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‘I always considered I needed injury prevention to become an elite athlete’: the road to the Olympics from the athlete and staff perspective
  1. Oriol Bonell Monsonís1,
  2. Evert Verhagen2,
  3. Jean-Francois Kaux3,
  4. Caroline Bolling2
  1. 1Department of Movement Sciences, Department of Epidemiology, Maastricht University, Maastricht, Netherlands
  2. 2Amsterdam Collaboration on Health & Safety in Sports, Department of Public and Occupational Health, Amsterdam Movement Sciences, Amsterdam UMC, University Medical Centres – Vrije Universiteit Amsterdam, Amsterdam, Netherlands
  3. 3Physical Rehabilitation Medicine and Sports Traumatology Department, SportS2, University of Liège and University Hospital of Liège, French-speaking Research Network for Athlete Health Protection & Performance (ReFORM), Liège, Belgium
  1. Correspondence to Professor Evert Verhagen; e.verhagen{at}amsterdamumc.nl

Abstract

In this study, we explored the perspectives about sports injury prevention of Belgium Olympic level athletes, coaches, managers and healthcare providers from various Olympic sports. We conducted a qualitative study, including 17 semistructured interviews. All interviews were transcribed verbatim and analysed by two independent coders through constant comparative data analysis based on Grounded Theory principles. Our findings overview the athlete’s journey to becoming an elite athlete, and how an elite sports context influences and modulates injury prevention practice at this level. Participants described an elite athletic career as a continuous and adaptive evolving process. According to athletes and all stakeholders, sports injury prevention is a learning process shaped by individual experiences. This embodiment provides athletes with insight into the importance of ownership of their bodies and self-awareness. Thus, experience, communication, empowerment, knowledge, education, the elite athlete context and sports culture, all play a fundamental role in sports injury prevention. Our findings support the importance of contextual factors in sports injury prevention in an elite sports context. These results also bring practical implications on how we should approach injury prevention differently along an athlete’s journey to becoming an elite athlete. Considering specific contextual factors and influencing the process through awareness, communication and a shared responsibility is essential to develop a healthy and successful athlete.

  • education
  • injury
  • athlete
  • prevention

Data availability statement

Data are available on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Key messages

What are the new findings

  • Qualitative methods can be applied to understand injury prevention as a complex and dynamic system and gain insight into the role of contextual factors and their interactions in sports injury prevention.

  • Contextual factors greatly influence the athlete’s journey towards becoming an Olympic level athlete.

  • Awareness, exposure and guidance regarding injury prevention in the early stages of an athlete’s career can impact future preventive behaviour and athletic success.

How might it impact clinical practice in the future

  • Injury prevention demands engagement and empowerment of multiple stakeholders who should communicate openly and share responsibilities.

  • Experience plays a crucial role in athletes’ careers and how athletes and their staff perceive and deal with injury prevention. This learning process contributes to shaping sports injury prevention strategies.

  • The approach to develop and sustain injury prevention strategies for less or more experienced athletes should be tailored according to their different demands, maturity level, knowledge and ownership of their careers.

Introduction

Elite athletes coexist in a performance-driven environment in which the aim is to increase sports performance. In such a context, there is a substantial risk of sports injuries,1 which directly impacts the athlete’s ability to perform.2 3 As a consequence, injury prevention plays a crucial role in the context of elite sport.4 With a growing research interest in the field over the last decades, we now have access to diverse and efficacious injury prevention strategies within various sports.1 5 However, the adoption of these measures in elite sports is limited, and the results presented in studies are not commonly translated into practice.6–9

Likewise, we know that the challenges to prevent injuries are also related to the complex nature of the problem, which requires a better understanding of the injury in a specific sport-related context.4 10–12 So, to successfully implement sports injury prevention interventions, it is fundamental to investigate the context of injuries and give voice to stakeholders.4 13 14 The perspectives of athletes, coaches, and healthcare providers can provide insights to improve injury prevention.15–17 Yet, these views are currently under-represented in the literature.18 Findings from qualitative research indicate that coaches, health professionals and athletes acknowledge the importance of injury prevention as a means to achieve the best performance, taking into consideration their elite sport context.19–21 However, the preventive measures described in such studies are related with open and effective communication, teamwork and empowering athletes rather than the exercise-based interventions widely documented in our literature.22 23 Qualitative research methods4 24 provide insight into the meaning and understanding of the contextual factors and can help us understand how and why injury prevention is adopted (or not) in the context of elite sports.4 15 22 Thus, identifying these aspects may benefit the adoption of injury prevention strategies and lead to more context-driven prevention measures. Therefore, this qualitative study aimed to explore perspectives around sports injury prevention of Belgian Olympic level athletes, coaches, and healthcare providers.

