AKADEMIN FÖR HÄLSA OCH ARBETSLIV
Avdelningen för hälso- och vårdvetenskap
PAIN AMONG FEMALE SOCCER PLAYERS
A study on high-level athletes
William Lind
2017
Examensarbete, Grundnivå (kandidatexamen), 15 hp
Idrottsvetenskap
Idrottsvetenskapliga programmet, inriktning hälsofrämjande livsstil
Handledare: Per-Erik Ervasti
Examinator: Göran Svedsäter
Introduction
The motivation behind choosing to explore pain among athletes is heavily inspired by
own experiences. As an elite athlete, I have both experienced and endured pain to a high
extent during my career. By knowing which affect pain has had on myself, the will to
explore the area arose. There is also a knowledge gap on the matter, which strengthened
the motivation to make this study.
I would like to thank all the players who participated in this study as well as all the
coaches who were very cooperative and willing to help and make the collection of the
data as smooth as possible.
Hopefully the results from this study can be a revelation for coaches and
physiotherapists in clubs and make players reflect on their view on pain.
2
Abstract
Background: Physical pain affects mental performance as well as many
physical factors and is often associated with injuries. Injuries are common
among athletes and a higher level of play coheres with a higher prevalence of
injuries. Since injuries are so common among high-level athletes, it is
reasonable to assume that pain is also connected to the high level of play. Also,
since experiencing pain has its side-effects, it is interesting to investigate
physical pain among high-level athletes.
Purpose: The purpose of the study was to investigate the presence and
experience of pain among high-level female soccer players in Sweden, as well
as their relationship to pain.
Method: 68 players between 14-30 years old who had played at a high level for
1-13 years participated in the study. A questionnaire was used to collect the
data and SPSS was used to analyse it with descriptive statistics.
Results: 50 % of the players rated their pain extent before, during and after
practices and games with 3 or more on a scale from 1-5, where 1 is “no extent”
and 5 is “high extent”. The results were scattered regarding the influence pain
had on carefulness, ability, potential, emotions and concentration, but the
players felt that pain had the biggest influence on their ability to play and their
emotional wellbeing. 42.65% of the players continue as normal when
experiencing pain during practice and 44.12% of them continue but take it
easier, while 83.82% continue as normal when experiencing pain during game.
All of them thought that playing and practicing with pain could lead to future
complications in some way.
Conclusion: Most of the players struggled with pain to varying degrees. Even
though being convinced that playing with pain can lead to complications, they
kept on playing when they experienced pain themselves.
Keywords: pain, women, soccer, sport, questionnaire
3
Table of contents
Background…………………………………………………………………....1-6
The mechanisms of pain………………………………………………………………………..1
Pain and soccer……………………………………………………………………………...1-2
Pain and performance………………………………………………………………………2-3
Pain and injuries among athletes……………………………………………………………4
Problematisation…………………………………………………………………………...4-5
Purpose………………………………………………………………………………………..5
Research questions………………………………………………………………………….5
Method…………………………………………………………………………5-9
Design………………………………………………………………………………………….5-6
Selection………...........................................................................................................6-7
Data-collection method…………………………………………………………………….7-8
Statistics………………………………………………………………………………………..8
Ethics……………………………………………………………………………….............8-9
Results…………………...................................................................................9-13
Experienced pain during career…………………………………………………………......9
Pain extent during practice and games………………………………………………...9-10
Influence of pain in the past month…………………………………………………...10-11
Reactions to experienced pain………………………………………………………..11-12
Pain and injuries……………………………………………………………………….12-13
Discussion…………………………………………………………………...13-19
Method discussion…………………………………………………………………………13-16
Result discussion………………………………………………………………………….16-19
Future studies………………........................................................................................19
Conclusions…………………………………………………………………….19
References…………………………………………………………………..20-23
Appendix 1 Questionnaire Questions…………………………………………24
Appendix 2 Comments from the participants………………………………..25
4
Background
The mechanisms of pain
The perception of physical pain (also referred to as just “pain” in this study) is
something that the majority can relate to. Our bodies induce the feeling of pain to
protect us from injuries. As soon as a structure gets exposed to what is considered as a
physical threat, such as extreme heat or cold, high impact, inflammation, high muscular
strain etc., receptors in the affected structure send nerve signals to the spinal cord,
which responds by subconsciously making the muscles in the concerned structure
perform a reflexive manoeuvre. Signals are then sent to the central nervous system
which causes the body to react to the physical danger with for example tachycardia
(increased heart rhythm), hyperventilation, increased blood pressure and physical pain.1
In conclusion: if a part of your body starts hurting, your body is telling you that you are
exposing yourself to harm and that you need to change something to protect it.
