei ed: 30 Ma ch 2023 Re ised: 16 May 2023 Accep ed: 7 June 2023 Published: 15 June 2023 Copy igh : © 2023 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). In e na ional Jou nal o En i onmen al Resea ch and Public Heal h Re iew Associa ion be ween Musculoskele al Inju ies and Dep essi e Symp oms among A hle es: A Sys ema ic Re iew P iscila Ma concin 1,2 , Ana Lúcia Sil a 1,2, Fábio Flô es 1,3 , Alexand e Nunes 1, Joana Filipa Lou enço 1, Miguel Pe al a 2,4 and Bea iz Minghelli 1,* 1KinesioLab, Resea ch Uni in Human Mo emen , Piage Ins i u e, A . João Paulo II, lo e 544, 2º anda , 1950-157 Lisboa, Po ugal 2 Cen o In e disciplina de Pe o mance Humana (CIPER), Faculdade de Mo icidade Humana, Uni e sidade de Lisboa, C uz-Queb ada-Da undo, 1499-002 Lisboa, Po ugal 3Resea ch Cen e in Spo s Pe o mance, Rec ea ion, Inno a ion and Technology (SPRINT), 4960-320 Melgaço, Po ugal 4Ins i u o de Saúde Ambien al (ISAMB), Faculdade de Medicina, Uni e sidade de Lisboa, 1495-751 Lisboa, Po ugal *Co espondence: [email p o ec ed] Abs ac : Musculoskele al (MSK) inju ies ha e a signi ican physical and psychological in luence on an a hle e’s li e. A sys ema ic e iew o p ospec i e coho , c oss-sec ional, and case-con ol s udies was unde aken in his s udy o analyze he associa ion be ween MSK inju ies wi h dep essi e symp oms in a hle es. We sea ched on PubMed, Web o Science, and Scopus, wi h da a incep ion o 15 Feb ua y 2023. The me hodological quali y was assessed using he Newcas le-O awa Scale (NOS). O he 3677 po en ial s udies only nine we e included. These s udies showed a bidi ec ional associa ion be ween MSK inju ies and dep essi e symp oms. A hle es wi h MSK inju ies had highe le els o dep essi e symp oms, which aises he likelihood o expe iencing dep ession in he u u e. Women a hle es had highe le els o dep essi e symp oms compa ed wi h men. The p esence o dep essi e symp oms is a signi ican p edic o o disabili y in a hle es. Ou indings sugges ha coaches should be mo e awa e o dep essi e symp oms, in o de o p e en MSK inju ies, and o moni o a hle es ollowing an MSK inju y. Keywo ds: men al heal h; damages; compe i ion 1. In oduc ion Despi e he ac ha he li e a u e has ex ensi ely s udied he heal h and psychosocial bene i s o spo s in ol emen , he esea ch on spo - ela ed inju ies and hei associa ion wi h dep essi e symp oms has only ecen ly a ac ed g owing in e es and a en ion [ 1 ]. A spo s- ela ed inju y can be de ined as any physical damage sus ained by an a hle e as a esul o pa icipa ing in spo s. These inju ies can occu du ing compe i ions o aining sessions, ega dless o medical a en ion o ime-o s spo - ela ed [ 2 ]. Musculoskele al (MSK) inju ies a e he mos common ype o spo - ela ed inju ies and o en p edispose a hle es o u he inju ies o e ime [ 1 ]. MSK inju ies can in ol e issue-le el o s uc u al damage o he bone, endon, muscle, ligamen s, o a combina ion o hese s uc u es [ 3 ]. Hence, he ypes and loca ions o hose inju ies a y depending on he spo . Acco ding o he Na ional, Collegia e A hle ic Associa ion es ima es ha o e a million inju ies ha e occu ed among college s uden -a hle es in he las yea s [ 4 ]. Ankle sp ain, o example, had an incidence o 1.00 pe 10,000 among men’s oo ball playe s, w es le s, and ice hockey a hle es [ 5 ]. Ano he no able example is he la e al ligamen complex o he ankle, which has impac ed nea ly i e baske ball playe s pe 10,000 [ 6 ]. Fu he mo e, he li e a u e also poin s ou ha a squad o 25 oo ball playe s can expec abou 15 muscle inju ies pe season [7]. In . J. En i on. Res. Public