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Who ‘owns’ the injury or illness? Who ‘owns’ performance? Applying systems thinking to integrate health and performance in elite sport
  1. Mitchell Mooney1,
  2. Paula C Charlton2,
  3. Sadjad Soltanzadeh3,
  4. Michael K Drew2,4
  1. 1 Department of Performance Analysis, Australian Institute of Sport, Bruce, Canberra, Australia
  2. 2 Department of Physical Therapies, Australian Institute of Sport, Bruce, Canberra, Australia
  3. 3 Faculty of Education, Science, Technology and Mathematics, University of Canberra, Canberra, Australia
  4. 4 Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
  1. Correspondence to Michael K Drew, Department of Physical Therapies, Australian Institute of Sport, Leverrier Cr, Bruce, Canberra 2617, Australia; mick.drew{at}

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Systems thinking frameworks have gained attention in both modelling athlete performance and injury prevention in sports medicine.1–3 We believe that these fields may contribute valuably and interdependently within a larger high performance system.1 The purpose of this editorial is to explain how ‘injury’ and ‘performance’ interact within a system-based framework3 and to provide three practical implications of an integrated performance system.

Systems thinking in high performance sport

The basic premise underpinning any systems model is that parts of a system are inter-related, and the objective of the whole system defines the function of each part. Therefore, the interaction between parts cannot be reduced to a number of linear cause and effect relations.1 The influence of a part on the outcome of the whole system depends on the state of the other parts. Any change to a part of the system can affect the objectives of the whole system as well as the function of the contributing parts.

In a systems framework, it is illogical to understand or evaluate the performance of individual athletes independently of other factors (eg, teammates, opponents, tactics, health, training load). Here the function of each athlete is defined in relation to the objectives of the entire team.1 Similarly, new studies on the interaction between training load and injury prevention have shown that training prescription and athlete health (where the athlete remains injury and illness free) are intertwined and therefore cannot be considered separately.4 High training loads, once directly associated with the development of injuries, protect against injury and therefore, also have health benefits. This shifts the paradigm of training load prescription to consider both cost (eg, injury or illness)5 and benefits (likely improved performance) to the optimal functioning of the integrated system.6

We support the idea that the principles of systems thinking should be extended into the research fields of health and coaching and how this relates to performance. We should start viewing these systems as parts of a larger and overarching system1 as demonstrated in figure 1. This overarching system has been referred to as an integrated performance system. 3

Figure 1

An example of how the injury risks and performance systems can be viewed in the same system.

Three important implications of applying systems thinking: an integrated performance system

Interconnectivity of health/injury prevention and coaching as subsystems

The function of each subsystem and its respective parts needs to be understood and redefined in terms of the objectives of the integrated performance system. As a result, any intervention applied to one part should be justified based on its impact on the whole system (positive, negative or neutral). For example, the non-linear interaction of training load on injury incidence7 and thus, the non-linear impact on performance5 demonstrates the interconnectivity of the health and coaching subsystems with performance. These two ‘subsystems’ of the integrated performance system are clearly linked given that an injured athlete cannot perform at his/her best, if at all. Equally, a healthy athlete who is not capable will also not be able to contribute to team performance.8 Instead of approaching health and coaching separately, future research and practice should focus on the interconnected nature of the subsystem objectives.

Greater understanding of how many and complex subsystems impact the whole

Future research should focus on maximising our understanding of the functions of the subsystems of interest and their impact and relationship to the objectives of the larger system. It is expected that greater knowledge of the functions of each subsystem will lead to new revelations in sports science and medicine. Again, a recent publication highlighting the interdependence of health and performance outcomes is one such example.9

Joint ownership of the integrated performance system

When working within a systems framework, everyone is responsible for the output of the system at various levels. An integrated performance system provides a framework on which an integrated performance system can be built and removes such conflicts as ‘who owns the injury or illness’? or ‘who owns performance’? It moves us towards cohesive shared decision making, where the health and success of the athlete have interdependent responsibilities by the coaching team, medical staff, performance coaches and most importantly, the athlete.



  • Contributors All authors equally contributed to the writing of this editorial. All authors approved the final version.

  • Funding MM, MKD and PCC were supported by the Australian Institute of Sport. The Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP) is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the IOC.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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