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J Am Acad Orthop Surg Glob Res Rev
J Am Acad Orthop Surg Glob Res Rev
JAAOS Glob Res Rev
JAAOS Glob Res Rev
JAAOS Global Research & Reviews
2474-7661
Wolters Kluwer Philadelphia, PA

39284016
JAAOSGlobal-D-24-00195
10.5435/JAAOSGlobal-D-24-00195
00005
3
008
Research Article
Athletic Identity Associations in Young Sports Medicine Patients
https://orcid.org/0000-0002-5003-7632
Christino Melissa A. MD
Coene Ryan P. MS rcoene18@gmail.com

Williams Kathryn A. MS Kathryn.Williams@childrens.harvard.edu

Daley Mary MD mdaley521@gmail.com

Ackerman Kathryn E. MD, MPH kathryn.ackerman@childrens.harvard.edu

Stracciolini Andrea MD andrea.stracciolini@childrens.harvard.edu

Kramer Dennis E. MD dennis.kramer@childrens.harvard.edu

From the Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA (Mr. Christino, Mr. Coene, Dr. Ackerman, Dr. Stracciolini, and Dr. Kramer); the Harvard Medical School, Boston, MA (Dr. Christino, Dr. Ackerman, Dr. Stracciolini, and Dr. Kramer); the Biostatistics and Research Design Center, ICCTR, Boston Children's Hospital, Boston, MA (Ms. Williams); and the Children's Hospital of Philadelphia, Philadelphia, PA (Dr. Daley).
Correspondence to Dr. Christino: melissa.christino@childrens.harvard.edu
9 2024
16 9 2024
8 9 e24.0019530 5 2024
06 6 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.
2024
American Academy of Orthopaedic Surgeons
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Introduction:

Few studies have assessed athletic identity levels in young patients. This study examined athletic identity in adolescents and explored associations between athletic identity, patterns of sport participation, and coping skills.

Methods:

Patients aged 12 to 18 years who received sports medicine care completed a one-time, voluntary, anonymous survey. Surveys included demographics, sport participation information, Athletic Identity Measurement Scale (AIMS), and Athletic Coping Skills Inventory (ACSI). Statistical analysis included Fisher exact test, Student t test, Wilcoxon rank sum test, Kruskal-Wallis test, and Pearson correlation.

Results:

Three hundred thirty-four patients (mean ± SD age 15.0 ± 1.8 years, 64.7% girls) completed questionnaires. The mean AIMS and ACSI scores were 45.2 ± 11.5 and 50.2 ± 10.9, respectively. No notable differences were observed in AIMS scores between age groups or sexes. An increase in mean AIMS scores (higher athletic identity) was seen with greater weekly hours of sport participation (P < 0.001) and months per year of primary sport participation (P < 0.001). Multisport per season athletes had higher AIMS scores than single-sport athletes (48.2 ± 10.1 vs. 43.0 ± 11.9, P < 0.001). Team sport athletes reported higher athletic identities than individual sport athletes (47.0 ± 10.7, 41.4 ± 11.4, P < 0.001). Athletic Identity Measurement Scale scores positively correlated with ACSI scores (r = 0.31, P < 0.0001). Athletes with the highest athletic identity had markedly higher scores on ACSI subscales of Coachability, Concentration, Confidence and Achievement Motivation, Goal Setting and Mental Preparation, and Peaking Under Pressure than athletes with the least athletic identity. However, those with the highest athletic identities reported significantly lower scores on the ACSI Freedom From Worry subscale (P < 0.001).

Discussion:

Athletic identity did not differ among adolescents by age or sex. Athletic identity was higher in team sport athletes and those with increased sport participation volumes. While high athletic identity was associated with higher scores on favorable coping skill dimensions, these athletes may also worry more, potentially placing them at greater psychological risk after injury.