Heal h 2023,20, 6130. h ps://doi.o g/10.3390/ije ph20126130 h ps://www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2023,20, 6130 2 o 10 Fu he mo e, olde playe s a e mo e likely o sus ain inju ies han younge playe s, and a p e ious inju y is a isk ac o o knee, ankle, hams ing, and g oin sp ains [ 8 ]. Some Scandina ian s udies also ound ha spo s inju ies accoun o app oxima ely 19% o all acu e inju ies, wi h knee and ankle sp ains being he mos common [9,10]. Dep ession is a common men al diso de ha a ec s 5% o he adul popula ion and is a global cause o disabili y [ 11 ]. The mos common dep essi e symp oms a e he loss o ene gy and inc eased a igue, he di icul y hinking, concen a ing, o making decisions [ 12 ]. The loss o in e es o pleasu e in physical ac i i ies is also associa ed wi h dep essi e symp oms [ 12 ]. The p e alence o dep ession in a hle es is conside able, wi h app oxima ely 34% o eli e-le el a hle es epo ing dep essi e symp oms [ 13 ]. Acco ding o Wolanin e al. [ 14 ], 23.7% o college a hle es showed clinically ele an dep essi e symp oms, and 6.3% had mode a e- o-se e e le els o dep essi e symp oms. The au ho s also ound ha emale college a hle es had a 1.8 imes highe isk o ha ing dep essi e symp oms compa ed o hei male pee s [ 14 ]. Fu he mo e, dep ession ep esen s a ha m ul e ec on spo ing pe o mance [15]. The high le el o dep essi e symp oms among a hle es can be explained by di e en easons. The s ess and he p essu e o high-pe o mance, he high amoun o a eling du - ing he season, and he social s anding demands, a e associa ed wi h playe s’ inju ies [ 16 ]. Despi e he abo emen ioned s udies, he associa ion be ween dep ession and MSK inju ies equi es u he in es iga ion o de e mine whe he dep essi e symp oms a e, in ac , isk ac o s o MSK inju ies o on he o he hand, i he occu ence o MSK inju ies ha p edisposes a hle es o dep essi e symp oms. Fu he mo e, mo e esea ch is needed in o sex- ela ed and hei associa ion wi h MSK inju ies, and how di e en spo s p edispose o MSK inju ies and dep essi e symp oms. To he bes o ou knowledge, nume ous pape s ha e compa ed MSK inju ies and dep essi e symp oms, bu no o he s udy has a emp ed o ex ensi ely analyze he e- la ionship be ween MSK inju ies and dep essi e symp oms. The e o e, his sys ema ic e iew aims o summa ize exis ing s udies desc ibing he associa ion be ween MSK inju ies and dep essi e symp oms in a hle es o di e en spo s, in o de o add ess he esea ch ques ion: “How a e dep essi e symp oms ela ed o musculoskele al inju ies in a hle es?” 2. Ma e ials and Me hods This sys ema ic e iew p o ocol was egis e ed a PROSPERO (CRD42023399334) and was conduc ed acco ding o he P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses (PRISMA) 2020 guidelines [17]. 2.1. Li e a u e Sea ch S a egy A e he de ini ion o sea ch e ms, ex ac ed om desc ip o s o Medical Subjec Heading (MESH), we de ined he ollowing e ms: (a hle e* OR a hle ics* OR spo *) AND (dep ess* OR “men al heal h” OR mood OR “psychological heal h” OR “men al unc ion*” OR wo ies OR wo y OR “dys hymia” OR “men al ill-heal h” OR a ec i e) AND (inju y* OR sp ain OR s ain OR endon* OR ascii is OR bu si is). The same e ms we e used o all da abases. To selec manusc ip s, wo esea che s (PM and AN) sc eened he a icles based on i les and abs ac s, ollowed by ull- ex eads. A hi d esea che (FF) was eques ed o media e any disag eemen s. A ho ough sea ch was conduc ed on a icles published un il 15 Feb ua y 2023, and no s a ing da e has been se . The da abases used o he sea ch we e PubMed, Web o Science, and Scopus. The sea ch was limi ed o pee - e iewed s udies published in English and assessing humans. 