By: Amy Barrette, AT, M.Sc (Rehab Res)
Did you know that high jump champion Derek Drouin competed in the Olympics with stress fractures in his spine? Did you know that despite atypical plantar fasciitis in her foot, deteriorating cartilage in her knees, a bone spur on her heel and bilateral Achilles tendonitis, point guard Teresa Gabriele played for our country in international basketball tournaments? Did you know that NHL hockey player Joe Thornton played with a sprained knee in the playoffs this year? Did you know that diver Roseline Filion battled through a talus fracture as she prepared for the Rio games?
Athletes are constantly playing through their pain to reach their ultimate goal of becoming the best at what they do. Pain has been normalized to the point where athletes have reported being expected to ignore pain and to remain in the game despite the possible detrimental consequences associated with playing through pain (Deroche et al., 2011; Hammond et al., 2014a). From a physiotherapist’s perspective, the athlete’s readiness to put themselves at risk, the existence of a culture encouraging this risk-taking behaviour and the possibility for long term health-related consequences raise concerns. While physiotherapists may not have an influence on an athlete’s competitive nature or the culture of risk they operate in, seeking a better understanding of playing through pain is definitely in their area of responsibility in order to develop effective harm reduction strategies for the athletes they work with.
Even after centuries of studying pain, the concept is so complex that no set definition of the term has been agreed on. Pain is understood to be an individual’s experience, it is defined by that individual and then communicated outwardly according to how the individual has perceived it (Craig, 2009). The most widely endorsed definition of pain, to this day, is that pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" (International Association for the Study of Pain, 2005).
Playing through pain is often addressed in the media but not much research has been conducted on the topic. Despite this, the studies that have been conducted are unanimous in reporting that there is a high incidence of athletes playing injured (Hammond et al., 2014b; Nixon, 1996; Simon & Docherty, 2014). Frequency of athletes playing injured rather than playing through pain is most often assessed in studies. This
is most likely due to the fact that pain is subjective and a variable, like an injury, is more easily measured. However, acknowledging the fact that pain is the most common symptom associated with injury (Beers et al., 2003), it can be assumed that in most cases, athletes who reported having played injured were also likely playing through pain. In the qualitative literature, athletes are unanimous in saying that they have played through pain at least once in their career (Curry, 1993; Hammond et al., 2014a; Young, McTeer, &White, 1994).
In our research, we chose to explore the factors associated with sub-elite athletes playing through pain in the individual sports of: gymnastics, rowing and speed skating. The sub-elite athlete was targeted because they are at the level where they are competing for national team status and aiming to make it to the Olympics. They have everything to win and everything to lose and are therefore more inclined to take all the necessary measures to achieve their goals, including playing through the pain of an injury (Curry, 1993; Safai, 2003). This made them an ideal group of athletes to explore the topic of playing through pain. Only athletes taking part in individual sports were included because we believed that there are additional factors that influence the decision to play through pain that are experienced by team sports athletes, and this would have added another level of complexity that we chose not to include in our study. The sports of gymnastics, speed skating and rowing were specifically targeted to optimize the recruitment process, given that there was a fairly large pool of sub-elite athletes in these sports in Eastern Canada, where we conducted the research.
To get a comprehensive representation of the phenomenon being studied, data was not only gathered from the athlete’s perspective but also from the coach’s and the rehabilitation specialist’s. Dyads were formed between the athletes and the coaches but the rehabilitation specialists were studied independently. In total, 12 participants were recruited. The sample includes 5 coaches, 4 athletes and 3 rehabilitation specialists. Overall, 7 different coach-athlete dyads were formed.
The study consisted in an observation session followed by interview sessions. The observation session involved photographing the athletes during a regular practice shortly before an important competition to capture the expression of pain behaviours. All the participants were then interviewed after the athlete participated in the important competition. The interviews were semi-structured and the photographs taken during the observation session were used during these interviews to stimulate conversation. The interviews were transcribed verbatim and thematic analysis followed using NVivo™ software.
The participant interviews revealed three main themes related to playing through pain. These themes are: Listening to your body, Decision making and Who decides.
Listening to your body
When athletes were considering if they should stop training/competing or keep going, many participants spoke about the difficulty of knowing the difference between being sore and being in pain. Other studies suggest that age could influence the perception of pain (Broome, 1985; Twycross, 1998; Lafleur and Raway, 1999; Malcom, 2006). However, besides indicating that exposure to injury increases the athletes’ awareness of their body’s limits, the participants could not identify a clear method to learn how to navigate the fine line between being sore and being in pain.
All of the participants described how challenging it is to decide whether or not they should play through their pain. The sub-themes of "Decision making" represent the different counterforces that athletes experience as they are making this decision: Impact & Consequences versus Dreams & Goals and Support versus Pressure. Our interviews revealed that the athletes’ desire to reach their dreams and goals outweighed the potential consequences of playing through pain. In addition, the athletes themselves appeared to be their biggest source of pressure. Coaches and rehabilitation specialists were found to be mainly supportive.
The theme "Who decides" whether an athlete should keep going or stop when they are training through the pain of an injury was shown to depend on the involvement of pain behaviours and the dynamics of the relationships between the athlete and the coach, the athlete and the rehabilitation specialist and the coach and the rehabilitation specialist. When asked about their pain behaviours, participating athletes admitted to at times masking their pain so that their coaches would not be able to tell what they were feeling. Hiding this information could affect who decides when to stop the athlete. The findings from this study also suggest that a good relationship between athletes and their coaches /rehabilitation specialists could have a positive impact on injury management.
Overall, the athlete who is playing through pain was shown to be constantly navigating a fine line of decision-making. Although external factors such as pressure and the culture of risk were shown to have an influence, the decision-making itself was revealed to be mostly internal. The athlete’s perception of what they were feeling and how those feelings are expressed appeared to highly influence decisions about playing injured. Athletes admitted to modulating their verbal and non-verbal expressions of pain. Masking their pain from the people observing them, such as their coaches and rehabilitation specialists, allowed them to have more control on the decision to keep going or stop. Another finding of interest was that athletes did not express much
concern about the potential long term consequences of playing through pain. The importance they attributed to reaching their goals appeared to have a bigger impact on their decision-making.
So what does this imply for physiotherapists? Given that much of the decision-making happens internally, when inexperienced athletes have difficulty discerning soreness from pain and that these athletes are at the sub-elite level with aspirations of the Olympics, they are in some ways quite vulnerable to making poor decisions in regards to potential long term consequences. In this case, it becomes the physiotherapist’s role to guide the athletes in making more informed decisions. In doing so, it is pertinent for physiotherapists to keep in mind that the athletes’ dreams and goals appear to outweigh the significance of the potential consequences of playing through pain. Educating them about the possible impact of playing through pain would therefore be valuable. Then, the fact that athletes admitted to modulating their expression of pain sheds doubt on the value of observing pain behaviours to get a truthful reading of how the athletes are feeling and to manage their injuries based on that. Instead, relying on functional limitations such as altered movement and decreased performance, and mood changes to assess the athlete’s condition appears as a more appropriate approach (in particular when one doesn’t have a close relationship with the athlete). Finally, a good relationship between the athlete and their rehabilitation specialists was shown to contribute to a greater involvement of these people in their injury management. This finding therefore highlights the importance of physiotherapists focusing on building good relationships with the athletes they work with.
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