Methods

Study design

This study used a qualitative research design based on grounded theory (GT) principles25 26 focusing on building new theories from data, involving an inductive approach. Our analysis intended to address processes and interactions by interpreting and generating connections from multiple perspectives and participants’ realities within an interpretive paradigm.27 Results are reported according to the Consolidated Criteria for Reporting Qualitative Research.28

Participants

The participants in this study were elite athletes and their respective coaches, team managers and medical staff representing the Belgian Olympic and Interfederal Committee. A contact person (J-FK) from the IOC Research Centre from Belgium (from French-speaking Research Network for Athlete Health Protection & Performance, site of Liège, Belgium) contacted the sports federations which provided the contacts of the participants. All potential participants were first contacted through an invitation email containing an information letter. After acceptance to participate, they were contacted by the research team. All participants had to be Olympic level athletes or staff, who either participated in the previous Olympic Games were available for selection or had already qualified for the upcoming Olympic Games.

Our aim was to include a heterogenic group of participants. Therefore, a maximum variation sampling method29 was adopted and our contact person had instructions to recruit a diverse sample. Consequently, we included young and experienced participants from different individual and team sports. While this provided us with various perspectives, backgrounds and experiences.

Data collection

Data were collected through online semi-structured interviews between March and May 2020. All interviews were conducted in English by CB. The mean length of the interviews was 33 min (range 23–47 min). The topic list is presented in table 1. After 17 interviews, the same constructs were repeated, and no additional new themes emerged from the data, indicating that saturation had been reached.30

Table 1

Topic list and interview questions

Data analysis

All interviews were audiorecorded and transcribed verbatim and further inductively analysed based on constant comparative data analysis,31 32 employing principles of GT.

In the first stage, two researchers (CB and OBM) independently open-coded seven interviews, using the ATLAS.ti software (Scientific Software Development, Berlin, Germany; V.8.4.5). Subsequently, codes and memos were discussed, and researchers refined the analysis by merging related codes into categories and making connections between codes. Once consensus was reached, OBM coded the remaining interviews (n=10). CB and OBM discussed the emergent findings over two meetings and presented an overview to EV, who was unfamiliar with the interviews. In the same meeting between the three researchers (OBM, CB and EV), codes, categories and discrepancies were discussed and compared until agreement was reached. Consequently, the preliminary results of the analysis were developed by developing the main concepts of the analysis. Finally, a diagram was developed to illustrate the athlete’s journey with the main topics and their interconnections with injury prevention.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

Seventeen interviews were conducted with eight athletes, three managers, two coaches, two physical therapists, one medical doctor and one strength and conditioning coach (S&C). Participants were working in basketball, judo, athletics and equestrian sports. To guarantee confidentiality, no further details will be provided on demographics. Our findings are presented according to the main themes and the respective codes and quotes available on the tables.

Shaping injury prevention behaviours

Participants defined injury as an event that prevents them from performing independently of any pain perceived (table 2). Athletes and staff reported that biomechanical, physiological, psychological and contextual factors could influence injury (table 3). However, the main preventive interventions detailed by participants focused on exercise-based strategies, performed primarily during the warm-up. Additionally, recovery strategies, nutrition, staying physically and mentally healthy, and managing training loads were reported. Furthermore, some athletes acknowledged the importance of visiting physiotherapists periodically. Preseason assessments were mentioned to identify any weaknesses and risk factors to be addressed during the season.

Table 2

Themes, subcodes and exemplary quotes on injury prevention behaviours

Table 3

Themes, subcodes and exemplary quotes on responsibilities and elite athlete’s context

Athletes and staff mentioned that they choose the injury prevention strategies based on experience and what athletes liked or, as an athlete stated, on ‘what makes me feel good’. Also, physiotherapists and S&C coaches choose their recommended interventions considering the scientific evidence and their own experiences.

Staff members recognised the importance of planning, organisation and the potential ‘marginal gains’ when considering the smaller details as part of injury prevention and performance. The latter is the ultimate goal in elite sports.