2.2. S udy Selec ion The inclusion c i e ia we e samples composed o a hle es wi h MSK inju y o a hle es who had su e ed an MSK inju y; epo ed dep essi e symp oms using a alida ed ins u- men o wi h a clinical diagnosis o dep ession; analyzed he associa ion o dep essi e In . J. En i on. Res. Public Heal h 2023,20, 6130 3 o 10 symp oms and MSK inju y; a coho , case-con ol o a c oss-sec ional s udy design. Exclu- sion c i e ia included a icles w i en in languages o he han English, li e a u e e iews, non-pee - e iewed s udies, o opinion a icles. 2.3. Da a Ex ac ion Da a ega ding he coun y whe e he s udy was conduc ed, design, pa icipan s’ cha ac e is ics, spo modali y and le el o pa icipa ion, dep ession assessmen , MSK inju y ype, and loca ion and esul s we e ex ac ed by one au ho (PM). Ano he au ho (FF) pe o med he e i ica ion o all ex ac ed da a o ensu e accu acy. 2.4. Me hodological Quali y Assessmen Two esea che s (AN and ALS) independen ly assessed he me hodological quali y o he lis ed s udies. Fo coho and case-con ol s udies, he Newcas le-O awa Scale (NOS) was employed [ 18 ], while a modi ied e sion o he NOS was u ilized o c oss- sec ional in es iga ions [ 19 ]. A inal sco e was ob ained o each s udy wi hin h ee b oad pe spec i es: selec ion o he s udy g oups; compa abili y among di e en g oups; and he asce ainmen o ei he he exposu e o ou come o in e es . The esul s we e compa ed and any inconsis encies we e discussed un il a inal sco e was eached. A hi d esea che (PM) was consul ed in case o no ag eemen be ween he i s wo esea che s. Quali y sco es lowe han 4 we e a ed as low-quali y s udies, whe eas hose equal o o highe han 5 we e a ed as high-quali y s udies [20]. The s eng h o ag eemen be ween e iewe s was de e mined h ough Cohen’s kappa [21]. In e p e a ion o k alues was es ablished using he scale p oposed by Landis and Koch [ 22 ]: 0 = poo ag eemen , 0.01–0.20 = sligh ag eemen , 0.21–0.40 = ai ag eemen , 0.41–0.60 = mode a e ag eemen , 0.61–0.80 = subs an ial ag eemen , and 0.81–1 = almos pe ec o pe ec ag eemen . 3. Resul s 3.1. S udy Selec ion Ou sea ch iden i ied 3677 po en ial s udies. We emo ed 1706 duplica es and 194 sys ema ic e iews, esul ing in 1777 s udies analyzed by i le and abs ac . A e excluding s udies ha did no mee he inclusion c i e ia, 77 s udies we e assessed o eligibili y. Ou o hese, 41 did no analyze a hle es, and 11 did no assess dep essi e symp oms using a alida ed ins umen o clinical diagnosis. Fu he mo e, in 10 s udies he inju ies we e no MSK, and in i e s udies he associa ion be ween MSK inju y and dep essi e symp oms was no explo ed. Thus, nine s udies we e included in he inal analysis [ 23 – 31 ]. The PRISMA lowcha ha summa ized he s udy’s iden i ica ion p ocess is shown in Figu e 1. 3.2. S udy Cha ac e is ics The s udy cha ac e is ics included in his sys ema ic e iew a e p esen ed in Table 1. Two included s udies we e om he 1990s [ 25 , 28 ], one om he 2000s [ 23 ], and he o he six we e published om 2014 un il 2020 [ 24 , 26 , 27 , 29 – 31 ]. Rega ding loca ion, one s udy was om Canada [ 25 ], i e om he USA [ 23 , 26 , 28 – 30 ], and he o he h ee om Eu- ope [24,26,31] . Mos s udies we e p ospec i e coho s udies (n = 5) [ 23 , 27 , 28 , 30 ], h ee s udies we e c oss-sec ional [24–26] and one was a case-con ol s udy [31]. In . J. En i on. Res. Public Heal h 2023,20, 6130 4 o 10 In . J. En i on. Res. Public Heal h 2023, 20, x FOR PEER REVIEW 4 o 10 Figu e 1. PRISMA lowcha . 