Interpersonal dynamics influencing the risk of injuries

Seven studies provided significant insights on the interpersonal dynamics within athletes’ immediate environment that influence the risk of injuries.25–28 30 31 35 Overall, coaches had a substantial influence on the health of athletes, often leading them to push through injury and pain. Podlog et al’s35 study of the experiences of youth athletes recovering from injuries noted the direct influence of coaches on athlete perceptions of return-to-sport experiences. It included examples such as athletes themselves reporting that they were ‘trying harder [in rehabilitation] because [the] encouragement from … [their] coach was motivating’.35

Barker and Bailey25 examined the cumulative life events in a 19-year-old female athlete and how her relationship with her coach influenced her engagement in distance running. Their study illustrated the power coaches wield in shaping the identities and experiences of those they coach. This particular coach–athlete relationship resulted in the athlete becoming dependent on being told what to do and led to habitual compliance with her coach’s instructions. Although this resulted in numerous injuries, the athlete pushed through injury and pain as she feared that the coach would not respect her as an athlete:

I told Dave about a knee injury. I had told him I was in pain, as he always has a go if you don’t tell him before the session. But I always feel like I have to push through an injury for fear that he won’t respect you as an athlete. I never have an issue with pushing, but then part of me feels he should be the one telling me to stop. At no point did he say stop, so I carried on.25

Athletes sometimes went well beyond simply pushing through injury and pain. In Barker-Ruchti and Schubring’s26 study of the experiences of a female elite gymnast transitioning in and out of the sport between the ages of 6 and 15 years, for instance, a difficult relationship between the coach and the athlete led, ultimately, to self-inflicted injury:

Upon returning from the second competition, Marie wanted to go home. Her coach, however, had other plans and ordered Marie to continue training. At that point, Marie could only see one way out: being injured. In her first training session, Marie “hurt” her ankle, which once a medical practitioner confirmed her inability to train, allowed her to leave [the training camp].26

This study, in particular, highlighted the enduring influence of coaching practices on young athletes and underscored the importance of coaches recognising the value of supportive sports relationships and environments and the potential health costs of not doing so.

Kuhlin et al’s30 study of the long-lasting impact of a coach-athlete relationship on a former female figure skater showed how an athlete’s self-investment could create a relationship characterised not only by the trust but also by dependence and obedience. In this instance, the complex interconnection between the coach and the athlete meant that the athlete could not realise the severity of her injury or the detrimental impacts it was having on her health, well-being, personal development and sporting career. For example, she unquestioningly worshipped her coach, even when met with dismissive responses like a smirk and eye roll, minimising her absence from training due to illness and a knee injury as a mere exaggeration. She noted:

If I am sick or injured, will she [the coach] think that I am not dedicated enough? My coach is probably right about Michaela [another skater in her training group]. If she wanted to become a figure skater, she should be here.30

Importantly, athlete behaviour and decision-making processes related to injury management are not only influenced by coaches. One study of young German athletes’ experiences in elite sports highlighted specific instances in which physicians also affected the health of athletes by downplaying the severity of the athletes’ injuries and encouraging them to return to sports prematurely.31 Effectively, this meant that the athletes in the study were made to prioritise short-term performance over long-term health considerations, particularly during competitions:

But I still did some competitions then [when her body was hurting], including youth championships. I did it with shots. So there the doctor gave me a shot. And then I could do stuff for two days and then, after that, nothing again. So then, before quals, Jason [the supervising physician] injected me. Just at youth championships, because when we were abroad another doctor injected me. And he had arranged with Jason, somehow, what the shot was and when and so on.31

Athletes are also affected by the wider dynamics between sports, school and home settings within the mesosystem. These dynamics can prompt athletes to make inappropriate compromises related to their injuries and to become more tolerant of enduring pain. For example, the (in)appropriate balance between sports and academic requirements and leisure time and the (insufficient) coordination across different contexts such as clubs and sports and school training and competitions may influence how youth athletes experience pain. Bjørndal and Ronglan28 have shown that well-functioning coordination between different practice settings appears to be central to successful long-term talent development. However, a breakdown in coordination may lead to insufficient recovery and can, in turn, increase the risk of longer-term injuries. Bjørndal et al’s27 study of the transition from junior to elite handball in Norwegian female handball provided further examples of how injuries occurred from inadequate support, notably from coaches and medical staff:

Nobody took me seriously. I said that [the injury] hurt. … When I got back home, we were on a pre-season training camp and there [the coach] did not take me seriously. I told him that it hurt but he commanded me to run high-intensity intervals with the rest of the team. When I came back home I was totally wrecked.27

In this study, repeated injuries were caused by factors such as the extensive number of activities across the talent development context, the high-risk nature of competitive handball, and the coaches being unable to mutually and sufficiently adapt to each other’s constraints.28

Contextual dynamics influencing the risk of injuries

Eight included studies provided significant insights into the wider contextual dynamics that influence the risk of injuries in youth athletes. The impact of the ethos, rules, norms and expectations of sport on youth sports injuries emerged as a key theme.29 32–34 36–39