Pain and soccer
Soccer as a sport had its rise in England in the late 1100s where it was seen as the “sport
of the people” because everyone could play it: the only thing needed was an object
which could be used as a ball.2
The sport is mostly characterized by kicking and running with a ball. Being a contact
sport, a lot of player collisions and turf collisions (mostly due to initial player collisions)
occur during matches and practices. Added with muscle overload and injuries occurring
when making explosive movements with the shoe stuck in the turf, these were the
biggest injury mechanisms among the female soccer players participating in a study.3
Studies on pain in soccer mostly cover groin and back pain. One study showed that 45
% of the soccer playing women who participated in the study had experienced an
episode of groin pain at least once during a 6-week period. They also found that groin
pain was more common among male soccer players than women, which was also
confirmed in another study which examined the same field. Among 894 patients with
hip pain, hip joint pathology was the biggest cause for the pain with 55.98 % of the
cases. A study on back pain in different sports noted a 3 % prevalence of back pain
during the past 7 days among the 266 soccer players which participated in the study.4-7
1
Research has covered the experience of physical pain among children and young
people, with focus on the coaching culture and how coaches invite and praise aggressive
and violent play between players. The results from the study showed that physical pain
is common, especially in sports where there is a lot of physical contact between players,
which occurs frequently in soccer.8
Another study on 6945 adolescents between 15 and 16 years of age from the North
Finland Birth Cohort made the finding that playing many different sports leads to less
experience of pain in neck, shoulders and lower back than playing a single sport, at least
on a recreational level. What these findings mean in this context is that only playing
soccer lead to a higher risk for injuries than playing several sports.9
Pain and performance
Firstly, the experience of pain has a negative impact on the ability to multitask and think
with a broad focus, according to one study where people made complex tasks while
wearing heat pads and another study where a comparison was made between people
with and without back pain when multitasking.10,11 Furthermore, it impairs the working
memory performance, which in short is the skill to use your senses and long-term
memory to process information, which was shown in a study with 78 participants which
subjected themselves to pain from cold pressors while performing a test in working
memory.12
Studies found a decrease in maximal voluntary contraction, flexibility and muscle
endurance in body structures which were hurting compared to when they weren’t
hurt.13,14 Physical soreness can also lead to, not necessarily in a negative sense, but,
changes in dynamic motor function which causes a difference in how impact is
distributed on your joints, muscle fibres and bones.14-16
A study that compared muscle activation and motor function among injured and
uninjured badminton players demonstrated that, when performing the same motions,
injured players activate their muscle fibres to a higher extent than uninjured ones. They
are also more conservative in their movement patterns, which presumably is induced by
a conscious or subconscious fear of pain or injury.17 Other studies, one interview study
2
on 49 recreational athletes and one questionnaire study on 14 elite team gym athletes,
show that a fear of injury can lead to anxiety and that it can prolong return to play after
an injury.18,19 According to an interview study made by Chase, Magyar and Drake
(2005), the main reason behind being afraid of getting injured among gymnasts is not
being able to practice and compete as well as the difficulties in rehabilitating an
injury.20
Makhni (2014) showed, in his study made on 203 baseball players, that as much as 74
percent of the participants experienced pain when throwing baseballs. Another
interesting find was that 75 percent of the respondents felt that pain restrained them in
their throwing power. Fifty-five percent of the players also agreed on the statement that
pain decreased the amount of joy that they got out of playing baseball.21
Aside from sports-related symptoms, pain is also something which can cause several
serious mental conditions, such as depression, anxiety and other psychological
symptoms, which is shown by studies involving patients from hospitals and cohorts for
different pain disorders.22-26 In a study about the relationship between knee-pain and
depressive symptoms among 6599 middle-aged and elders, it was concluded that severe
knee pain independently was associated with depression, with an odds ratio of 2.55.27
An article on the Swedish newspaper Aftonbladet shared the story of the young talented
national team player Ivo Pekalski, who fought with back problems and eventually
developed spinal disc herniation which led to depression. The depression caused
sleeping disorders, panic attacks and social problems. Ivo was close to ending his
career, but after getting proper help he eventually found joy in playing soccer again, and
today he plays in Halmstad BK in the highest division in Sweden. 28 Emotional issues
can affect perceived mental effort and concentration as well as performance in sport:
two studies indicated that players believed that their mood affected their concentration
and performance, and two intervention studies showed increases in performance when
the players were happy.29-32
If you feel that you don’t perform optimally, your confidence might go down.
