1.1 Pain is part of being an athlete

Participants shared how pain is an inherent aspect of being an athlete, shaping their identity. Participants found that the interaction between pain, exertion and fitness is an enmeshed aspect of athlete pain experience with athletes acknowledging that pain or muscle soreness can be a sign of effort towards the attainment of fitness. In line with contemporary research, playing through pain whether it be exertion-related or otherwise was commonplace behaviour reported by both sports physiotherapists and athletes although with potentially negative consequences.29 The main concern athletes had was the impact pain has on their performance, particularly during competitive parts of the season. Physiotherapists also acknowledged the impact the time of the season has on pain behaviours.

I find that you live with pain. It’s not that you wait for the day for pain to come or go. (A01)

You’ve put in a good effort in a training session. at the start of the season you’re sore but you know it’s a good thing. (A06)

I’m happy to run through pain all summer and just my only worry is that it impacts performance. (A08)

Because depending on time of season, what’s coming up, changes someone’s, maybe not how they experience pain but certainly how far they’re willing to take it. (P04)

1.2 Pain impacts and shapes the life of an athlete

Athletes and physiotherapists alike defined pain as something that influences an athlete’s ability to participate and perform in their sport. Athletes described how pain also impacts their daily life outside of sport with the combination of the physical and emotional experience having the potential to influence their identity. Athletes highlighted how pain interfered with activities of daily living which is something they often judged to indicate increased severity. Additionally, they shared how persistent and severe pain can change how they live their life through inability to take part in their sport. Previous research has documented how the impact of pain on daily life and mental wellness can force athletes to contemplate their future in sport, something one athlete in this study resonated with.30

If it’s in the back of your mind that you can’t … you know you are thinking of something that may be impacting your performance. (P03)

I suppose physical pain can often translate into being an emotional pain, not being able to participate can change the life of an athlete. (A04)

When I get more concerned it is, say power on stairs, or power on a kerb while walking or something like that. So it’s when it impacts on my outside running life. (A01)

When I’m sitting down it would just knot up and get really sore, I’d have to straighten my leg, I wouldn’t be able to sit down for long periods of time, driving would be really difficult. (A11)

It happens me all day, every day, there’s times that I limp because of it and I can’t walk. I’ve had to adjust my lifestyle. I can’t wear certain shoes, I can’t just run for a bus I need a good long warm up and I am meant to be an athlete. (A08)

I’m able to run through it but it causes me so much pain that I contemplate retiring. (A08)

The altered identify or sense of self and negative affective aspects discussed earlier speak to the experience of suffering associated with pain31 beyond the sensory experience of pain alone, and will be discussed in further detail in theme 3.

2.1 The athlete pain spectrum

In line with contemporary research which outlines a continuum from pain to injury,3 34 pain experience existed along a spectrum for athletes and physiotherapists alike who described a variety of pain presentations from routine training-related muscle soreness, to ‘niggles’, to pain that is more sinister and may be a cause for concern. The IASP definition of pain highlights how pain perception has both sensory and emotional aspects.32 In our study, participants described how these sensory and emotional aspects are influenced by a multitude of sports-related activities from a routine warm-up to the rush of adrenalin and intense focus experienced when competing. Athlete’s shared how this situational and contextual pain perception served the purpose of deferring the pain experience and facilitating their performance during competition.

I’ve seen lots of different injuries and lads and girls experiencing different levels of pain from injuries as well. I’ve had injuries myself. (P04)

It kind of has physical implications and psychological as well yeah. (A11)

For the majority of anything from a niggle to an injury, if you warm up you can still run on it. (A01)

The adrenaline of it all takes over I’m able to finish the rep or finish the race but as soon as I stepped off the track, I said to my coach on both occasions like ah somethings gone wrong. (A08)

2.2 Making sense of pain

Differentiating between pain and injury is a challenge athletes and physiotherapists often grapple with. In many cases, injuries may be indicated by pain, while in others it is not. The amount and intensity of pain an athlete perceives are influenced by factors beyond tissue damage,2–4 something which athletes and physiotherapists in our study found frustrating to reconcile.

That is something I definitely struggle with from an athlete perspective is when does pain become something that stops you from competing … as opposed to finding that place where you know it’s safe to continue. (A12)

I don’t think it relates to pain, I don’t think pain relates to level of injury, I think it’s a very loose connection to make, especially an acute injury. (P04)

Exploring the meaning of pain, athletes and physiotherapists acknowledged the individual nature of pain enlisting individual pain descriptions and language to describe their experiences. Accurately representing pain required consideration and time for reflection with successful communication hinging on the physiotherapist understanding and valuing the athlete’s unique lexicon.

I think everyone kind of expresses themselves differently. (A11)

I suppose as long as your physio understands your language, that’s the key thing and that’s where the relationship with your physio is actually kind of important. (P03)

Contributing to feelings of frustration, athletes are also faced with an abundance of information from different sources. Previous research suggests that availability of large swathes of information makes it difficult to identify the most important elements when it comes to managing pain and operating in a contemporary world adds additional complexity.33 Athletes and physiotherapists in our study discussed how the internet, social media and data derived from wearable technologies might provide a source of helpful information but often exacerbates the dilemma of deciphering pain due to the nature of comparison on social media and the abundance of non-evidence based information, particularly for athletes who have poorer levels of digital health literacy.