3.2. S udy Cha ac e is ics The s udy cha ac e is ics included in his sys ema ic e iew a e p esen ed in Table 1. Two included s udies we e om he 1990s [25,28], one om he 2000s [23], and he o he six we e published om 2014 un il 2020 [24,26,27,29–31]. Rega ding loca ion, one s udy was om Canada [25], i e om he USA [23,26,28–30], and he o he h ee om Eu ope [24,26,31]. Mos s udies we e p ospec i e coho s udies (n = 5) [23,27,28,30], h ee s udies we e c oss-sec ional [24–26] and one was a case-con ol s udy [31]. Table 1. Cha ac e is ics o included s udies. Fi s Au ho , Yea , Coun y Design Pa icipan s Cha ac e is ics Spo Modali y and Le el Dep essi e Symp oms Assessmen MSK Inju y Main Resul s Appaneal, 2009 [23], USA P ospec i e Coho S udy 164 s uden -a hle es (108 men), mean age 19.7 ± 2.0 46% oo ball, 17% baske ball, 15% socce , 9% olleyball, 6% baseball, 4% gymnas ics, 3% ack and ield, and 1% w es ling 71% s a e s a hle es and 85% collegia e le el CES-D and POMS Join s (ligamen and disloca ions), muscle, bone ( ac u es), head (concussions) and neck (ce ical spine), low back (disc) A hle es wi h inju ies had highe dep ession a es han hose wi hou inju ies a e one week and emained ele a ed o up o one mon h. Women had g ea e dep ession symp om se e i y han men. Men had mo e se e e inju ies han women. Figu e 1. PRISMA lowcha . Table 1. Cha ac e is ics o included s udies. Fi s Au ho , Yea , Coun y Design Pa icipan s Cha ac e is ics Spo Modali y and Le el Dep essi e Symp oms Assessmen MSK Inju y Main Resul s Appaneal, 2009 [23], USA P ospec i e Coho S udy 164 s uden -a hle es (108 men), mean age 19.7 ±2.0 46% oo ball, 17% baske ball, 15% socce , 9% olleyball, 6% baseball, 4% gymnas ics, 3% ack and ield, and 1% w es ling 71% s a e s a hle es and 85% collegia e le el CES-D and POMS Join s (ligamen and disloca ions), muscle, bone ( ac u es), head (concussions) and neck (ce ical spine), low back (disc) A hle es wi h inju ies had highe dep ession a es han hose wi hou inju ies a e one week and emained ele a ed o up o one mon h. Women had g ea e dep ession symp om se e i y han men. Men had mo e se e e inju ies han women. Belz, 2018 [24], Ge many C oss-sec ion design 154 compe i i e a hle es (49% men), mean age 18.7 ±5.0 No in o ma ion PHQ-2 Back pain Risk o dep ession was a signi ican p edic o o disabili y among a hle es wi h back pain. La allée, 1996 [25], Canada C oss-sec ion design 55 a hle es, only men, mean age 22 42 oo ball, 13 ugby POMS Did no speci y Among ugby a hle es, dep ession/dejec ion was ela ed o inju y equency. In . J. En i on. Res. Public Heal h 2023,20, 6130 5 o 10 Table 1. Con . Fi s Au ho , Yea , Coun y Design Pa icipan s Cha ac e is ics Spo Modali y and Le el Dep essi e Symp oms Assessmen MSK Inju y Main Resul s Li, 2017 [26], USA P ospec i e Coho S udy 958 Collegia e a hle es (65.9% men), aged be ween 18 and 22 Male a hle es (i.e., baseball, baske ball, oo ball, and w es ling) Female a hle es (i.e., baske ball, ield hockey, so ball, oo ball, and olleyball) 20-i em CES-D Sp ain (49.1%), s ain (13.1%), ac u e (9.5%), concussion (9.0%) The p e alence o dep ession a he p eseason was 21.7%. The inju y isk did no inc ease among emale a hle es no in male a hle es who epo ed p eseason dep essi e symp oms bu no in he p esence o anxie y symp oms. Anxie y combined wi h dep essi e symp oms inc eased he isk o inju y in men. San-An olin, 2020 [27], Spain Seconda y Case-Con ol 50 a hle es (25 case g oup, 25 con ol g oup), 27 men, mean age 41 ±11.7, case g oup and 38 ± 11.8 con ol g oup Foo ball, a hle ics, unning, i