Elite female footballers stories of sociocultural factors, emotions, and behaviours prior to anterior cruciate ligament injury

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International Journal of Sport and Exercise Psychology

ISSN: 1612-197X (Print) 1557-251X (Online) Journal homepage: https://www.tandfonline.com/loi/rijs20

Elite female footballers’ stories of sociocultural

factors, emotions, and behaviours prior to

anterior cruciate ligament injury

Andreas Ivarsson, Urban Johnson, Jón Karlsson, Mats Börjesson, Martin

Hägglund, Mark B. Andersen & Markus Waldén

To cite this article: Andreas Ivarsson, Urban Johnson, Jón Karlsson, Mats Börjesson, Martin Hägglund, Mark B. Andersen & Markus Waldén (2019) Elite female footballers’ stories of sociocultural factors, emotions, and behaviours prior to anterior cruciate ligament injury, International Journal of Sport and Exercise Psychology, 17:6, 630-646, DOI:

10.1080/1612197X.2018.1462227

To link to this article: https://doi.org/10.1080/1612197X.2018.1462227

Published online: 19 Apr 2018.

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Elite female footballers

’ stories of sociocultural factors, emotions, and

behaviours prior to anterior cruciate ligament injury

Andreas Ivarssona*, Urban Johnsona, Jón Karlssonb,c,d, Mats Börjessone,f, Martin Hägglundd,g, Mark B. Andersenaand Markus Waldénd,h,i

a

Center of Research on Welfare, Health and Sport, Halmstad University, Halmstad, Sweden;

b

Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden;cSahlgrenska Academy Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden;dFootball Research Group, Linköping, Sweden;eDepartment of Neuroscience and Physiology, Gothenburg University & Sahlgrenska University Hospital/Östra, Gothenburg, Sweden;fDepartment of Food, and Nutrition, and Sport Science, Gothenburg University, Gothenburg, Sweden;gDepartment of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden;hDepartment of Medical and Health Sciences, Division of Community Medicine, Linköping University, Linköping, Sweden;iDepartment of Orthopaedics, Hässleholm-Kristianstad-Ystad Hospitals, Sweden (Received 18 October 2016; accepted 31 March 2018)

The aim of the study was to examine how players’ perceptions of sociocultural factors and intra- and interpersonal aspects of sporting experiences may have influenced the emotions, cognitions, and behaviours of elite female soccer players prior to the occurrence of ACL injuries. The research questions guiding the study were: (a) how did female elite soccer players perceive that their psychosocial experiences were related to their cognitive, physiological, and emotional states prior to their ACL injuries, and (b) how did the players feel their perceived states influenced their behaviours prior to injury occurrence. The participants consisted of the total population of female players (N = 18) competing in the Swedish women’s elite league, who incurred a total ACL tear during the 2012 season. Using a semi-structured interview guide, all players were interviewed post-season. We represented the data using a storytelling approach of aggregated creative nonfiction. The aggregated stories showed sociocultural rules and expectations of overtraining and placing pressure on athletes to play even if they were not physically or psychologically fit. Responding to pressures with potentially risk-increasing behaviours might raise the probability of becoming injured through a number of pathways. Team managers, coaches, and members of the medical team are recommended to develop environments that stimulate the players to engage in adaptive stress-recovery and risk-decreasing behaviours.

Keywords: anterior cruciate ligament; athletic injuries; elite athletes; female athletes; psychosocial factors; soccer

Women’s professional and semi-professional soccer has, during the last few years, grown in a number of countries (Martinez-Lagunas, Niessen, & Hartmann,2014). In line with this develop-ment, the intensity of the games has increased, generating higher physical demands on the players (Andersson,2014). Difﬁculties in coping with these demands are related to increased injury risk. Among injuries, ruptures of the anterior cruciate ligament (ACL) are considered some of the most

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

*Corresponding author. Email: andreas.ivarsson@hh.se

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dramatic events that may affect players’ careers (Volpi et al.,2016). Also, women are, in compari-son to the men footballers, exposed to a two to three times higher risk of ACL injury (Waldén, Hägglund, Werner, & Ekstrand,2011). Incurring a severe injury is associated with several nega-tive emotional (e.g. anger, anxiety, depression), cogninega-tive (e.g. perceptions of pain and stress), and behavioural (e.g. substance use) outcomes (Mainwaring, Krasnow, & Kerr,2001; Wiese-Bjorn-stal,2010).

Given the negative outcomes associated with severe sports-related injuries (Hagger & Orbell,

2003), research aimed to prevent sport injuries is warranted (Vriend, Gouttebarge, Finch, van Mechelen, & Verhagen, 2017). To do so the ﬁrst step is to identify risk factors for injuries (Bahr,2016). Sports injury prediction research has traditionally focused primarily on physiologi-cal and demographic predisposing factors (e.g. Almeida, Olmedilla, Rubio, & Palou,2014; Bahr & Krosshaug,2005), but the importance of psychosocial variables in relation to injury suscepti-bility has attracted increased attention (Johnson, Tranaeus, & Ivarsson,2014; Wiese-Bjornstal,

2010). In this study, we consider risk factors to include previous injuries and returning to training and competition before physical healing and psychological recovery are complete, overtraining behaviours (e.g. slowly wearing out joints and muscles that eventually results in acute tears or ruptures), re-injury anxiety, and the psychosocial antecedents of injury identiﬁed in the literature (e.g. history of stressors, personality factors, coping resources; Williams & Andersen,1998).