We learn by doing: the power of experience

Sports injury prevention was regularly mentioned as a learning process influenced by an athlete’s experience (table 4). This experience was mostly associated with the years of being an elite athlete and the lessons learnt through previous injuries. Throughout this process, athletes gained more knowledge. Athletes raised awareness and acknowledged the importance of injury prevention by taking care of and listening to their bodies, which allowed them to push their limits more ‘consciously’. Moreover, the participants repeatedly compared their current injury prevention behaviour with their early career, commenting about how they had become more aware of and proactive in implementing sports injury prevention measures.

Table 4

Themes, subcodes and exemplary quotes on the role of experience

Previous injury and avoiding the consequences were noted as the main motivations to practice injury prevention strategies, again showing the importance of experience. Some staff members were former athletes and mentioned that their previous experience could benefit their athletes. Also, once athletes reached the elite level, they considered being an athlete their job and preventing injuries their responsibility.

Responsibilities and the influence of elite athlete’s context

All participants considered the athlete the main responsible person for preventing injuries, but they also stated the supporting role from the stakeholders (table 3). Likewise, athletes and staff members mentioned the importance of teamwork and shared responsibility to prevent injuries.

All participants recognised that an elite context entails athletes being surrounded by a qualified and specialised group of professionals, sometimes chosen by athletes themselves. This promotes a sports culture of injury prevention. However, athletes admitted they were more susceptible to injury due to their high physical demands, which provide a greater focus on injury prevention. Being an elite athlete places more responsibility on the individual, leading to more available resources for injury prevention and a more comprehensive team around the athlete with easier access to medical care.

Communication within the team as a cornerstone

Reinforcing the value of teamwork, open and effective communication between all stakeholders was reported to be an important foundation for the injury prevention process (table 5). Constant communication, especially between athletes and coaches and athletes and physiotherapists, was crucial to building trusting relationships. In the particular context of Belgium, participants described the differences between the Flemish and the French-speaking regions regarding the organisation, equipment, facilities, structures, economic resources and interventions implemented, and how eventually these differences influenced injury prevention.

Table 5

Themes, subcodes and exemplary quotes on communication

Some issues on communication were mentioned. For example, a participant stated that ‘Belgium is different as there are two parts’ where ‘everything is duplicated’. Moreover, an athlete has a national coach and, often, a personal coach whose visions on injury prevention may differ. Collaboration and open and free communication between these two stakeholders is vital for the athlete’s success at all levels. Specifically, the coaches’ role in injury prevention was related to their communicative skills. Strong communicative skills forged a bond with the athletes through guidance and shared decision making and transmitting coaches’ knowledge and experience to their athletes. This ultimately diminished injury risks.

Sports culture evolution and elite context impact on injury prevention

When athletes and the staff were asked how their elite context influenced their careers and injury prevention, they stated that ‘it is evolving’ even though there was still work ahead (table 6). The most experienced athletes and staff members who were former athletes constantly compared the early years of their careers with their current situation, underscoring a remarkable evolution in resources, professionalism and specialised care to support the athlete. Participants reflected on these differences in experience, pointing out the need to educate and raise awareness of injury prevention from a young age to make it a habit.

Table 6

Themes, subcodes and exemplary quotes on ongoing evolution in sports culture on sports injury prevention

Despite the evolution as mentioned above, certain challenges were mentioned. On the one hand, early in their careers, athletes mentioned having limited body awareness and not taking care of their bodies. Participants highlighted that no or limited injury prevention measures were implemented. At this stage, some athletes recognised that they normally did not engage in any injury prevention strategy until they sustained an injury. For instance, equestrian athletes reported that it was considered as part of the sports culture that riders suffered from back pain, as one rider stated that ‘I don’t know one rider who doesn’t have back pain’. Also, from the staff and community standpoint (ie, federations, clubs), injury prevention was not perceived as a priority in the athletes’ daily routine.

Thus, all stakeholders advocated the importance of improving facilities and organisational structures and implementing injury prevention strategies for athletes. Furthermore, according to participants, improvements in education and awareness on prevention (to young athletes and all stakeholders) would impact injury prevention and performance. Moreover, it was mentioned that sports popularity and success in international competitions influence the availability of economic resources and personnel.

The lack of a comprehensive nationwide structure was also mentioned as part of the context. This limitation can impact the recovery time. For example, some athletes had to travel for more than an hour between their home and training facility. On the other hand, the top sport school system (National programme for talented young athletes) was mentioned as a relevant structure at the beginning of athletes’ careers.

