To understand elite athlete, coach and support staff experiences, perceptions and beliefs in women’s water polo with managing upper limb injuries and monitoring training loads. Inductive qualitative design. Twenty athletes, coaches and support staff were purposively recruited and participated in semistructured interviews. Participants either had experienced an upper limb injury or had experience managing athletes with upper limb injuries. Interviews were conducted in-person or virtually, audio-recorded, deidentified, transcribed verbatim and cleaned to ensure accuracy. Data were thematically analysed. Analysis identified five cohesive themes: (1) upper limb injury management is adequate—but prevention, communication and knowledge need improving, (2) current training load monitoring generates uncertainty and lack of consistency of processes—due to reliance on internal, and lack of external load monitoring, (3) optimal training load monitoring requires objective measurement of training load—that accurately measures the external load of athletes’ upper limbs, (4) athlete-centred philosophy matters—including athlete-centred care to facilitate individually tailored rehabilitation programmes and their inclusion in management decisions, (5) mental, social and emotional aspects of upper limb injury management matter—acknowledging feelings of loss of team inclusion, fear of missing out and frustration felt by athletes as well as the emotional labour felt by coaches when supporting athletes with an upper limb injury. Upper limb injury management and training load monitoring are evolving areas where objective measurement of training load may assist in increasing consistency of communication, collaboration and coordination between all stakeholders, and to address uncertainty. Stakeholders placed value in intangible qualities such as trust and care in their relationships with other collaborators—facilitating athlete physical, mental and emotional recovery following upper limb injuries.
- water polo
Data availability statement
No data are available.
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What is already known?
Upper limb injuries pose a considerable burden to training and competition in elite women’s water polo.
Communication, teamwork and shared responsibility are likely key factors in successful injury prevention in elite sport.
Individual and contextual stakeholder experiences/perceptions on injuries may inform future injury prevention programmes.
What are the new findings?
Sports-specific knowledge, injury prevention programmes and guideline development are needed to further improve upper limb injury management in elite women’s water polo.
Communication, collaboration, consistency of processes and coordination of systems between stakeholders are essential attributes to optimise upper limb injury management.
Objective measurement of training load was perceived as a potential mechanism for facilitating more consistent communication and thereby increasing opportunities for collaboration and coordination.
Qualities such as care and trust in stakeholder relationships are perceived as optimising athlete physical, mental and emotional health during upper limb injury recovery.
Water polo is the oldest Olympic team sport with men’s participation commencing in 1900 and women’s participation in 2000.1 The sport involves high volumes of swimming, throwing and contact skills, exposing players to upper limb injuries.2 Women water polo athletes appear to have higher vulnerability to upper limb injuries than men athletes. In US collegiate water polo, women athletes were more than twice as likely to sustain a shoulder injury than their male counterparts (8.09 vs 3.4 injuries per 100 participant years).3 Women’s water polo injury incidence has significantly increased over time (2004: 3.57 injuries/1000 player matches, 2009: 23.8 injuries/1000 player matches), possibly due to the intensity of the game increasing to that of the men’s game.4 There is currently a dearth of information about out-of-competition injury data—likely underestimating injury incidence in training thereby impeding the development and implementation of possible prevention practices.5 6 During a video analysis of seven athletes at a national women’s water polo camp, 74% of all shoulder soreness could be explained by increases in goal shooting volume and decreases in rest time between shots.7 It is apparent that there is a need to address shoulder injuries, which are prevalent in women athletes and likely related to training. If we are to effectively manage shoulder injuries in women water polo athletes, it is imperative that their experiences, perceptions and beliefs along with those of their coaches and support staff are understood.
In other sports such as swimming and athletics, stakeholder’s perspectives on injury prevention have been investigated. Bolling et al found that communication, teamwork and shared responsibility were key factors in successful injury prevention within elite sport.8 Yet it is unknown whether water polo stakeholders, defined as athletes, coaches and support staff, have similar views and the context within which they operate. Injury prevention frameworks have advocated for individual, societal and contextual factors to be investigated and incorporated in the design of injury prevention programmes.9 Within this context, qualitative research is critical, as it provides insights on stakeholder experiences and perceptions, which can inform the design and implementation of future injury prevention programmes.10 The aim of this study was to investigate experiences and perceptions of water polo athletes, coaches and support staff with managing upper limb injuries and monitoring training loads—with a view to understanding any perceived individual and contextual barriers or enablers.