Psychosocial risk factors for sport injuries

The most cited theoretical framework for investigating the impact of psychosocial variables on athletes’ risks of becoming injured is the model of stress and athletic injury (Williams & Ander-sen,1998). In this model, the psychosocial variables are divided into three categories: personality factors, history of stressors, and coping resources. These three categories of psychosocial factors will influence the athlete’s appraisals of a potentially stressful situation (e.g. match/competition), which in turn, will have a bidirectional relationship with cognitive and physiological stress responses, such as perceptual disruptions and increased generalised muscle tension The magni-tude of the stress responses will, in turn, influence injury risk (Rogers & Landers,2005; Williams & Andersen,1998). This framework was supported byfindings in a recent review where athletes with high levels of some personality traits (such as trait anxiety), high levels of history of stressors (e.g. negative life event stress, daily hassles), and low levels of coping skills when accompanied by high stress responsivity, were more likely to become injured than players with the opposite profiles (Ivarsson et al.,2017).

Even though the model of stress and athletic injury is the one most used in previous studies, a few limitations have been identiﬁed. First, the model’s primary focus is on acute injuries, and it does not take into account overuse injuries or overtraining factors that might lead to acute injuries. Such factors may include behavioural mechanisms related to the stress response (e.g. impaired self-care), psychophysiological stressors (e.g. intense physical training), and physiological mech-anisms (e.g. impaired skeletal muscle repair as a result of inadequate recovery time). Inclusion of such factors may contribute to a better understanding of how to design comprehensive interven-tion programmes (Appaneal & Perna,2014). Second, environmental and sociocultural risk factors (e.g. team norms) that may lead to acute and/or chronic injuries are not included into the model of stress and athletic injury (Hackfort & Kleinert,2007).

To explain how the sociocultural context can inﬂuence injury risk through internal processes and behavioural factors, Richardson, Andersen, and Morris (2008), based on theoretical models (i.e. Kenttä & Hassmén, 2002; Meyers & Whelan, 1998), and the empirical ﬁndings from coaches’ and experts’ opinions along with four in-depth aggregate case studies, developed what they described as the overtraining risks and outcome model. In this model several different

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risk factors for overtraining symptoms and injuries are suggested. These risk factors are divided into intrapersonal variables (e.g. personality traits), interpersonal inﬂuences (e.g. past and present relationships), situational factors (e.g. poor performance), and sociocultural contexts or environ-ments (e.g. sport culture, societal inﬂuences). The sociocultural context is a broad array of factors (e.g. norms, imperatives, values, demands, traditions, history) in which the three other categories of risk variables are embedded. The interactions between those risk factors could lead to imbal-ance between stress and recovery, which in turn can generate several physiological (e.g. increased fatigue level, decreased performance) and psychological (e.g. increased anxiety, emotional labi-lity) responses. In the model, an athlete could thereafter follow one of two different paths of be-havioural responses to deal with the physical or psychological stressors/reactions. If athletes engage in adaptive behavioural responses, such as increased recovery activities, or adjustments in training load, it is likely that they will return to a balance between stress and recovery. The other types of behavioural responses athletes can select are potentially risk increasing such as ignoring the physical or psychological reactions associated with the imbalance between stress and recovery, increasing training effort, and neglecting recovery. These types of behaviours are associated with adverse outcomes, such as increased likelihood of becoming injured and increased risk for both overtraining syndrome and chronic fatigue.

Even though the overtraining risks and outcome model (Richardson et al., 2008) and the model of stress and athletic injury (Williams & Andersen, 1998) have different structures, there are some overlaps between the categories of injury risk factors. For example, in the model of stress and athletic injury the history of stressors category contains a number of the socio-cultural as well as the interpersonal aspects that are present in the overtraining risks and outcome model. Also, the recovery strategies from the overtraining risks and outcome model could be incorporated in the coping category within the model of stress and athletic injury.

Recent research has shown that sociocultural factors (e.g. norms within the team), psychophy-siological factors (e.g. overtraining symptoms), and interpersonal elements (e.g. poor communi-cation with the coach) as well as intrapersonal features (e.g. re-injury anxiety) are risk factors for injuries (e.g. Gabbett,2010; Ivarsson, Stambulova, & Johnson,2016; Janse van Ransburg et al.,

2013; Laux, Krumm, Diers, & Flor,2015; Soligard et al,2016; Tranaeus, Johnson, Engström, Skillgate, & Werner,2014).

In line with these empirical results and Richardson et al.’s (2008) suggestion that imbalance between stress and recovery is a risk factor for injury, a model focusing on risk factors for ACL injuries in female athletes was created (Elliot, Goldberg, & Kuehl,2010). According to this model fatigue, overtraining and burnout symptoms, stress (e.g. depression, anxiety, and low self-esteem), inadequate sleep, and performance climate are potential risk factors for ACL injuries in female athletes.

Even though sociocultural factors might increase the risk of injury, only a few studies have focused on these factors in terms of injury prediction research. This limited focus is somewhat surprising because sociocultural factors can have substantial inﬂuences on athletes’ attitudes, emotions, and behaviours (Kidd,2013; Tibbert, Andersen, & Morris,2015). More speciﬁcally, sport cultures transmit standards for what types of behaviours are expected and accepted. In some elite sport environments, several sociocultural norms exist where athletes are expected to play through injury and pain (Richardson et al.,2008; Wiese-Bjornstal,2010). These types of behaviours may increase the risk of becoming injured.

One study on youth female soccer players, addressing social environments and injury, showed that players who perceived their teams as having mastery motivation climates were exposed to higher injury risks than other players (Steffen, Pensgaard, & Bahr,2009). The authors’ most plaus-ible explanation to this somewhat unexpected result was that players who practice in mastery cli-mates may be more likely to develop perfectionism, which, in turn, could increase injury risk.

