sports injury research paper

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• BMJ Open Sport Exerc Med
• v.7(1); 2021

Youth sport injury research: a narrative review and the potential of interdisciplinarity

Solveig elisabeth hausken-sutter.

1 Department of Food and Nutrition, and Sport Science, University of Gothenburg, Gothenburg, Sweden

Richard Pringle

2 Faculty of Education, Monash University, Melbourne, Victoria, Australia

Astrid Schubring

Stefan grau, natalie barker-ruchti.

3 School of Health Sciences, Örebro University, Örebro, Sweden

To prevent sports injuries, researchers have aimed to understand injury aetiology from both the natural and social sciences and through applying different methodologies. This research has produced strong disciplinary knowledge and a number of injury prevention programmes. Yet, the injury rate continues to be high, especially in youth sport and youth football. A key reason for the continued high injury rate is the development of injury prevention programmes based on monodisciplinary knowledge that does not account for the complex nature of sport injury aetiology. The purpose of this paper is to consider and outline an interdisciplinary research process to research the complex nature of sport injury aetiology. To support our proposition, we first present a narrative review of existing youth football and youth sport injury research demonstrating an absence of paradigmatic integration across the research areas’ main disciplines of biomedicine, psychology and sociology. We then demonstrate how interdisciplinary research can address the complexity of youth sport injury aetiology. Finally, we introduce the interdisciplinary process we have recently followed in a youth football injury research project. While further research is necessary, particularly regarding the integration of qualitative and quantitative sport injury data, we propose that the pragmatic interdisciplinary research process can be useful for researchers who aim to work across disciplines and paradigms and aim to employ methodological pluralism in their research.

What is already known?

• Youth athletes sustain injuries.
• Youth sport injuries have been researched from multiple scientific disciplines.
• There is growing support for the application of a complexity approach to sport injury research.

What are the new findings?

• An overview of youth football and youth sport injury research from the scientific disciplines of biomedicine, psychology and sociology.
• Paradigmatic distinctions in youth football and youth sport injury research create scientific differences between bodies of injury research.
• Youth football and youth sport injury research lacks integration across disciplines and paradigms.
• Our proposed interdisciplinary research process consists of five phases that demonstrates the working process of a project researching youth football injuries.
• The five-phase process can be considered a response to the call for interdisciplinarity in sport injury research as well as a practical guide.

Introduction

Youth sport injury research has during the past years produced important knowledge concerning injury aetiology and injury prevention. Most of this scholarship has emerged from research conducted in specific scientific disciplines, primarily biomechanics, sport medicine, exercise physiology, sport psychology and sport sociology. 1 Broadly speaking, researchers of these disciplines follow distinctive assumptions of what an injury is and what research questions, ethical stances, research methods and interpretations and explanations of results are most appropriate to study this phenomenon. 2 3 These constellations of beliefs, values and methodologies are referred to as scientific paradigms . Existing youth sport injury research can be categorised by three paradigms: positivism, postpositivism and interpretivism. The positivist paradigm is closely related to reductionism, and reality and truth are understood as singular and identifiable. Positivist sport injury research has specifically focused on identifying and separating risk factors. 4 Methodologically, objectivity is paramount, which requires researchers to detach themselves from the study object. In analysis, the identified risk factors are used to generalise causality. 3 5 In the postpositivist paradigm, reality and truth are understood alike positivism. However, researchers adopt diverse research methods to establish causality, including through qualitative methodology. 3 In the interpretivist paradigm, reality and truth are understood as multiple and relative. 2 3 Researcher objectivity is not considered possible as it is assumed that truth is constructed between researchers and the researched. The overall aim is to gain a deeper understanding of what an injury means, and how it is experienced and made sense of.

Scientific paradigms guide researchers and research, 2 3 5 and they have shaped research on youth sport injury aetiology. The existing body of knowledge is comprehensive, however, seldom brought together to understand sport injury and sport injury aetiology from the perspectives presently adopted. Thus, an interdisciplinary understanding that is interparadigmatic is missing. Recently, a number of sport injury researchers have critiqued the reductionist methodology that characterises most research on sport injury aetiology and suggested a turn to complexity to account for the multidimensional nature of sport injury aetiology. 4 6–9 At present, however, relatively few researchers adopt a complexity approach and scholarship is only at the conceptual level. Moreover, current discussions have not included ways to integrate the influence socio-cultural context has.

