Athlete health protection: Why qualitative research matters

The balancing act - Physiotherapists' experiences of managing rugby-related concussion in the community

BACKGROUND

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP) to improve management at the community level. Physiotherapists play an important role in the CMP.

OBJECTIVE

This study explored physiotherapists' experiences in the management of community rugby-related concussion as part of the CMP.

METHODS

We adopted a pragmatic, descriptive qualitative approach to explore perceptions of twenty-four physiotherapists involved in the CMP. Thematic analysis was used to analyze data.

RESULTS

Four themes represented participants' experiences: 1) 'walking the tight rope between player welfare and performance' described the balancing act between different attitudes and priorities of the various rugby stakeholders; 2) empowering physiotherapists' authority and responsibilities, described the influence of physiotherapists' authority within the team and concussion management responsibilities; 3) multi-directional communication, described the role of communication between multiple stakeholders; and 4) the influence of context, which included the complexity of concussion, concussion knowledge of the physiotherapists and team, resource support for the physiotherapist, and access to a medical doctor.

CONCLUSION

Physiotherapists had positive attitudes toward the CMP and are well-positioned to play an active role in the pathway. Priorities of other stakeholders, authority of the physiotherapist and the communication flow influences physiotherapists' ability to optimally manage players with concussion.

'I want to ski and race, not just ski': a qualitative study on athletes' and stakeholders' perspectives on return-to-sport in high-performance Snowsports

This study explored stakeholders' perspectives on current practices, challenges and opportunities related to the return-to-sport (RTS) process in high-performance Snowsports. We conducted fourteen semi-structured interviews with athletes, coaches and health professionals from multiple countries using online video platforms. The data were transcribed verbatim and analysed based on constant comparative analysis employing the principles of Grounded Theory. Codes were grouped into categories and main concepts and a conceptual model were derived. According to the participants, RTS should be considered a continuous process to bring the athlete back to competition as fast and safely as possible, whereas speed is often prioritised over safety. Participants described the need for a structured and criteria-based process. Despite the multiple phases and the diversity of involved professionals, the process is individualised and unique, highlighting the value of having the athlete at the centre of the RTS process. It was considered essential to provide a safe environment and build trustworthy relationships. Additionally, access to resources, communication and cooperation among all experts was perceived as critical to successful RTS. Our participants described the value of continuity and an athlete-centred approach to the RTS process. The challenges, such as interprofessional communication, the lack of objective sport-specific criteria, and the diversity of resources and network structures, were perceived as practical issues that influenced the process, which should be tailored for each athlete accordingly to reach a successful RTS.

Epidemiology, etiology and prevention of injuries in competitive ice speed skating-limited current evidence, multiple future priorities: A scoping review

Long-track and short-track ice speed skating are integral to the Winter Olympics. The state of evidence-based injury prevention in these sports is unclear. Our goals were to summarize the current scientific knowledge, to determine the state of research, and to highlight future research areas for injury prevention in ice speed skating. We conducted a scoping review, searching all injury and injury prevention studies in competitive ice speed skaters. The six-stage Translating Research into Injury Prevention Practice (TRIPP) framework summarized the findings. The systematic search yielded 1109 citations. Nineteen studies were included, and additional searches yielded another 13 studies, but few had high-quality design. TRIPP stage 1 studies (n = 24) found competition injury rates from 2% to 18% of participants with various injury locations and types. Seasonal prevalence of physical complaints was up to 84% (for back pain) in long- and short-track. Ten studies covered information on TRIPP stage 2, with two small etiological studies linking injuries to functional strength deficits (short-track) and training load (long-track). Questionnaire studies identified various perceived risk factors for injuries but lacked further scientific evidence. Most TRIPP stage 3 studies (five out of eight) focused on developing protective measures, while two studies found short-track helmets performed poorly compared to helmets used in other sports. No study evaluated the efficacy, the intervention context, or the effectiveness (TRIPP stages 4-6) of the measures. Scientific knowledge on injury prevention in ice speed skating is limited. Future research should prioritize high-quality studies on injury epidemiology and etiology in the sports.

The meaning of injury to the elite athlete: A systematic review

In the pursuit of a successful career in elite sports, athletes mostly rely on their physical abilities. An injury can threaten such a career, thereby representing a potentially critical life event that carries considerable meaning to the affected athlete. Qualitative literature exploring injury experiences in elite athletes is therefore seeking to frame injury through the athlete's own voice. With this systematic review, we aimed to answer the research question What is the meaning of injuries to the elite athlete? by reviewing existing qualitative research exploring the meaning of injury as told from the athlete's perspective. We constructed five overarching themes of meaning through thematic synthesis of 29 original studies: (1) unwelcome disruption - Injury as potential career threat; (2) destruction - My life (as an athlete) is over; (3) reinforcement - Relighting the fire; (4) going through the motions - Injury as an inherent part of elite sport; and (5) time-out - Respite and perspective. These meanings were neither exclusive nor static but constructed according to the situation at the moment of injury and could later be adapted depending on social context and specific circumstances. To better support injured athletes, practitioners need to be aware of the importance of the subjective meaning that athletes construct for individual injuries. Understanding these meanings enables practitioners to aid athletes in changing previously negative meanings into more positive ones. Our findings therefore call for improvements in the individualized support of elite athletes that leaves space for open communication about the meanings that athletes attach to their injury experiences.

