The mental toll of injury nightmares that threaten players’ World Cup dreams

It’s every athlete’s worst nightmare. The biggest sporting event of their lives — say, a FIFA World Cup in one’s home country — is on the horizon. A lifetime’s worth of work is about to be put to the ultimate test. Dreams are poised to be fulfilled, and then an injury hits.

Doubts creep in. Will I make it back? If so, what level will I be at? If not, what then?

It can leave a player staring into the abyss.

The scenario is one that several on the U.S. men’s national team have grappled with in the past six months. PSV Eindhoven defender Sergiño Dest is in a race against time to recover from a hamstring injury he suffered on March 7, although last Monday he said via the USMNT’s Instagram page, “I’m doing really well … I’m almost back.” AFC Bournemouth midfielder Tyler Adams has sustained multiple injuries, including a torn MCL, since December, although he’s back on the field now.

Then there are injuries of the devastating variety.

Derby County forward Patrick Agyemang suffered a torn Achilles tendon on April 6. His World Cup hopes, at least for this cycle, are over.

So how does one cope — and recover — from these scenarios, especially if playing in a big event like a World Cup is still a possibility? The process involves multiple challenges. There’s the obvious physical side, but for Dr. Jessica Bartley, who is the director of psychological services for the U.S. Olympic and Paralympic Committee and was previously part of U.S. Soccer’s mental health task force, the mental aspect is just as important.

“We’ve actually incorporated psychology into every injury,” Bartley said. “We have what’s called our athletes recovery program at the USOPC. And so psych is a part of all of those components. And we’re talking about athletes on timelines, and what do [they] think, and how do we put [them] in the best situation?”

The tools used include mental imagery, visualization and even virtual reality. Bartley added, “We actually are understanding that that mindset is incredibly powerful when you’re trying to recover.”

The awkward dance around injuries

The possibility of injury lingers like a shadow over every athlete — a sporting Grim Reaper, if you will — except in this case, the specter is holding a scalpel instead of a scythe. This is especially true at the professional level. Athletes essentially make a living through their bodies, spending countless hours training to make sure they are in optimal physical condition. Yet when it comes to preparing for a big event, the mind and the body remain connected.

“What’s been interesting is the number of athletes now who do what we like to call ‘prehab,'” Bartley said. “That’s the way that you can kind of get ahead of it. There’s so much preventative stuff that you can do for the body and the mind now to just put yourself in the best position.”

The odds are that an athlete will encounter an injury at some point in their career. What emerges is an awkward mental dance in which athletes try not to think about injuries, even as they go to extremes in trying to prevent them.

“[If] it’s something that you’re constantly thinking about, then it’s like destiny, right? It happens anyway,” said U.S. and Charlotte FC defender Tim Ream about injuries. “So yeah, you try not to think about it, but you also know that sometimes things happen.”

Indeed. Ream hobbled off at halftime of last weekend’s match against New York City FC with a groin injury.

There are varying levels of emotional response when an injury hits, especially as it relates to a player’s long-term prospects. When Adams injured his MCL in December, outwardly, he wasn’t the slightest bit concerned about how it might affect his chances for the World Cup.

“I knew exactly what I did as soon as it happened,” Adams told ESPN. “Typical MCL; ball hits your toe, can’t really control it. And I just figured, ‘Yeah, I’ll be back in a couple months.'”

Ricardo Pepi had a similar response. The PSV Eindhoven striker broke his arm on a freak play in which he landed awkwardly in a game against Excelsior on Jan. 10. Although there were fleeting moments when he thought about the World Cup implications, he had more immediate concerns.

“It’s going to be something that worries you a little bit,” he told ESPN as he looked back on the injury. “But in the moment, you’re just really worried about getting back on the pitch as fast as you can.”

But injuries that are longer term, or involve setbacks, have a way of affecting the mind in a way that shorter-term ailments don’t.

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When U.S. and Fulham defender Antonee Robinson underwent surgery last May to address tendon calcification in his right knee, he thought there was plenty of time to recover. He was expected to be back in time for the start of the Premier League season, but although he returned in late August, he was soon back on the bench, unable to get over the hump physically. The delay began to play on his psyche.

“There was a lot of concern, to be honest,” Robinson told reporters last month about whether he would make it back for the World Cup. “There was no sort of certainty on my end that I was going to be fit and available and make it, because it just seemed like there was kind of no light at the end of the tunnel.”

Robinson turned a corner in December and has been a consistent presence in the Fulham and USMNT lineups since. That doesn’t diminish the mental toll such an experience can have on a player.

Battling ‘the voice within your head’

Former U.S. international Stu Holden is all too familiar with the emotional roller coaster that is involved when a player sustains an injury close to a World Cup.

In March 2010, Holden was flying high. He was in the process of breaking into the first team at English side Bolton Wanderers, then in the Premier League, and had done the same with the USMNT. A significant role at that summer’s World Cup beckoned.