OPEN-ACCESSTRUE
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pmcYouth and adolescent sport participation continues to rise,1 creating increased competition within the youth sport environment. Many young athletes are specializing in sports at earlier ages and may participate in multiple sports simultaneously.2345 Sports participation can be a defining activity for children and adolescents, yielding many psychological and physical benefits including increased self-confidence and self-esteem, learning to be part of a team, and establishing a healthy relationship with exercise and fitness, all of which have positive real-life implications beyond the athletic arena.6-8

Athletic identity is defined as the degree to which one identifies as an athlete or the extent to which one devotes specific attention to sports over other engagements or activities.9,10 Britton Brewer suggested that athletic identity has both cognitive and social functions, originating from self-connection and responses from others, including teammates, coaches, and parents.9 Studies have demonstrated that higher athletic identity has positive effects on athletic performance11 and that athletic identity is positively correlated with motivation, goal setting, and commitment to training in sports.12 However, higher levels of athletic identity have also been linked to increased gender role conflict and decreased tendencies to seek out help.13 In addition, for those with high athletic identities whose self-worth is derived primarily from sport participation, the negative effect of loss of sport involvement after an injury may result in notable emotional disturbances.14

While the concept of athletic identity is important, there is a scarcity of studies on this topic in exclusively pediatric and adolescent populations in the United States. The purpose of this study was to examine levels of athletic identity in young patients and to explore associations between the degree to which one identifies as an athlete and patterns of sport participation and coping skills. We hypothesized that levels of athletic identity would be higher in those who spend more time participating in sports but are unlikely to differ between different ages or sexes. We also hypothesized that coping skills may be higher in those with stronger athletic identities.

Methods

Study Design

This study was designed as a cross-sectional survey study at a single academic tertiary care pediatric hospital over a 3-month period. Institutional review board approval was obtained, and participation consisted of a one-time, voluntary, anonymous survey for all patients, aged 12 to 18 years, who received care at sports medicine clinics during the defined study period. A cover page described the study, the survey, and contact information for the research staff and was given to the guardian or 18-year-old patient. Implicit consent to participate in the study was obtained if patients and their guardians elected to complete the survey. Assistance from parents was encouraged for minors filling out the survey. Non-English–speaking/reading patients were excluded from the study because resources were not available for adequate survey translation.

Survey Details

The survey was designed to evaluate patient demographics, injury characteristics, sport participation patterns, and validated measures to assess athletic identity, sport specialization, and coping skills (Appendix A—Supplemental Data File, http://links.lww.com/JG9/A359). Patients were divided into early (ages 12 to 14 years) and later adolescent (ages 15 to 18 years) categories for data analysis. An institutionally designed portion of the survey was administered to assess basic patient demographics, injury characteristics, and sport participation patterns. Injury characteristics were assessed by asking about the presence/absence of injury, chronicity of symptoms, and whether surgery had been performed for the injury. Sport participation patterns were assessed with questions asking about primary sport participation, other sport participation, participating in multiple sports per season, number of hours per week and number of months per year spent in sport participation. A primary sport was defined as a sport in which an athlete spends most of their time. Primary sports were categorized as individual or team sports for data analysis, as presented in Table 1.

Table 1 Primary Sport Categorization for Individual and Team Sports

Individual Sports	Team Sports	
Cycling	Baseball	
Dance	Basketball	
Figure Skating	Cheerleading	
Gymnastics	Football	
Racquet ball	Field Hockey	
Running	Hockey	
Skiing	Lacrosse	
Snowboarding	Rugby	
Swimming	Soccer	
Wrestling	Volleyball	

Athletic identity was assessed using the Athletic Identity Measurement Scale (AIMS), which is a validated patient-reported survey instrument.15 This is a 10-item scale, where scores range from 10 to 70, with higher scores indicating higher levels of athletic identity. The Athletic Coping Skills Inventory (ACSI) is a validated 28-item scale, scored from 0 to 84, with higher scores indicating greater coping ability.16,17 There are seven different subscales assessed which include Coping with Adversity, Coachability, Concentration, Confidence and Achievement Motivation, Goal Setting and Mental Preparation, Peaking Under Pressure, and Freedom From Worry.