Becoming an Olympic level athlete

From early on in their careers, experience played a leading role in athletes’ careers, influencing their knowledge, motivations and responsibilities on injury prevention. Thus, sports culture, experience, communication, empowerment, knowledge, education and the elite athlete context play a fundamental role in sports injury prevention. Additionally, their experiences guided them through their sports journey to contribute to their preventive strategies. The team around the athlete also evolves along the process, making communication and trusted relationships essential for shared-decision making. The preventive strategies are developed based on motivations, knowledge, evidence and the athletes’ opinion of what ‘feels good’ for them. The evolution of injury prevention itself is influenced by the constructs of the journey (sports culture, experience, team and context). By the time athletes reached the elite level, they had more resources and a better supporting structure in general. Becoming an elite athlete was the endpoint of the process; it comes with a higher risk of injury and brings more responsibility because it is a job. This embodiment provides athletes with insight into the importance of ownership of their bodies and self-awareness. Figure 1 depicts this development process from young athletes to elite athletes as a visual summary of our results.

Figure 1

Following our data analysis, this figure summarizes the athletes’ path from their early careers towards becoming elite athletes. In the first years, athletes have limited awareness and knowledge about injury prevention and need more guidance. The development process of an athlete is represented in the central arrow, which contains the main constructs that evolve during their athletic journey; sports culture, experience, injury prevention, teamwork, and elite context. In the centre of the process, injury prevention is influenced by the other constructs as well. At the end of the road, the elite athlete has more responsibility and a greater risk to get injured. Still, they are more actively engaged in injury prevention and push and respect their limits based on self-awareness.

Discussion

This qualitative study captured perspectives from athletes, coaches, managers and healthcare providers regarding fundamental factors on injury prevention strategies in the Olympic level sports context. Our findings overview the athlete’s journey to becoming an elite athlete and how the elite sports context influences and modulates injury prevention practice.

Experience defines an athlete’s journey

Our findings show that preventive behaviours are built on athletes' experiences. Experiences guided a constant learning process in which age, maturity and previous injuries influenced injury prevention throughout their careers. Participants highlighted that this process was part of becoming an elite athlete,33 since they consistently compared their current behaviour with their previous preventive strategies from the past. The experience of sustaining injuries plays a role in this development of preventive behaviours.22 33 34 Yet, the influence of experience in sports injury prevention has not been fully investigated in sports medicine.

Less experienced athletes take less responsibility when making decisions, signifying they need more guidance earlier in their careers. Meanwhile, experienced athletes have acquired more understanding and responsibility, which allows some autonomy and independence in their decisions around sports preventive strategies.34 Therefore, as suggested in return-to-sport literature, engaging and empowering athletes provides an athlete-centred approach that promotes the athlete’s athletic, personal and professional development.35 Thus, different approaches should be considered when dealing with youth or experienced elite athletes. Nonetheless, further studies on the athlete’s ownership within the injury prevention field are needed.

Investing in education is needed: but for whom and how?

Athletes emphasised the necessity of awareness and better education regarding injury prevention at their early career stages, facilitating their learning process. However, based on the results discussed, early-career athletes need a different preventive approach (and education) than later career athletes. Previous studies support the idea that this process also needs close supervision by all stakeholders who support the athlete.36 37

The experienced athletes reported a more active role in their education and the decision-making process. Previous studies confirm our findings that athletes gained experience through trial and error, with their previous experiences shaping their current preventive behaviours. For young and less knowledgeable athletes, we must consider the relationships and interactions that impact their positive health behaviours, and extend the latter throughout their elite athletic career.36 It has also been suggested that rugby players of different ages should have different approaches for their education.38

Education in sports injury prevention is of utmost importance. For instance, providing athletes with educational resources greatly influenced rugby players’ attitudes towards injury prevention.39 Although recent research has been conducted on the importance of knowledge and information in sports injury prevention, there is little literature regarding athletes’ perspectives on education resources. Based on our results, different strategies regarding education should be taken based on the athlete’s experience.

The culture around high-performance sports should also be considered. Previous studies focused on the socio-cultural environment and its negative impact on injury risk, with athletes competing injured and accepting such behaviour as normal.40 41 On the other hand, as our participants recognised the value of injury prevention that is needed to reach the elite level and the changes in culture compared with previous generations, our study indicates that it is possible to develop a positive culture of reducing injury risk through awareness and education.