Like Instagram and people influencing you and you know like I was changing exercises every single day trying to solve my pains … the stress and the thought process. (A07)

I think people get really confused about the whole situation, they’ve read stuff, they’ve probably been to other practitioners before, they’ve gone around the mill so they can be a little bit of a challenge in terms of figuring out where they are from both a pain point of view, function point of view. (P03)

Despite the challenges, athletes valued the protective role pain plays and were intrigued to learn more both about, and from, their pain. Pain acted as a warning sign or indicator that athletes and physiotherapists used when deciding which pain and load management strategies to apply.

But for me, it’s kind of a feedback mechanism for the injuries to kind of guide me on what I can and can’t do. If the body signals to kind of back off on things and try to kind of use it as a guide or to teach you how far to push things with injuries and stuff. (A09)

3.1 Challenging emotions

Athletes reported that they often feel worried and anxious owing to the lack of certainty of the potential causes, consequences and outlook of pain, which physiotherapists concurred with. Pain persisting beyond expected timeframes encroached on everyday life and heightened concerns. Pain and feelings of doubt negatively impacted athletes’ capacity to make sense of and manage their pain effectively. Fear, doubt and frustration were often synonymous with athletes’ experiences of pain in this study and emotions have previously been found to impact an athlete’s ability to maintain activity levels when injured.37 Athletes in this study spoke about how they fear pain intensifying and are acutely aware of the impending impact it may pose on their ability to participate in sport. At times, the inertia accompanied by this cocktail of emotions left athletes feeling guilty for not being more proactive and blaming themselves for their situation.

The fear that it’s going to get worse or feeling like it’s going to stop me from playing. (A02)

Exactly they (athletes) are afraid it’s going to get worse. (P04)

When you go through the pain for that long you want it to not be there you start to not trust your own perception. (A03)

But then I do kind of feel bad because if it’s something that happened before, then I know I should have been doing my rehab so it’s kind of my fault. (A01)

3.2 The impact of time on the emotional aspects of pain

The trial-and-error nature of pain assessment and management was often at odds with the protracted timelines athletes have to make decisions and be ready for their next competition, leading to frustration. Participants described how repeated pressurised decisions contribute to the cumulative emotional toll which negatively impacts an athlete’s physical and mental well-being, reflecting previous research findings.30 Athletes discussed the negative impact of pain on their ability to participate in their sport and how the psychological toll of not being able to train or compete impacted sleep, contributing to fatigue and further fuelling a negative pain and quality of life cycle.

Obviously when pain would reach a point that it takes you out of the field of play it can really affect you mentally and it’s difficult to deal with and it can affect all walks of life just away from the sport. (A05)

Yes it was really frustrating because it was like a circle of not being able to sleep and that kind of causing disruption to feel just tired and generally fatigued throughout the day and then fairly anxious and depressed that you can’t train. (A10)

You know the chronic stuff, especially when its more chronic the more cloudy that person becomes in terms of their own thoughts on it, what’s sore, what’s not sore be it a persistent thing in their life. (P03)

4.1 Coping with pain

Applying transferable skills acquired in their sports, athletes in this study discussed using a variety of coping strategies including managing their attention and maintaining their fitness with non pain-provoking cross-training modalities. When pain is associated with injury requiring time out from sport, or when pain management requires a period of rest, athletes shared how they can use the additional time to reflect and foster other interests and hobbies away from their sport which may help manage stress, an important aspect of pain management that has been discussed in previous research.6 In this study, athletes acknowledged the often-unrelenting nature of the pursuit of excellence within sport and the opportunities afforded during a period of rest required to manage pain or injury.

Sometimes you just want to ignore pain and just get through it or whatever. (A05)

Just kind of did my own thing, kind of eased off worked around it because I do kind of a broad range of stuff like and almost always work around injuries. (A09)

You have other parts of your life that you can focus on like you’re able to focus on different types of training and like for example I really enjoy gardening so like whenever I’m injured, I tend to go and garden more because well I can’t train but also it’s a really nice outlet for me to relieve some of that stress. (A08)

4.2 Influence of community and support networks

Understanding and managing pain can be a solitary pursuit; however, athletes in our study identified that they are part of a wider community. Prior research has found that relationships with friends, family, partners, teammates, colleagues, coaches and healthcare practitioners play a pivotal role in athletes understanding, managing and coping with pain.38–41 Emotional support for athletes in this study came from personal relationships and teammates who were often the most appropriately positioned to offer context-specific empathy and advice. Conversely, athletes involved in individual sports were acutely aware of the void of comradery.

