Objectives To explore how sports injury prevention takes place in elite sport practice and to describe the perspectives of athletes, coaches and physiotherapists regarding the most critical factors that help prevent injury in the elite sports context.
Methods Qualitative study. Semistructured interviews with 19 international level athletes, coaches and physiotherapists, from different Olympic sports. Interviews were transcribed verbatim and analysed using comparative data analysis based on Grounded Theory.
Results The participants perceived injury risk as an inherent part of elite sports, because athletes try to enhance performance by pushing their limits. Participants described injury prevention as a learning process that changed over time, based on their sports experience and the injuries that they had sustained along their career. Communication among the athletes, coaches and physiotherapists was described as a key component of the injury prevention process. Study participants emphasised the relevance of teamwork and shared responsibility. Performance was presented as the core of the athlete’s daily practice, indicating that injury prevention can be a means to that end but is not a goal in itself for this community.
Conclusion Participants perceive injury prevention as part of elite sports and thus embrace the need for injury prevention. Injury prevention strategies in elite sports were described as a learning process, following the dynamic nature of training for maximal performance. Performance is the participants’ main goal.
- injury prevention
- sports medicine
- elite performance
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Elite athletes have an increased risk of sustaining sports injuries.1 Injury directly affects performance through reduced load capacity, which impacts, for example, muscle strength, tissue integrity and thus the ability to perform.2 The elite sports context is a performance-driven environment, where the goal is to improve performance and where injuries impact sport performance negatively.3 Along the lines of the above descriptive features, injury prevention should be an essential element in the context of elite sports.
Despite the fact that numerous effective injury prevention strategies have been described in the literature, the uptake of such interventions in elite sports is suboptimal.4–6 This can be interpreted as a gap between practice and science. To overcome this implementation gap in the sports injury prevention field, Finch has proposed the ‘Translating Research into Injury Prevention Practice’ (TRIPP) framework.7 The TRIPP framework has added two steps to the ‘sequence of prevention of sports injuries’:8 the need for understanding the implementation context (eg, personal, environmental, societal and sports delivery factors); and the evaluation of the implementation process of preventive interventions. Therefore, understanding the context is a critical aspect to be able to implement sports injury prevention strategies successfully.9 10
Qualitative research provides meaning and understanding to the context by gathering information from the athletes’ and staff’s perspectives.11 12 Therefore, applying qualitative methods enable a more comprehensive understanding of many aspects of health, including prevention.13 14 Views of elite sport athletes and stakeholders are not frequently represented in sports injury prevention studies and little is known about ‘how injury prevention takes place in the high performance context of elite sports’.15 If we learn about ‘how’ and ‘why’ injury prevention is dealt with in elite sports, we can help to improve the uptake of injury prevention measures and also help to develop context-driven prevention strategies.
Therefore, the objective of this study was (1) To qualitatively explore how sports injury prevention takes place in elite sport practice. (2) To describe in the elite sports context the perspectives of athletes, coaches and physiotherapists regarding the most critical factors related to injury prevention strategies.
This study followed an emergent design and applied principles of Grounded Theory (GT).16 17 Emergent design involves data collection and analysis procedures that evolve over the course of a study, in response to what has been learnt in earlier parts of the study. GT is a systematic method applied in the social sciences involving the inductive construction of theory through an iterative analysis of data. Our data were analysed continuously while they were collected, and the interview questions could evolve and could be adjusted in response to newly gained insights. Taking GT as our core method leads to the identification of a multiplicity of perspectives and participants’ ‘truths’. GT also implies interpretative work which includes interpretations of the perspectives and voice of the participants. Therefore, a constructivist-interpretative paradigm underpins this study.
Elite athletes, coaches and physiotherapists from eight Olympic sports participating in one or more international competitions in the 2016–2017 and/or 2017–2018 seasons competing/working in Western Europe were invited to partake in this study. The participants were recruited from different sports associations, based on personal contacts with athletes and coaches. Initial participants provided contacts for further potential participants, using a respondent-driven sampling method. We aimed to include a diverse group from different sports, from individual and team sports, including young and experienced participants, following the maximum variation sampling method.18 All participants provided verbal informed consent. All approached subjects agreed to participate in this study. The participants’ demographics are presented in table 1. Reporting followed the recommendations for qualitative studies, based on interview data communicated in the Consolidated Criteria for Reporting Qualitative Research19 (online supplementary appendix 1).
