Athletes get injured. But when they leave the stadium lights -- and the public eye -- what happens?

To be a college athlete is to perform. The court, the field, the pool, the mat -- this is the venue in which the culmination of a lifetime of hard work, dedication and sacrifice comes to fruition.

But to perform such feats of athleticism also exposes oneself to risk. With the intensity of collegiate athletics comes an increase in injury risk. The cuts become quicker, the impacts harder, the stakes higher and the opponents larger and more imposing.

"Injuries are so commonplace in sports that it's almost an expectation at some point during an athletic career that you're going to have an injury," Dr. Michael Boyd, assistant professor of orthopedics at Duke and sports medicine specialist, told The Chronicle.

The data bear this out, too. Compared to high school sports, overuse injuries are seen over three times as often in collegiate athletics, and as many as 91% of athletes experience an injury during a college career. When an injury happens -- when the mission of the athlete is interrupted -- the true hardship sets in.

The athlete disappears. Relegated to the sidelines, away from the spotlight, they fade from the awareness of casual spectators. But this is where athletes are tested the most -- mentally and physically. Situated away from the common consciousness and in the confines of the training room is an arena with battles more challenging than the toughest opponent.

Picture an athlete. Now, picture an injury. What did that injury look like? Perhaps a football helmet collision, a basketball player falling on her wrist or a lacrosse midfielder checked on his knee. The injuries that happen in front of us are often the ones that stay in our minds. But injuries aren't always sudden or acute.

What began as a periodic ache soon became an unavoidable problem, one that threatened her athletic ambitions. The risk of reinjury lingered, but the call to compete -- to live up to her own expectations -- was louder.

"Initially I was in denial," Pyne said. "I didn't in any world think I wouldn't be able to come back, or it would be a recurrent injury."

But her chronic overuse injuries became too great to ignore, and recovery became more difficult. Doctors began with small operations, 'Band-Aid' operations as Dr. Boyd would say, to keep Pyne on the field. As damage accumulated, her surgeries became more invasive. Faced with the reality of her injuries, Pyne medically retired from the team after her sophomore season.

"I think that once you get to the point when you have a surgeon saying, 'I can't, in good conscience, clear you to play sports again, the long term prognosis is not good, and we don't have good answers for you' -- I think that's a whole other level of truly feeling like you've had the rug ripped out from underneath you, a loss of direction, a loss of purpose, and then you are trying to figure out what your new direction in life will be. What sort of turn you'll take from there," Pyne said.

While chronic injuries creep up slowly, acute injuries strike with sudden, devastating force. In a single moment, an athlete's career can be put on hold. In the 2023-24 Duke men's basketball season, star guard Caleb Foster, then a freshman, suffered a season-ending stress fracture just before the team would go on to the NCAA Tournament.

"It was definitely hard going out. Nobody wants to go out," Foster said. "It's the longest time I've been without basketball."

Whether the injury is sudden and unexpected or has been building over time, the mental effects of sitting out are undeniable. Countless hours are spent perfecting a technique, conditioning the body to astounding physical fitness. When the reason for being on the sidelines is not energy or performance, but instead inevitable physical changes to the body, it can feel like a betrayal.

For many NCAA Division I athletes, sports are all they have ever known.

"I don't ever remember a time where I wasn't playing sports," Pyne said.

The concept of an athletic identity is recognized and studied in sports psychology -- the degree to which an individual identifies with being an athlete. This mental schema is self-perpetuating -- significant time in sports begets a strong athletic identity, and a strong athletic identity begets greater passion, commitment and investment. While this identity drives motivation to perform, it risks harming self-esteem and outlook on the future when career-threatening situations arise.

"It really is all-consuming in really wonderful ways, and also can be really negative ways," Pyne said. "When you've poured so many thousands of hours into something, particularly when you're on the precipice of moving -- finally -- from high school to being a collegiate athlete, which in the United States is one of the most exciting jumps you can make in sports, I think that there's that initial devastation of losing this dream that you've spent so long working for."

In 1950, Erik Erikson, a developmental psychologist, proposed the humanist theory of development, which describes identity formation as an ongoing process that lasts well into adulthood and is defined by identity crises and resolution. An identity crisis, he says, is a period of uncertainty in which we question who we are, what we want in life and how we envision our future. When identity is threatened, it can lead to reassessment and crystallization into a firmer, more stable identity, or it can lead to identity confusion in which the individual is left lacking confidence and certainty.

