Perceiving, reporting and managing an injury – perspectives from national team football players, coaches, and health professionals

Figures & data

Table 1. Interview guide.

Topic 1 Sports injury definition How would you define a sports injury? What do you consider an injury? Based on which criteria? Topic 2 Factors influencing the decision to play with injuries Do you play with injuries? Why? If you play with injuries, how do you feel about that? Which injuries do you consider playing with? Which are the injuries that you do not play with? Topic 3 Injury reporting practices Do you report all the injuries that you have? What makes you report an injury? What hinders you from reporting injuries? What are the factors which are out of your control that change the way you report injuries? Do you report injuries differently during different phases of the season (pre-season, in-season, tournaments)? Why?

Table 2. Demographic data of the participants.

Participant Type	Number of participants	Sex		Median age (years)
		Male Female
Players	7	4	3	23 (range: 21–33)
Coaches (head coaches and physical trainer coaches)	3	3	-	36 (range: 24–55)
Health professionals (medical doctors and physiotherapists)	3	2	1	33 (range: 31–35)

Figure 1. The process of thematic analysis involving six interactive phases (adapted from Braun & Clarke, 2006).

Figure 2. Main thematic map illustrating the relationships between themes and their associated sub-themes. Participants highlighted their definition of a football injury, mainly in terms of consequences on pain, performance and participation (theme 1). Their perception of an injury influenced how they approached injury management. When in pain, players self-managed their symptoms before reporting them. injury reporting was based on the perceived pain severity, with injury management becoming a shared responsibility between different members of the team (theme 2). Yet, various interacting modulators, namely, player, relational, situational, and cultural related factors, modulate injury perception and, consequently, the way players manage and report their injury (theme 3).

Table 3. The theme of injury preception, presented with its subthemes, basic themes and supportive quotes

Global Theme	Sub-theme	Basic theme (codes)	Quotes
How do I perceive an injury?	Pain	Normalising pain Being in pain ≠ injury	‘Sometimes, you just feel pain, and you can still play’ (player) ‘you have to play with the pain. So that is an injury, an injury type..injury? Not exactly an injury. Maybe that is some form of discomfort that you have to play with’ (physical trainer)
	Impact on optimal performance	Injury means a limitation of performance Unable to give 100%	‘It (an injury) is something which renders me unable to perform or unable to give my maximum performance because I can still play with an injury, but I won’t be able to give my best’ (player) ‘If a player has something and it is limiting him in a way that he is giving his 80% or 90% and not his 100%, I can consider him injured. Because I want my players to give their best during the games’ (head coach)
	Impact on the level of participation	No longer able to perform Modification of training load Absence from training or competition	An injury is that pain that holds you back from performing. So in that case, you have to slow down and at times stop from training until you can train again’ (player) ‘The player has to work with the physio and the physical trainer during the training sessions. So he is still there with us, but he can’t do all the things that all the other players will be doing during a training session’ (head coach) ‘when you feel more pain, that limits you or even stop you from playing for a certain period’ (player)

Figure 3. Injury definition diagram, supported by quotes from participants. This figure describes an injury as a process, with performance limitation described as the main indicator of a football-related injury, while pain and impact on the level of participation are described as subcomponents of an injury within this process.

Table 4. The theme of injury management, presented with its subthemes, basic themes and supportive quotes

Global Theme	Sub-theme	Basic theme (codes)	Quotes
How do I manage an injury?	I self-manage my pain	Self-management of pain Experience of previous injuries	‘If my leg is aching a bit, I won’t go to the physio. I know what I have to do to ease down the pain’ (player) ‘From my experience, if you have it on both legs, that is always helpful, because you say listen, it is impossible I injured both hamstrings, so that is DOMS, but if you have one hamstring, are feeling more pain than the other one, than you may need to see a physio, then you need to see what is wrong there’ (player) ‘I got to a point now through experience when I know what my body needs. I know when I can do it myself or when I have to report it’ (player)
	I report the injury	Severity of injury	‘if I am in a lot of pain, I will speak up. So I’ll report it and try to get the best medical until the game.’ (player) ‘if it is affecting my performance, then I will let my physio know about it’ (player)
	It is about teamwork	Injury risk acceptance Team role in the injury management process Collaboration between the club and national team Timely management of the injured player	‘I report my injury so I can take care of it and still be able to play’ (player) ‘It depends on the level of pain …that correlates clinically in terms of, whether there is no tear. In that case, if they can perform then it is more acceptable’ (medical doctor) ‘It’s not a decision that I will take by myself or the player takes by himself or the coaches take by themselves, but more like a team decision. Whenever I am informed, I try to make it happen that way’ (medical doctor) ‘It’s quite a two-way process like I will give them input during the season, and they do the same when it comes to just before training’ (medical doctor) ‘….so we can mend the player, I can send him to the right people, I can do a strengthening programme. Not when it is too late, and we can’t do much’ (physical trainer coach)

Figure 4. The injury management process, supported by quotes from participants. This figure represents the process of dealing with an injury, with players self-managing their pain before reporting it. In reporting an injury, based on its severity, the interaction between all stakeholders is essential in managing the injury.