Lost in transition: Exploring injury risk in academy footballers shifting between the second and first teams

OBJECTIVES

To compare the injury profiles of football players shifting between second and first teams with those of second- and first-team players, and to examine the opinions of shifting players.

DESIGN

Prospective cohort study.

METHODS

170 male players from Athletic Club (second team = 90, shifting = 20, first team = 60) were followed over eight seasons. Injuries and exposure time were recorded following the FIFA consensus, and 18 shifting players answered a seven-item questionnaire on their experience.

RESULTS

35 % shifting players became full-time first-team players, in contrast to only 8 % of second-team players (odds ratio = 6.4, p < 0.01). There were no differences in the overall injury incidence, but the overall burden of injuries was higher in second-team (172 days lost/1000 h) and shifting players (194 days lost/1000 h) compared with first-team players (114 days lost/1000 h, p < 0.01). Shifting players had a higher burden of knee joint/ligament injuries compared with first-team players (137 vs. 18 days lost/1000 h, p < 0.01) and anterior cruciate ligament (ACL) ruptures (122 vs. 10 days lost/1000 h, p < 0.01). There was a trend towards a higher burden of ACL ruptures in shifting players than in second-team players (122 vs. 41 days lost/1000 h, p = 0.07). Shifting players reported constant pressure and better communication with the second-team coaching staff than with the first-team staff.

CONCLUSIONS

The high burden of injuries in shifting players, particularly from ACL ruptures, highlights the need for action. Ensuring high-quality communication between second- and first-team staff remains a key challenge.

'Considering the reality, I am very lucky': how professional players and staff perceive injury prevention and performance protection in women's football

OBJECTIVE

To explore the beliefs and perceptions of professional female footballers and staff regarding injury prevention and performance protection in professional women's football.

METHODS

This qualitative study applied semistructured interviews with 18 participants from 3 top-tier teams from 2 countries (Portugal and England) and 4 nationalities, including 2 physiotherapists, 5 players, 3 team doctors, 2 head coaches, 3 strength and conditioning coaches, 2 managers, and 1 head of performance. Data analysis applied constant comparison analysis, using principles of grounded theory. There were no major differences in the perspectives of players and staff, and the findings are presented together.

RESULTS

Identifying and reporting injuries and recognising potential injury risk factors were mentioned to influence the prevention of injury. Participants stated that the growth and evolution of women's football could influence injury risk. Before reaching the professional level, exposure to potential risk factors, such as lack of recovery, limited awareness and opportunities for prevention (eg, preventive exercises and load management strategies), was believed to impact players' injury risk. Players further described their experiences and the 'bumpy road' to becoming a professional player, their current context and potential future improvements for women's football regarding injury prevention and performance protection.

CONCLUSION

Professional female football players face different injury risks during different moments of their careers. According to elite players and staff, amateur and semiprofessionals have limited resources and lack injury prevention strategies. Professional players and staff perceived the current preventive measures as good and relied on the value of individualised care and a multidisciplinary approach. In the future, more resources and structured injury prevention strategies are needed in youth and non-professional levels of women's football to reduce injury risk and allow more players to reach their maximal performance.

What contextual factors influence pain management decision making concerning player availability in professional men's football? A qualitative analysis of practitioner perceptions

PURPOSE

Football practitioners must regularly assess the risk of participation when determining player availability. At present, there is a lack of information detailing the factors that influence risk assessments. Accordingly, the following research question was explored: what contextual factors influence pain management decision-making when determining player availability in professional men's football?

METHODS

20 semi-structured interviews were conducted with club doctors (8), physiotherapists (6), and heads of medicine and performance (8) working in professional men's football in the United Kingdom. The methodology is reported using COREQ criteria and data were analysed using thematic analysis.

RESULTS

Three themes were created that explain how decision-making concerning analgesia was influenced by: (1) access to medical resources, (2) trust between staff and players, and (3) prioritising short-term success. First, the time, resources, and medical information available to staff impacted the ability to assess players and their risk tolerance in relation to analgesia. Second, decision-making was perceived as a multi-stakeholder process and the nature of relationships with players and performance staff could increase or decrease risk tolerance. Third, player decisions are made against a performance and working environment that privileges short term success over long term wellbeing.