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Qualitative approaches to injury research

Although most frequently used in sports injury risk factor research, quantitative approaches may not capture some of the important aspects of athletes’ actual lived experiences and psychological and emotional states prior to injury occurrence (Hackfort & Kleinert,2007). By contrast, when using qualitative research designs, in which participants tell their stories, a number of different types of meaningful data can be collected. For example, storytelling makes it possible to describe experiences in a sequential framework and weave narratives that include sociocultural processes, cognitions, emotions, behaviours, identities, and personal histories in all their inter-relatedness. This storytelling, or rather re-storytelling (Cozolino, 2010), captures the person’s perceived reality, which is not usually accessible when using quantitative methods. To date, only a few studies have used qualitative approaches to investigate injured athletes experiences of the time prior to injury occurrence (e.g. Johnson et al., 2014). In one of these qualitative studies (Johnson,2011), the author reported in a thematic analysis that the risk factors athletes experi-enced prior to injury occurrence could be divided into four broad categories. These categories were history of stressors (e.g. life-event stress); personal factors (e.g. performance anxiety); fatigue (e.g. psycho-physiological fatigue); and limited coping resources (e.g. limited social support).

Sport, in some cases, can put pressure and stress on athletes that subsequently might increase the risk of becoming injured (Richardson et al.,2008), so it is of interest to investigate how elite athletes perceive connections among their sociocultural contexts and demands, their emotions, and their behaviours prior to their ACL injuries. The interweaving of life histories, sport impera-tives, stress reactivity, and individual personalities in relation to injuries lends itself to research methodologies that construct illustrative narratives of these complex social cultural, intra-, and interpersonal processes.

The aim of the study was to examine how players’ perceptions of sociocultural factors and intra- and interpersonal aspects of sporting experiences may have inﬂuenced the emotions, cogni-tions, and behaviours of elite female soccer players prior to the occurrence of ACL injuries. The rationale for focussing on women elite soccer players and ACL injuries was twofold. First, recent systematic reviews have shown that women are underrepresented in the soccer psychology litera-ture in general (Gledhill, Harwood, & Forsdyke,2017) and in the psychology of sport injury lit-erature in particular (Forsdyke, Smith, Jones, & Gledhill,2016). Second, the authors had access to the total population of ACL injured women athletes in elite Swedish soccer for the year the study was conducted, which is a type of research opportunity that is rare in sport injury investigations. The research questions guiding the study were: (a) how did elite female soccer players per-ceive that their experiences of sociocultural factors and intra- as well as interpersonal aspects might have been related to their cognitive, physiological, and emotional states prior to their ACL injuries?, and (b) how did the players feel their perceived states might have inﬂuenced their behaviours prior to injury occurrence?

Method Design

This study is based on critical realist social constructionism (Harper,2011). By adopting this per-spective we“take the position that, alongside an awareness of the importance of studying quali-tative data in detail, it is also important to go beyond the text in order to add a further layer of interpretation – by setting what is said in a broader historical, cultural and social context” (Harper,2011, p. 90). Through having a critical realist social constructionism perspective we pos-ition ourselves as ontological realists but epistemological relativists.

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Participants

In Sweden, the highest women’s soccer league started in 1988. The league consists of 12 teams. The competitive season in Sweden lasts for approximately eight months a year, and each team play 24 domestic matches (Andersson, 2014). Of all players in this league, only 12% of the players had at-least a 50% employment (Hägglund, Waldén, & Ekstrand,2009).

The participants consisted of the entire population of soccer players (N = 18) who incurred a total ACL tear in the Swedish women’s elite soccer league during the 2012 season. We identified participants through a prospective injury surveillance study carried out during the season. After the last competitive match, we contacted all potential participants for possible inclusion, and all agreed to take part. Nine of the players (50%) reported contact ACL injuries while the other nine (50%) had non-contact ACL injuries. All players underwent surgical ACL reconstruc-tion using patella tendon or hamstring autografts. For a majority of the participants (n = 13), the current injury was thefirst ACL rupture in their careers. For the five other participants, three had experienced a previous ACL injury on the contralateral knee, and two had experienced a previous ACL injury on the same knee.

The interviews

Thefirst author conducted all the interviews, and in the beginning of each interview he asked the participants to describe their backgrounds in soccer, their general life situations, and specific details of any previous ACL injuries. Thefirst author used an open-ended, semi-structured inter-view guide consisting of questions and requests for information covering broad areas of what was happening in their sport and in their lives, including their physiological and emotional states, in the two months prior to when their injuries occurred. The participants were also requested to reflect on any relationships they perceived between their life experiences and their cognitive, physiological, and emotional states, and their thoughts and behaviours during those two months. The first author asked additional questions and probes, such as “can you elaborate more on how you perceived your emotional state might have influenced your behaviour?” to help form and expand their narratives.

Procedure

The interviews took place during the post-season (December 2012 to January 2013). On average, the interviews occurred six months (range 3–9 months) post-injury. At the time of the interviews, 16 of the 18 invited players were living in Sweden, and the other two were located abroad. Due to logistical problems related toﬁnding suitable times and places for meetings during the off-season, we conducted six of the interviews using video communication (Skype; Microsoft Corporation, Washington, USA). Theﬁrst author completed all the interviews, lasting 25–65 minutes and tran-scribed verbatim all the material prior to analysis and data representation (total amount of inter-view data was approximately 10 hours).

The study was reviewed and approved by the Regional Ethical Review Board, Linköping University, Sweden.

Results

Data analysis and representation

To analyse and present the data we used a thematic content analysis and a narrative storytelling approach, respectively. This procedure sits loosely within the framework of narrative analysis (Smith & Sparkes,2008).

