A hidden mismatch between experiences of young athletes with overuse injuries of the wrist and sports physicians’ perceptions: a focus group study

Design

A qualitative study design using focus groups was applied in order to acquire as many signals and limitations as possible. We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for reporting focus group studies (Additional file 2) [17]. The study was performed according to the Declaration of Helsinki and the Medical Ethics Review Committee of the Academic Medical Center decided that it is not subject to the Dutch Medical Research Involving Human Subjects Act (reference no. W15_142#15.0170).

Participants

By way of purposive sampling, invitations to participate were sent to national sports federations, inviting paediatric and collegiate athletes aged 12 to 25 years with a current or previous overuse wrist injury in six popular Dutch wrist-loading sports: gymnastics, field hockey, tennis, judo, volleyball and rowing, in accordance to two previous studies [2, 4]. Each focus group contained a sample of athletes in at least three different sports, in order to encourage discussion among these athletes about potential differences and similarities in perceptions on overuse wrist injuries. The age range was chosen to achieve adequate variation in the population sample, including children as well as adolescents as their perceptions on sports performance and injury would likely differ. Fifty-one athletes volunteered and were contacted by e-mail to inform them further about the study’s purpose and methods. One of the researchers (LK) explained the study’s intentions within her research project on signalling overuse wrist injuries in young athletes. All participants and their parents or guardians (for athletes younger than 18 years) provided written informed consent to participate before the meeting.

Setting

The meeting was supervised by one moderator, a female medical doctor and PhD (LK) currently working as a full-time researcher, with substantial experience in supervising focus group meetings and who was trained for this task by two researchers (MFD and PK). Two assistant moderators, a female PhD and medical doctor in training (CN), and a female medical student (JO), were present to take notes and ask additional questions.

Data collection took place in five meetings of approximately two hours at the Amsterdam UMC, University of Amsterdam (location AMC), in January through June 2016. During the fifth focus group interview no new information was derived from the interview, indicating that data saturation was reached. Participant numbers per focus group varied from three to five. Participants were offered drinks, snacks, travel expenses reimbursement and a gift certificate. The moderator (LK) and at least one of the other three researchers (JO, CN and EC) were present during each meeting.

Data collection

At the end of each meeting, participants filled out an anonymous questionnaire rating the session’s setup and content on a 10-point scale (0= “not satisfied at all”; 10 = “very satisfied”).

Data analysis

The audio recordings were transcribed verbatim by two researchers (LK, EC). The transcript was corrected and approved by all participants. One author (LK) coded the transcript using specialized software (MAXQDA, V12, Udo Kuckartz, Berlin). The coded transcript was checked by another researcher (PK) and coding discrepancies were discussed until 100% agreement was achieved. An inductive approach was used to organize coded items into themes derived from the data, based on the study’s research questions (Table 1). A framework on overuse wrist injuries in young athletes, derived from sports physicians, was used as guideline [4].

Signals: pain

“Acute cause of pain” was marked as important by participants who recalled a specific day or event when first experiencing pain caused by their overuse wrist injury. This moment also played an important role in the urge to seek help. When wrist pain arose right before a training event, tournament, or championship, many participants indicated to seek help sooner. Other aspects of the timing of pain, such as pain at night or in the morning, with heat or cold, or pain in rest, were also considered worrisome and a reason to seek help.

In the category “severity of pain”, participants mentioned specific pain scores that they viewed as indicative of overuse wrist injury, which varied widely between 4 and 9 out of 10 (Fig. 3). Thresholds of 8 and higher were seen mainly in judokas and volleyball players, whereas tennis players and field hockey players chose thresholds of 7.5 or lower, and rowers and gymnasts found pain scores between 6 and 8 acceptable. However, none of these pain scores were considered important signs to identify a serious overuse wrist injury. Instead, “high pain score” and “crying because of pain” were preferred indicators of pain severity. Several participants mentioned a visual analogue scale (VAS) as a means for sports physicians and physiotherapists to evaluate severity of pain, some finding it difficult to use and others preferring it.

In contrast, the discussion of pain during specific activities generated numerous specific items: athletes shared extensive examples of moments when they experienced pain that made them decide to seek help. This included 18 school and work-related activities (e.g. writing, typing, carrying plates).

Participants indicated to often try various types of self-treatment before seeking medical help for overuse wrist symptoms, such as taking a period of rest, or using pain medication, tape or a brace.