This study used an inductive qualitative design where we drew meaning and concepts from participants’ responses.11 Our knowledge and patterns of meaning did not begin with a preconceived theory but emerged organically out of the process of interviewing, coding and thematically analysing the data.12 Our study’s methodological underpinning was centred in relativist–contextualist paradigm—acknowledging that multiple realities exist both within and between individuals and that knowledge and understanding are viewed through an individual’s interpretation and context.13 14 In this study, we were interested in gaining a comprehensive understanding of both the lived experience and context of participants, as their insights will inform the future development of tools and resources to address their needs.15
Participants were included in our study if they were: athletes who had sustained an upper limb injury, and coaches and support staff who had managed an upper limb injury over the previous 12 months. Athletes who had not sustained an upper limb injury and coaches and support staff not involved with state or national athletes were excluded.
Participants were recruited over 3 months (December 2020 to March 2021) as a purposive sample by two Australian water polo staff who were not involved in the study. These staff were informed of the selection criteria and sought a broad representation of athletes, coaches and support staff in elite level water polo. We sought to include athletes from different geographical locations, different training ages, playing position and levels of injury experience as well as support staff and coaches who had different levels of coaching experience and philosophies from different geographical locations. The two Australian water polo staff emailed potential participants within the high-performance system database. Those interested in participating replied by email and received a participant information and consent form. We ceased participant recruitment when sufficient saturation was reached, that is, when there was sufficient depth and repetition in the themes that addressed the study aims.
Semistructured interviews were conducted from December 2020 to March 2021, either in-person or via Zoom. One of the investigators (MHK) works as a physiotherapist in elite women’s water polo and was known to some of the interviewees. To protect participants’ confidentiality and ensure the trustworthiness of the data, we engaged a physiotherapist with extensive experience in qualitative research (NC) who was not known to the interviewees. Two investigators (MHK and NC) interviewed participants. To ensure consistency of the data collection, MHK, NC and BV cowrote the interview guide (online supplementary appendix 1). A series of consistent prompting and clarifying questions were formulated in case participants did not elaborate on their responses. MHK and NC conducted mock interviews with each other to ensure commonality in interview structure and prompting questions. NC then checked both the transcript and audio recordings of MHK’s first two interviews to ensure to ensure consistency of interview technique and appropriateness of structure. Both MHK and NC read the transcripts of each other’s interviews during the data collection period to ensure consistency of interview structure and content. No one else apart from the participant and the investigator (MHK or NC) was involved in the interview process.
Athlete’s lived experience of having an upper limb injury were explored through questions about training, rehabilitation, return to play and perceived factors that influenced their experiences within this context. Athletes were also questioned regarding their perceptions of current training load monitoring and what they believed could be done to improve both the management of upper limb injuries and training load monitoring. As water polo within Australia currently has significant financial limitations towards resource development, we were particularly interested in stakeholder perceived wishes in terms of resources or tools to improve upper limb injury management and training load monitoring, both with or without financial limitations. We prompted them to elaborate on their thoughts using hypothetical scenarios (eg, ‘blue sky scenarios’ with no resources constraints and also scenarios with limited resources available). Coaches and support staff were asked similar questions, with minor changes in wording to adjust to their experiences (online supplementary appendix 1). MHK and NC wrote field notes after each interview. In order to validate accuracy and to empower participant’s control of transcription content,16 the interview transcript was sent to each participant, who then could provide further input. Findings were not sent to participants because these were finalised during a competition season and most participants were unavailable to provide feedback. No repeat interviews were conducted.