The first author (CB) conducted all the individual semistructured interviews based on participants’ availability. Six interviews were done face to face and 13 by phone or Skype. The interviews lasted 28 min on average, ranging from 23 min to 42 min. Interviews were conducted in English or Brazilian Portuguese language and covered three main topics: (1) Sports injury definition. (2) Factors related to sustaining a sports injury. (3) Injury prevention strategies (online supplementary appendix 2). The data from the question regarding injury definition have been published in a previous study.20 The current study focused on the injury prevention strategies that were applied. In an ongoing data collection and analysis, the questions to be asked could evolve and be adjusted in response to newly gained insights. Additional data collection was driven by the notion of theoretical sampling and further participants invited would be selected to confirm or verify insights that had emerged from preliminary analysis (different stakeholders, different sports and different levels of experience). After 18 interviews, same constructs repeated themselves and no additional new themes emerged from data. We conducted one more (nineteenth) interview to ensure that data saturation was achieved.21
Interviews were audio-recorded, transcribed verbatim and analysed based on comparative data analysis,22 23 employing principles of GT.17 24 The interviews that were conducted in Portuguese were coded and analysed also in Portuguese, as both coders (CB and SDB) are native Portuguese speakers. Only the presented quotes of these interviews were translated into English by CB. These translations were checked, and if needed revised, by SDB.
While data were being collected, CB and RP preliminarily analysed the interviews to decide on further sampling and the next steps of the data collection. After the data collection was concluded, the authors CB and SDB separately open coded six interviews. The open coding is the initial stage of the comparative analysis and the focus is only to open up and label the data to what the subjects themselves were saying. Subsequently, they discussed codes and the memos (ie, the respective impressions derived from the coding process) with each other and merged related codes into categories. Once consensus had been achieved on this process the remaining interviews (n=13) were coded by CB using the ATLAS.ti software (V.1.5.4). Thereafter CB, SDB and RP analysed the relationships between codes, categories and subcategories to identify the core category that was presented in the results as main themes. A schematic representation of this process is presented in figure 1.
The description of the preventive strategies applied by the participants is presented in figure 2 and is structured according to the main themes, related to the research questions and the associated main codes.
Injury risk is an inherent part of elite sports
Every participant mentioned injury prevention to be part of their daily routine. They also stated to believe that it is possible to prevent sports injuries. Athletes, coaches and physiotherapists acknowledged that the risk of sustaining a sports injury is an inherent part of elite sports participation, because athletes are always trying to perform better and are pushing their limits to improve their performance (table 2).
Most participants described the challenge of finding a balance between pushing their limits to reach their best performance and to avoid injuries. There is a perception of injury risk, and, in some cases, an acceptance of such a risk. An athlete with a high risk of injury can accept the risk due to the importance of a competition, for example, if participation in the Olympic games is at stake. Athletes, coaches and physiotherapists also described injury prevention as a usual component of the training schedule and as a necessary effort to reach the best sport performance.
Injury prevention is a learning process
The prevention of sports injuries was consistently referred to as a learning process and often described as being based on trial and error experiences (table 3). The influence of the athlete’s experience was referred to as positive for injury prevention behaviour. This experience was related to the number of years of training as an elite athlete, as well as to sometimes experiencing injuries. The difference between experienced athletes and less experienced athletes was very often mentioned in the interviews. The athletes many times compared their behaviour regarding injury prevention in the beginning of their career with their current behaviour, highlighting that they had become more conscious of and proactive in applying sports injury prevention strategies in the course of their career.
When asked about what motivates athletes to prevent injuries, athletes stated that having sustained a previous injury was the main motivating factor. The learning process of preventing injuries was described as getting older and gaining experience in the sport, and as getting injured and learning from previous injuries.
Communication is a key component of injury prevention
Communication between stakeholders was mentioned many times during the interviews. The dialogue between athlete and coach was described as one of the essential components of injury prevention. The trusted relationship between the athlete and the coach needs the active voice of athletes, while coaches should be open to listen to the athletes. More than coach and athletes, the entire teamworking with the athletes needs to establish a constant and open communication. The participants described a broad pallet of sports injury prevention strategies, emphasising the relevance of teamwork and shared responsibility (table 4).
Performance is the main goal in elite sports
The participants also mentioned the relationship between sports injury prevention and performance. Performance enhancement was presented as the main goal of elite sports and sports injury prevention was perceived as a parallel goal that helps to achieve optimal performance (table 5). The culture of elite sports accepts injury risk and pain and the need to push one’s body and deal with pain, as mentioned above, implies that performance is the main goal in elite sports. However, sports injury prevention is also part of elite sports, since the ultimate goal is to perform better.