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First, theﬁrst author performed a thematic content analysis to identify key themes (Riessman,

20082008). In this process thefirst author read the verbatim transcriptions several times to gain familiarity with the content. Then he coded the content in each interview. Categories of codes where then organised into themes. These codes and themes were then discussed with the second author. In this step of the analysis two distinct (meta) themes emerged. These two themes were: (a) fatigue/perceived lack of recovery and (b) worry/anxiety. Within these meta-themes there were several submeta-themes (e.g. frustration, coach and medical personnel communi-cation, teammate pressures and responses, athletic identity, financial worries, work outside sport issues), and these subthemes were used toflesh out the aggregated creative nonfiction nar-ratives. More specifically, the themes were used to provide the foundational content for classic storytelling with a beginning, a middle, and an end. Each of the themes and subthemes are con-nected in some way to one of the three stages of storytelling in a dramatic arc.

Second, we selected creative non-fiction for representing the results of the study (for more information about the creative nonfiction method see Richardson, 2000; Smith, 2013). More specifically, creative nonfiction “offers a story using factors developed from systematic research, but uses many of the techniques of fiction … to communicate results in compelling and emotionally vibrant ways” (Smith, 2013, p. 135). We selected creative nonfiction as the appropriate approach to represent the data for several reasons. First, given that some of the interview transcripts contained sensitive (and sometimes identifying) information, the creative nonfiction approach increased the chances of protecting the confidentiality of the participants. Second, by using the creative nonfiction approach it is possible to both “portray[ing] a com-plexity of lived experience, and minimise interpretation and theorising” (Erickson, Backhouse, & Carless,2016, p. 93). In line with this approach, some examples of techniques offiction are allusions, aggregated characters, and contextualised language (Smith, 2013). In the present study, the contents and forms of the two stories are based on the results of the thematic content analysis, where the aim of the created stories was to represent the findings within that analysis. Due to the two distinct themes emerging in the first step of the analysis, we decided to create two stories using aggregated characters. This type of creative nonfiction approach, aggregated storytelling, was used to protect the anonymity of the participants (Erick-son et al.,2016). The major goal was, therefore, to provide stories that synthesised the partici-pants’ experiences but to not present direct quotes from individual athletes (Blodgett & Schinke,2015).

When performing qualitative research, Smith and Sparkes (2008) suggested that, “research-ers-as-authors need to indicate their positioning in relation to the research process” (p. 17). This recommendation is in line with Tracy’s (2010) suggestion that researchers should reflect about their subjective values and biases that might influence the interpretation of the findings. To position myself (first author) within the context of the study, I am a former competitive soccer player, who had multiple ACL injures during my career. These experiences probably in flu-enced each step of the interview and analysis procedures.

To increase the credibility of thefindings in qualitative research, it is also suggested to use a triangulation process where, for example, two or more researchers are involved. If the researchers in such a process agree on the conclusions or interpretations then research out-comes may have an increased credibility (Tracy, 2010). To ensure that the participants’ stories were reflected within each step of the process, and to improve credibility in the analysis and narrative constructions, the themes and stories were critically discussed in the authors’ group and then reinterpreted some parts to better illustrate the participants’ meanings. Also, the themes that emerged in the thematic content analysis together with the participants’ real words, phrases, and sentences (modified for storytelling purposes) were intertwined in the fol-lowing narratives.

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Narratives of injury Case 1: Malin’s tale

So here is my story. I am a good footballer and have been at the top level of Swedish soccer for a couple of years, and I am one of the youngest members of theﬁrst squad. What really irritates me is that I still have not broken through to actually playing matches. My bum has a full-time job warming the bench. Sure, I have played a couple matches, but only as a sub, and only for a short time. A couple matches in two years at the top. What is that?

It is now the middle of February, and the pre-season has already started. Still no real playing time in sight, plus I have become a stress puppy. You see, the club did not give me a full-time con-tract, and I have to work another job to keep myﬂat and have some food in the fridge. A girl has to eat. I think I am turning obsessive. When I bike to practice, I keep repeating in my head what my coach said to me a couple weeks ago,“You’re real close to being a starter this year,” “You’re real close to being a starter this year,” “You’re real close to being a starter this year,” over and over again. Sometimes my brain is like a hamster on a wheel, just going round and round over the same old things and never getting anywhere. Other times my mind is all over the place jumping from ideas about training to worries to what is for dinner. It is a mess in there inside my head.

But here is the good news. At the end of last season, and the very start of training this season, myﬁtness was just bad. I mean really crappy – probably the worst on the team, but I have been training like a Viking oarsman in calm weather. And the other girls on the team call me Marathon Girl. I like that. Big difference since last season.

So, it is another usual day at training. I cycled all the way here and parked my bike in the usual spot. When I get to the locker room, theﬁrst person I see is Maria. She is OK, but she irritates me a bit. I cannot really say why. She asks how I am doing. I say,“Good, hard training yesterday, but the body feelsﬁne.” Maria quickly responds, “Yeah, same here.” But then she adds, “You have to admit that we have had a lot of heavy strength training the last few weeks.” Sounds like she is complaining and is trying to get me on her side regarding the heavy training loads. Maybe that is why she irritates me. My only response is, “Yeah,” and I leave the locker room. I do not need to be around negative people.

After the training I have this meeting with my coach because I want to show him that I am very serious when it comes to my soccer. I feel that perhaps I need to train even more to get the starting position I think I deserve. So I ask him to give me a training programme that I can follow in addition to the programme that we have with the team. I am really pleased when I see him smile, and he says,“OK, we can sit down together and go through what I think you have to focus a bit extra on to become an even better player.” Bingo! I got a new programme. It will add three additional training sessions a week, but now no one is going to be able to stop me from performing my best.

Three weeks later I am sitting in front of my TV, and I cannot understand that there is nothing but crap on television for a Saturday evening. Is there really anyone who cares about food pro-grammes? I should have said“yes” when Jenny and Kate asked me to hang out with them, but I have no energy to meet anyone. I have felt this way for a few weeks. I am so tired of feeling exhausted. I will probably feel better if I can get some good sleep!