In a study exploring perceptions and experiences of injury by Swedish adolescent athletes across multiple sports, a male participant expressed in a focus-group interview that injuries had become normalised in competitive sports: ‘Everybody gets injured, and you have to accept the injury to be able to continue with sports participation’.37 The authors interpreted this normalisation as a coping strategy to adapt to a new situation, such as getting an injury. Athletes in the study learnt, for example, to adapt and to behave in ways that compromised their health, such as perceiving pain as a natural part associated with normal sports participation, and consequently became socialised into accepting pain. Similar findings were echoed in a 2016 ethnographic study exploring the psychosocial influence of sports culture on overuse injuries in Italian rhythmic gymnastics. The study illustrates how athletes adopt and embody sociocultural values and norms such as self-discipline, commitment and responsibility. This was evident in the display of ‘mental toughness’, where athletes accepted pain as part of the sport and continued training despite discomfort:

The pain starts shooting up through the left side of my back, as if wanting to prove who is stronger, urging to stop me. I remind the pain that I am a gymnast, and I’ll do what any ‘good’ gymnast would do: I [will] grit my teeth and smile.29

In another study conducted by Fenton and Pitter, 15 to 18-year-old male rugby players were also found to be strongly influenced by their coaches, peers and medical staff:

Just like in games, if I jam my fingers or break my fingers, I’ve broken fingers and still had to play in the game; that’s something if you still feel you can still play you have to keep it down so you don’t get pulled off.33

Such studies indicate that athletes are expected to disregard and minimise pain and that doing so is not only common but also expected. They indicate, too, that tolerating pain is almost a socially accepted expectation. One 15-year-old female aesthetic sport athlete in the study by Thiel and colleagues stated:

At the end of the day it is like THAT: In competition, nobody is interested in whether you suffer pain or not. You don’t get extra points for clenching your TEETH. Therefore you don’t tell it to anybody or SHOW it but you try to play (laughs) the HARD guy.36

The studies of Fenton and Pitter33 in Canadian male rugby and Thiel and colleagues36 across multiple German sports demonstrate how athletes’ injuries are frequently caused by a disconnection between athletes’ physical capabilities and the demands imposed on them by the broader sporting culture in which such sports are located. These include social norms and risk-taking behaviours learnt from other players and coaches. These studies also suggest that such conflicting demands force athletes to make difficult or inappropriate health decisions. Similarly, conflicting pressures and demands were evident in Schubring and Thiel’s32 study of the growth experiences of adolescent athletes in German elite sport. In their interviews with athletes, the authors noted that the combination of factors, such as an increase in training load and ignoring pain, overloaded athletes’ physical capacity. One handball player, for example, experienced severe knee problems after she was transferred to a sports academy. In her new environment, she faced more intense training loads and a culture that normalised the concealment of pain. As a result, she felt guilty for not participating in training sessions despite her injury:

That’s a tremendous change [in training load] and my knees were already not that healthy before and now they are damaged. … Well, in the beginning, it didn’t make a difference to me—it still hurt but I played because I absolutely wanted to play. That’s it too. My ambition, that’s really quite dumb, because I always want more than I should.32

The studies we identified included many examples of athletes pursuing elite sporting careers. However, similar contextual dynamics revealing cultural norms and values have been reported across many other age groups and performance levels. A 3-year ethnographic study conducted by Malcom34 (working as an assistant coach for a softball team) noted that adolescent girls entering recreational softball gradually conformed to the norms of the sport and coaching environment. In this environment, the girls learnt to cope with pain and injuries by ‘shaking them off’ and ‘toughing them out’ (ie, disregarding them). Significantly, Malcom34 observed that it was the coaches themselves who promoted this behaviour of disregard and even ‘occasionally glorifying pain’ by ignoring the girls’ complaints, making jokes when the athletes experienced pain and telling the girls to ignore minor injuries. The girls, as Malcom noted, learnt to conform to these expectations and modelled their responses to pain and injuries on those demonstrated by the coaches:

“Fire it home! Come on, throw it in here!” Liz threw the ball hard, and it landed in Joe’s hand with a smack. With a smile on his face, Joe said loudly, “That’s it! THAT HURT. Good throw!” When Joe caught their hard throws in his bare hand without flinching, he demonstrated his “toughness” as a ballplayer and modelled the sports ethic to the girls on the softball team.34

Malcom’s34 study demonstrates how the socialisation process of young athletes in competitive sports and the sport’s ethos is a dynamic and ongoing interactive process learnt over time.