The purpose of this paper is to advance existing youth sport injury aetiology scholarship by considering and outlining an interdisciplinary research process to research the complex nature of youth sport injury aetiology. In our view, an interdisciplinary approach that is interparadigmatic has potential to generate data that can address the complexity of an injury. To support our proposition for interdisciplinarity, the paper aims to: (1) present the results of a narrative review that examined multidisciplinary literature on youth sport injury aetiology; (2) discuss interdisciplinary research to consider how such an approach can address the complexity of youth sport injury aetiology and (3) introduce an interdisciplinary research process that we have adopted in a research project on youth football injury aetiology.

To achieve the above aims, we draw on the research context of the ongoing project ‘Injury free children and adolescents: towards best practice in Swedish football’ (FIT project). 10 The purpose of the FIT project is to provide evidence-based interdisciplinary injury prevention strategies. To achieve this, the project aims to produce a comprehensive picture of injury aetiology in a sample of male and female Swedish football players aged 10–19 years through integrating natural and social science and producing quantitative and qualitative data. The research team includes scholars from biomechanics, sport medicine, sociology and sport coaching. The project started in January 2017 and involved a prospective questionnaire to record incidence and prevalence of injuries over a 5-month period, one-time biomedical testing (clinical examination, isometric strength measurements, running analysis and knee stability), a 5-month analysis of training protocols, observation of training sessions of players and their coaches and interviews with players and coaches. At present, the project is working towards the integration of collected quantitative and qualitative data.

Narrative review of youth football and sport injury research

We conducted a narrative review of literature relevant to youth football injury aetiology to provide a critical synthesis of existing literature and to specifically identify paradigmatic and methodological assumptions, research approaches, research methods and data analysis procedures. The focus on existing literature’s paradigmatic distinctions is an important first step in interdisciplinary work. 3 According to Phoenix et al 3  (p. 220), a ‘step back’ to understand underlying assumptions can advance knowledge and awareness of the respective research field as a way to ‘move beyond debates about right or wrong ways of approaching research’.

The first author has from January 2017 to May 2020 searched for literature on youth football injuries in the databases PubMed, Scopus, PsycINFO and Web of Science. Search terms included various combinations of ‘youth’, ‘soccer’, ‘football’, ‘injury’, ‘aetiology‘ and ‘risk’. Inclusion criteria were set to youth football players aged approximately 10–19 years and injury aetiology, injury prevention and/or injury risk factors. The search revealed a paucity of sociological youth football injury research. Thus, the search was broadened to sociological injury research in different sports and age groups, which identified research in biathlon, figure skating, rhythmic gymnastics, rugby and softball. To identify assumptions underlying paradigmatic distinctions, we predefined three analytic areas: body and injury perspective (state of the art regarding how an injury is explained and defined); paradigmatic assumptions (reality/truth/knowledge) and research approaches (methodology). Based on how these categories were approached in the literature included in the review, as well as discussions in the FIT project team and a presentation at a scientific conference, 11 we placed the literature in the three paradigms dominant for youth sport injury research: positivism, postpositivism and interpretivism. Furthermore, five dominant disciplines of youth sport injury research were identified based on the reviewed literature; biomedicine (biomechanics, sport medicine and exercise physiology), sport psychology and sport sociology. Table 1 summarises key findings of the narrative review.

Distinctions of youth football and sport injury aetiology research

Table 1 summarises the key findings of a narrative review of existing youth football and youth sport injury research, which demonstrates an absence of paradigmatic integration across the research areas’ main disciplines of biomedicine, psychology and sociology.