ness, and paddle. BDI-II Myo ascial pain (n = 25), heal hy a hle es (n = 25) G ea e dep ession symp oms in a hle es wi h gas ocnemius myo ascial pain e sus heal hy a hle es. Smi h, 1993 [28], USA P ospec i e Coho S udy 276 a hle es (238 men), no age in o ma ion Hockey, baske ball, baseball, and olleyball eams POMS Did no speci y Signi ican inc emen s we e no ed among dep ession symp oms om p einju y o pos inju y s ages. Tomlinson, 2021 [29], USA P ospec i e obse a ional s udy 51 collegia e a hle es (22 men), mean age 20.0 ±1.4 Foo ball and c oss-coun y CES-D F ac u e Inju ed a hle es showed ewe dep essi e symp oms compa ed o non-inju ed a hle es. Yang, 2014 [30], USA P ospec i e Coho S udy 330 uni e si y a hle es (only men), no age in o ma ion Foo ball CES-D Knee inju y (22.35%) mos common egion, and sp ain mos common ype (46.3%) Dep ession was associa ed wi h a g ea e likelihood o inju y. Foo ball playe s who expe ienced dep ession a baseline we e 10% less likely o emain inju y- ee han hose who did no ha e dep essi e symp oms. Gou eba g, 2016 [31], i e coun ies in Eu ope C oss-sec ional 540 a hle es (men), mean age 26.7 ±4.4 Foo ball 54% playing in he highes leagues GHQ-12 Did no speci y P o essional oo balle s who had sus ained one o mo e se e e MSK inju ies du ing hei ca ee we e wo o nea ly ou imes mo e likely o epo symp oms o common men al diso de s han p o essional oo balle s who had no su e ed om se e e MSK inju ies. Abb e ia ion: MSK, musculoskele al; CES-D, Cen e o Epidemiologic S udies Dep ession; POMS, P o ile o Mood S a es; PHQ-2, Pa ien -Heal h- Ques ionnai e-2; BDI-II Beck Dep ession In en o y-II; GHQ-12, 12-i em Gene al Heal h Ques ionnai e. 3.3. Pa icipan s’ Cha ac e is ics The o al sample size was 2578 a hle es (men: n = 2026; women: n = 552), wi h ages anging om 18 o 27 yea s old. Only one s udy looked a olde a hle es (case g oup had a mean age o 41 and he con ol g oup had a mean age o 38) [ 27 ]. Two s udies omi ed o p o ide age in o ma ion [ 28 , 30 ]. The s udy wi h he la ges sample had 958 a hle es [ 27 ] ollowed by 540 a hle es [31]. Two s udies had 330 [30], and 276 a hle es [28], whe eas he emaining s udies had less han 200 pa icipan s [23–25,27,29]. 3.4. Spo Modali y and Le el The majo i y o a hle es pa icipa ed in eam spo s, p ima ily Ame ican oo ball, ollowed by baske ball, oo ball, olleyball, baseball, hockey, ugby, so ball, and ield hockey, wi h a mino i y pa icipa ing in indi idual spo s such as gymnas ics, ack and ield, w es ling, a hle ics, unning, i ness, and paddle. In e ms o spo expe ience, only In . J. En i on. Res. Public Heal h 2023,20, 6130 6 o 10 wo s udies dis inguished playe expe ience [ 23 , 31 ]. In he s udies om Appaneal e al. [ 23 ] 71% we e s a e s a hle es and 85% we e collegia e a hle es. And in he Gou eba ge e al. s udy [ 31 ], 53.5% o oo ball playe s belonged o he highes le el ( op league). No in o ma ion ega ding he pa icipan s ´ le els o spo s pe o mance was men ioned in he emaining s udies. 3.5. Dep essi e Symp oms Assessmen Di e en ins umen s we e used o assess dep essi e symp oms, wi h he Cen e o Epidemiologic S udies Dep ession Scale (CES-D) being he mos commonly used (used in ou s udies) [ 23 , 26 , 29 , 30 ]. The P o ile o Mood S a es (POMS) was used in h ee s ud- ies [23,25,28] . One s udy used he Pa ien -Heal h-Ques ionnai e-2 (PHQ-2) [ 24 ], ano he s udy used he Beck Dep ession In en o y-II (BDI-II) [ 27 ], and he o he s udy used he 12-i em Gene al Heal h Ques ionnai e (GHQ-12) [31]. 