Confidence is very important in sports, and a lack of confidence can lead to a decrease
in performance, according to an interview study on world class athletes and a review
study on confidence and performance.33,34
3
Pain and injuries among athletes
A factor which can provoke pain is injuries. Injuries which are not treated correctly can
lead to future complications such as chronic impairment and hampered mobility.
Athletes who expose themselves to more loading than their body can take for a long
period of time can end up with problematic injuries and physical strain.35-39
When encountering injuries, the standard procedure to optimally rehabilitate the injury
is in most cases to cut down on or remove any physical loading, and, in time, slowly
progress the exercise intensity to get towards the pre-injury state.35,36,40-42 It is not
always applied in reality though: a study on lower back pain and physical activity
showed that 93% of the involved athletes maintained their physical activity despite
being in pain.41 Another study made on soccer playing females displayed that 69,9% of
the players admitted that they had played a game while being injured.44
Injuries are common among athletes; different studies showed that between 62-70
percent of high-level soccer players were injured in some way during a one-year
period.43-45 Other studies found a correlation between amount of practice and playing
time and risk for overuse injuries. 39,48-50
Problematisation
It is reasonable to assume that it is common for athletes who compete on a high level to
experience pain since injuries are so common among high-level athletes. It is interesting
to know how present pain is for them since it can affect them in so many ways. It is also
interesting to know what their standpoint is on personal pain management as it can lead
to further complications if you don’t respect the pain and treat injuries properly.
There is a knowledge gap regarding general physical pain among soccer players. Most
studies investigate pain in certain areas, mostly groin and back pain. There is also a lack
of research on physical pain among high-level athletes in general. In addition, women
are underrepresented in studies on pain in sports and soccer is an explosive contact sport
which makes pain research more relevant in this field. What also makes this study stand
out is its focus on how pain is experienced and treated by the players, as well as which
risks they think playing with physical pain can lead to.
4
What this study hopes to achieve is for it to lead to a higher focus on pain management
among coaches, doctors and physiotherapists working with players in elite teams. An
understanding of how elite players perceive and treat pain could also be useful when
having conversations with players about injuries and pain management. For example, if
a player doesn’t rehabilitate correctly due to an “easy-going” relationship to pain, it
would be interesting for the physiotherapist to be aware of this, and therefore put more
effort into motivating the player to rehabilitate correctly.
Purpose
The purpose of the study was to investigate the presence and experience of pain among
first and second-division female soccer players in Sweden, as well as their relationship
to pain.
Research questions
•
To what extent is pain present before, during and after practices and games?
•
To what extent does pain affect the players?
•
How do the players react to experienced pain?
•
Do the players show an understanding of the fact that prolonged physical
activity can lead to physical complications? If so, which complications?
Method
Design
A quantitative method with at descriptive design was chosen, as it was considered the
best method to be able to generalize the results and focus on the “what” question, rather
than “how”, “when” or “why”. 51-54
A deductive basis was used for this study. A deductive method is characteristically
chosen when the motivation is to answer a hypothesis which originates from previous
research.51-55
The inspiration behind the setup of the study was taken from two books about writing
reports and essays. For example, the choice of referencing system and the overall
language in the study were inspired by these books.48,52 To ensure that a clear research
5
question was formed for the study, inspiration was taken from Mayo´s report from
2013.56
Selection
Four teams were selected in the study: two division 1 teams and two division 2 teams
(of which had both played in division 1 the previous season). The characteristics of the
players are shown in Table I. A total of 68 female soccer players participated in the
study. The mean age among the players were 19,9 and the age gap between the
youngest and the oldest was sixteen (14-30). The mean height was 168,5 centimetres,
with a range from 155-185 centimetres in height. 41,2 % of the participants had
encountered a previous injury which resulted in at least 3 months off play. The mean
amount of years which the players had played at a high level was 4,2 years, ranging
between 1 and 13 years.