Contextuality of injury prevention: when, where, for whom and how?

Athletes and staff compared the current sports and injury prevention situation with their earlier careers, mentioning evolution and generational gaps. The contemporary medical resources and professionalism were not always in place. Although participants defined and perceived injury alike, sports culture across athletes and their teams substantially influenced their awareness, willingness, adoption and implementation of injury prevention.

Our study reported the diversity in economic, structural, and personnel resources among sports and Belgian communities. However, such diversity is not exclusive to the Belgium context and should be considered when planning and implementing injury prevention strategies. A recent study showed medical service quality and access variations among international elite adolescent athletes from different countries.42 This diversity of resources and structure can impact the quality of care. This contrast in providing such resources suggests that only the fittest or the least injured athletes survive their elite journeys.

Athletes highlighted a mismatch in terms of resources. Young athletes had limited awareness of resources or access to information on injury prevention. Experienced elite athletes are better equipped than their younger, more inexperienced counterparts and have access to resources that they may not need to the full extent. Providing young athletes with more resources will allow them to develop athletically and personally,36 43 through education leading to injury awareness and procurement of strategies to lower injury risks. This supports the developing athlete to reach an elite level.

Given the dynamism and complexity of injury prevention strategies, creating a functional, collaborative interdisciplinary team is critical to share responsibility for developing and implementing preventive behaviours.7 10 11 44 Therefore, all stakeholders should be involved in injury prevention and be aware of the contextual factors around athletes that change over time.

Methodological considerations

The trustworthiness of our findings was reinforced by applying different methods.45 Data and investigator triangulation were employed for credibility by including different stakeholders such as athletes, coaches, managers and healthcare providers, and different researchers with different backgrounds and cultures conducting the data analysis process. Multiple meetings and discussions validated the analysis and the relationship with previous literature to increase confirmability. Regarding transferability, our participants comprise a diverse sample of Belgian Olympic level athletes and staff with diverse experience, backgrounds and cultures concerning injury prevention. This provided a broad insight into the complexity and dynamism of sports injury prevention. Still, we need to understand that these findings are contextual and circumstantial. Dependability was accomplished by creating an audit trail in which memos were written to record the development and reporting of the findings.

Conclusion

Our findings provide an insight into the contextual factors that influence sports injury prevention at an Olympic level. These results also bring practical implications on how we should approach injury prevention in different ways along the journey of becoming an elite athlete. Considering specific contextual factors and influencing the process through education, communication and shared responsibility is essential to develop a healthy and successful athlete. Future investigations should explore contextual factors of different sports, settings and levels to develop more comprehensive and context-driven injury prevention strategies.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Amsterdam UMC Ethics Committee. Protocol number 2020.2014.

Acknowledgments

All authors that analysed data are trained and experienced in conducting qualitative research with athletes. OBM is a sports physiotherapist with experience in sports injury prevention. CB is also a sports physical therapist with experience in elite sports injuries and a postdoctoral researcher. EV is a sports scientist and epidemiologist with broad experience in injury prevention. The diversity of perspectives and backgrounds represented by the authors supports the rigour and trustworthiness of the findings. This study is part of a larger project involving 12 partners across the IOC Research Centres of Excellence (Canada, South Africa, Denmark, Australia, Belgium, and France (ReFORM - French-speaking Research Network for Athlete Health Protection & Performance), South Korea, United Kingdom, Qatar, the Netherlands, Austria, United States of America). We would like to acknowledge the participants who participated in this study for their time.

References

Footnotes

  • Twitter @evertverhagen, @cs_bolling

  • Contributors CB and EV designed the study. CB coordinated the study. J-FK recruited athletes and staff. OBM and CB conducted the data analysis. OBM, CB and EV interpreted the results. OBM drafted the first version. CB, J-FK and EV contributed intellectually and provided feedback on various drafts. After that, all authors were involved in editing the manuscript and approved the final manuscript. EV is the guarantor of this study, and responsible for the overall content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests EV is Editor in Chief of BMJ Open Sports & Exercise Medicine.

  • Patient and public involvement Patients and/or the public were not involved in the design, reporting, or dissemination plans of this research. As this was a qualitative study, participants were invovled in the conduct of the research and the results present the participants' voice.

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

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