CONCLUSION

The data support that pain management decision-making in professional men's football is influenced by the player and staff's working context. Further, practitioners viewed potential harm to a player from a socio-economic and physical perspective. These findings support the adoption of a patient-centred care approach and can inform clear recommendations from international and national governing bodies.

'Every turn can be the last one I do' - Perceptions of injury risk in high-performance snow sports and its implication for injury prevention

OBJECTIVES

High-performance snow sports (HPSS) athletes compete in a performance-driven context with a high risk of injury. While there is a lack of evidence on effective prevention measures in snow sports, this study explored the perspectives and perceptions of HPSS stakeholders on sports injury prevention.

METHODS

We conducted an exploratory qualitative study based on the grounded theory principles through 11 semistructured interviews with athletes, coaches and healthcare providers from different national teams about sports injury prevention. The interviews were inductively analysed through constant comparative data analysis.

RESULTS

Participants defined risk management as a central concept in which they approached injury prevention by assessing, managing and sometimes accepting risks. Many factors, such as athlete-related and external factors, are considered in this process, ultimately influencing their decision-making. Participants acknowledged the value of experience when managing and dealing with risks, a key aspect of their learning process and career development. Within this context, open and trustworthy communication and shared responsibilities among all stakeholders influenced and shaped injury prevention strategies and behaviours. Understanding and balancing out speed and risks was considered pivotal in their daily practice. Therefore, injury prevention awareness, ownership, communication, teamwork and shared responsibilities may contribute to the success of sports injury prevention in HPSS.

CONCLUSION

These findings substantiate the significance of such contextual factors in sports injury prevention. Considering the high-risk nature of HPSS, injury prevention suggests a shift towards risk management strategies, with a strong emphasis on contextual factors and their interactions. Young athletes might benefit from educational interventions centred on developing skills to assess and manage risks.

'More than likely the men come first. That's just very frustrating'. A qualitative exploration of contextual factors affecting the implementation of injury prevention initiatives and the provision of effective injury management in elite-level women's club football in Ireland

OBJECTIVES

The aim of our study was to explore the contextual factors that affect the implementation of football injury prevention initiatives and the provision of effective injury management in the Irish Women's National League (WNL).

METHODS

We used a criterion-based purposive sampling approach to recruit coaches (n=7), players (n=17) and medical personnel (n=8) representing eight of the nine clubs in the WNL to participate in one-to-one semistructured interviews. Our study was located within an interpretivist, constructivist research paradigm. The interview data were analysed using reflexive thematic analysis.

RESULTS

The participants identified academic and work pressures, financial challenges, conflict with college football, inadequate facilities and gender inequity as being barriers to the implementation of injury prevention initiatives and the provision of effective injury management. Financial constraints within clubs were perceived to limit the provision of medical care and strength and conditioning (S&C) support and this was deemed to be associated with a heightened risk of injuries.

CONCLUSION

Specific contextual factors were identified which curtail the implementation of injury prevention initiatives and the provision of effective injury management in elite-level women's club football in Ireland. Gender inequity was identified as one of the factors impacting the availability of high-quality medical care, S&C support, as well as access to training and match facilities. Our results provide new insights that could be used to inform the design and implementation of injury prevention and management initiatives for women football players in Ireland.

We know a lot about little and little about a lot: A contextualized scoping review on injury prevention in alpine ski racing

BACKGROUND

Our goal was to summarize and contextualize the available literature on alpine ski racing injury epidemiology, injury etiology, injury prevention measures, injury prevention context, and implementation issues.

MATERIALS AND METHODS

We searched four electronic databases using predetermined search terms. We included original studies that assessed injury, injury risk factors, and injury mechanisms, and assessed and reported the effect of an injury prevention measure in alpine ski racing. Two authors independently conducted title-abstract screening, and one performed the full-text review. For data synthesis and categorization, we used the Translating Research into the Injury Prevention Practice framework and a modified and adapted version of the Haddon matrix.

RESULTS

Of the 157 included studies, most corresponded to injury epidemiology and etiology, whereas few studies encompassed injury prevention measure development, implementation and evaluation. Preventive interventions targeting equipment, rules and regulations, course design and snow preparation were the most prevalent in the literature. Furthermore, various contextual factors in the current literature have been found, including gender, competition level, countries and federations, and time periods within a season.

CONCLUSIONS

We provided an in-depth and comprehensive overview of the current state-of-the-art in the alpine ski racing context. We know a lot about little and little about a lot across all the areas associated with injury prevention in such context. The limitations in the literature yield a road map for designing future injury prevention studies to address the key gaps identified. A more comprehensive context-driven approach throughout all stages of injury prevention would benefit the ultimate implementation of effective preventive strategies.

Injury prevention in ladies Gaelic football referees: Understanding the barriers, facilitators, and preferences of referees

OBJECTIVES

The injury prevalence in Gaelic games refereeing is high, however few are adopting injury prevention programmes. This study aims to identify the barriers and facilitators to injury prevention strategy success and determine Ladies Gaelic Football referees' preferences for injury prevention strategies and education.