"Sports are a large part of many people's identity -- varsity athletes and non-varsity athletes -- so when you lose that huge part of your identity, there's definitely a huge risk for mental health changes," Dr. Johnston said. "I've seen student-athletes become depressed. I've seen withdrawal from friends. We know that it can affect schoolwork and grades as well. I think we're lucky in that in the last couple of years, there has been a big shift in identifying student-athletes as people first and athletes second ... And I'm hopeful that that will be a positive thing, especially as athletes work through injuries."

This disruption of identity can lead to self-doubt, posing risks to mental health as athletes grapple with feelings of loss and a lack of purpose. An injury therefore is a coin with two sides; on the face of it, an injury is a physical disruption to the body that must be repaired and rehabilitated, but on the underside is the emotional and mental challenge of the interruption of self.

Recovery is never a straightforward journey. It begins with evaluation, rehab, medications. Gradual improvement may plateau, or improvement may not be seen at all. What works and what doesn't depend on the athlete and their injury.

"What you try to avoid, especially for an in-season athlete, is a surgery," Dr. Boyd said. "Recovery from that is going to be a lot more than a non-operation. So if you can do rehab, medication, bracing, injections, you try to do that first. And then surgery, if possible, as a last resort."

However, the length of recovery varies. Once the initial stabilization of the athlete has been addressed and a plan has been formed, the team switches focus to returning to play. For this, there is a precise protocol for getting these athletes competition-ready. Only when they can move without pain and regain full mobility, step by step, can they safely return to their sport stronger and more aware of their body's limits. Sometimes, though, safety requires sacrifice.

"The number one part of our job is to do no harm and to promote the safety of the student-athlete," Dr. Johnston said. "At times, that's challenging, because we do have to set some firm boundaries with our student-athletes in order to keep them safe."

Yet physical healing is only part of the recovery story. While the emotional fallout immediately post-injury is challenging itself, the ongoing mental toll of being sidelined can be just as overwhelming. Athletes go from executing explosive movements and contributing to the team's success to sitting in a training room, working through small, seemingly insignificant motions.

"You're now a sideline player," Pyne said. "You're now a support team member -- a cheerleader rather than the star. That can be very hard mentally, but I found it most tolerable and most enjoyable when I was able to lean into being that support person for my team and genuinely finding joy and happiness in the success of others."

Sometimes, though, the break from sports can provide a renewed sense of purpose. Forced to step back from the intensity of competition, athletes reflect on their approach to training and the role that athletics has in their lives. Vanessa de Jesus, a graduate guard for Duke women's basketball, missed the entire 2023-24 season due to a knee injury.

"It made me miss basketball even more and showed how much I really loved basketball. The time away gave me a perspective of the game that I never had before, and to observe my team from the outside, which was very different than I'm used to," de Jesus said in an Oct. 25 media availability. "At the end of the day, I think it just motivated me to get back on the court and continue pushing through my rehab, which was a long journey."

For many, the time spent on the sidelines reignites their appreciation for the game and the drive to return stronger, wiser and more prepared. And throughout it all, athletes at Duke are supported by a diverse and dedicated team of experts to guide the process.

When injury rears its head and an athlete falls from their peak of performance, there is an army of support waiting to catch them. A massive, highly-trained team of professionals -- coaches, athletic trainers, physical therapists, physicians and mental health experts -- are ready to spring into action.

"The team is really as broad and diverse as you can imagine ... They're there to support student-athletes when things are going well, and also when things are not going so well," Dr. Johnston said. "We have so many resources, especially here at Duke. We have a really robust behavioral health team, we have in-house physical therapists, we have in-house dietitians -- you think of a resource that you might need for the care of varsity athletes, and we have it, or we can get it, at Duke."

Athletes have near 24/7 access to their athletic trainers. From primary care to surgery, Duke benefits from its own sprawling healthcare system. When an athlete needs treatment, they get it. In addition, Duke Athletics picks up the tab for expenses uncovered by insurance, allowing athletes the space to focus on their training and education.

"I got hurt, and right after the season, I got surgery in the next day or two. It was phenomenal," Foster said. "They've been with me every step of the way. They called me to make sure I'm straight, and then when I got to the rehab classes, it was smooth. They make sure I'm doing all the right things to get back on track, and now I feel better than I ever felt before in my life."

Whether the injury is a sprain, a fracture or something more complex, this team is prepared to address not just the physical rehabilitation but the emotional and psychological hurdles as well. And this system kicks in immediately.