My head hurts! It is like an explosion has taken place inside my head during the night. What is the time? 10:45; it is time to get up. Everything is just spinning around in my head, and my body feels like a bag of garbage. I think I wanna stay here in bed for the whole day. 16:07; now I really have to get up. Cannot spend the all day here. Ahhh, I feel more tired now than before, but I cannot stay here just staring up at the ceiling. Must drag myself over to the TV at least.

New day, back on the bike again to ride to training. I hope that I will manage to go 100% in training today. Been lying in the bed for the whole day and feel pretty much like a zombie. But I

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have got to go to training and talk to my coach. You see, I do not want to be as tired as I have been the last few weeks. I am not sure that I should talk to him because it will probably take me 1000 miles from the starting position I so desperately want, but, as for now, I do not see any other way. I run into the coach before the training starts and ask him if we could sit down for a quick chat. “Ok, no problems” the coach says. “We can sit in my office.” I go with heavy steps towards the office, and there is this voice in my head saying “You are weak. You will never make it into the team if you tell the coach you can’t practice.” When the coach asks me what I wanted to talk about I feel some tears about to well up. Inside my head a movie is running where I see myself sitting on the bench without playing a second. Then I just dive in and start to tell the coach about how I have felt during the last few weeks. I tell him that I have felt like a bag of garbage without any energy to do anything. I can see in his eyes that he looks surprised to hear me say this, but that does not surprise me at all. He looks into my eyes and says“This does not sound good. I know that it has been a tough training schedule, but it is probably normal that you feel a bit tired at this point in the season. Of course you need to talk to me again if this fatigue does not go away by the time we start more soccer-specific training. You are still in a good place to take a starting pos-ition when the competitive season starts.” Yes, that was exactly what I wanted to hear. Those last words were music to my ears. And it is probably nothing to worry about. Perhaps it is normal to feel this way in order to become a top player.

Game day,finally! I am still a bit tired, but I really want to start in the first competitive match, and I will be really bummed out if I do not get some playing time. It will go justfine when the game starts.

Yikes!!! What just happened? My knee is exploding! Seems like I have been lying here on the pitch forever. Finally, the doctor and physio are here. What took them so long? It was just a weenie tackle from the back when I was chasing the ball. What is going on? I can hear my team-mates and the doctor talk, but I do not understand what they are saying. Damn! The pain is killing me. Just take me off the pitch!

One day later and I have just been talking to the doctor again, and right now I feel my world is falling apart for me. About 15 minutes ago they told me that I have an ACL injury. This could be one of the worst days in my life.

Case 2: Sara’s tale

Hi, I am Sara, and I have played soccer at the highest level in Sweden for a couple of years. I do not have much to complain about; I have a full-time contract, and I recently bought a new apart-ment. I am pretty satisfied with life. But I have a tendency to worry about all sorts of things. Right now I am on my way to a meeting with my coach and the chairman of my club. I wonder what they want. I have to admit that I am a little nervous, but it cannot be that bad. I had an OK season last year, so it is probably nothing to worry about. Nice office, I have not been here before. “Hi Sara! Glad that you could make it.” I turn around to the direction where the voice came from and see the chairman and the coach. Has he lost some weight? I am not sure. We go towards the chair-man’s office, and I sit down in a chair. I look at the chairman when he starts to talk, “We want to have this meeting because we think that you are a role model for the younger players in the team, and we wanted to let you know that you are an important member of the group. We also want to ask you if you are willing to take part in a couple of events to promote our club during the season.” Hmm … interesting. So they want me to represent the club. Feels like the time in school when I was elected to represent my class in track andfield competitions. Must be a good thing to do so I quickly respond that I am very proud to be in the club, and that it is great to hear that they see me as a role model. I also tell them that I will try my best to support the younger players in the club and that I am also interested in promoting our club. Perfect! The chairman smiles. Just increased

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my chance to get a new contract. Great, so now everyone is happy.“Excellent” says the chairman and points at the coach.“Now Peter (the coach) has something that he wants to talk to you about.” The coach then starts to talk“Because you are one of the players I believe in I just want to discuss some smaller things in relation to the schedule we have for our matches.” So he wants to discuss our schedule with me. Must be that I have moved up the hierarchy this year.

It feels like they appreciate my work. I feel very glad that I have been able to come back to this level again after the injuries that I had experienced during the last seasons, I say to myself as I walk into my apartment. What a lovely smell. I look into the kitchen and there stands my boy-friend in an apron cooking some kind of soup. Nice honey, exactly what I need.

A few weeks later. Why did I do that? I am sitting in the kitchen just looking at the empty chair in front of me. Feel hopeless, will never be happy again. Broke up with my boyfriend a few days ago after a long series of arguments. Why could he not understand that I have to train so much now that the competitive season has started? Why me! Have to hit something. Why did I do that? Nothing will get better with me sitting here and crying. Best to go to bed now.

Where am I? I look up and see our physiotherapist looking down at me. I am lying on theﬂoor in the locker room.“You got an elbow smacked into your head” our physio answers. Aha, that is why I have a headache. Ok, nothing to do about it now.“Did we win the game?”

I have to change the ringtone on my cell-phone. A rainforest theme, come on, what did I have in mind when I selected that? I pick up the phone and hear a familiar voice.“How do you feel and when do you think that you will be able to play?” are the ﬁrst two questions my coach asks. Why does he have to call me now? I have been lying in bed with a headache for two days now. Does he not understand that I cannot play? I think a few moments and respond that I do not know because I still have a headache.“OK, we could wait for a couple of days” he answers. Of course you can wait for a couple of days because it is not you who is injured. Now stop annoying me and let me go back to sleep. Hope that he will hang up the phone if I tell him that I will drop by the training tomorrow and say hi to my teammates.