Statistical Analysis

Categorical variables were compared using Fisher exact test and are presented as counts with associated percentages. Continuous variables were presented as means ± SDs, and comparisons were done using Student t test, Wilcoxon rank sum test, Kruskal-Wallis test, and Pearson correlation. All tests were two-sided, and a P-value <0.05 was considered statistically significant. SAS (version 9.4, SAS Institute) software was used.

Results

A total of 334 of 430 eligible patients completed the surveys, representing a 78% response rate. The mean age of respondents was 15.0 ± 1.8 years, and a majority identified as female (64.7%). Table 2 depicts patient demographics, injury characteristics, and sport participation patterns. The large majority (94.3%, n = 314/333) of patients seeking sports medicine care reported participation in sports or performance arts, and the average number of sports played was 2.1 ± 1.3. Nearly all athletes (95.2%, n = 299/314) designated a primary sport and reported playing their primary sport an average of 8.7 ± 3.2 months per year. The top three primary sports were soccer (19.1%, n = 57), basketball (13.0%, n = 39), and baseball/softball (12%, n = 36). Nearly 74% (n = 220/299) of respondents reported participating in team sports compared with individual sports. In addition, 44.3% (n = 136/307) of athletes reported playing multiple sports per season. Most of the athletes sought medical care because an injury (91.8%), and 59.3% reported chronic symptoms. Additional sport participation and injury characteristics are listed in Table 2.

Table 2 Patient Demographics, Sport Participation Patterns, and Injury Characteristics

Characteristic	N = 334
N (%) or mean (SD) range	
Demographics	
 Sex		
  Boy	118 (35.3)	
  Girl	216 (64.7)	
 Race/ethnicity		
  Hispanic/Latino	20 (6.0)	
  White only (non-Hispanic)	273 (81.7)	
  Black only (non-Hispanic)	15 (4.5)	
  Asian only (non-Hispanic)	6 (1.8)	
  Other (non-Hispanic, multiracial, AIAN, etc.)	17 (5.1)	
  Not reported	3 (0.9)	
 Age (yr)	15.0 (1.8) 12.0-18.0	
 Age groups		
  12-14	129 (38.6)	
  15-18	205 (61.4)	
Sport participation patterns	
 Participate in sports or performance arts, n = 333	314 (94.3)	
 Average number of sports played	2.1 (1.3)	
 Participate in a primary sport, n = 314	299 (95.2)	
 Participate in multiple sports in a season, n = 307	136 (44.3)	
 Age started primary sport, n = 298	7.2 (3.7) 1.0-16.0	
 Type of sporta (n = 299)		
  Individual	79 (26.4)	
  Team	220 (73.6)	
  Months per year playing primary sport (n = 297)	8.7 (3.2) 2.0-12.0	
Injury characteristics	
 Reason for visit: injury (n = 305)	280 (91.8)	
 Duration of symptoms (n = 275)		
  Acute		
   Less than 1 mo	48 (17.5)	
   1–3 mo	64 (23.3)	
  Chronic		
   4–6 mo	40 (14.6)	
   More than 6 mo	123 (44.7)	
 Past surgery for injury (n = 278)	84 (30.2)	
 Missed sports due to injury in past (n = 277)	256 (92.4)	
AIAN = American Indian and Alaska Native.

a See Table 1 for categorization of team versus individual sports.

Athletic Identity

The mean AIMS score was 45.2 ± 11.5. Table 3 provides AIMS score comparisons. No differences were observed in AIMS scores among different age groups, sexes, or race/ethnicities. Athletes who presented to the sports medicine clinic for an injury had higher mean AIMS scores compared with those whose chief complaint was not an injury, but there were no notable differences in athletic identity based on symptom duration or whether surgical intervention had been performed. Increased AIMS scores were seen in those with greater weekly hours of sport participation (P < 0.001) and more months per year of primary sport participation (P < 0.001) (Table 3). Athletic Identity Measurement Scale scores were also higher in athletes who played multiple sports per season, compared with those who played one sport per season (48.2 ± 10.1 vs. 43.0 ± 11.9, P < 0.001). Finally, team sport athletes reported significantly higher athletic identities than individual sport athletes (47.0 ± 10.7, 41.4 ± 11.4, P < 0.001).