Table I. Descriptive data of the players who participated in the study
Total N: 68
Age (years)
Mean
min-max
SD
Height (cm)
Mean
min-max
SD
Previous injury (< 3 months off
play)
N
%
Years on current (or higher) level
Mean
min-max
19,9
14-30
3,60
168,5
155-185
5,96
28
41,2
4,2
1-13
The number of participants which participated in the study was considered enough, as
the descriptive data among the players were scattered, which meant that they didn’t all
have the same background, and therefore the generalizability increases. The mindset
going into the study was to get as many participants as possible, while still being
convinced that all the data would be collected and analysed within the period of time at
hand.47 The generalizability of the results was also increased by targeting elite-teams
with no age-restriction in different parts of the country, as it increases the chance that a
wide array of individuals with different backgrounds are targeted. On the other hand,
6
the fact that the teams weren’t randomly chosen is not optimal when striving for high
generalizability.
Some requirements had to be fulfilled to get included in the study. Firstly, the players
had to be women. The least amount of team practices a week to be included was 4 and
the lowest division that the team could play in was division 2.
An exclusion criteria was the location of the teams. All the teams practiced at locations
which were moderately convenient to get to.
Data-collection method
The coaches in the teams were contacted via mail or phone call approximately 1 month
before the data-collection took place. They were briefly informed about the purpose of
the study, ethical considerations and what the results would be used for. After agreeing
to participate in the study, a time was set for collecting the data, with focus on making it
as convenient as possible for the teams. Therefore, the times were scheduled either
before or after a practice for the teams.
The decision was made to collect the data via paper questionnaire. The reasoning behind
the decision was that it is a good approach to successfully collect information from
people about knowledge, attitudes or behaviour to describe, compare or explain a
phenomenon.57 It was also considered the most efficient way to get a high number of
participants from different geographic locations while still being able to get relevant
results. It is also a very cheap way to collect data, and the respondents get enough time
to answer without getting stressed. By being present while the participants filled in the
questionnaires, the respondents had the opportunity to ask questions if any uncertainties
occurred. The players were all in the same room as they filled in the questionnaires,
mostly for convenience reasons. In addition, all the participants in the teams got the
same presentation of the questionnaire, which minimized the risk for different
interpretations and misunderstandings. 58
The main focus when designing the questionnaire was to compose understandable yet
comprehensive questions, while still making sure that the questions answered the
purpose of the study.54,55 Some of the questions were also inspired by the questionnaire
used in Makhni´s (2014) study on arm pain among baseball players.21
7
To assess if the questions were easily understandable and interpreted the way they were
intended, a pilot study was made on a group of 4 sports-related individuals with
different age and background, who got to fill in the questionnaire and give feedback. A
few tweaks were made to some questions in how they were formulated due to the
feedback from the test-participants. 56
Statistics
After receiving all the data, IBM SPSS Statistics (version 22) was used as statistical tool
to analyse the data. Tables and figures were then established to simplify the results and
patterns of the data to make them easier to read and comprehend.59,60 Lastly, the data
was analysed to establish mean values, median values, standard deviations, counts and
percentages for the results.
No comparisons were made nor strived for revealing with the results from this study,
such as comparisons between results and age or height, or the connection between
previous injuries and experienced pain. The sole purpose was to reveal a potential
problem, not to find connections or make any conclusions to answer why the problem
exists.
Ethics
To ensure absolute consent among the participants, forms were handed out and read by
the players before they got access to the questionnaires. The forms consisted of
statements regarding the full disclosure and anonymity among the players, the disposal
of the sheets after processing them and the option to drop out of the study if desired.
The information gathered from the questionnaires was only used for the sake of the
study. 58
For each team, the sheets were distributed simultaneously to the players and the results
were not processed until the data from all teams were acquired and shuffled, to prevent
the possibility of connecting questionnaires to certain individuals.61
The majority of the participants were strangers. A few of them were of mild
acquaintance which could be taken into consideration as one can argue about its
influence on the study results.
8
Lastly, the goal throughout the entirety of the study was to be objective, non-biased and
reflective, as well as being truthful and transparent.52
Results
Experienced pain during career
When rating their experienced pain during their career on a scale from 1-10, the
majority (29,41%) of the players chose a 7 (Figure I). Only one player chose the lowest
rating on the scale, and almost 62 % of them rated their experienced pain with a 5 or
more. Despite this, only six of them rated an 8 or 9, and none of the participants
answered with a 10.