It is a bit windy. Cannot really say why I decided to walk to the training instead of taking the car. Stupid choice. But now I am almost there.“Hi Sara. Do you think that you can play on Satur-day? The team really needs you.” What! Who said that? I turn around and see a little middle-age man.“What do you know about football?” I mutter to myself, but I did not say anything to him. Best to walk fast so I do not have to speak with anyone else. Do I really have to play on Saturday, I think to myself when I slam open the door to the locker room.

Great, now I have to talk to the coach again. Cannot he understand that I do not want to talk. “Do you think that you could play on Saturday?” Why cannot he leave me alone? I do not want to play. But I know that I am important for the team. Cannot say that I do not want to play. I just tell him that I do not know. Hope that he will understand that I do not feel ready. OK, but I think that you should do a test to see if you are recovered and after that we can make a decision.“OK, so I will do the test.” Hopefully that will make him stop nagging me. “Perfect, I’ll manage it so you can do this test tomorrow” he says and grabs his cell phone.

I feel so wobbly. I have biked for 20 minutes, and it does not feel good at all. Here comes the coach. Hope he noticed that I did not perform well on this test.“That went ﬁne” he says. Fine! Is he crazy? I feel a big lump in my throat because I still have to tell him that I do not feel ready to play. My anxious stress puppy is jumping all around. I mean, that if I had problems staying focused during the test, and it just lasted for a couple of minutes, then I am potentially in trouble. I blurt it out,“I will not be able to play on Saturday.” “Are you sure?” he asks. “We really need our best midﬁelder on the pitch.” What is it that he does not understand? Would I have to have a broken leg to get him understand that I do not want to play?“I don’t feel ready to play” I tell him again. Just a few seconds later he leaves the room. This did not go well. Maybe I have to play on Saturday. After all, they are paying my salary.

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I am not ready for this. I have just practiced on my own during this week, and I had problems concentrating during those sessions, but I do not have the energy to stand up to the coaches, team-mates and supporters who all have tried to convince me to play the match. After the last match that we lost they looked at me as if I was a traitor. I have to play.“Hopefully it will feel better once the match starts” I say to myself before I join the rest of the team for the line-up.

What am I doing here? I have just made a header, and the only thing I have in my mind is that question. It seems like things are not quite real. I think my brain is on another planet. I am so disappointed that I cannot focus. I must tell the coach that I have to be subbed. I will just wait for this corner kick. How long time should it take to shoot a corner kick? Oops, it is too long. Best that I run after the ball. I see that tackle coming in slow motion, and there is pain, and I am down on the pitch, but I am also sort of watching myself. This is all weird. So much horrible pain in my knee! When the physiotherapist helps me off the pitch all these thoughts goﬂashing through my brain. It was too early to return to play; I had not even done proper testing to see if I was physically recovered. I knew that I was not ready to play, but I felt that I was important for the team. I should not have played the match because I was not mentally there. How could I be so stupid?

Discussion

The aim of the present study was to examine how players’ perceptions of sociocultural factors and intra- and interpersonal aspects of sporting experiences may have influenced the emotions, cogni-tions, and behaviours of elite female soccer players prior to the occurrence of ACL injuries. The mainfindings, were that with our chosen qualitative approach we were able to reveal several factors that might have influenced the risk of having an ACL injury, as illustrated by the two nar-ratives, put together from the stories of all the athletes. Although some of these potential risk factors are in line with the ones suggested in the Williams and Andersen (1998) model of stress and athletic injury, some of them are not.

In Malin’s tale she describes that she was both mentally and physiologically exhausted prior to injury occurrence. To experience fatigue and overtraining symptoms can increase the risk of ACL injuries through compromised coordination as well as decreased alertness (Elliot et al.,2010). More speciﬁcally, mental (i.e. cognitive) fatigue might inﬂuence one’s abilities to direct attention towards important cues in the environment (Chaudhuri & Behan,2000), which in turn could increase injury risk through impaired decision-making or by being easily distracted (Appaneal & Perna,2014; Williams & Andersen,1998).

One interesting aspect in Malin’s tale is that she expressed that the team psychological climate, together with limited support from the coach, could be some potential reasons for her high levels of fatigue. Indeed, poor quality interaction with coaches and teammates potentially can increase the risk for fatigue and burnout symptoms, as shown in several studies (Eklund & Defreese, 2017). Malin was, quite simply, wearing herself down, and as Richardson et al. (2008) suggested, people on their way to becoming overtrained often get injured due to specific body parts being overused and breaking down long before the systemic overtraining syndrome becomes apparent. These sociocultural aspects (e.g. the coach-athlete relationships, team cli-mates) that appear to have influenced injury risk, through their substantial impact on cognitive, emotional, and physiological states, are not explicitly described in the model of stress and athletic injury (except possibly as fitting under the broad category of social support). To not consider sociocultural factors and their potential influence on athletes’ perceptions of their psychosocial worlds should be considered a limitation because research has shown sociocultural aspects to have substantial influences on thoughts, emotions, and behaviours (Kidd, 2013; Tibbert et al.,2015).

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Another potential factor that might have inﬂuenced Malin’s level of exhaustion is that she also had to engage in additional work, outside soccer, to earn enough money to pay the bills. Because a majority of the players within the league are not full-time employees (Hägglund et al.,2009) this might be a risk factor experienced by a number of players within the league. Employment outside sports has been suggested to put additional stress on professional athletes (Quarrie et al.,2016). This additional load in combination with, for example, physical (e.g. matches, training) and inter-personal (family, friends, team mates) demands might increase the risk of high levels of fatigue and the player becoming injured (Quarrie et al.,2016).