DESIGN

Semi-structured interviews were conducted with 11 Ladies Gaelic Football referees (10 men, 1 woman). Two were club level, two were provincial level and 7 were national level referees. Interviews were audio-recorded, transcribed verbatim, and reflexive thematic analysis was completed. This analysis involved examining the data repeatedly and gradually developing sub-themes, themes, and categories related to each core concept.

RESULTS

The barriers to injury prevention success included negative attitudes, accessibility issues, lack of education, the state of refereeing and undesirable injury prevention strategy characteristics. Injury prevention promotion, suitable strategy characteristics and open communication were believed to facilitate success. Referees gave their preferences for injury prevention programmes, strategy logistics, and stakeholder roles along with their preferred topics, delivery, educators, characteristics, rollout, and timing for injury prevention education.

CONCLUSIONS

Reducing referee injury is critical to the success of Ladies Gaelic Football and other community sports. Governing bodies must develop and support injury prevention programmes and education for referees. These should be designed according to referees' preferences and consider the barriers and facilitators referees have identified to maximise adoption.

Elite skiers' experiences of heat- and moisture-exchanging devices and training and competition in the cold: A qualitative survey

Background and Aims

Winter endurance athletes have a high prevalence of exercise-induced bronchoconstriction (EIB) and asthma, probably due to repeated and prolonged inhalation of cold and dry air. Heat- and moisture-exchanging devices (HME) warm and humidify inhaled air and prevent EIB. The aim of this study was to share cross-country skiers and biathletes' experiences of training and competition in low temperatures, views on temperature limits, usage of HME, and consequences of cold exposure on their health.

Methods

Eleven Swedish World Championship or Olympic medalists in cross-country skiing and biathlon were interviewed and transcripts were analyzed using qualitative content analysis.

Results

Participants described how cold temperatures predominantly affected the airways, face, and extremities. During training, extreme cold was managed by choosing warmer clothing, modification of planned sessions, use of HME, delaying training, or changing location. In competition, participants described limited possibility for such choices and would prefer adjustment of existing rules (i.e., more conservative temperature limits), especially since they understood elite skiing in low temperatures to present an occupational hazard to their health. Participants had at times used HMEs during training in cold environments but described mixed motives for their use-that HMEs warm and humidify cold inhaled air but introduce additional resistance to breathing and can cause problems due to mucus and ice build-up. Skiers also perceived that they had become more sensitive to cold during the latter part of their careers.

Conclusions

The present study gives a unique insight into the "cold" reality of being an elite athlete in skiing and biathlon. Cold exposure results in negative health consequences that are preventable, which means that rules must be followed, and organizers should acknowledge responsibility in protecting athletes from occupational hazards. Development of evidence-based guidelines for protection of athletes' respiratory health should be a focus for future translational research.

Players', Head Coaches', And Medical Personnels' Knowledge, Understandings and Perceptions of Injuries and Injury Prevention in Elite-Level Women's Football in Ireland

BACKGROUND

To manage injuries effectively, players, head coaches, and medical personnel need to have excellent knowledge, attitudes, and behaviours in relation to the identification of risk factors for injuries, the implementation of injury prevention initiatives, as well as the implementation of effective injury management strategies. Understanding the injury context, whereby specific personal, environmental, and societal factors can influence the implementation of injury prevention initiatives and injury management strategies is critical to player welfare. To date, no qualitative research investigating the context of injuries, has been undertaken in elite-level women's football. The aim of our study was to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish Women's National League (WNL) to injury prevention and injury management.

METHODS

We used qualitative research methods to explore the knowledge, attitudes, and behaviours of players, head coaches, and medical personnel in the Irish WNL to injury prevention and injury management. Semi-structured interviews were undertaken with 17 players, 8 medical personnel, and 7 head coaches in the Irish WNL. The data were analysed using thematic analysis. Our study is located within an interpretivist, constructivist research paradigm.

RESULTS

The participants had incomplete knowledge of common injuries in elite-level football, and many held beliefs about risk factors for injuries, such as menstrual cycle stage, which lacked evidence to support them. Jumping and landing exercises were commonly used to reduce the risk of injuries but evidence-based injury prevention exercises and programmes such as the Nordic hamstring curl, Copenhagen adduction exercise, and the FIFA 11+ were rarely mentioned. Overall, there was dissatisfaction amongst players with their medical care and strength and conditioning (S & C) support, with resultant inadequate communication between players, head coaches, and medical personnel.

CONCLUSION

Poor quality and availability of medical care and S & C support were considered to be a major obstacle in the effective implementation of injury risk reduction strategies and successful return-to-sport practices. More original research is required in elite-level women's football to explore injury risk factors, injury prevention initiatives, and contextual return-to-sport strategies, so that players, head coaches, and medical personnel can use evidence that is both up-to-date and specific to their environment.