Figure I. Extent of experienced pain during their career on a scale from 1-10, with 1 being “no extent”
and 10 being “high extent”
Pain extent during practice and games
50 % of the players put 3 or higher on a scale from 1-5 regarding the amount of pain
they had experienced during and after practice in the past month (Figure II). However,
the majority (35,3 %) of them rated a 2 in their sheet.
Only 4 people gave the highest rating for their perceived pain.
9
Figure II. The extent of experienced pain in connection to practices and games according to the players on
a scale from 1-5, with 1 being “no extent” and 5 being “high extent”
Influence of pain
The highest average score was given on the worsening of their play and their emotional
wellbeing. Over 23 % of the players rated a 4 on the influence of pain leading to
worsening their level of play, and 44,8 % of them rated 3 or more on the matter (Table
II).
Also, almost half of them thought that pain had affected them emotionally to an extent
of 3 or more on the scale.
The players did not experience that pain had such a high influence in making them more
careful, with 79,4 % of them rating a 3 or lower on that statement. Most of them (35,3
%) chose the lowest number on the scale. Neither did they feel that pain had hampered
their potential to such a high extent, with 81,2 % crossing in a 3 or lower.
Most players (47,1 %) gave the lowest rating on pain causing them concentration issues.
Most players gave the highest rating on pain making them more careful, worsening their
level of play and hampering their potential (7,4 % each).
10
Table II. Influence of pain the past month according to the players on a scale from 1-5, with 1 being “no
extent” and 5 being “high extent”, n (%)
Total number: 68
Median
1
1
24 (35,3)
19 (27,9)
1,5
19 (27,9)
Pain hampered my potential
2
Pain affected me emotionally
Pain caused concentration issues
Pain made me more careful
Pain worsened my level of play
2
3
4
5
11 (16,2)
9 (13,2)
5 (7,4)
19 (27,9)
9 (13,9)
16 (23,5)
5 (7,4)
19 (27,9)
28 (41,2)
7 (10,3)
9 (13,2)
5 (7,4)
2
18 (26,5)
19 (27,9)
12 (17,6)
15 (22,1)
4 (5,9)
1
32 (47,1)
14 (20,6)
9 (13,2)
11 (16,2)
2 (2,9)
Reactions to pain
Two areas were explored, reactions to pain during practice (Figure III) and reactions to
pain during game (Figure IIII). Most players would continue as normal or continue but
take it easier (86,77 %) when experiencing pain during practice. The majority of them
said that they would continue but take it easier, with 30 out of 68 choosing that
response. 5 of the participants stated that they would choose step off the practice, at
least temporarily. The ones who chose to write their own answer stated, for example,
that it depended on the location of the pain and that they would try to make adjustments
to put the loading on different structures than the hurt one.
Figure III. The players reactions to experienced pain during practice
11
83,82 % of the participants chose that they would continue as normal if they
experienced pain during game, whilst 4 of them would step off for the rest of the game
(Figure IIII). Compared to the reactions during practice, 2 instead of 30 would continue
and take it easier when experiencing pain during game. 2 of the participants chose to
write alternative answers, stating that they continued until it got worse and that it
depended on the location as well as the severity of the pain (Appendix 2). When looking
at the two diagrams, the biggest difference is that during practice the players are more
likely to take it easier when experiencing pain, but in games the players keep on playing
to their fullest potential.
Figure IV. The players reactions to experienced pain during games
More players (4) were prone to step off games when experiencing pain compared to
practice (1). For the comments made by the participants who choose “other” as an
answer, see appendix 2.
Pain and future complications
Every single player believed that playing and practicing with pain could lead to future
complications (Table III).
12
Table III. Belief that playing and practicing with pain can lead to future complications
N
68
0
Yes
No
%
100
0
When asked which complications they believed could be caused by playing and
practicing with pain, 79,4 % of the participants stated that they believed it could lead to
long term injuries (Figure IIIII). 60,2 % of them thought that it could lead to chronic
pain and over half of the players thought that chronic hampered mobility and short-term
injuries could be caused as a result of playing and practicing with pain. The
complication which the least number of players believed could occur (34) was chronic
impairment of structures, which means that you lose strength from either muscles or
joints losing their ability to build force. In short, all the players were convinced that
playing and practicing with pain could lead to complications in some way.
Which complications they believe playing/practicing with pain can lead to a
60
54
50
41
40
34
36
36
30
20
10
0
Short term injuries
(weeks
Long term injuries
(months/years)
Chronic pain
Chronic hampered Chronic impairment
mobiity
of structures
Figure V. Injuries which they believe can be caused by playing with pain.
a
Results are shown in n of responses. Several alternatives could be chosen by the same respondent.