My current partner she was just like go back and get some sleep and take care of yourself for a few weeks. (A10)

The players we all live together they are the ones who would probably check in on you more in that aspect asking you from the perspective of how you are feeling about it. (A05)

I think it’s better that if you’re in a team sport, you could talk to some of your teammates like A02 could. Like it’s sometimes hard on your own. (A01)

Athletes described how they spend a significant amount of time with coaches with relationships developing over years in many cases. The support an athlete feels from their coach and the trust and honesty encompassed within their relationship is inextricably linked to the athlete’s attitude and response to pain.42 Participants discussed how some coaches tend to ignore pain, focusing on return to play, while others respond to pain acknowledging the impact it has on the athlete and the strategies needed to best manage it. Physiotherapists acknowledged the integral role coaching staff play in managing athlete pain, investing time in explaining the complexities behind return-to-play timelines and the variable nature of pain that is unique to each athlete.

The coaches very rarely ever asked about how are you getting on, how are you dealing with it, it was always just when are you back. So, they don’t tend to look at you as much as a person and ask you about how you are getting on with it and how are you feeling about it. (A05)

Because in different scenarios management play a huge role in it like is there somebody that is going to look and say you know, we’ll sit you out this game or you don’t have to train Wednesday but you’re still playing Saturday or trying to get a balance. (A07)

I find I spend a lot of time actually educating managers on injuries and the likely timeframes and how that might change depending on how they’re doing. (P02)

4.3 Communication—the broken key

Central to successful and supportive relationships is effective communication regarding the experience of pain. Previous research has highlighted how the quality of communication between members of the athlete’s support team is linked with availability to train and compete as well as risk of injury.39 A concept mapping study of a group of 33 athletes, coaches and clinicians identified coach–clinician relationships and interdisciplinary team communication as key factors associated with recovery for athletes experiencing low back pain.41 Additionally, a set of 11 guiding principles has been provided for sports rehabilitations clinicians outlining how we can all contribute towards improved communication.40 These include actively listening to and empathising with the athlete, respecting and exploring an athletes beliefs around pain and injury, being transparent specific and concrete in communication to all members of the team and working in a cooperative and collaborative manner. Physiotherapists and athletes in this study spoke about how they work together and with other members of the interdisciplinary team at various stages throughout the pain journey. Adequately reporting and describing pain to clinicians was often challenging for athletes owing to the time constraints of clinical and sports-based assessments.

Because I, actually, before I go into a physio, I do write down what I’m going to say, because more often than not I’d leave forgetting to mention things and you’re like, oh god, well it’s gone now and I’m never going to say anything. (A11)

Athletes and physiotherapists discussed how physicians often sit at the top of the decision-making tree when it comes to managing athlete pain medically. As a result, some athletes find the decisive nature of these clinical decision-making interactions refreshing, providing clarity. In stark contrast, athletes can also find interactions with physicians limiting and reductionist, with physiotherapists also echoing this frustration.

Whenever I feel pain, I go to the Doctor and they confirm what my pain was and I’m reassured that what I felt was real and then I follow the rehab protocol. (A08)

That’s very hard yes this pain like that thing in my foot I’m like I’ve had this years how do you get a sports doc to see that beyond just the MRI and what it shows you? (A08)

With the doctor instead of constantly saying to everyone we’ll just MRI your back maybe they start to get a bit better too at knowing who they should be referring for medical imaging because we’re picking up the bloody pieces after it. (P02)

Athletes shared how in sport, the pressure to perform and rapidly return to play, a deep sense of responsibility to teammates and playing through pain culture can be at odds with the time and space needed to effectively communicate the pain experience within their support network. Physiotherapists also noted the effect the team dynamic of sport has on an athlete negotiating their pain.

The team environment and how competitive it was at the time, you couldn’t really say to the management unless it got to a point where like there’s fairly you know something sinister or something. (A07)

There is a little bit of a sense of community, teammates and stuff that’s going on as well where ‘who am I letting down?’ so you know. (P03)

When communication and the ensuing support are hampered, athletes found that their resources for coping are reduced and the likelihood of seeking medical and surgical interventions can increase. Conversely, when communication is effective, collaborative decision-making can occur with comprehensive pain management plans being devised. This was often accompanied by a more positive outlook with athletes reporting feelings of acceptance and empowerment as key markers of moving forward and coping with pain. Similarly, physiotherapists acknowledged the importance of cumulative short-term goals for athletes to focus on as a strategy to address the complexity of coping with and working through pain. They discussed how the process is dynamic, requiring the physiotherapist to be in tune with the changing nature of an athlete’s pain experience.

Until you kind of accept it and then you sort of say to yourself okay right, what’s my path to recovery? I think you’re at nothing with most injuries to be honest like you have to have that level of acceptance. (A09)

Like okay what do you want to do here to make or to help you reach your goal and look it has to be a fluid and agile situation as well when to pull, when to push, what things that work and what things are not working. (P03)

Athletes resourcefully employ a range of strategies to improve their understanding and manage their pain. An athlete’s personal, sporting and medical community forms an ecosystem which offers additional strategies beyond those available on an individual level. Accessing these strategies often hinges on effective communication between the athlete and their support network.38 39 41