In Øydna and Bjørndal’s39 study of the culture of athlete development in Norwegian female handball, pervasive cultural beliefs regarding what constitutes appropriate training and development were associated with an overemphasis on the amount of training. Athletes exhibited individualised caution, denial or self-censorship to reduce the training load. Such self-expectations were found to affect the health and well-being of the athletes negatively:

I feel like I am failing myself, and that I am seen as ‘she who is always injured’. That is not how I want to be recognised. I want to be identified as ‘The handball player’, not as the one who always sits in the stands because she cannot train, and cannot play matches. For me, it is more about [what I think about] myself than what others think of me.39

In Wall et al’s38 investigation of athletes who reported sport-related lower back pain, cultural beliefs in sport, in turn, were found to influence the belief systems of the athletes:

I've been told by pretty much everyone that back pain is part of [sport], um, and that I’m just gonna have to live with it and that everybody gets a little bit of back pain. It’s just part of the sport.38

Collectively, these findings underscore how the ethos, rules, norms and expectations of sport shape athletes’ decision-making processes and lived experiences.

Implications for developing complex interventions to reduce injuries and promote sustainable practice

This narrative review has identified and summarised how interpersonal and contextual dynamics influence the risk of youth sports injuries, place pressure on athletes and even lead them to compromise their health. This pressure often results in athletes, coaches and medical staff making inappropriate decisions and engaging in behaviours that may harm athletes. Many examples underscore the detrimental effects of sociocultural influences, particularly the normalisation of staying silent about injuries and the pressure to continue playing while injured. The findings from the included studies were observed across various youth age groups and performance levels. They highlighted the pervasive nature of these challenges and the complex interactions between coaches, athletes and medical staff. Moreover, insufficient coordination across different contexts, such as between school and club practice settings, exacerbates these challenges. It also significantly increases the risk of injuries and compromises athletes’ overall health and well-being. These findings have implications for developing complex interventions to foster healthier practices in youth sports.

Athletes who have coaches who underplay injuries are more likely to be willing to compete with injuries.40 This indicates that the health of youth athletes can be negatively affected by coach–athlete relationships and the pressures that coaches apply. Interventions that address the vulnerability of youth players are, therefore, essential, and positive coaching practices related to injury prevention and athlete well-being should be encouraged. Further, coach education programmes should include modules on the interpersonal and contextual dynamics that influence youth sports injuries and strategies for creating a supportive training environment.

It is worth noting that coach education content is often normative, decontextualised and fragmented. It is typically focused on individual coaching elements such as exercise physiology, sport psychology and training methodology rather than on the interpersonal relationships and contextual factors important for sustainable athlete development.41 Coaches seldom adopt a dynamic biopsychosocial perspective of athlete learning and development.36 42 A more comprehensive approach is essential, contextualising youth athletes’ experiences and behaviours, underscoring the important role of coaches and integrating diverse perspectives regarding injury prevention. The complexity of interpersonal relationships, including peer pressure and social support, makes it important that interventions focus on enhancing communication among athletes, coaches and medical staff. It is also important that interventions foster a culture of openness and support within sports teams and offer more suitable approaches to injury management.

The effects of mesosystem dynamics on athletes indicate that achieving a balance between academic and athletic commitments is important.43 The increasing pressure of sports commitments during adolescence may lead athletes to neglect other aspects of their lives, such as spending time with friends and family or doing other leisure activities that promote well-being.30 Hence, there is a need for closer collaboration between educational institutions and sports organisations to ensure well- and better-coordinated schedules that allow for sufficient athlete recovery time. Doing so is especially important given the increasing involvement of public actors (such as community, voluntary-based sports clubs and sports organisations) and private actors (such as sports schools and private football academies) in youth sports. This growing complexity underscores the importance of enhanced coordination across such settings, emphasising preventing athlete burnout, reducing injury risks and preserving athlete health and well-being. This coordination is essential for maintaining the quality of opportunities provided to youth athletes by sports organisations.

Contextual dynamics, such as cultural beliefs and norms within specific sports settings, significantly shape athletes’ behaviours and attitudes toward injuries.21 44 For example, youth athletes involved in elite sports systems, such as talent development pathways, are shown to be more willing to risk injuries and compromise their health.45 Reducing and preventing such risks necessitates context-specific interventions that emphasise a holistic approach to athlete development and a focus on reducing the pressures experienced by athletes within their wider social environment.

Our review identified instances where athletes lacked sufficient awareness or understanding of the consequences of pushing through injuries.30 We, therefore, recommend implementing educational programmes, both for athletes and parents, to promote a more proactive approach to injury management. These programmes should stress the importance of seeking professional advice when needed. Doing so can help athletes manage their injuries better before they escalate into more serious and career-threatening issues. It is also imperative that health management strategies not treat health problems as sudden events but recognise the important influence of psychological and sociological factors on athlete health.36

While constructive policies and guidelines are important, their effectiveness is limited without constructive, high-quality interpersonal relationships and positive coach-athlete care and support. Intense, sport-specific, year-round training and competition, coupled with the pressure of competing for selections, heighten the risk of injuries and should be avoided by sports organisations.46 Instead, appropriate demands and balanced competition schedules are needed. In addressing the quality of interpersonal relationships, coach education should prioritise the need for ethical and appropriate coaching practices.47 The examples in this review (and other relevant sources) of (in)appropriate interpersonal and contextual dynamics could be useful ways to educate coaches about best practices and help them to improve athlete health and well-being.