Discussion
Result discussion
The high general rating among the respondents on the first question (about pain
experience) cohere with previous studies about injuries among athletes, if the
13
assumption is made that pain and injuries are linked together.35-39 Research has shown
both that pain is common in sports where being physical is needed to perform and that
pain is experienced at a higher rate when playing a single sport compared to when
playing multiple sports. Soccer is a physical sport and the participants in the study play
on a high level, which probably means that they only play soccer. Therefore, the high
rating among the players might not be out of order. The fact that many players
experience pain means that they can’t perform optimally, since pain affects performance
in so many ways.10-34 Since pain and injuries often are associated, these results also
mean that players are exposing themselves to a high risk for injuries every practice.35-39
Among the questions in the second part (about the influence of pain on carefulness,
level of play, potential, emotions and concentration) of the questionnaire which were
related to Makhni´s questions in his study, the results are moderately equal, although the
players in this study generally had a bit higher score.21 In addition, the previously stated
data about pain decreasing flexibility, motor functions and muscle endurance show that
it might be reasonable that players experience those factors themselves.13-16 Many of the
players thought that pain affected their emotions. That might be problematic, since
having emotional problems affects concentration, performance and mental effort.28-32
Since the players experienced that they played worse due to pain, their confidence might
have gotten affected. That lack of confidence could have led to a decrease in
performance.33,34
The relevance of this study’s results regarding reactions to pain during games and
practices are strengthened by the fact that they are similar to the study presented in the
introduction about lower back pain and physical activity, where 93 % of the athletes
maintained their physical activity despite being in pain.43 Also, Babwah´s (2014) find
that 69.9% of the soccer playing females which were targeted had played a game while
being injured correlates with the finds from this study.44 These results mean that players
regularly expose themselves to danger by playing with pain, since that is linked with a
high risk for injuries.35-42
The answers from the last two questions (about the belief that physical activity can lead
to complication and which complications that could be) in the questionnaire indicate
that players are convinced that they expose themselves to danger by playing with pain.
14
This might lead to a fear of pain/injury which affects performance, rehabilitation length
and anxiety. 18-20
There are some additional parts about the two last questions which could be discussed
as well. One could assume that the players figured that the questions about the
correlation between playing with pain and future complications wouldn’t be in the
questionnaire if it wasn’t true. That the purpose of the study was to investigate a
possible problem, which would be that players don’t understand the consequences of
playing with pain, and therefore the respondents assumed that it must be true. A related
problem could have affected the answers in the last question, about which complications
playing with pain could lead to. The thought process for some of the players could have
been “if these factors are all brought up, I’m sure that all of them are true”. It could also
have affected them in the opposite way, meaning that the players would assume that one
or more of the stated complications probably are false to test them on their knowledge.
Giving the highest rating on a scale could be hard. If, for example, one would rate the
influence pain has had on one’s emotions, the thought process could be that rating a 5
would equal that pain has led to depression. “It could always be worse” is an attitude
which could lead to a likeliness for renouncing from rating the highest number on a
scale.
The entirety of the answers could also have been affected by bias. Maybe the presence
of the other players or coaches had an influence on the answers in some way, making
the responses weight over to either side of the spectrum to live up to some standard
which is set in the team.
The results might also have been influenced by the fact that the respondents know, or
have an idea about what the purpose of the study is and what it wants to achieve. Since
one of the purposes of the study was to investigate the commonness of pain among
high-level athletes, the players might have been a bit more generous in their estimations
to confirm what was sought after in the study.
By some, these finding might have been expected beforehand, but concretizing them
helps to pinpoint the problematic issue which exists in the teams which were included in
15
this study, and probably also in other teams as well as in other sports. There is a culture
of normalizing pain and injuries among the players which must come from somewhere,
supposedly their parents, their club or role models. This culture means that players fight
with pain and injuries during their whole careers which could shatter their whole
experience of being high-level athletes. From a performance point of view this could
also lead to worse results for certain teams due to injuries and weakened skill level from
the players.
Method discussion
The reason why this study was made on women was because it was perceived that men
were overrepresented in studies on soccer and pain or injuries. Therefore, the decision
was for this study to focus on women. The study could have included both men and
women, but the decision was made that it would be better to keep to one gender as
possible differences between the genders could make the results non-applicable to
neither men nor women, since the purpose wasn’t to make comparisons between
genders.