Biomedical research

Biomedical research on injuries in youth football has mostly focused on individual injury risk factors relating to kinematics, kinetics and spatiotemporal variables, physical development and amount of training and competitions. Key findings from our literature search show that age, growth and biological maturation contribute to an increased risk of injuries, especially during the year of peak height velocity. 12–14 Possible risk factor for injuries in youth football players during this period include muscle strength, 15 familial disposition, 16 previous injury, 17 physical stress (ie, training and match duration and perceived exertion) 18 and match playing. 12 16 Furthermore, external factors such as playing turf and type of shoes are associated with injuries among youth football players. 19 Findings from the biomedical discipline have resulted in the development of injury prevention interventions applied to youth through programmes such as the Nordic hamstring strengthening exercise, 20 the FIFA 11+ exercise programme 21 and a neuromuscular warm-up programme called ‘Knee control’. 22 These exercise-based programmes include multiple training components, such as agility, balance, mobility, running and strength activities.

In addition to identifying risk factors, biomedical research has contributed with a number of sport-general models on injury causation, including the Sequence of Prevention model, 23 and the Multifactorial Model of Athletic Injury Aetiology, 24 which was later revised and updated to a more dynamic model. 25 McIntosh 26 also proposed a multifactorial model of injury causation but with a biomechanical focus on tissue properties and injury. Furthermore, sport injury research frameworks such as the Translating Research into Injury Prevention Practice framework, 27 and the extension of the Reach; Effectiveness; Adoption; Implementation; Maintenance framework 28 have been developed in order to close the gap between research and implementation of interventions. These models and frameworks have, in general, been used by youth football injury aetiology researchers.

Biomedical youth football injury research reviewed in this paper is situated in the positivist paradigm. Given its assumptions of a singular and identifiable reality and truth, an injury is objectively defined as a specified damage to the physical body. Injury aetiology is often linear and related to identifiable individual physical factors. Methodologically, researchers are required to stay objective and abstain from interacting with research participants. A hypothetic-deductive reasoning leads the research from broad hypotheses to testing using quantitative methods (eg, physical testing, questionnaires), often in isolation and through manipulation of typical risk factors, often in a laboratory setting.

Psychological research

Psychological research on injuries in youth football players has mainly focused on psychosocial dimensions. Main risk factors identified in this research are personality traits (eg, high level of trait anxiety; low level of mistrust; ineffective coping), 29 history of stressors (eg, negative life event, daily hassles), 30 mental and physical fatigue 31 and team climate (eg, lack of support from coach and teammates). 31 32

Findings from the psychological discipline have resulted in prevention and research focusing on stress management techniques and goal setting skills. 33–35 Furthermore, the Model of Stress and Athletic Injury, 36 37 which demonstrates how the magnitude of stress and athletes’ appraisal of the situation may be influenced by the interplay between various psychosocial factors (eg, personality, history of stressors, coping resources), has become one of the most cited research models. In extending this model through the Biopsychosocial Model of Stress Athletic Injury and Health, the authors suggest that behavioural mechanisms associated with stress response (eg, impaired self-care; poor sleep quality) should also be addressed. 38 Moreover, emotions and environmental factors have been included in the Biopsychosocial Sport Injury Risk Profile, 39 as important risk factors related to sport injury.

Psychological youth football injury research reviewed in this paper is mainly situated in the positivist paradigm, with some research fitting into the postpositivist paradigm. Like the positivist paradigm, injury and injury aetiology definition is specific and related to the physical body, but adds the mind. Methodologically, researchers keep interaction with athletes to a minimum, and similar to positivist researchers, tend to follow a hypothetic-deductive reasoning as a method to gain knowledge. Assuming that establishing truth requires diverse sets of data, some researchers test the hypotheses by using qualitative methods, such as questionnaires and in-depth interviews.

Sociological research

Sociological research on youth sport injury has examined injuries from the perspective of athletes and by analysing the sporting culture athletes are immersed in. Key findings from our search show that sociocultural values (eg, sporting success; discipline and striving for perfection), social norms (eg, femininity; masculinity; power; being on time; respecting the coach), 40–43 pressure to play through injury and pain (especially socialisation to accept training/competing with pain; silence around pain and injury), 41 44 45 medical support (eg, lack of medical support; information being withheld) 44 46 and coach-athlete relationships, 42 47 can influence injury aetiology among athletes.