3.6. Musculoskele al Inju ies The majo i y o s udies lacked cla i y in desc ibing he ype o inju y sus ained by he a hle e in e ms o MSK inju ies. None heless, all s udies ag eed on he de ini ion o inju y as “Physical auma ha esul ed in es ic ed (no) pa icipa ion o a minimum o one week”. Th ee s udies did no de ine he ype o MSK inju y [ 25 , 28 , 31 ]; one only looked a myo ascial pain [ 27 ], while he o he only looked a ac u es [ 29 ], and ano he s udy in es iga ed back pain [ 24 ] One s udy highligh ed he mos common egion o inju y (knee) and he mos common ype (sp ain) [ 30 ]. Sp ain inju y was he mos p e alen ype o MSK inju y in one s udy [ 26 ], whe eas ano he s udy displayed bo h he loca ion and ype o he a hle es’ inju ies, and as he ollowing: join s (ligamen and disloca ions), muscle, bone ( ac u es), neck (ce ical spine), and low back (disc) [ 23 ]. One s udy looks only o ac u es [29]. 3.7. Main Resul s Two s udies concluded ha MSK inju y inc eases dep ession symp oms [ 23 , 28 ]. In con as , one s udy [ 29 ] concluded ha inju ed a hle es showed ewe dep essi e symp oms compa ed o non-inju ed a hle es. Two s udies analyzed i dep essi e symp oms inc eased he isk o MSK inju y, and concluded ha dep essi e symp oms a e isk ac o s o inju y [ 25 , 30 ]. I is impo an o highligh ha , in one s udy, he isk o inju y in men a hle es only inc eases when dep ession is combined wi h anxie y [ 26 ]. Fu he mo e, one s udy poin ed ou he p e alence o 21.7% o dep ession among inju ed a hle es [ 26 ] and one s udy ound ha women had mo e dep essi e symp oms han males, al hough men had mo e se ious inju ies [ 32 ]. Th ee c oss-sec ional s udies analyzed di e en pe spec i es conce ning dep ession and inju ies [ 24 , 25 , 31 ]. One s udy ound ha he isk o dep ession was a signi ican p edic o o disabili y among a hle es wi h back pain [ 24 ], while ano he ound ha dep ession is ela ed o inju y equency [ 25 ], and Gou eba ge e al. [ 31 ] epo ed ha a hle es wi h pe sis en se e e MSK inju ies du ing hei spo s ca ee we e up o ou imes mo e likely o epo symp oms o common men al diso de s han hose who had no su e ed om se e e MSK inju ies. The au ho ’s indings we e suppo ed by a la ge sample in a c oss-sec ional s udy. In he case-con ol s udy, a hle es wi h MSK inju y had g ea e dep ession symp oms compa ed wi h a hle es wi hou MSK inju y [ 27 ], co obo a ing he e idence ga he ed in he coho and c oss-sec ional s udies. 3.8. S udies Quali y Assessmen The me hodological quali y based on NOS is summa ized in Tables 2–4. The NOS anged om 0 o 7 poin s, wi h a median o 4 poin s. O he i e coho s udies, h ee we e conside ed o be high-quali y [ 24 , 27 , 31 ] and wo we e conside ed low-quali y in es- iga ions [ 28 , 29 ]. The case-con ol s udy was conside ed high-quali y [ 27 ] and he h ee c oss-sec ional s udies we e conside ed o be low-quali y s udies [ 24 , 25 , 31 ]. Cohen’s kappa In . J. En i on. Res. Public Heal h 2023,20, 6130 7 o 10 o he s eng h o ag eemen be ween e iewe s conce ning s udy quali y was k = 0.62 showing subs an ial ag eemen . Table 2. The me hodological quali y o coho s udies. S udy Selec ion Compa abili y Exposu e To al Sco e 1 2 3 4 5 6 7 8 9 Appaneal e al., 2009 [23] + + + + + −+− − 6 Li e al., 2017 [26] + + −+ + + −+−6 Smi h e al., 1993 [28] + + −+−−−−− 3 Tomlinson e al., 2021 [ 29 ] −+−+−−−−− 2 Yang e al., 2014 [30] + + −+ + + −+ + 7 Newcas le-O awa quali y assessmen scale: Legend: +, sco e ul illed; − , sco e no ul illed/ oo li le in o ma ion; 1, ep esen a i eness o he exposed coho ; 2, selec ion o he non-exposed coho ; 3, asce ainmen o exposu e; 4, he demons a ion ha ou come