Also, in Sara’s story factors within the sociocultural context, such as the coach and other people around the team, inﬂuenced her cognitions, emotions, and behaviours. The pressure that Sara experienced from these persons made her feel more or less forced to play even when she did not feel fully prepared to return to competition. In Sara’s tale the pressures and norms (subcultural imperatives), set by the coach and teammates, forced Sara to play well before she was ready. To continue to play through injuries and pain are common behaviours within pro-fessional soccer. The values associated with these behaviours are commonly discussed as a part of the life of professional soccer players and are “normalised” in the soccer context. To play through injuries and pain is one way to demonstrate for the manager or coach that the player has the“right attitude.” One of the potential explanations for engaging in these behaviours, even if most players know they are associated with increased risk of becoming injured, are fears over losing their places in the team (Roderick, Waddington, & Parker,2000).

Sara’s story highlights the complexity of injury risk and the multiple layers and situations in which injury risk can arise. For example, past injury is a risk factor for future injury, but how that risk manifests may be determined by a variety of factors. Past injury and trauma can set athletes up for becoming anxious when they re-enter similar situations in which the past injury occurred (e.g. sympathetic nervous system activation, re-injury anxiety). Also, from a healing point of view, if an athlete is not physically ready to return to training and competition, then the stresses and strains on incompletely healed joints can result in re-injury. So, incomplete psychological recovery from the trauma of past injuries, re-injury anxiety, and returning to competition before fully healed are all part and parcel of the complex world of psychological and physical factors that increase injury risk.

To submit to the pressures to play before she was physically and psychologically ready to return could be considered potentially risk’ increasing and is related to an increased risk of becoming injured (Bizzini, Hancock, & Impellizzeri, 2012; Kraemer, Denegar, & Flanagan,

2009), through, for example, worry, anxiety and stress reactions over not being fully recovered (Walker, Thatcher, Lavallee, & Godby,2004). More speciﬁcally, high levels of worry have pre-viously been found to be predictive of injury (Noh, Morris, & Andersen,2005) and that some of the experiences in Sara’s story were related to previous injuries is of particular interest. This ﬁnding is also clinically relevant, as it suggests that worry in the form of fear of re-injury could be a contributing factor to the link between previous injury and the risk for future injury (Tagesson & Kvist,2016). These results add to existing studies that have mainly investigated whether previously injured players are exposed to a greater injury risk in general. In harmony with this, Tagesson and Kvist (2016) found that high levels of re-injury anxiety among ACL-injured individuals, both before and after ACL surgery, increased the risk of having a future con-tralateral ACL injury.

Sara’s story illustrates how worries over previous injuries (e.g. fear of re-injury) could have an impact on players’ thoughts, emotions, and behaviours prior to their ACL (and other) injuries. Most experiences of worry were, in the present study, related to attention and concentration pro-blems (e.g. not being able to focus fully on the tasks at hand). Instead, for Sara, part of her focus during training and matches was directed towards the previous injury and, more speciﬁcally,

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thoughts and anxieties (e.g. worries) about readiness to return to sport appeared to compete with her attention in matches or at training.

One potential explanation for the link between worry and injury risk is through changes in brain activation. For example, activations that are associated with worry and fear tend to direct attention towards potential (and imagined) sources of the threat and to stimulateflight, fight, or freeze responses (Loewenstein, Weber, Hsee, & Welch,2001). The direction of attention may be towards internal fantasy processes (e.g. imagined pain, anxiety about future injuries) and might decrease the athlete’s ability to focus on relevant cues in the environment. Such distractions may, according to the stress-injury model, increase injury risk. This attention towards the source of the threat (imagined re-injury) is exemplified in Sara’s story when she described that she focused on the thoughts associated with her injury instead of paying attention to more important stimuli (e.g. ball, teammates, opponents).

In Sara’s tale the risk of having an ACL injury might also have been increased because she probably suffered from a concussion. Concussions are associated with poorer neurocognitive per-formance, for instance, processing speed and reaction time (Herman, Zaremski, Vincent, & Vincent, 2015), which has been found to increase the risk for noncontact ACL injuries (Swanik, Covassin, Stearne, & Schatz,2007).

The main issue in Sara’s tale is that she acquiesced to the demands of the coaches, team-mates, and administrators and played when she should have been recovering. Her injury may have stemmed from her anxiety and distraction related to becoming re-injured or poor neurocognitive performance due to a concussion, but one of the major risk factors probably sits outside of Sara in the sport cultural demands of playing even when injured. If the goal of sport injury research is to lower injury incidence, then, in cases such as Sara’s, where does one intervene? If a sport culture is pathogenic then that would appear to be the level at which interventions should be aimed, but changing a culture is a monumental task that sport psychology researchers have almost no power to influence. Cultural change has to come from stakeholders (e.g. coaches, administrators) who do have the power to influence sport traditions and imperatives, and maybe it is the injury research-ers’ job to help stakeholders understand that injury may be a systemic problem and not necessarily an individual athlete concern. The importance of creating an environment, where key stakeholders collaborate around issues related to sport injuries has been addressed in previous studies. For-sdyke, Gledhill, and Ardern (2017), highlighted that one of the key elements related to increasing the chances of successful return to play after sport injuries is to adopt an interdisciplinary, shared decision-making approach where stakeholders collaborate to have a better foundation for making adequate decisions. This logic can also be adopted when it comes to prevention of sport injuries. In Malin’s tale we see a story of overtraining, perfectionism, and potentially risk-increasing responses to excessive training load (e.g. train even harder because more is better) that fits well within the Richardson et al. (2008) overtraining model. But where does that perfectionism and overtraining come from? We do not know; these constructs could have their roots way back in childhood with anxious attachment to parentalfigures who dispensed highly contingent love based on good performance, or they could stem from pathogenic sociocultural traditions. For an extended discussion of the connections between perfectionism, childhood development, cul-tural pressures, overtraining, and sport injuries see chapters 9 and 10 in Richardson et al. (2008). In both Malin’s and Sara’s cases, their relationships and communications with their coaches were problematic. From our experiences as applied practitioners, the most common problems for athletes are not things such as performance anxiety, but rather they are interpersonal issues between athletes and coaches. It is undeniable that coaches can have important and positive in flu-ences in athletes’ lives. For example, coaches have been found to be important social agents in: (a) developing female soccer players (Gledhill & Harwood,2015), (b) reinforcing positive environ-ments during rehabilitation of sport injuries (Forsdyke et al., 2016), and (c) helping with