Interviews were audio recorded and transcribed verbatim. Interview transcriptions were deidentified and cleaned for accuracy. Interviews were inductively and thematically analysed,12 allowing us to explore participants’ experiences at an individual level while comparing and identifying patterns. Two investigators (MHK and NC) coded the interviews using NVivo V.12 Plus (QSR International, Doncaster, UK). MHK is a female who has a master’s degree in sports and musculoskeletal physiotherapy, 20 years of clinical physiotherapy experience with 4 years of involvement with water polo. MHK is also a former elite rower, having competed at senior world championship and Olympic level and served on her sports athlete’s commission. MHK has received training in qualitative analysis. NC is female who has a PhD in physiotherapy and is an experienced qualitative researcher. The analysis was iterative and involved six steps: (1) both investigators repeatedly read the transcripts then discussed initial ideas emerging from the data; (2) MHK and NC coded one transcript together then each coded the remaining transcripts independently with MHK coding 11 transcripts and NC coding 8 transcripts; (3) during the coding process, MHK and NC had five meetings to discuss coding refinement and emerging preliminary themes addressing the research question; (4) MHK and NC collated and revised theme names and descriptions; (5) MHK and NC presented the themes to BV, AL and KW, who contributed by further theme refinement and wording alterations; (6) an experienced qualitative researcher (KM) uninvolved in the study was asked to confirm the appropriateness of the themes, codes and quotes in regards to the research question.
We interviewed 10 athletes, 5 coaches and 5 support staff for this study with interviews that ranged in duration from 27 to 53 min. The participant group characteristics are outlined below (table 1). Support staff professions included sports medicine, physiotherapy, strength and conditioning and physiology. Only one participant dropped out of the study prior to the interview due to competing priorities.
Athletes, coaches and support staff provided their views on opportunities for improvement of managing upper limb injury and monitoring training load—which on thematic analysis appeared interrelated. In brief, they highlighted the need for better rehabilitation strategies, including the acknowledgement of the mental and emotional health impacts of upper limb injury. Participants stressed that prevention and rehabilitation should be aligned with veracious monitoring of training loads—optimally using objective measurements of training load. Participants suggested that collaboration between all stakeholders with the athlete at the centre of the process was essential with open communication channels also vital for optimal management. The themes are described in greater detail herein and represented visually in figure 1.
Upper limb injury management is adequate - but prevention, communication and knowledge need improving
Reflecting on current upper limb injury management, most participants contrasted their past and current experiences and seemed to believe that the management of upper limb injuries has improved over time (table 2). Such improvement was discussed as a consequence of greater communication between current support staff, having staff members who collaborated effectively and who had extensive knowledge and/or experience in the field. Although the management of upper limb injury was perceived as generally adequate, some participants highlighted aspects of injury management that deserve further attention. Athletes highlighted a lack of strategies to prevent injuries from happening, differing levels of communication and coordination between athletes and support staff, and a need to further develop knowledge regarding water polo and its specific injuries. Likewise, support staff emphasised the importance of enhancing athlete’s involvement, the need of having a physiotherapist and/or coach assistants integrated into training programmes (eg, at the pool) and further coach education. Guidelines and diagrams were also highlighted as important tools that had the potential to enhance training planning, communication and coordination across stakeholders.
Current training load monitoring generates uncertainty and lack of consistency of processes
Both support staff and athletes discussed several issues regarding the current athlete self-report of training load on the Australian Institute of Sport Athlete Management System—as a surrogate internal training load.17 Participants raised concerns regarding athletes being asked, when concluding training, to provide a single numerical rating of perceived exertion during the training session (table 3). They were concerned that a single numerical rating of perceived exertion did not accurately reflect variations in intensity that athletes experience in a training session—leading to athlete uncertainty on how to rate their perceived exertion in the session. There was also concern about the retrospectivity of the rating—in terms of monitoring within session exertion (internal training load) and planning future training sessions.
Another important issue discussed by athletes was a single rating of perceived exertion for a session may not validly reflect or measure the intensity and volume of upper limb activity—known as external load.18 The lack of a valid measure of external load often required further contextual interpretation. Athletes believed that this contextualisation required greater communication between them, coaches and support staff. Notably, discussions about shooting volume relative to high-intensity swimming were perceived as important, but they varied depending on time of year and geographical location of the training environment. Participants also discussed potential solutions to monitor upper limb training activities and suggested that internal load measures could be supplemented by external training load measures—specifically using wearable technology.