"We think acutely about their class load and their class schedule," Dr. Johnston said. "Is this something that's going to impact their ability to go to class? Do we need to let the academic advisor know? We think quickly about how this might impact their mental health ... about their nutrition. A lot of athletes, if they're injured, may not have the appetite that they usually do when they're going full tilt, but they still need that nutrition to heal from whatever injury they're recovering from."

While a tight meshwork of professionals see athletes through their injuries, they also lean onto their teammates for support and solidarity. Sharing the daily grind of practice and the highs and lows of competition, teammates offer a unique bond formed through countless hours and can empathize with a level of understanding that few others can provide.

"I had great teammates. [They] kept me positive. I got to live through them, experience the tournament through them. I learned a lot sitting on the bench from a new perspective," Foster said of the NCAA Tournament.

"Some days are going to be tough -- and it was tough -- but having my teammates to support me and just seeing that growth over time has really helped me stay motivated to where I am now," de Jesus said.

With this vast network of specialists and the camaraderie of their teammates, athletes find themselves surrounded by a robust support system. With medical intervention and emotional support, athletes are cared for in every aspect of navigating the fallout after an injury.

While the system is to care for an athlete, the primary goal is to avoid injury in the first place. For the athletic trainers, coaches and medical staff, maintaining the health of Duke's athletes is the highest priority. A new emphasis on training techniques and careful analysis of strain affords the opportunity to enhance performance and reduce the likelihood of injury.

"We do 'prehab,' or a pre-injury assessment," Dr. Boyd said. "That's a big part of it, how much they can protect their joints, identifying those people who are at risk and putting them through a more rigorous prevention program."

This hasn't always been the case, though. The emphasis on prevention and building strength with comprehensive stretching and warm-ups specifically to protect from injury is a relatively new phenomenon, says Dr. Boyd.

Also new are the monitoring techniques that coaches employ. Catapult, an athlete monitoring device, is often worn in the back of a tank top or sports bra, between the shoulder blades. About the size of a bar of soap, these devices collect information on chronic load, or overall cumulative strain, and on acute stresses, or brief high-impact movements.

"We are collecting so much data, which is a huge trend in varsity athletics," Dr. Johnston said. "Coaching staffs and teams are more systematic."

With a focus on prevention, Duke Athletics ensures its athletes fulfill their highest physical potential and maintain the integrity of their bodies beyond college.

"It's so vital to be at a place like Duke that has such incredible support, both on and off the field, in terms of finding your new purpose and your new path in life," Pyne said.

Despite the best efforts of the medical staff, injuries take their toll. The wear that top-level athletics has on the body not only risks injury in the moment, but physical consequences down the line.

"There are consequences to overuse injuries later in life," Dr. Boyd said. "Do you risk more damage and try to push through people's injuries and put a Band-Aid on it through the end of the season? Or do you consider medically retiring? That's a very personal, very, very serious thing, but it's a real conversation that we have on a pretty frequent basis."

Pyne's experience is not an unusual one. About one in 10 college women's soccer athletes are medically retired due to injuries sustained during their time in sports. When the identity of the student-athlete is disrupted, the results can be lasting. Some athletes have trophies, medals, rings -- physical reminders of their time in sports and the glory they achieved. Others, though, have physical reminders of a different kind.

"Physically, I'm still feeling the effects. I can't run, I can't jump. I'm very limited by my knees, and I've had to have a huge perspective shift with just being grateful to be able to go on long walks, for instance," Pyne said. "But I'm definitely feeling the effects of the injury."

The long-term implications of injuries can, sometimes, become impossible to ignore. The road to recovery may not always lead back to the playing field. For some, it necessitates a profound reevaluation of their identity and future. Pyne found a way to turn her injuries into motivation; having been through the trials of multiple surgeries, she was opened to the world of medicine and is now a medical student at Duke. As she reflects back on her time with Duke women's soccer, she encourages athletes who get injured to find joy in each other and in the journey, as difficult as it may be.

"I would tell athletes to try to find purpose in the day-to-day. So obviously, give yourself time to grieve and give yourself time to be down in the dumps about whatever situation happened, because it is unfortunate and is a crappy hand to be dealt," Pyne said. "And it's exhausting to show up day-to-day and do the small things, but if you can sort of visualize how those small things will add up and get you back on the field or on the court, and figure out how you can show up for your teammates even as you're dealing with all that that can make this journey much more enjoyable ... If you can still find a way to show up and be a great teammate on the sideline, you will find much more joy and purpose."