In their book about questionnaire studies, Phillips, Phillips & Bruce (2013) bring up
four possible errors which might occur when working with questionnaires: coverage
errors, sampling errors, non-response errors and measurement errors.57
When a coverage error occurs, the range of the respondents is outside the field of the
purpose. For example, if a high number of participants was strived for, which led to a
group of individuals with very different training backgrounds, some on elite-level and
some on recreational level, the results wouldn’t answer the purpose of the study.
Therefore, a priority in the selection of teams was to choose teams on a high level to
prevent this error from occurring.
A sampling error is an error which is caused by targeting groups which differs from
how the general population is. This is hard to prevent in any sort of study, but by using
a high number of individuals from different locations the results get a bit more
generalizable.
Another risk with using questionnaires is the risk of people deciding not to participate.
These risks are formulated as non-response errors. If the sheets had been sent to the
individuals online, it would have been easier for them to ignore it. By handing them out
16
physically on practice time with the coaches being present, it increased the chances of
the players deciding to participate in the study.
Measurement errors are errors which are caused when the questions are misinterpreted
by the participants and therefore don’t give relevant results. These errors were reduced
by presenting and explaining the questions and the purpose of the study before handing
out the sheets. The participants were also informed that they were welcome to ask
questions if they were unsure about anything in the questionnaire.
Aside from the four risks stated above, the liability of the study could also be impaired
by the respondents not taking their time to answer the questionnaire to the best of their
ability, due to, for example, laziness, lack of time or other more attractive activities to
attend to while filling in the sheet. This was also taken into consideration, by trying to
make the questionnaire short and easily understandable, and by being enthusiastic about
the importance of the study.
More disadvantages of questionnaires are brought up by Göran Eljertsson, such as the
limited information which can be gathered from it, the inability of following up on
interesting finds with further questions and the struggle with making complex questions
due to the high risk for misunderstanding. 58
Although the questionnaire was partly based on the one by Makhni,21 it was mostly selfdesigned and non-validated. The weakness by that is that there was no guarantee that
the questions were formulated well enough to make them understandable and answer
the purpose of the study. On the other hand, the questions were custom made which
made it easier to make them relevant for this particular study.
When deciding which method to use to answer the purpose of the study, there were two
more approaches aside from the method which was chosen which were considered; a
longitudinal study or a qualitative interview study. If one of those methods would have
been chosen instead, the outcome of the results would have been different.
If a longitudinal study would have been made, the answers could have been more
precise. If, instead of making a general estimation of the influence of physical pain, the
players would have had diaries where they answered a number of questions about pain
after every practice and game, it would have been easier for the players to give a precise
17
answer. It would also have been easier to generalize from the results since data would
have been held from every practice and game.
If an interview study was chosen as the method, the depth of the results would have
been greater. Follow-up questions could have been asked to get a greater understanding
behind the standpoints of the players. The study could have brought up more about why
they treat injuries the way that they did and how different situations could lead to
different answers, instead of finding a general answer.63
The thought process behind ultimately deciding to use a questionnaire to get the results
for the study was that it would have been hard to make a longitudinal study, due to a
shortage of time to finish the project, as well as the difficulty in supervising all the
players in the study, since the study was made on four different teams from different
parts of the country. It increased the risk of players forgetting to fill in their diaries and
inattentively filling them in several days after the practice or game took place. The
reasoning was also that it would be bothersome for the players to both remember and be
motivated to fill in their diaries almost every day for several weeks. Interviews would
have been relevant to make to answer the purpose of the study. The motive behind not
choosing that method was the lack of participants which would have been possible to
include. The decision was made that it was more important to be able to illustrate a
problem via generalization than to get a deeper view on the attitudes of a few
individuals.
The reasoning behind including a question in the questionnaire about previous injuries
was because injuries increase the prevalence of reoccurring injuries in the same
proximities, and therefore the conclusion was made that pain also could be more
prevalent for players whom had been injured before.64
In the first question about experienced pain during career, the fact that the respondent
must make a general rating based on their whole career could be problematic, especially
if said player have had a long career. It might be hard to recall and evaluate perceived
pain which occurred several years ago,65 and chances are that the rating is mostly
influenced by experiences from more recent years. The same problem also applies to the
question about experienced pain connected to practice and games the last month. Even
if it concerns a month instead of several years, it might be hard to make a collected
18
evaluation from all the practices and games, and you might also be more affected by the
most recent practices when rating the perceived pain.