Most participants thought the lack of external load monitoring impacted on rehabilitation and return to play due to the dearth of valid data on training and performance prior to injury. The lack of longitudinal data was also highlighted by support staff as a barrier for effective planning regarding training progressions across multiple stakeholders and sites.
Optimal training load monitoring requires objective measurement of training load
When questioned about improving current upper limb injury management and training load monitoring, participants highlighted the need for concrete data to quantify number, intensity and speed of shots, passes, drills, strokes, blocks and swimming. Participants believed such information could have several benefits, such as: foster stakeholder discussions, assist training prescription, create opportunities for readjustments, track movement mechanism and progression, enhance use of internal load monitoring and improve understanding of water polo demands (table 4). Some athletes, coaches and support staff who had experience with wearable sensors discussed the value of objective information as an evaluation mechanism for collaborative training load planning. Some coaches reflected on the objective measurements as assisting in establishing a well-balanced weekly training activity structure and providing a feedback loop for future planning collaboration and communication.
Athlete-centred philosophy matters
All participants discussed athlete-centred practices as enhancing upper limb injury management and training load monitoring (table 5). Participants emphasised the importance of individually targeted approaches as opposed to blanket rules. Athletes perceived regular screenings as a valuable strategy to monitor both improvement and setbacks, with some highlighting the value of having their bodies assessed and treated as a whole rather than just the injured area. Likewise, coaches discussed the importance of tailoring return to play to the context of each athlete, accounting for training background and previous injuries. Both athletes and coaches emphasised having exercise programmes tailored to athletes’ needs and adjusting them over time. Individual athlete training statistics were also discussed as a rehabilitation programme tool which could align with the specificities and needs of each athlete. Some athletes who had experience using wearable sensors mentioned how individual sensor information helped their understanding of their physical assessment results, increasing confidence in their recovery process.
Participants discussed needing experts involved whom they could develop trust with and who sought out collaboration with other staff and athletes. Athletes mentioned qualities such as listening, addressing and validating their concerns and assisting their understanding of situations were important for establishing trust and care. Coaches and support staff discussed the development of trust through effective, regular communication and approaching collaboration with a sense of humility and acceptance of others’ ideas and potential for contribution. Developing trust and collaboration was reflected on as a key component of athlete-centred philosophy within high-performance environments.
Mental, social and emotional aspects of upper limb injury management matter
Going beyond dealing with physical aspects, all participants discussed the need to manage significant mental and emotional impacts of upper limb injury (table 6). Athletes highlighted the impact these injuries have on their feelings of team inclusion, making them feel frustrated for having to refrain from training and competition. Some participants disclosed that the fear of missing certain opportunities, such as being selected for national and international competitions, often led them to put up with significant symptoms. Likewise, coaches and support staff acknowledged the emotional labour involved in supporting athletes through these injuries. Some coaches believed they had let some athletes down, due to lack of time to engage in conversations and give them the necessary attention.
Financial considerations were also an important factor for injury management. Some athletes reported feeling conflicted due to the need to financially support themselves through work while simultaneously, being expected to take time off work to access healthcare. Social factors such as time, financial and work pressures were discussed as barriers for rehabilitation. This was also emphasised by a few coaches, who believed athletes could perform better if they had financial support to play water polo.