Table 3 Association of AIMS Score With Patient Characteristics, Injury Characteristics, and Sport Participation Patterns

Characteristic	AIMS Score Mean (SD) range	P Valuea	
Sex		0.447	
 Boy	46.0 (11.9) 17.0-70.0	
 Girl	44.8 (11.3) 10.0-66.0	
Race/ethnicity		0.454	
 Hispanic/Latino	44.5 (15.1) 19.0-70.0	
 White only (non-Hispanic)	45.4 (11.0) 10.0-70.0	
 Black only (non-Hispanic)	40.4 (14.4) 20.0-70.0	
 Asian only (non-Hispanic)	40.6 (16.9) 13.0-58.0	
 Other (non-Hispanic, multiracial, AIAN, etc)	49.6 (10.8) 29.0-67.0	
 Not reported n = 1	50.0 ( ) 50.0-50.0	
Age groups		0.839	
 12-14	45.1 (11.9) 10.0-70.0	
 15-18	45.3 (11.3) 16.0-70.0	
Reason for visit		0.015	
 Injury	46.0 (11.1) 13.0-70.0	
 No injury	39.2 (12.3) 10.0-57.0	
Missed playing sports due to the injury n = 277		0.121	
 No	41.9 (13.0) 16.0-63.0	
 Yes	46.4 (11.0) 13.0-70.0	
Surgery for this injury in the past		0.940	
 No	46.1 (11.1) 13.0-70.0	
 Yes	45.9 (11.4) 16.0-67.0	
Type of primary sport		<0.001	
 Individual	41.4 (11.4) 13.0-62.0	
 Team	47.0 (10.7) 18.0-70.0	
No. of primary sport months per year		<0.001	
 2-7	42.5 (11.8) 17.0-70.0	
 8-11	45.0 (10.2) 13.0-65.0	
 12	49.0 (10.3) 22.0-70.0	
Participate in multiple sports in a season		<0.001	
 No	43.0 (11.9) 10.0-70.0	
 Yes	48.2 (10.1) 18.0-70.0	
Sports hours per week (school year)		<0.001	
 Less than 1 h	33.6 (15.6) 13.0-64.0	
 1-5 h	40.3 (14.2) 10.0-70.0	
 6-10 h	44.4 (10.7) 19.0-66.0	
 11-15 h	45.9 (10.7) 17.0-70.0	
 16-20 h	47.8 (9.3) 30.0-64.0	
 More than 20 h	54.1 (9.4) 31.0-70.0	
Sports hours per week (summer)		0.003	
 Less than 1 h	35.6 (17.1) 10.0-64.0	
 1-5 h	43.5 (11.8) 18.0-67.0	
 6-10 h	46.8 (9.9) 22.0-70.0	
 11-15 h	45.6 (9.9) 17.0-64.0	
 16-20 h	51.2 (8.1) 32.0-64.0	
 More than 20 h	49.3 (10.3) 33.0-70.0	
AIMS = Athletic Identity Measurement Scale, AIAN = American Indian and Alaska Native.

a Comparisons based on Wilcoxon rank sum and Kruskal-Wallis test.

Coping Skills

The mean ACSI score was 50.2 ± 10.9, and AIMS scores positively correlated with ACSI scores (r = 0.31, P < 0.001). Furthermore, when athletes with the highest athletic identity were compared with those with the least (top versus bottom quartiles), athletes with the highest athletic identities had significantly higher scores on ACSI subscales of Coachability (P = 0.034), Concentration (P < 0.001), Confidence and Achievement Motivation (P < 0.001), Goal Setting and Mental Preparation (P < 0.001), and Peaking Under Pressure (P < 0.001) (Table 4). However, those with the highest athletic identities reported significantly lower scores on the ACSI Freedom From Worry subscale (P = 0.001).