In addition, there is a risk that the previous month doesn’t give a just reflection on how
affected the player usually is by physical pain. Maybe some players felt more or less
pain that specific month than they usually do, which makes the results less
generalizable. Regarding the reactions to pain during practice and games, a response by
some of the players was that it was hard to answer those questions since it often
depends on the amount of pain which is felt. The instruction was to try and make a
general estimation on the amount of pain they would imagine experiencing, but
nevertheless it could be hard to give a clear answer to those questions.
Future studies
Since this study has a broad orientation, there are many fields which could be further
explored, such as connections between pain in sports and age, nationality, previous
injuries, level of play etc. Studies could also target the coaches, physiotherapists or
parents of athletes. Quantitative studies could be made were pain during practice and
games were examined more precisely by letting players fill in diaries where they
summarize the level of pain experienced during every practice and game, as well as
whenever they don’t play due to pain. Interview studies could also be made to extract
more qualitative information from the players to get a view on what their thoughts are
on pain.
Conclusions
The majority of the players in a team struggle with pain to varying degrees. Even
though players are convinced that it might be dangerous to practice and play games
while being in pain as well as that it can lead to several lifelong complications, most of
them keep on playing when they experience pain, especially during game.
Coaches and physiotherapists can, by being inspired by this study, be warier of the state
of the players that they work with to prevent injuries by letting players play games and
practice with pain as well as putting more effort into pain prevention when setting up
their practices. The players should be properly informed about the risks in playing with
pain and encouraged to treat their body better when experiencing pain by not continuing
practices and games when being in pain.
19
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23
Appendix 1 Questionnaire Questions
Characteristics
Q1
Q2
Q3
Age, height, amount of years played at current (or higher) level & if
they had encountered a serious injury (more than 3 months away from
play) in their career.
“To which extent do you think that pain has been present during your
sports career?” On a scale from one to ten where one is no extent and
ten is high extent.
“Mark the box which fits in the most depending on the extent you’ve
been affected the last month.” On a scale from one to five where one is
no extent and five is high extent. They took a stand on six statements:
1. I experience physical pain during/after practice/games
2. Physical pain has made me more careful in my motions
3. Physical pain has worsened my ability to play soccer
4. Physical pain has hampered my potential as a player
5. Physical pain has affected me emotionally
6. Physical pain has caused me problems with concentrating
“If you start experiencing pain during practice; how do you react to it?
Choose 1 alternative.” Five alternatives were available:
1. Continue as usual
2. Continue but take it easier
3. Step off until it feels better
4. Step off completely
5. Other
Q4
“If you start experiencing pain during game; how do you react to it?
Choose 1 alternative.”
1. Continue as usual
2. Continue but take it easier
3. Step off until it feels better
4. Step off completely
5. Other
Q5
“Do you think that practicing and playing games despite being in pain
can lead to future complications?” Yes/No
Q6
“If yes; which complications do you think it can lead to? You can mark
several alternatives.”
1. Short term injuries (weeks)
2. Long term injuries (months/years)
3. Chronic pain
4. Chronic hampered mobility
5. Chronic impairment of structures
6. Other
24
Appendix 2 Comments from the participants
“Others” from
reactions to pain
during practice
1. “It depends on where the location is: if I feel pain in a
previously injured area I tend to get more careful.”
2. “I try to continue as normal. If I can’t I take it easier”
3. “I continue practicing but adjust the practice to avoid
getting hurt, for example by putting load on a different
muscle group.”
“Others” from
reactions to pain
during game
Other comments
4. “It depends on where and how much pain I feel”
1. “I try to continue but if it gets worse I step off the
game”
2. “It depends on where and how much pain I feel”
“I think that many injuries occur because you are too
physically weak in different parts of your body.”
“Depending on what kind of pain you feel, I think that I
can lead to future complications.”
“I have had Schlatters Disease in both of my knees as
well as periostitis but still kept on going.”
“Many of the questions are hard to answer as I
experience many different kinds of pain which I treat in
various ways.”
“I have had this high extent of pain because I’ve had
four cruciate ligament and meniscus injuries in the
same knee”
“I am always in pain due to chronic periostitis”
“I have had a meniscus injury for the past year and I
am on my way back after two surgeries. My cruciate
ligament is also torn since earlier which has prolonged
my rehabilitation. I have been injured for a total of two
years.”
25