Our investigation found five inter-related themes. In brief, our themes indicate that optimisation of upper limb injury management is an ongoing process which can be assisted by emerging objective measurement of training load, but also by recognising and addressing the emotional and mental impacts of injury. With regards to training load monitoring, all participants acknowledged the limitations of the current training load monitoring structure and the need for further advancements in objective measurements and processes. Further to this, we identified four key processes which underpinned the themes—communication and collaboration which were further influenced by consistency of processes and stakeholder coordination of systems. These processes were perceived by participants as: enabling the optimisation of upper limb injury management; improving training load monitoring; and facilitating care and trust—all essential features to optimise high-performance environments. This is consistent with and builds on previous injury prevention research which found open communication and shared responsibility as vital attributes of high-performance environments.19 20
Upper limb injury guidelines and knowledge need further development
Our first theme emphasises the need for ongoing development of stakeholder communication, injury prevention education and guideline development in water polo. In injury prevention research, contextual, environmental and equipment interventions have been proposed to have a greater impact on injury prevention efficacy than attempting to change individual athlete behaviours.21 Athlete viewpoints must be sought to develop contextual tools and resources which maximise impact of injury prevention strategies.22 Similar to the findings of Ekstrand et al,23 our participants perceived a deficit of consistent communication and collaboration between staff or organisations as factors that hindered injury prevention and return to play optimisation. In agreement with our first theme, others have argued that successful shared decision-making on return to play processes relies on effective communication within teams in order to build trust.24
According to coaches, educational programmes and tools such as guidelines could improve their knowledge and enable them to better support athletes. Findings from previous qualitative research in other sports such as gymnastics and handball also emphasised the potential benefits of further coach education and training to optimise athlete support.25 26 Currently, no water polo injury guidelines exist in Australia. Acknowledging a lack of guidelines, athletes and support staff contrasted water polo with other sports that have return to play guidelines and injury prevention educational programmes such as rugby27 and Australian Rules Football.28
Current training load monitoring relies on subjective internal training load monitoring and does not currently use objective external training load monitoring
The findings of our second theme were linked to a perception that current subjective internal training load monitoring practises do not fully describe intrasession changes in perceived intensity. Athletes expressed uncertainty in processes associated with giving a single numerical rate of perceived exertion and subsequently felt disconnected from the current training load monitoring platforms. Athletes acknowledged the differing perception of session rate of perceived exertion compared with the perception of the coach. Other studies have highlighted communication, feedback to the athlete from staff about injury surveillance and training load monitoring data as vital for athlete engagement and continual use of monitoring systems.29 Additionally, other research has recognised that context plays a profound role in influencing the athlete’s reporting of rate of perceived exertion.30 For these reasons, it has been recommended that both subjective internal measurements as well as objective external measurements of training load to be adopted.18
In water polo, the lack of objective measurements of external training load was perceived by participants as generating uncertainty and possibly be detrimental to the effectiveness of rehabilitation in returning athletes to play, as well as planning training load. Central to this uncertainty is a lack of data on usual shooting and passing volumes in healthy, full training athletes. A previous study of seven water polo players used a cumbersome video analysis method and showed that there was increasing shoulder soreness with increasing shooting volumes and reducing rest times.7 It then seems plausible to consider that current practices and systems could benefit from these data.
Objective measurements of training load as a facilitator of consistency of processes, communication and collaboration
Our third theme emphasises that athletes and coaches perceived that objective measurement of training load were required to accurately measure upper limb activity during training. Stakeholders perceived that this information could then increase communication and collaboration regarding training planning. Consistent with the integrated eHealth approach proposed by Verhagen & Bolling,31 athletes and coaches identified that advancements in objective training load monitoring could be used to facilitate more consistent communication and collaboration between stakeholders, producing greater efficiency in athlete injury recovery. Pilot trials of novel external training load monitoring were mentioned by some participants involved. Consistent with our third theme, other sports have considerable use of both external and internal training load monitoring and support both measures as providing a more complete overview of training completion and adaptation compared with using solely one monitoring process.32 33
Athlete-centred philosophy is perceived as optimising both performance and injury recovery
Our fourth theme highlights the importance of athlete centredness and individualisation in optimising both athlete performance and injury recovery. Similar to the findings on injury prevention practices in Australian Rules Football,34 this theme identified that all stakeholders valued individual approaches to upper limb injury assessment and rehabilitation. Previous literature suggests that coaches with transformational or democratic leadership style had a lower incidence of severe injuries in their teams and actively encouraged, communicated positively and promoted trust with their staff and athletes.35
Within this theme, participants identified that developing caring and trusting relationships between athletes, coaches and support staff can mediate mental and emotional challenges facing athletes recovering from an upper limb injury. Similar to findings in individual sports,36 athletes and staff expressed the need for time with practitioners for developing trusting relationships in training environments. In agreement with Nodding’s care ethics and reflected in other team sports,37 38 one of the most important factors to optimal rehabilitation was the physical and emotional availability to listen, validate and assist with their injury concerns.