But in a March friendly against the Netherlands, a reckless tackle from Nigel de Jong fractured the fibula in Holden’s right leg. Holden’s immediate reaction revealed the severity of the injury and the challenge that lay ahead.

“My instant reaction, my head’s in my hands. I know my World Cup is in jeopardy at that moment,” he told ESPN. “Straightaway it’s what I’m thinking about.”

Holden was left with two options: He could let the bone heal naturally, or he could undergo surgery to have a plate inserted to expedite the recovery period. With the 2010 World Cup in South Africa quickly approaching, he opted for the latter. After the operation, Holden dove headlong into his rehab, but progress was slow. “I wasn’t myself,” he said.

He returned to the Bolton lineup before the end of the season, but that was by no means the end of his recovery. When Holden reported for the USMNT’s pre-World Cup camp in Princeton, New Jersey, he realized he still wasn’t 100%.

He had always prided himself on his fitness, and among USMNT players he was usually in what he called the “Tier 1 group” during fitness drills. That was true on the first day of camp, but he soon realized he was way behind. The next day he was demoted to Tier 2. The day after that, Tier 3. He was also continuing to experience intense pain in his leg, and the doubts that he would recover in time were very real.

“I always used to say the voice within your head, you’re battling yourself in those moments,” Holden said. “And I remember moments of, I’m doing running by myself off to the side of the field. I equated it to like, you’re at Disneyland, but you can’t go on any of the rides with your friends. You’re grinding.

“And I remember saying like, ‘F— you, don’t let this get away from yourself. This is your chance to make a World Cup. Dig deeper, push harder, don’t stop running.’ These are all the conversations you’re having with yourself, trying to motivate yourself, but it was all about the World Cup. That was everything and anything that was motivating me through those moments that were so hard and difficult. That’s the reason you’re getting out of bed every day.”

Those kinds of conversations are all too familiar to Bartley in her dealings with Olympic athletes. And trips to Negative Town, like the one Holden took, aren’t necessarily bad. It’s a case of whatever is needed in the moment.

“I will say that for the most times, [self-talk] is something really positive, but maybe you just need to tell yourself like, ‘Don’t [mess] this up. Come on,'” she said. “There are things that you can say. And so I think that’s really important to know that the self-talk needs to be really believable, that it’s going to motivate you and help really kind of push you through.”

Self-talk is just one tool that can be used to get into a good headspace. Athletes also can use affirmations, the support system around them, or routines to achieve that aim. These days, finding that self-belief is made more difficult when video of an athlete’s injury can be posted on YouTube or social media within minutes. Bartley said that seeing those videos and reliving these episodes can be traumatizing for athletes.

“When we have all these images that we’re inundated with, we’re often having to reason through, ‘Look, that’s not going to happen,’ or ‘We’re doing this and we’re doing all of this rehab. And honestly, the results actually look like you’re going to come back stronger. It’s going to be nearly impossible that you have the same injury if you do X, Y, and Z.’ A lot of times, how I think of it is you’re having to use science to kind of combat all of those fears.”

Triumph, and then disappointment

Holden eventually reached a tipping point in his bid to make the 2010 World Cup squad. He started a pre-World Cup friendly against Czechia, and his two set piece deliveries led to both U.S. goals in a 4-2 loss. Even after that match, he felt his chances of making the roster were “50-50.” But then-manager Bob Bradley saw enough to bring Holden to South Africa. He even made an appearance at the World Cup, coming on as a late substitute against England.

As much as Holden’s ability got him on the team, though, it was also his mental strength that pushed that World Cup door open. The voice in his head provided the springboard that he needed to recover.

“Talent gets you so far. The mentality at the top is what separates the best from the very best. It’s this ability to ride through challenging moments to have this incredible, unwavering self-belief,” Holden said. “I believed in myself during that time. As much as I was like, ‘Oh, I don’t know, man,’ I knew I belonged. It was just that I had to continue to prove that through my soccer, I think to myself, again, of a reminder of like, ‘Is my body letting me down or am I there?’ And I think that was probably what I was going through at that training camp.”

Holden wasn’t so fortunate during the 2014 cycle. In a reserve match against Everton in March, Holden retore the same ACL that he injured the previous year.

Then-manager Jürgen Klinsmann reached out to Holden after. “[Klinsmann] was so important; to give me hope,” Holden said. “He called me after and just said, ‘I’m so sorry.'”

History has shown that no team heading to the World Cup will be 100% healthy. That goes for the U.S. as well.

In 2002, midfielder Chris Armas was unable to recover in time from a torn ACL to make the squad. Four years later, a knee injury felled defender Cory Gibbs after he had been named to the team. In 2022, it was a lingering hamstring injury that ruled out defender Chris Richards.

But there are triumphs, too. Oguchi Onyewu recovered from a knee injury in 2010, and Weston McKennie did the same from a quad injury in 2022. So it goes. As the 2026 tournament approaches, the members of the USMNT will be hoping to avoid the injury nightmare and achieve their long-held dreams.