"Back pain is part of sport … I'm just gonna have to live with it": Exploring the lived experience of sport-related low back pain in adolescent athletes

OBJECTIVES

To examine the lived experience of adolescent athletes reporting an episode of sport-related low back pain (LBP), including effects on daily life, relationships with parent/guardians, teammates, and coaches with relation to LBP, experiences of management/treatment, and understanding of LBP.

DESIGN

Qualitative interviewing using online video conferencing platforms.

PARTICIPANTS

Athletes aged 10-19 years old who experienced low back pain within the year prior to interviewing.

MAIN OUTCOME MEASURES

Interview transcripts, Modified Oswestry Disability Index, and International Physical Activity Questionnaire.

RESULTS

Three main themes were developed 1) The culture of normalising LBP in sport negates safeguarding efforts aimed at protecting adolescent athletes against injury and pain 2) LBP changes how athletes are perceived and perceive themselves 3) LBP has broad effects on the well-being of adolescent athletes.

CONCLUSIONS

The lived experience of LBP for adolescent athletes is impacted by the culture of tolerance of pain and injury in sport. Further steps should be taken to implement safeguarding measures in a way that adequately protects adolescent athletes who experience pain.

A qualitative examination of injury prevention strategy and education in Ladies Gaelic football: Understanding the preferences of players and coaches

The high rates of injury in Ladies Gaelic football impact the wellbeing of players and are a major financial burden for the Ladies Gaelic Football Association. Effective injury prevention programmes have been developed for Gaelic games, but these are not currently widely adopted. The aim of this study was to qualitatively investigate adult Ladies Gaelic football players and coaches' preferences for injury prevention strategies and injury prevention education using a constructivist grounded-theory approach. Semi-structured interviews were conducted with 23 currently active Ladies Gaelic football coaches and adult players. The core strategy preferences discussed by participants were the properties of an injury prevention programme, the role of stakeholders, strategy logistics and the need for guidance and support. If the uptake and long-term adoption of an injury prevention programme is to be maximised, the preferences of the players and coaches who will ultimately utilise the programme must be understood and integrated into a wider implementation strategy developed around their needs. For education preferences, the core categories identified were the focus of education, who needs education, the format, educator, roll-out strategy, and time required. Future educational strategies must incorporate the preferences of stakeholders into their design if they are to be successful in spreading injury prevention knowledge and achieving change. To give injury prevention strategies, programmes, and education the best chances at successful adoption, it is crucial that the preferences of end-users are addressed and implemented.

"It's always the bare minimum" - A qualitative study of players' experiences of tackle coaching in women's rugby union

OBJECTIVES

Tackle coaching forms a cornerstone of training in rugby and is designed to enhance performance and mitigate tackle injury. The athlete voice can help key stakeholders understand the psychosocial determinants that shape skill development in relation to tackle coaching. We aimed to capture player experiences of tackle coaching in women's rugby union.

DESIGN

Qualitative study using the grounded theory approach.

METHODS

Current women rugby union players, with at least 1-year senior level experience, were recruited from Europe, Africa and North America between December 2021 and March 2022 to participate in the study. Data were collected through semi-structured interviews and analysed in line with grounded theory coding procedures.

RESULTS

The 21 players were aged 20-48 years with a mean 10.6 years of rugby playing experience. Analysis revealed that the experiences of tackle coaching that shaped women's tackle skill development and sense of preparedness ranged from constraining to empowering, and gender was a pivotal influence in creating meaning. Participants expected and accepted the bare minimum in tackle coaching as the price that they had to pay for inclusion in rugby.

CONCLUSIONS

Participants' experiences of tackle coaching were entangled in inequitable club structures and cultures where men's rugby is the norm. Empowering tackle coaching in women's rugby union must be bespoke to the given context and the needs of women players. The recommendations offered in this paper encourage discussion as to how best to empower women's tackle development in rugby.

"Is the focus in professional rugby ever really on health?": A qualitative study on the uptake of illness prevention guidelines in rugby

Illness prevention is essential for athlete health management, but little is known about its uptake in sport. Prior to the pandemic, the International Olympic Committee (IOC) published a consensus statement recommending illness prevention guidelines are implemented in sports. Yet, little is known about guideline uptake. Therefore, this study aimed to explore the (1) illness experiences of rugby players and athlete support personnel and (2) barriers and enablers to illness prevention guideline uptake in rugby, using the lens of behaviour change theory. In a bid to inform and enhance athlete welfare, we sought to amplify the voices of participants through qualitative inquiry. Between August 2020 and May 2021, 16 semi-structured interviews were undertaken with players and athlete support personnel working across rugby. Analysis was conducted using Braun and Clarke's reflexive thematic analysis. Prior to COVID-19, participants deemed illness to be of little concern, with experience of illnesses and the global pandemic critical enablers to guideline uptake. The rugby environment was a barrier to illness prevention, particularly in women's and academy teams where resource deficiency was highlighted. 'Rugby identity' acted as both a barrier and enabler with participants' passion for rugby driving both guideline adherence and non-adherence. Tackling resource inequalities between men's and women's cohorts is critical to effectively implement guidelines. Coach and player education is essential, and emphasis must be placed on continuing preventative behaviours adopted due to COVID-19. Our findings offer new insight into illness prevention, moving away from prevailing quantitative research, and instead voicing players' experiences.