o in e es was no p esen a he s a o he s udy; 5 and 6 compa abili ies o coho s based on he design o analysis; 7, assessmen o ou come; 8, was ollow-up long enough o ou comes o occu ; 9, adequacy o ollow-up o coho s. Table 3. The me hodological quali y o he case-con ol s udy. S udy Selec ion Compa abili y Exposu e To al Sco e 1 234567 8 9 San-An olin e al., 2020 [ 28 ] −+++++−+−6 Newcas le-O awa quali y assessmen scale: Legend: +, sco e ul illed; − , sco e no ul illed/ oo li le in o ma ion; 1, Is he case de ini ion adequa e; 2, ep esen a i e o he cases; 3, selec ion o con ols; 4, he de ini ion o con ols; 5 and 6, compa abili y o cases and con ols based on he design analysis; 7, asce ainmen o exposu e; 8, he same me hod o asce ainmen o cases and con ols; 9, non- esponse a e. Table 4. The me hodological quali y o c oss-sec ional s udies. S udy Selec ion Compa abili y Ou come To al Sco e 1 2 3 4 5 6 7 8 Belz e al., 2018 [24] + −−−+− − + 3 La allée e al., 1996 [25]−−−−−−−− 0 Gou eba ge e al., 2016 [31] + + −−−−− + 3 Newcas le-O awa quali y assessmen scale: Legend: +, sco e ul illed; − , sco e no ul illed/ oo li le in o ma ion; 1, ep esen a i e o he sample; 2, sample size; 3, non- esponden s; 4, asce ainmen o he exposu e; 5 and 6; compa abili y o subjec s in di e en ou come g oups based on design o analysis; 7, assessmen o ou come; 8, s a is ical es . 4. Discussion Spo s pa icipa ion ca ies a signi ican isk o inju y o bo h eli e and ec ea ional a hle es, as a hle es mus possess a high le el o physical (and men al) abili ies o achie e peak pe o mance [ 32 ]. The e o e, his sys ema ic e iew explo es he associa ion be ween MSK inju ies and dep essi e symp oms among a hle es. We analyzed nine s udies ha mee he inclusion c i e ia and ound a bidi ec ional associa ion be ween he in es iga ed a iables. I seems ha an MSK inju y inc eases he isk o dep essi e symp oms, ag eeing wi h o he indings [32–34]. Al hough pos inju y dep ession sco es seem o g adually dec ease owa d baseline sco es, one s udy [ 28 ] ound ha dep essi e symp oms peaked one week a e he inju y and hen declined a e one-mon h pos inju y. These esul s a e suppo ed by McDonald and Ha dy [ 34 ] who disco e ed inc eased le els o dep essi e symp oms one week a e he inju y and a dec ease o e ime. Su p isingly, Tomlinson e al. [ 29 ] ound ha inju ed a hle es exhibi ed ewe dep essi e symp oms han non-inju ed a hle es, howe e , he educed sample and i s me hodological low quali y migh nega i ely bias hese esul s. Despi e hese con o e sial indings, i is impo an o no ice he mechanisms behind MSK inju ies and he associa ed dep essi e symp oms. One explana ion could be he In . J. En i on. Res. Public Heal h 2023,20, 6130 8 o 10 ela ion be ween he inju y eco e y imeline (which p e en s a hle e pa icipa ion in aining/compe i ions) and he eeling o iden i y loss o ange caused by an inju y [ 35 ], which leads o inc eased dep essi e symp oms [30,35]. The s udy om Belz e al. [ 24 ] explo ed he associa ion be ween MSK inju y and pain. The in es iga ion indings showed back pain is associa ed wi h s ess and dep ession in compe i i e a hle es, bu no signi ican di e ences we e ound ega ding sex. I is impo an o highligh ha MSK inju y may lead a hle es o inc ease pain s a us, and pain is an impo an p edic o o dep essi e symp oms [ 36 ], howe e , dep ession i sel is a isk ac o o di e en ypes o MSK pain [ 37 , 38 ]. Also, h ee s udies [ 25 , 26 , 30 ] ound ha dep essi e symp oms inc eased he isk o MSK inju y. O e all, expe iencing dep essi e symp oms could lead o physiological and a en