The sports injury prevention routine, in the view of the participants of this study, needs to follow the characteristics of the training schedule: that is, the prevention routine should be flexible, adaptable and dynamic. It was also mentioned that sports injury prevention activities should not hamper the training goal in achieving the best possible performance. In this way, the participants described that they continuously adapted their sports injury prevention strategies, depending on training load, season planning and/or athlete fatigue status, in the light of their performance goals. Coaches also described scheduling training sessions with continuous follow-up and adaptations of the training plan, according to the athlete's responses (and performance measurements).
This qualitative study explored how sports injury prevention takes place in elite sport practice and described the perspectives of athletes, coaches and physiotherapists regarding critical factors related to injury prevention strategies in the elite sports context. Our findings provide insights in how sports injury prevention is executed in practice, from the perspective of elite athletes, coaches and physiotherapist. All participants described sports injury prevention as part of their daily practice. The main themes revealed indicated that sports injury risk is perceived as part of the sports routine and that sports injury prevention is perceived as a learning process where individual experience plays an important role. According to athletes, coaches and physiotherapists, the critical factors for sports injury prevention were the communication between stakeholders and the balance between performance enhancement and the implementation of sports injury prevention strategies.
Injury risk management is like tightrope walking
Sustaining a sports injury was perceived as an inherent risk of elite sports participation. Fagher et al 25 presented comparable results regarding risk-taking behaviour, as Paralympic athletes acknowledged the risk of sports injury, while they continued training. Such an acknowledgement was also mentioned in other qualitative studies in different sports25–27 and is exemplified by high sports injury rates observed in previous epidemiological studies.1 If the risk of sustaining sports injuries in elite sport is part of the process of sport participation, one can argue that we should change the current sports injury prevention paradigm to a risk-injury management paradigm. Such a paradigm shift was suggested by Fuller et al,28 who have applied risk management concepts to sports and who have presented concepts, such as risk acceptance, a phenomenon that was described in our study also. The paradigm of managing risk of sports injury requires risk perception, risk acceptance (sometimes) and management of the risk. Hence, at least in elite sports, preventing sports injury it is not about avoiding a sports injury to happen in a concrete way but, it is about ‘playing’ with injury risk, like walking on a tightrope; balancing the risk while keeping on going.
In the present study preventive behaviour was described as a learning process. Athletes sustained sports injuries along their career and, subsequently, developed and/or implemented strategies to protect themselves against sports injuries. The significance of experience for sports injury prevention behaviour was consistently mentioned in our interviews. Athletes compared their current behaviour regarding sports injury prevention after some years of experience with their early career behaviour. They had learnt over the course of time how to apply preventive strategies and had become more accountable for their own health protection. In this sense, less experienced athletes may need more guidance on sports injury prevention. The role of experience in the preventive behaviour has not been widely studied in sports medicine, with the exception of a few studies.26 29 30 These few studies have described that the experience of being injured is part of the development of superior sports performance. To a certain extent this change can be seen as a sign of empowerment of experienced athletes, who have gained more insight and responsibility in the decision-making process towards sports injury prevention.29 In the ‘return to sport’ and ‘sports rehabilitation’ literature there is a call to engage and empower athletes,31 32 but sports injury prevention efforts still lack listening to the athlete’s voice. Based on our findings, experience seems related to how athletes deal with sports injury prevention. If sports injury prevention is a learning process for the athletes, this learning process should be facilitated by coaches and physiotherapists.
We need to communicate if we want to prevent sports injuries
Athletes indicated perceiving the impact of load on their body and also on their performance. Consequently, they need to communicate health complaints with the coach or the physiotherapist in case ‘something feels not right’. Such communication should go both ways. The coach and physiotherapist should monitor the athlete and should be aware that changes in performance can be related to a potential sports injury. A critical point in the development of sports injury prevention strategies, according to our participants’ views, was based on giving a voice to the athlete, thus establishing an open communication channel in the team and sharing responsibility in the decision-making process regarding athletes’ health and performance. The importance of communication for sports injury prevention has been addressed in the recent literature. Poor communication in the team has been associated with injuries in soccer.33 Staff communication and teamwork has been suggested as important components of successful implementation of sports injury prevention strategies.34–36 Also, load management was referred to many times as a continuous process that depends on communication and teamwork. This relationship between performance monitoring and sports injury risk has been addressed in the literature,35–37 where shared decision-making to adjust training schedule, or where competition participation depends on a ‘good’ communication and on an integrated team.
It is all about performance!