When context creates uncertainty: experiences of patients who choose rehabilitation as a treatment after an ACL injury

Up to 50% of patients who suffer an anterior cruciate ligament (ACL) injury receive or opt for rehabilitation alone as initial treatment in Scandinavia. Knowledge of whether patients treated with rehabilitation alone after ACL injury are satisfied is lacking. This study aimed to explore the experiences of patients treated with rehabilitation alone after an ACL injury. Fourteen patients (35.9 (19-56) years old) who suffered an ACL injury treated with rehabilitation alone, a mean of 32 months before inclusion, were interviewed. The interview transcripts were analysed using qualitative content analysis with an inductive approach. The experiences of patients treated with rehabilitation after an ACL injury were summarised in one theme: 'Is the grass greener on the other side? Context characterised by uncertainty', supported by three main categories and nine subcategories. Uncertainty permeated the context of all levels of knee-related life following ACL injury: (1) in the past, patients felt uncertainty regarding treatment choices, (2) in the present, patients felt uncertainty regarding their physical capacity and knee self-efficacy, and (3) for the future, patients felt uncertainty regarding what might happen. With few exceptions, patients' experiences after an ACL injury treated with rehabilitation alone are characterised by uncertainty regarding their physical function, psychological impairments and possible future limitation of knee function. Uncertainty is experienced by patients in the past, the present and the future. Patients experience the knee as a symptomatic obstacle and need to adapt the physical activity to the presence of symptoms.

Barriers and facilitators to injury prevention in ladies Gaelic football: A qualitative study

OBJECTIVES

Injury rates have remained high in ladies Gaelic football over the last decade and treatment costs continue to increase significantly. Injury prevention programmes are a proposed solution and their efficacy has been demonstrated in Gaelic games, however, anecdotally their adoption is low. The aim of this study was to determine the barriers and facilitators to uptake, implementation, and long-term adoption of an injury prevention strategy for adult Ladies Gaelic football players and coaches.

DESIGN

Semi-structured interviews were conducted with 23 participants (13 coaches, 10 players). Four coaches were at intercounty level and nine were at club level, while two players competed at intercounty and club level and eight played solely at club level. The interviews were audio-recorded, transcribed verbatim and thematically analysed.

RESULTS

Stakeholder attitudes, accessibility, education, communication, and injury prevention programme characteristics were perceived as key barriers to an injury prevention strategy succeeding. Injury prevention promotion, injury prevention programme characteristics, leadership, and communication, were identified as the main factors that would facilitate the success of a strategy.

CONCLUSIONS

By utilising the views of stakeholders, the initial uptake, adherence, and long-term adoption of an injury prevention strategy in Ladies Gaelic football may be maximised.

Youth athletes at Swedish sports high schools with an athletics specialism emphasise environmental support for injury risk management: a focus group study

In this study, we examined knowledge and understanding of sport-related injuries among youth athletics (track and field) athletes and assessed their needs in managing any health problems. Qualitative data were collected via 12 focus groups with youth athletes (16-19 years) studying at Swedish sports high schools with an athletics specialism. All focus group discussions were audiorecorded and transcribed before being analysed using a thematic analysis approach. Four researchers independently reviewed the transcripts, generated codes and developed themes. Three overarching themes related to the athletes' knowledge and understanding of sport-related injury were developed: (1) awareness of injuries, (2) perception of injuries, and (3) factors contributing to injuries. The youth athletes were typically uncertain about how to acknowledge a sport-related injury. They expressed that knowledge about injuries was obtained in part by reflecting on the lived experiences of their peers. It was also demonstrated that there appears to be a 'culture of acceptance' regarding injury occurrence. In contrast, causes of injuries were viewed as dependent on multiple factors (eg, lack of context-specific knowledge about training practices). Regarding athletes' needs in managing injuries, an additional three themes were developed: (1) creating functioning elite sports environments, (2) application of knowledge and (3) fostering athletes. An apparent lack of structure and organisation related to the school environment was identified as an important issue to review to create opportunities for sustainable athletic development. The study identified areas that can be improved in Swedish sports high schools with an athletic specialism and could be applied in other youth sports contexts. The results of this study guide school stakeholders, alongside the sport governing bodies who have the mandate to influence activities in youth sports contexts, whereby special attention should be directed towards improving the social environment for youth athletes.