Mental and emotional impacts of injury affect sense of team belonging and can generate frustration
Our fifth theme was linked with the perception that upper limb injury has considerable mental and emotional impacts on both athletes and coaches. A recent consensus statement highlights that injury has significant impacts on athlete’s mental and emotional health.39 It is important to acknowledge the contextual and social impacts of injury in terms of athletes lacking a sense of team inclusion or the emotional labour felt by coaches managing an upper limb injury within a team sport.22 Similarly, previous research confirms our finding that athlete’s frustration and fear of missing out on selection opportunities or training leads athletes to ignore considerable symptoms.36 In a novel finding, our study found participants acknowledged that athletes often have a conflicted choice between time spent accessing healthcare to optimise injury recovery and supporting themselves financially through employment. Notably, participants perceived this conflict as increasing mental and emotional stress on injured athletes. Further research into this phenomenon is required to begin to understand the impact of this on athletes, coaches and support staff.
Strengths and limitations
There are a number of important factors to consider when interpreting the results of this study. We studied women water polo athletes, coaches and support staff who were part of an Australian elite high performance environment—potentially limiting our findings to this context. Translating our findings to other sports’ contexts and/or countries should take this into consideration. The interviews were conducted over a time period that some participants were involved in Olympic selection trials, which may also have influenced the perceptions and views they expressed during the interviews. We also did not include others in the sport who may have administrative, organisational and financial roles to play in implementing our findings—for example, high performance directors and chief executive officers. They may have a different viewpoint on the topics canvassed. Future studies may seek to investigate the role of leadership, governance structures and financial investment in transforming the context in which upper limb injury management and training load monitoring occurs.
A strength of our study is that we studied upper limb injury management and training load monitoring in elite women’s water polo—a neglected field of sports injury research.40 Our study is also the first qualitative study of the experiences, perceptions and beliefs of women’s water polo athletes, coaches and support staff on the topic of upper limb injury management.
Upper limb injury management and training load monitoring in elite women’s water polo are evolving areas that could be advanced by facilitating sports-specific knowledge, education and the objective measurement of training load. Advancements in the objective measurement of training load would assist in resolving the current uncertainty regarding training load monitoring and their utilisation in managing an athlete. Athletes, coaches and support staff valued intangible qualities of trust and care in their relationships—these values were seen as facilitating athlete physical, mental and emotional recovery following upper limb injuries.
Our findings offer national and international organisations in water polo some direction in optimising upper limb injury management and training load. For example, they are encouraged to (1) develop guidelines to manage injuries and to improve education of coaches in monitoring training and injury rehabilitation; (2) foster trust and care in athlete-coach-support staff relationships; and (3) further develop objective measures as a mechanism for facilitating consistency of processes. Our stakeholder perceptions support this as a means to more open and engaged high performance environments. Overall, participants perceived that encouraging four processes—communication, collaboration, consistency of processes and coordination of systems would facilitate the optimisation of upper limb injury management and training load monitoring.
Data availability statement
No data are available.
Patient consent for publication
This study involves human participants and was approved by University of Queensland Ethics Committee (Approval Number: 2020001700) and Australian Institute of Sport Ethics Committee (Approval Number: 20210301). Participants gave informed consent to participate in the study before taking part.
We would like to acknowledge the Queensland Academy of Sport and Water Polo Australia for their assistance with this investigation. We would like to acknowledge Karime Mescouto (KM) from the University of Queensland for her contribution to this paper.
Twitter @margueritehoust, @Bill_Vicenzino
Contributors All authors were involved in conceiving the study’s aims and approved the submitted manuscript. MHK and NC both coded and interviewed participants, formed the foundational themes and codes of the study and drafted the manuscript. BV, KW and AL provided sequential feedback on analysis and were involved in drafting the final manuscript. MHK accepts full responsibility for the work, has access to the data and controlled the decision to publish.
Funding This study was funded by Sports Performance Innovation and Knowledge Excellence, Queensland Academy of Sport (149), Australian Government (33583743), Water Polo Australia.
Competing interests MHK is a Queensland Academy of Sport SPIKE scholar and has received an Australian Government research training scholarship. She has funding contributions from both Queensland Academy of Sport and Water Polo Australia.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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