Performance was many times referred to as the main goal in the career of the elite sports participants of this study, while the importance of sports injury prevention was acknowledged because of the detrimental effect that sports injuries may have on sports performance. How sports injuries affect performance has already been described in the literature, suggesting that high injury rates can negatively affect the success of a team.3 31 Our participants perceived that performance was impaired because of sports injuries. In a previous study, this same group of participants described injury based on performance limitation.20 Our participants acknowledged the idea that sports injury prevention strategies are ‘part of training’ and can improve performance. The sports medicine literature has already described that sports injury prevention interventions can be associated with performance enhancement.6 38
Due to the dynamic nature of the training routine in elite sports, sports injury prevention strategies need to be continuously adjusted to the athlete’s condition and to the training/competition schedule. When including some strategies as preventive exercises and strengthening training, load will increase and the delicate balance between load and load capacity will need to be monitored. The uptake of sports injury prevention interventions and the challenges of their implementation has been a topic in several studies.4 9 39 It was stressed by some of our participants that sports injury prevention efforts should never impact performance negatively. In this sense, fixed protocols with proven efficacy presented in the literature do not seem to be applicable to the individual athlete. The most part of sports injury prevention interventions neither allow adjustments of the athlete’s training programme, nor of the shared decision-making process that shapes the individualised programme. If in other domains of the management of the athlete’s health, such as return to sports and rehabilitation, there is a plea to develop more individualised and athlete-centred strategies,31 40 41 then the sports injury prevention domain lags behind. One can argue that there is a mismatch between described effective and fixed protocols, and the dynamic context of elite sports.
The trustworthiness of our findings was strengthened by the applied methodological strategies.42 To increase the credibility of our findings we used triangulation of sources by including different groups (ie, athletes, coaches and physiotherapists). We also had two coders analysing the data independently. The fact that the third coder was someone outside the sports medicine field but with vast experience in qualitative research, provided a degree of neutrality to our findings. This improved the confirmability, and also the dependability of this study. Regarding transferability, our participants were part of a very specific group participating in Olympic games and international competitions from different sports. We covered a wide range of perceptions to capture the broadest possible set of information and experiences from the participants. However, no comparison should be made with other sports contexts.
Regarding our sample, most athletes were women. In contrast, all coaches and physiotherapists were men. This situation reflects every day in elite sports reality.43 Many women athletes are trained and treated by men. We cannot estimate how this gender difference may have affected our results. To our knowledge no literature has addressed the potential effects of these gender differences on the perceptions of elite sports professionals. Also, differences in experience and culture regarding injury prevention should be considered, since our participants were from different countries.
Additionally, the number of participating coaches and physiotherapists was relatively small, compared with the number of participating athletes. However, the coaches and physiotherapists dealt with a diverse group of athletes. In our opinion, this diversity has enriched the coaches’ and physiotherapists’ professional experiences, and we believe that they were able to represent the main perspectives of this specific group of elite sports staff.
Sports injury prevention is a fundamental element of the performance-driven context of elite sports, as sports injury is a threat for achieving the best performance possible. Therefore, athletes, coaches and physiotherapists apply in their daily routine different strategies to reduce the risk of sports injuries. Such sports injury prevention strategies follow the dynamic nature of training for maximal performance, which relies on teamwork, shared responsibility and open communication. The inherent sports injury risk is acknowledged by athletes, coaches and physiotherapists working in the elite sports context, which suggests that preventing sports injury in such a context is about ‘playing’ with injury risk along the season. If the sports injury prevention field aims to make progress regarding the uptake of sports injury prevention in elite sports, one needs to understand that strategies need to be built specifically tailored for the elite context, where it is all about performance.
What are the findings?
Athletes, coaches and physiotherapists in the elite sports acknowledge the inherent injury risk associated with performance enhancement; they ‘play’ with injury risk along the season, learning from their experiences.
Injury prevention strategies in elite sports follow the dynamic nature of training for maximal performance, which relies on teamwork, shared responsibility and open communication.
Sports injury prevention can be a means but the major goal, in the elite sports setting, is to achieve the optimal performance.
How might it impact on clinical practice in the future?
The entire staff needs to be engaged in sports injury prevention and needs to communicate openly with athletes about symptoms and injuries.
Injury prevention strategies should allow a certain level of adaptation following the dynamic nature of the training routine of elite athletes, and should have performance as a primary aim.
A learning process of experiences influences how athletes deal with injury prevention, and this learning process should be facilitated by coaches and physiotherapists.
Contributors CB, the main coder and interviewer, developed the reasoning for this paper and drafted the first version. SDB, WvM and RP contributed intellectually and provided feedback on various drafts.
Funding CB is supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq, Brazil, grant number 202242/2015-3. No other sources of funding were used to assist in the preparation of this article.
Competing interests None declared.
Ethics approval This study was approved by the Vrije University Medical Center Ethics Committee, Amsterdam, the Netherlands; protocol METc FWA00017598.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.