Some, but not all, patients experience full symptom resolution and a positive rehabilitation process after ACL reconstruction: an interview study

PURPOSE

To gain a deeper understanding of patients' experiences over 5 years after anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventeen semi-structured interviews were performed with patients treated with ACL reconstruction at least 5 years earlier without a second knee injury. Interviews were transcribed and analyzed using qualitative content analysis according to methods described by Graneheim and Lundman.

RESULTS

Patients' long-term experiences after an ACL reconstruction were summarized as: "to cope or not to cope, that is the question", and five main categories: (1) Adapting life after knee symptom: the past will not come back; (2) An arduous and demanding rehabilitation: sailing against the wind; (3) Accepting what cannot be changed: biting the bullet; (4) Being satisfied with results: end of a chapter; (5) Apprehensively peregrinating on an unknown road.

CONCLUSIONS

More than 5 years after ACL reconstruction, patients can experience full symptom resolution and the ACL injury process as positive, or experience persistent symptoms and are forced to accept negative life-changing choices due to the injury.

LEVEL OF EVIDENCE

IV.

Throwing in the deep end: athletes, coaches and support staff experiences, perceptions and beliefs of upper limb injuries and training load in elite women's water polo

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.

"Yeah, I Mean, You're Going to Handball, so You Want to Use Balls as Much as Possible at Training": End-Users' Perspectives of Injury Prevention Training for Youth Handball Players

Young handball players experience high injury rates. Specific injury prevention programs reduce injury rates but are not well implemented into youth players’ training. The ‘Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)’ project addresses this challenge. The aim of this study was to investigate how youth handball coaches and players experienced the recently developed I-PROTECT GO pilot program, by focusing on barriers and facilitators. Three focus group interviews were conducted with coaches and players, and their answers were analyzed using a general inductive approach. The participants appreciated the program and found it useful for their context. The participants’ statements about facilitators and barriers centered around the categories of resources, exercises, program design, and learning. Facilitators that emerged were motivating exercises (e.g., handball-specific), a helpful set-up (e.g., variation), having a clear purpose of exercises, the possibility to fulfil basic psychological needs while training, receiving instructions and feedback, and having role models. Barriers that emerged were limited space and material, difficulties with exercises, an unhelpful set-up (e.g., too repetitive), and undisciplined training. It is important to address perceived barriers and facilitators among coaches and players when developing injury prevention training programs to enhance the uptake of such training.

Perceptions of experts on key injury risk factors in alpine ski racing as a function of stakeholder role and associated level of competition

Objectives

(1) To update experts' priorities of perceived key injury risk factors in alpine ski racing based on a framework and list derived 10 years ago, (2) to identify additionally emerging risk factors since then and (3) to compile a list with countermeasure suggestions.

Methods

A sample of 532 expert stakeholders (athletes, coaches, team medical staff, Ski Racing Suppliers (SRS) and International Ski Federation (FIS) representatives) from the World Cup (WC), European Cup (EC) and FIS-race level participated in a cross-sectional online survey. Experts were asked to name those risk factors with the highest believed impact on injury risk and rank them according to their current priority from a predefined list. In addition, experts were encouraged to name additional (not listed) risk factors and to suggest countermeasures.

Results

Regardless of stakeholder role and competition level, snow-related factors appeared to have the highest perceived priority. However, WC athletes' and coaches' perceptions were also related to equipment, while at the EC and FIS-race level fatigue and physical fitness-related factors were considered important. Athletes' perceptions were largely in agreement with SRS (ie, snow-related and equipment-related factors). At the same time, while coaches, team medical staff and FIS representatives additionally emphasised fatigue and physical fitness-related factors.

Conclusion

Experts' perceptions on key injury risk factors in alpine ski racing depend on the stakeholder role and differ between the competition levels. Thus, to develop effective prevention measures and to successfully implement them, all relevant stakeholders should be given a voice, and prevention efforts should be targeted to the specific level.

Asthma medication in athletes: a qualitative investigation of adherence, avoidance and misuse in competitive sport

OBJECTIVES

The purpose of this qualitative study was to utilize the Capability, Opportunity, Motivation - Behavior model (COM-B) to: (1) evaluate athlete knowledge and understanding of current asthma-related anti-doping regulations, (2) explore the impact of environmental and societal influences on athletes with asthma, and (3) examine athlete perception of asthma medication use in competitive sport.Methods: Semi-structured interviews were conducted with ten competitive endurance athletes (five athletes with asthma and five without asthma). Interviews were guided by the COM-B model and transcripts were analyzed inductively and deductively using reflexive thematic analysis.Results: Mapping the experiences and perceptions of athletes against an established behavioral framework identified that: (1) athletes' possess limited knowledge and understanding of the World Anti-Doping Agency (WADA) Prohibited List and Therapeutic use exemption (TUE) policy with respect to asthma medication; (2) the use of sub-optimal diagnostic methods is commonplace and increases the risk of misdiagnosis and unnecessary inhaler therapy; (3) negative media portrayal of high-profile asthma-related doping allegations impacts public opinion and contributes to the perception of wrongdoing within the sporting community.Conclusion: The novel application of behavioral science highlights several factors that may contribute to asthma medication avoidance and promote misuse in competitive sport. The findings from this study provide a foundation for the development and implementation of targeted education programmes, and it is hoped that employing this approach will ultimately improve overall perceptions of asthma treatment in athletes, which is necessary to maintain respiratory health, optimize performance and protect the integrity of sport.