ion- ela ed changes, such as heigh ened muscle ension and dis ac ibili y, which may inc ease he isk o an MSK inju y [ 39 ]. Ano he a gumen is ha ailu e in decision-making o isk managemen , caused by insu icien assessmen o po en ial isk, may inc ease he isk o inju ies [ 40 ]. One included s udy [ 30 ] also conside ed he p e ious inju y as a s ong isk ac o o subsequen inju y. Li e al. [ 26 ] ound ha dep essi e symp oms a e only a isk ac o o inju y in men when pai ed wi h anxie y. Despi e he ac ha one s udy [ 23 ] ound ha women exhibi ed g ea e dep essi e symp oms han men, Belz e al. [ 24 ] and Li e al. [ 26 ] ound no gende di e ences in he isk o dep ession among inju ed a hle es. No wi hs anding he con o e sial esul s, hese indings we e expec ed since he li e a u e poin ed ou ha dep essi e symp oms a e highe among women in he gene al popula ion [ 41 ], and speci ically among a hle es [ 14 ]. Only one s udy assessed he p e alence o dep essi e symp oms among collegia e a hle es, being 21.7% [ 26 ], lowe han was ound in o he s udies [13,14]. Despi e some in iguing indings, he cu en s udy had some limi a ions ha mus be add essed. Fi s , he s udies included in ou analysis in ol ed a a ie y o spo s and MSK inju ies ( ype and loca ion), he eby hinde ing ou abili y o pe o m analyses based on speci ic spo s o ypes/loca ions o inju ies. Mo eo e , mos s udies include a sample o young a hle es, so mo e esea ch wi h senio a hle es is needed o explo e he associa ion be ween MSK inju ies and dep essi e symp oms in mo e de ail. Finally, his e iew includes i e low-quali y me hodological s udies ( h ee c oss-sec ional s udies and wo coho s udies). The e o e, high-quali y s udies and longi udinal s udies a e manda o y o u he explo e he ela ionship and he cause-e ec be ween MSK inju ies and dep ession. 5. Conclusions The indings o his e iew e i ied a bi-di ec ional associa ion be ween he p esence o MSK inju ies caused by spo s pa icipa ion and he p esence o dep essi e symp oms in a hle es. Al hough psychological s a us is o en ecognized as a con ibu o o poo pe o mance and high le els o inju y, i is a ely conside ed a ac o in inju y p e en ion. Simila ly, i is i al o acknowledge ha MSK inju ies may inc ease he isk o de elop- ing dep essi e symp oms. One p ac ical implica ion o his e iew is he awa eness o dep essi e symp oms as a isk ac o o musculoskele al inju ies, as well as he need o an a hle e o ob ain psychological assis ance ollowing an inju y. Thus, u u e s udies could explo e he cause-e ec ela ionship be ween dep essi e symp oms and MSK inju y. Au ho Con ibu ions: Concep ualiza ion, P.M., F.F., A.N. and B.M.; Li e a u e Sea ch, M.P. and J.F.L.; Da a Ex ac ion, P.M. and F.F.; Me hodological Quali y Assessmen , A.N. and A.L.S.; W i ing— o iginal d a p epa a ion, P.M., A.L.S. and A.N.; W i ing- e iew and edi ing, P.M., A.L.S., F.F., A.N., J.F.L., M.P. and B.M.; Supe ision, B.M. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch ecei ed no ex e nal unding. Ins i u ional Re iew Boa d S a emen : No applicable. In . J. En i on. Res. Public Heal h 2023,20, 6130 9 o 10 In o med Consen S a emen : No applicable. Da a A ailabili y S a emen : Please con ac he co esponding au ho o discuss he a ailabili y o he da a and ma e ials. Con lic s o In e es : The au ho s decla e no con lic o in e es . Re e ences 1. A edesian, J.M.; Fo bes, W.; Co assin, T.; Du ek, J.S. In luence o cogni i e pe o mance on musculoskele al inju y isk: A sys ema ic e iew. Am. J. Spo s Med. 2022,50, 554–562. 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