Signals other than pain

Thirteen symptoms other than pain were mentioned, including specific feelings other than pain (e.g. “nagging”, “discomfort”), other sensations inside the wrist (“clicking”, “cracking”, “creaking”, “grinding”) and visible symptoms (e.g. swelling, redness, discoloration, stiffness, reduced strength). Symptoms that can be reliably assessed by others were often considered to be a reason to seek help.

Limitations

If athletes experienced limitations in their sport, most were of a general nature and sport-specific limitations were mentioned only for judo. Training-related limitations like “stopping during training” and “skipping training sessions” were considered important, in contrast to competition-related items.

Limitations related to performance (“put team at disadvantage”, “afraid to go all the way”) were considered to be a reason to seek help because the injury might be serious. With respect to limitations in activities of daily living and school or study, eleven items were marked as important (e.g. “brushing teeth”, “combing hair”, “writing”). Many participants considered limitations in daily activities more important than limitations in sport, because they could often still continue their sport despite certain limitations.

Indicators of overuse wrist injury

In this study young athletes provided 81 important signals and 20 important limitations that they experienced because of overuse wrist injuries. The athletes considered the items proposed by sports physicians important as well, but many viewed sport-related pain and limitations as a natural part of their sport, while they perceived pain and limitations in daily life activities as more important.

Athletes did not necessarily regard pain as indicative of overuse wrist injury. This is consistent with previous research showing that many young athletes view (minor) pain as normal, and that pain during sports performance is accepted easily. While in a study among 7542 high-school adolescents pain intensity measured by a VAS as well as duration and frequency of pain were found to be reasons to consult a physician [18], we found longer pain duration and continuous presence of pain to be more likely reasons for young athletes to seek medical help than pain measured using a VAS. Risky behaviour, including ignoring pain, was found to be common in young tennis players, and one out of every eight players aged 11–14 years reported playing with pain [3, 19]. In gymnasts aged 5–16 years, over 50% reported wrist pain during the previous 6 months, while only one third stated that pain interfered with their training [20]. Competing and training in spite of pain has been recognized as a common obstacle for accurately monitoring overuse injuries, and more focus on the consequential limitations in sports participation and performance in relation to full function has been suggested [21].

The athletes named many daily life activities that could cause pain, as well as numerous functional limitations in daily life, school, and work as important indicators of overuse wrist injury. This contrasts with statements by sports physicians discussing the same topic, who considered symptoms like pain more important than functional limitations [4]. Other studies have shown similar differences between young athletes and those around them. In one study all participating intercollegiate athletes described ways in which their injury affected their daily life activities, whereas only a third of coaches discussed the injury’s impact on an athlete’s daily life [22]. Incapacitation with respect to everyday tasks has also been identified as a major stressor in injured athletes by several other studies [23–25]. Our participants mentioned limitations in sport participation or in performance to a lesser extent than interference with everyday activities. Similarly, a study among Dutch talented young athletes (mean age, 16 years) found a fortnightly overuse injury prevalence of 12%, while athletes reported less than half of these injuries as having affected training volume or performance [26].

Several of our participants had an overuse wrist injury that first became apparent in an acute setting they remembered vividly. In studies on injury reporting, overuse is often defined as an injury that is not linked to a single identifiable event [27] and it has been suggested that overuse injuries present either gradually or acutely, after a period of chronic overload [21]. The previously mentioned focus group of sports physicians indicated that this applies to overuse wrist injuries as well [4].

Strengths and weaknesses

We used the COREQ checklist to ensure thorough reporting [17]. The study design included multiple focus groups in order to acquire as many items as possible, and data saturation was reached after the fifth meeting. We further attempted to reduce risk of bias by making sure athletes of various ages, from various wrist-loading sports, and with different types of overuse wrist injuries and training hours were represented.

Signals

The present findings show that young athletes’ perceptions of certain aspects of pain in relation to overuse and sports performance differ from sports physicians’ expectations. This discrepancy is, at least in part, caused by the athletes’ lack of experience with injuries at a young age. The previous sports physicians’ focus group viewed age and previous wrist injury as important signals of overuse wrist injury [4]. However, young athletes may have more difficulty discerning normal sensations of exertion from a (beginning) overuse injury than experienced adult athletes. The extensively researched concept of pain normalization and risk-taking behaviour by athletes may also be of influence [12, 28, 29]. Pain is thus often considered “part of the game”, especially by young athletes with a high drive to compete, as illustrated by studies among young gymnasts and softball players [30, 31]. Additionally, use of pain medication was considered regular practice by many participants. These factors, as well as the numerous daily activities indicated to cause pain, suggest that evaluation of pain severity using a VAS exclusively is helpful but does not provide sufficient information about the presence of an overuse wrist injury and its impact on the athlete’s life.