© 2021 The Author(s). Published with license by Taylor & Francis Group, LLC.

Male basketball players who report hip and groin pain perceive its negative impact both on- and off-court: A cross-sectional study

OBJECTIVES

To identify if basketball players aged <20 years (U20) self-report hip and/or groin pain and if they perceive this as a problem. To determine potential differences in self-reported playing (training and match play) loads and Copenhagen Hip and Groin Outcome Score (HAGOS) between those with and without hip/groin pain.

DESIGN

Cross-sectional.

METHODS

Fifty-one pre-elite (state/national representative level) male U20 basketball players (Australian n=38; Italian n=13) self-reported current/historical hip/groin 'discomfort/pain' and 'problems', and playing loads. A two-factor regression model was fitted including main effects for hip/groin pain and Cohort and their interaction, with outcome variables playing loads and HAGOS subscale scores and dependent variable hip/groin pain.

RESULTS

Twenty-one players (41%) self-reported hip/groin 'discomfort/pain', of which nine perceived no 'problems'. Two of these nine players reported training/playing time loss due to pain. Those self-reporting hip/groin discomfort/pain scored lower than those without in HAGOS subscales Symptoms (mean difference in score 8.94; 95%CI -25.24, -5.97), Pain (5.00; -16.42, -2.81), Function in daily living (0.00; -26.72 to -5.59), Function in sport and recreation (6.25; -21.24, -5.33), and hip and/or groin Quality of Life (5.00; -28.63, -8.10), indicating worse hip/groin problems. Participation subscale scores were different only for Italian players (36.25; -51.25, -20.00), with players self-reporting hip/groin discomfort/pain scoring lower.

CONCLUSION

Most players who perceive both hip/groin 'discomfort/pain' and 'problems' also report training/playing time loss, suggesting players' perceptions of problematic symptoms and time-loss are associated. Adolescent basketball players perceive hip/groin pain to negatively impact their daily lives and sporting function.

Environmental Barriers and Facilitators to Physical Activity among University Students with Physical Disability-A Qualitative Study in Spain

This paper qualitatively examines environmental factors operating as barriers and/or facilitators to participation in physical activity (PA) of people with physical disabilities. Interview data were collected from 27 Spanish university students through the innovative method of two-on-one interviews. Thereafter, data were subject to a flexible thematic analysis. Three themes were constructed: associations; PA practice spaces; and nonhumans. Concepts from different theories were used to generate meaningful interpretations around each theme. Drawing on our results, we offer several reflections and directions. Two key messages can be highlighted. First, environmental barriers and facilitators are context dependent and thus do not precede the circumstances in which they emerge. Second, Spanish universities should work harder to become relevant PA promoting environments for students with physical disability. The knowledge generated in this study is expected to inform the design, implementation and evaluation of programs promoting PA among Spanish university students with physical disability.

Where are all the men? Low energy availability in male cyclists: A review

Most of the low energy availability (LEA) research has been conducted in female populations. The occurrence of LEA in male athletes is not well known, even with an understanding of the components involved in and contributing to LEA. Cycling is a major risk factor for LEA due to inherent sports characteristics: low impact, high energy demands, and a common perception that leanness is a performance advantage. The purpose of this review is to discuss the cycling-specific studies that have documented components of RED-S. The review demonstrates male cyclists (1) experience energy deficits daily, weekly and throughout a season; (2) exhibit lower bone mineral density at the spine compared to the hip, and low bone mineral density correlating with LEA and; (3) demonstrate downregulation of the endocrine system with elevated cortisol, reduced testosterone and insulin-like growth factor 1. The complexity of LEA is further explored by the socio-psychological contribution that may impact eating behaviours, and therefore increase the risk of developing LEA. Future research directions include applying multifaceted research methods to gain a greater understanding of this syndrome and the effect of LEA on male cyclists.Highlights Competitive male cyclists tend to train and compete in low energy availability states, increasing the risk of developing low bone mineral density.The metabolic and hormonal changes in competitive male cyclists demonstrate a multifaceted downregulation of the endocrine system.The socio-psychological contributions may impact eating behaviours, therefore increase the risk of developing low energy availability in competitive male cyclists.Future research using mixed-method approaches will contribute to more multidimensional understandings of the risks and effects of LEA on male cyclists.