Table 5. The theme of modulating factors of injury perceptions and injury management, presented with its subthemes, basic themes and supportive quotes

Global Theme	Sub-theme	Basic theme (codes)	Quotes
What influences my perception, reporting and management of an injury?	The influence of culture	Culture of risk and pain National pride	‘In Maltese football, there is a macho factor as well..so it is like sometimes, they suck it up, sometimes, they fear like they have to suck it up, without really wanting to.’ (medical doctor) ‘if they trained with pain because that’s what they have been used to, they will definitely play if they have an important game or if they know that they will get a bonus. So, it’s really in the football culture to play with pain and then they will report it once it becomes difficult to play with the pain’ (coach) ‘…factors such as their remuneration, the pressure they feel from their coach, and even to show that they are available to play with the first team….all of these together emphasise this culture’ (medical doctor) ‘National pride is also a factor because they want to represent their country’ (medical doctor)
	The influence of situations	Forthcoming important matches Fixture scheduling Financial income and rewards Windows of opportunities Security of position within the first team Squad size	‘If there is an important match, for example at the end of the season or against our rivals, I will give everything, even though I am injured, in order to play’ (player) ‘they will play and hide their injuries, especially if it’s a very important game and they are pressured by the club, especially when it’s associated with financial rewards’ (coach) ‘If it is the last game of the season….I have an injury, but I can manage these 90 minutes, and then I know that I have three weeks off or whatever, versus the first game of the season, then I would play with my injury.’ (player) `‘They might be afraid in terms of National team, afraid of losing money, because they get paid quite well, and they get like appearance bonuses and things like that from UEFA. So we are talking about a few thousand a time’ (medical doctor) ‘… they know that they will be scouted, even when they are with their clubs, the national coach will be looking out for them, to see if they are performing.’ (physical trainer coach) ‘There are some players that are not the best players within the team……….so right now, they just fight to gain some playing time. So unlike other players who know that they have a fixed place, they have to fight and always prove themselves to be in that position’ (player) When she injures herself, and there is no reserve goalkeeper, or the reserve goalkeeper is still very young or inexperienced, she will keep on pushing to help her team, despite her injury.’(physiotherapist)
	The influence of relations	Relation with club Relation with support staff Relation with team-mates	‘If there is pressure as well… for instance, when I injured my shoulder, the club wanted me to take an injection, and I resisted, and then I ended up strapping it myself. Mind you…I didn’t have a good relation with them at that time’ (player) ‘The coach was like trying to push me to play, and that was the first time that I realised that I like I couldn’t, so I stopped him’ (player) ‘it depends on how much they trust me and how comfortable they are in reporting to me’ (physiotherapist) ‘I know that if I play with an injury, I risk making it worse. But if my coach gets to know that I am injured, most probably he will tell me to rest, and I can’t afford to lose my place. So it’s good that your physio knows you well so you can report your injury to him and he can talk to the coach in ways that he can convince him that I can still play. Because I tend to get injured quite often!’ (player) ‘There are some teammates who tend to underestimate my injuries at times and indirectly put on pressure not to report my injury. But that’s because they wouldn’t know me much and wouldn’t know that I’m not the type of guy who reports every ache that I have’ (player) ‘If I don’t report my injuries, I feel that I would be cheating on my teammates’ (player)
	The influence of the player	Ambition to play Motivation to play Team loyalty Individuality (risk-taking behaviour) Pain tolerance Experience (age and previous injuries)	‘They do anything to be on the team. So even for example, if we have the qualifiers in November and in October they have an injury, they still come, you see them, they take Catafast, to train’ (physical trainer coach) ‘You don’t want to stop what you are doing..you just want to train to be able to play the game’ (player) ‘He doesn’t report an injury, because he is afraid of letting down the team, letting down the coach, so it is a matter..you know..he wants to be there at all costs’ (physical trainer coach) You have that kind of player that is a fighter, that wants to play even with one leg, but you have players that are afraid to play. There are different characters, you know. So if they have a bit of a pain, they will tell you, I cannot play because I have pain’ (physical trainer coach) ‘It depends on the individual. Because there are some players who tolerate their pain much more than others’ (head coach) ‘The more experienced you are, you start like, holding back a bit more…like you reconsider things..’is it worth it?’ (player) ‘I find the more experienced players are the ones who seek advice and sort of volunteer themselves, that listen, if I rest and don’t play this National team game, I can be better or I can play in the second game if we have two games.’ (medical doctor)

Figure 5. The multi-level map reflects the personal and socio-ecological levels to describe individual factors and their interrelation. The dynamicity and fluidity of interactions between these factors during different times and situations influence how a player perceives and manages an injury. Starting at the centre of the map (injury) and moving distally, the perception of an injury is modulated by 1) individual (player) factors including demographic and psychological related factors; 2) player’s relations with club, support staff and teammates; 3) situational factors across the football season, and the 4) broad football-related cultural messages.