Symptoms other than pain that can be reliably assessed by others were also mentioned as important signals. In overuse injury monitoring, more focus on “any physical complaint” without specification has been emphasized, to reduce underestimation of overuse injuries [21]. Young athletes often experience external pressure that may keep them from reporting pain if they have no other – visible – symptoms. German elite athletes aged 14–18 years who attached great importance to their athletic identity and experienced pressure from their social environment were more willing to take physical risks (e.g. training or competing regardless of injuries) [15]. Such social pressure from coaches and parents has also been connected to overuse injuries [32, 33].

Social pressure and pain normalization may also explain why many participants regarded an identifiable acute cause of the injury as important. Although attention to acute-onset overuse injuries is increasing, many researchers still retain an overuse definition of gradual onset or absence of an acute, identifiable event. In light of the finding that pain is often considered normal by young athletes, an overuse injury may be present for some time before being acknowledged by the athlete after an acute moment of exacerbation.

Limitations in activities

The athletes found more limitations important than the sports physicians, in particular those regarding daily activities [4]. Many considered limitations more relevant than pain when describing their overuse wrist injury. Limitations in daily life activities normally taken for granted, may indeed have more impact on athletes’ lives than limitations in sport [34]. Impairment and disability have been suggested as relevant items besides pain for future overuse questionnaires [21]. The present results show that limitations in daily life can promote young athletes’ care-seeking behaviour and may therefore be indicative of overuse wrist injury in this population.

Additionally, young athletes’ attitudes towards pain as a normal aspect of sport may influence their perception of sport-related limitations. In the literature on overuse injuries, focus lies mainly on limitations in sport, such as inability to participate. More authors are suggesting a shift from this time-loss-to-injury definition to a functional definition, although a literature review found that 29 of 30 studies still used the former [21, 35]. Three of the four questions of a recently developed overuse questionnaire refer to limitations in performance, training and competition [36]. Yet “decreased performance” was not labelled important by athletes in the present study. Signals like the use of pain medication, braces, and tape, were considered important by athletes and sports physicians [4]. Many participants viewed these forms of (self) treatment as normal practice and they may allow athletes to perform adequately despite a beginning overuse wrist injury.

Clinical implications

These disparities between athletes’ and sports physicians’ perceptions raise the question whether symptoms and functional limitations related to overuse wrist injuries are to be interpreted differently in young athletes. Clinicians and trainers are advised to be aware that young athletes may have difficulty differentiating between “a minor pain” and a beginning overuse injury. Both pain and limitations in daily activities and their impact on quality of life require the physician’s attention as indicators of injury. The items proposed here can aid sports medicine professionals in gathering appropriate information about a possible overuse wrist injury. VAS pain scores can vary widely among athletes and suffice only in part to identify overuse-related wrist pain. Descriptive aspects of pain like acute onset and longer duration, and any other accompanying symptoms could be addressed additionally. Furthermore, explicit questions could be asked about use of pain medication, tape, or braces, even when the athlete’s performance has not (yet) been affected by the injury.

For the assessment of limitations in daily life activities, many functional questionnaires such as the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) and the Michigan Hand Outcomes Questionnaire (MHOQ) have been developed [37, 38]. However, these instruments have not been designed to identify early injury but rather to evaluate injury outcome, and have mostly been developed based on input from adult populations. We therefore recommend physicians to ask specifically about the daily life activities that young athletes in this study considered important, when evaluating the possible presence of overuse wrist injury.

Future directions

Various authors have suggested that overuse injuries in (mostly adult) athletes can be identified by means of questionnaires asking specifically about pain and functional limitations, instead of time loss [21, 39]. This study’s results emphasize that new studies on overuse injuries in young athletes, whether related to the wrist or to other locations, should focus on pain and limitations in daily and school activities besides sport-related limitations. For clinicians it is advisable to explicitly address functional limitations, and use of pain medication, tape, or braces during sports participation.

In order to help young athletes identify whether they should seek help because of a possible overuse wrist injury, we aim to develop a self-report questionnaire, the SOS-WRIST. The input of experts is required to compose a collection of relevant items and achieve adequate content validity for such a questionnaire [40, 41]. The items proposed in this study as well as those previously reported by experienced sport physicians can provide this expert-based input [4]. For professionals like trainers, coaches, and sports physicians involved with young athletes, such a tool can provide valuable information on young athletes’ experiences with (beginning) overuse wrist injuries. This may in turn contribute to earlier diagnosis and treatment of such injuries.