Table 4 Association of ACSI Total Score, Subscale Scores, and Highest and Lowest AIMS Scores

ACSI	Highest Athletic Identity (Top 25% AIMS 54-70) mean (SD) Rangea n = 67	Lowest Athletic Identity (Bottom 25% AIMS 10-38) mean (SD) range n = 72	P Valueb	
Total score	55.1 (8.6) 38.0-75.0	46.9 (11.1) 18.0-78.0	<0.001	
Coping with Adversity	7.0 (2.3) 2-12	6.6 (2.6) 0-12	0.390	
Coachability	10.4 (1.9) 6-12	9.8 (1.9) 5-12	0.037	
Concentration	8.3 (1.8) 5-12	6.9 (2.3) 0-12	<0.001	
Confidence and Achievement Motivation	9.5 (1.8) 4-12	7.3 (2.1) 0-11	<0.001	
Goal Setting and Mental Preparation	6.9 (2.8) 1-12	4.5 (2.8) 0-12	<0.001	
Peaking Under Pressure	7.6 (2.8) 2-12	4.8 (2.8) 0-12	<0.001	
Freedom From Worry	5.4 (2.7) 0-12	7.1 (3.2) 0-12	<0.001	
ACSI = Athletic Coping Skills Inventory, AIMS = Athletic Identity Measurement Scale.

a Range for the subscales is generally 0 to 12.

b Based on Student t test or Wilcoxon rank sum test to address non-normal distribution for Coachability.

Discussion

This study sought to explore levels of athletic identity in adolescent athletes. The main findings of the study were that athletic identity in young athletes did not differ between age groups, sexes, or races/ethnicities. Athletic identity was higher in team sport athletes, those who played multiple sports per season, and those who spent a greater amount of time playing sports. We also found a positive association between athletic identity and coping skills.

To our knowledge, this is one of the largest studies that investigates athletic identity characteristics in adolescents in the United States using the AIMS, as developed by Brewer and colleagues.15,18 Although the topic of athletic identity has been largely understudied in young patients, some larger population studies on pediatric/adolescent patients have been conducted by Anderson et al,19 using the Athletic Identity Questionnaire for Adolescents, a separate athletic identity assessment less targeted to athletes and more geared toward the general population.19,20 One of these studies found athletic identity to be associated with moderate-to-vigorous physical activity and organized sports team participation in school-age children. Our study is in line with these findings because we found hours per week and months per year of sport participation were positively associated with higher athletic identity. It is intuitive that those for whom sports holds a central level of importance would participate in more sports, but the question remains as to whether identification as an athlete drives increased levels of sport participation or whether experience in sports drives the evolution of athletic identity. Most likely, it is a combination of both, with bidirectional compounding relationships, but this deserves additional study.

Some key findings in this study were that levels of athletic identity did not differ markedly by age, sex, or racial or ethnic distinction. This is important because it speaks to the potential universality of the concept of athletic identity. Athletes come in all shapes, sizes, demographics, and abilities, and the lack of observable differences among patient categories suggests a commonality of experience for young athletes. Other smaller studies have reported similar results. For example, in a study of 24 patients with anterior cruciate ligament (ACL) injuries assessed with the AIMS, no differences were detected in athletic identity between patients of different ages or sexes.21 Piatt et al22 also found no notable differences in athletic identity among different sexes or academic levels. This study was conducted in 47 adolescents with mobility impairments who participated in Paralympic sports and described AIMS scores with similar ranges to our population. This is additional evidence that athletic identity is a concept that transcends athletic ability. Conversely, one larger study by Anderson et al20 did show differences in athletic identity among different ethnicities and sexes. This study showed that non-Hispanic White children reported higher levels of athletic identity using the Athletic Identity Questionnaire, participated in more sports, and were less overweight. However, there is a question as to whether this result was more reflective of disparity in sport access for different races and ethnicities within the study population, rather than a true athletic identity difference.