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successful return to sport after an injury (Podlog & Dionigi,2010). These results underline the importance of the coach in the development of positive sports environments.

Even though many of the issues addressed in Sara’s and Malin’s stories might stem from intra-and interpersonal factors, one disconcerting aspect is that most of the players who formed the foundations of their stories took on themselves much of the blame for their situations (and sub-sequently the injury). Self-blame has, in previous studies, been discussed as a problematic response to dealing with potentially stressful situations, and individuals with high levels of self-blame might be more prone to feel frustration and negative affective responses (Zahn et al., 2015). These responses related to self-blame in stressful situations might be one of the reasons for previous studies’ results that high levels of self-blame appear to increase the risk for sport injuries (e.g. Ivarsson & Johnson,2010; Timpka et al.,2015). The disconcerting part of the self-blame that so many of the participants reported is that it appears like a version of blaming the victim. One of the most striking features of all the individual stories, and the aggre-gated narratives, is that the women often received substandard and inadequate medical attention, assessment, and care, which was coupled with, to be honest, manipulative coaches who commu-nicated unreasonable demands and fostered guilt among their players. We would go so far as to say that some potential sources for these women’s injury problems might have had their roots in communication and relationship issues with the coaches, teammates, and the medical staff.

For future research and model building, in the area of developing healthy sports environ-ments, it could be of interest to further investigate athletes’ perceptions of their interpersonal relationships, between themselves and coaches (and maybe medical staff), both in terms of quality and importance. To investigate the athletes’ interpretation of their interpersonal relation-ships might generate more knowledge in how to prevent sport injuries, possibly through interven-tions targeted at improving interpersonal connecinterven-tions and communicainterven-tions. The recipients of such interventions would need to include coaches and medical support staff.

Methodological considerations and limitations

Based on the design selected, as well as the procedures, some limitations need to be discussed. A first potential limitation is that the interviews were carried out after the season ended, and recall may have been confabulated in ways that cannot be determined through our methods. Neverthe-less, because the brain constantly modifies our perceptions and memories and, therefore, also the stories we tell about specific experiences (Cozolino,2010), it is the athletes’ current truths that we are able to grasp in our interviews. Second, because the authors were responsible for constructing the aggregated cases, our interpretations and biographies will be reflected within the results. Applied implications

Changing culture is a big task, but based on the results of the current paper, we recommend that players, coaches, and members of the medical teams work together to formulate norms and rules that facilitate adaptive behaviours, both related to training load and return after injuries. Develop-ing a positive sociocultural environment will, possibly, decrease the risk of players experiencDevelop-ing excessive fatigue or anxiety. The ultimate goal of the both the coach, as well as the medical team, should be to optimise stress and recovery. The means of achieving this cultural shift are not addressed in the present study. We know, however, that relatively threat-free environments and relationships that are secure and caring with non-contingent positive regard may down-regulate cortical and subcortical stress circuits (Cozolino, 2010) and facilitate recovery behaviours, which will possibly affect subsequent injury risk. Thus, it seems to be important for the coach and medical team to develop a climate in which the players feel secure to talk freely. In the

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work of developing these environments, coaches and medical teams can model caring, curious, compassionate, and non-judgemental approaches to sport.

Conclusion

The stories illustrate how the players understood the experiences they had in the weeks prior to their injuries. In the stories, the players’ perceptions of the pressures and norms and their behav-ioural responses were sources of worry and fatigue, both of which are potential risk factors for injury. Contextual values and norms may influence players’ perceptions of what types of beha-viours are desired and valued within the team (Richardson et al.,2008). To be accepted and encouraged within the team, it is likely that players, such as (fictional) Malin and Sara, engaged in behaviours that were in line with the team’s norms and rules (both formal and infor-mal). To acknowledge the sociocultural dimensions’ potential impact on injury risk, as Richard-son et al. (2008) and Wiese-Bjornstal (2010) suggested, therefore appears to be an important step in gaining a full picture of risks within specific sporting environments. Entry points for interven-tions to help decrease risk can be at a variety of levels such as: individual athletes, coaching prac-tices, interpersonal communication and relationships, interactions with medical personnel, and team climate and culture.

Acknowledgements

Professor Jan Ekstrand, MD, PhD, and Håkan Bengtsson, RPT, MSc, from the Football Research Group at Linköping University, are acknowledged for their help with planning and conducting the prospective injury surveillance study.

The authors would also like to thank Annica Näsmark, RPT, and Matilda Lundblad, MD, for their support, together with all the players participating in the study. The Swedish Football Association was not involved in the analysis or interpretation of the data nor did it have the right to approve or disapprove publication of the study. The Football Research Group has been established in Linköping, Sweden, in collaboration with Lin-köping University and through grants from the Union of European Football Associations, the Swedish Foot-ball Association, the FootFoot-ball Association Premier League Limited and the The Swedish Research Council for Sport Science.

Funding

The study wasﬁnancially supported by Swedish Football Association.

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