Original research
A qualitative study on overuse injuries: The beliefs of athletes and coaches

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Abstract

Objectives

Preventive approaches for overuse injuries in sports will be more successful when synchronised with athletes’ and coaches’ beliefs. We interviewed athletes and coaches in order to better characterize their beliefs about the definition of an overuse injury, as well as the intrinsic and extrinsic risk factors that underlie overuse injuries.

Design

Qualitative study using in-depth interviews in athletes and coaches of different sports.

Methods

Athletes who had experienced overuse injuries and coaches who trained athletes who had sustained overuse injuries from sports clubs were invited to participate through interview. We explored each participant's individual definition of an overuse injury and the beliefs concerning the intrinsic and extrinsic risk factors concerning overuse injuries were explored.

Results

After nine athletes and nine coaches, sample size saturation was confirmed. Athletes and coaches integrate somatic as well as psychological and sociological factors into the definition of and risk factors for overuse injuries. Intrinsic factors for an overuse injury were related to physical factors, technique, psychological factors and heredity. The extrinsic factors were related to situational, social and training factors, as well as the individual coach.

Conclusions

Athletes and coaches have a holistic view on the definition of overuse injuries, and the intrinsic and extrinsic risk factors for overuse injuries. If preventive approaches for overuse injuries are developed and implemented, they should incorporate physical factors, as well as incorporate psychological and social factors. Based on the input of coaches and athletes, the latter are important risk factors for overuse injuries.

Introduction

In the last decades, research has supported the concept of regular involvement in sports or physical exercise as a significant positive prognostic indicator for general health and well being.1, 2 However, safety in sports and physical activity, is an important prerequisite for sustained participation in sports. A wide array of preventive measures for a variety of injuries within different sports is available, often focusing on ‘protective’ equipment (i.e. stability devices, attenuating devices) and training methods (i.e. stretching, power, coordination).3 These interventions are based on biomechanical and physiologic theories concerning the onset of sports injuries, and most often on traumatic or acute injuries. Unfortunately, prevention studies focusing on overuse injuries are scarce.3

Recently, debate has arisen about the “true” effect of the current preventive measures in a realistic sports setting.4, 5 One of the conclusions in this debate was that prevention will only be achieved if research efforts are directed towards understanding the implementation context.4 The behavior of athletes and their beliefs on the cause of injuries has been put forward as a key factor,6, 7, 8 preventive measures will only be adopted by athletes if the determinants and influences of sports safety behaviors are understood and accepted by the athletes and coaches using them.6, 7 Therefore, in order to improve the efficacy of prevention programs, one tries to motivate and manipulate the end-user's behavior and beliefs towards those that will improve safety and injury prevention. It would then be appropriate to include behavioral and cognitive aspects in the development process of preventive measures or programs by including behavioral and cognitive determinants of all stakeholders (i.e. coaches, athletes, researchers, policy makers and healthcare professionals) during intervention development. This ensures that the proposed intervention does not only consider theoretical evidence, but also fits the beliefs of end-users. Recently, a trial within the field of sports medicine has successfully applied such a behavioral approach for injury prevention lessons for school children. Before the trial, a needs assessment and an assessment of the different risk factors for physical activity injuries were determined with use of an intervention mapping protocol. These factors were incorporated in a clustered randomized control trail.9, 10, 11 From a preventive standpoint, this is crucial as end-users in general might have a different focus on health and preventive measures than health care professionals.12

To date, there are no published prevention programs focusing on overuse injuries. This void appears to be primarily related to gaps in etiological knowledge. Overuse injuries are related to repeated micro-trauma without a single, identifiable event, however, the etiology of overuse injuries remains largely unknown. Typically, the injury onset occurs well before the physical complaints, which creates a difficult setting in which to retrospectively understand the etiology of the injury. Nevertheless, at the onset of complaints, athletes and coaches will form their own beliefs regarding the cause of the injury and the prevention of further complaints. In order for a successful preventative strategy to be effectively adopted, these beliefs will need to be integral in developing this strategy, and it will be important to gain insight into these ruling beliefs. To our knowledge, no existing literature is available analyzing the beliefs of athletes and coaches concerning overuse injuries. For this purpose, we conducted a qualitative study to explore the narratives of athletes and coaches. The aim of the study was to describe the beliefs of athletes and coaches about the definition of an overuse injury, as well as the intrinsic and extrinsic risk factors that underlie overuse injuries.

Section snippets

Methods

Since no research has been conducted to investigate this phenomenon we conducted a qualitative study using in-depth interviews to understand the beliefs of athletes and coaches. Without a specific theoretical framework on the etiology and risk factors of overuse injuries available, the interviews were conducted according to intrinsic and extrinsic risk factors as postulated in the dynamic recursive model for the etiology of sports injuries.13 For our purposes, we will define an intrinsic factor

Results

After the 18th interview (nine athletes and nine coaches) saturation confirmed that the sample size was sufficient and no new themes were emerging from the data. All athletes and coaches were aware of the difference between acute/traumatic injuries and overuse injuries. According to the athletes and coaches, overuse injuries are very common and often sport specific, i.e. shoulders injuries are prevalent in swimming and wrist overuse injuries in rowing (Table 1). The descriptions of overuse

Discussion

This study was based on 18 interviews with Dutch athletes and coaches. The aim was to understand the subjective definition of overuse injuries, and beliefs about the intrinsic and extrinsic risk factors related to overuse injuries. Athletes and coaches integrate somatic, psychological (behavioral and cognitive) and sociological factors in the definition of overuse injuries. The beliefs about intrinsic factors were related to physical factors, technique, psychological factors and heredity. The

Conclusion

Athletes and coaches integrate somatic as well as psychological and social factors in the definition of and risk factors for overuse injuries. This view seems in contrast with the medical and somatic view on injuries described in the literature. Prevention programs for overuse injuries in order to increase effectiveness should not only contain somatic factors, but also incorporate the pre-existing beliefs of athletes and coaches about the intrinsic and extrinsic factors related to overuse

Practical implications

According to athletes and coaches overuse injuries are related to biopsychosocial factors and not only caused by ‘repeated micro-trauma without a single, identifiable event responsible for the injury’; this might be integrated in future research.

Prevention programs should incorporated not only equipment and training methods, but also behavioral strategies of athletes and coaches (i.e. monitoring pain, fatigue and stress).

Clinicians working with athletes suffering from overuse injuries should

Acknowledgement

The authors would like to thank all participating athletes and coaches and Christel Braaksma, Stijn Hoogwout and Erin Daly for their contribution to the study.

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