The concept of athletic identity is particularly interesting in adolescent patients because adolescence is generally accepted as a key time for identity formation. One study suggested that athletic identity in athletes markedly increases from late childhood into adolescence and then plateaus, staying elevated into young adulthood if sport participation continues.23 How much of one's overall self-worth is derived from their athletic identity varies by individual and can have important implications.15 Strong athletic identity has been associated with many positive sport performance metrics including commitment to training, goals, and persistence.12 High athletic identity in National Collegiate Athletic Association athletes has been linked to greater career exploration and engagement.24 In adolescent patients with ACL injury, strong athletic identity and desire to return to sport are important factors driving adherence to postoperative rehabilitation.25 These examples highlight some of the positive adaptations of high athletic identity. In our study, those with the highest levels of athletic identity (top 25%) reported overall higher coping skills than those with the lowest (bottom 25%) athletic identities, including higher scores on most coping skill subscales. It is possible that the qualities of persistence and motivation in sports associated with athletic identity confer some advantages in coping strategies that carry over into nonathletic life endeavors.

Having a high athletic identity can also have some disadvantages, however. Our study results also raise a potential concern for maladaptive responses to injury because those with the highest identity scored markedly lower on the Freedom From Worry subscale of the ACSI compared with those with lower athletic identity. This was the only subscale on which they scored lower, and this implies that high athletic identity athletes may worry more and be more psychologically at risk after injury, if their athletic identity is threatened. High athletic identity has been linked to pathologic overconformity to the athlete role, lower likelihood of seeking help, and gender role conflict.13,26 In addition, for the athlete who sports are supremely tied to their identity, loss of sport participation through injury, illness, or retirement can be devastating.10,15,27,28 Injury is the most common reason for unanticipated, abrupt cessation of sport participation in young athletes. In a longitudinal study of 48 injured adolescent athletes, Manuel et al29 found that those with higher athletic identity and exclusivity scores had higher levels of early depressive symptoms after injury. In addition, Brewer et al found a decline in levels of athletic identity in the 6 months after ACL surgery, suggesting a self-protection mechanism for the psyche, whereby an athlete may distance themselves from their identity as an athlete to better cope with the possibility of being unsuccessful upon returning to sport after injury.30

There are known limitations to a cross-sectional survey study. First, responses were self-reported and may be subject to self-report or recall bias. In addition, responses represented a single point in time, and we do not have longitudinal data to assess how athletic identity or coping skills may change over time for individuals. This will be the subject of additional studies. Our sample size was fairly large compared with other studies on athletic identity; however, included participants were from a single tertiary-level academic medical center (81.7% non-Hispanic White participants), and this may limit the generalizability of our findings. For better trend analysis, we also categorized age (early versus late adolescence) and sport type (individual versus team sport), and these categories were determined by the study staff and have not been validated or used in previous studies to our knowledge. This may also limit the strength of the findings. Our study population represents athletes seeking care over a 3-month period in this academic center, which may be subject to seasonal variation or access-to-care bias. In addition, there may be more important subtle differences in athletic identity that we were underpowered to detect, and additional study in larger patient populations is warranted.

In conclusion, this was one of the largest studies examining athletic identity characteristics in adolescent sports medicine patients in the United States. Athletic identity was positively associated with greater volumes of sport participation, playing a team sport, and higher levels of overall coping skills; however, athletes with high athletic identity may worry more, placing them at greater psychological risk after injury. Future research must aim at better defining how athletic identity relates to coping with adversity and injury recovery and may ultimately help us provide more comprehensive, individualized care for young athletes.

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Christino, Mr. Coene, Ms. Williams, Dr. Daley, Dr. Ackerman, Dr. Stracciolini, and Dr. Kramer.
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