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 .
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