Sociological injury researchers do not use models to conceptualise injury aetiology, but employ theoretical frameworks such as sport ethic (a set of ideas and beliefs that together comprise norms of traditional athleticism), 42 narratives of self, 47 culture of risk, 48 social control (eg, individuals become inscribed and normalised by particular dominant standards) and masculinity theories, 49 in order to understand and explain sport injury aetiology.

Sociological youth sport injury research reviewed in this paper tends to be situated in the interpretivist paradigm. An injury and its aetiology are interpreted by athletes and researchers and can be explained or understood by examining athletes’ sociocultural context. To examine injury aetiology, researchers interact with athletes and the context. Methodologically, sociological researchers sometimes use deductive reasoning as described above, but they also use inductive reasoning, where the process of creating insight develops from empirical data towards a theory (ie, patterns, themes and categories of analysis emerge out of the data). Researchers in the interpretivist paradigm apply qualitative methods such as observation and interviews, and interpretive analysis techniques such as thematic, content, discourse and narrative analysis.

Reflections on distinctions of youth football and youth sport injury research

The narratively reviewed literature on youth football and youth sport injury research shows two paradigmatic distinctions. First, the literature is monoparadigmatic and tends to focus on one subdiscipline of sport science. Most of the literature is biomedical, sport psychological and sport sociological, and often based on either quantitative or qualitative research techniques. The French philosopher and sociologist Edgar Morin 50 argues that by approaching research from single disciplines, complexity becomes invisible. The disintegration of complexity through monodisciplinarity is not due to the discipline in itself, but as Morin 50  (p. 2) emphasises, because ‘of the discipline as it is conceived, non-communicating with the other disciplines, closed to itself’. Monodisciplinarity in research reduces the phenomenon into separate parts, thus making the whole as well as interactions between parts and between parts and the whole, invisible. 7 50 Second, and related to monodisciplinarity, there is no integration of research across the three paradigms.

These limitations can be clearly seen in our narratively reviewed literature included in table 1 . Thus, current youth sport injury research can be seen to shield off—or in other words leave out—possibly important aspects, creating a picture that is not actually representative of the complex phenomenon under study (eg, injury aetiology). 51 For example, biomedical and psychological disciplines, by mainly focusing on athletes’ physical bodies and minds, leave out their interaction with and in the larger sociocultural context the athletes participate in. Similarly, sociological research, by focusing on sociocultural context, often ignores how the physical body and mind interact with and influence athletes.

Researchers operating in these paradigms and disciplines can and do apply different research approaches and methods, thus, paradigms do not confine. Indeed, researchers have adopted approaches to be more inclusive, such as an ‘ecological’, ‘integrated’ or more ‘real-world’ approach to sport injuries. 52–54 However, these approaches either miss to account for multiple and complex interactions between different ‘parts of the whole’, 7 or do not attempt to integrate disciplines across paradigms or use multiple quantitative and qualitative research methods.

The complexity approach to sport injury research

The recognition that sport injury aetiology involves numerous interactions between various variables across multiple dimensions has led some researchers to explore the potential of a complex systems approach for understanding and researching sport injury aetiology. 4 6–9 Although researchers understand and apply complexity to sport injury research differently, three elements characterise current discussions. First, a complexity approach embraces an understanding of context as open systems consisting of components that are actively connected through mostly non-linear relationships. 4 7 8 A non-linear relationship between components in the system implies that A plus B does not necessarily equal C. For example, a weak muscle plus psychological stress does not necessarily result in an injury. Second, these non-linear relationships between the components can induce dramatic new effects giving rise to unexpected structures and events, also known as emergence. 55 56 Emergence can, for example, be certain tendencies, powers or complex phenomena such as a sport injury. Emergence, or the injury and its aetiology is constantly evolving, and not strictly predictable. 55 In other words, emergence is self-organising, meaning a complex system can transform over time, either growing or shrinking. 55 Emergence should be accounted for when researching sport injury aetiology, for example, through longitudinal studies. Finally, and what Newell 55 argues is typically overlooked in the understanding of complex systems, is the importance of ‘local knowledge’, or knowledge of specific parts of the system. An athlete can, for example, be stressed over an upcoming exam at school and is injured right before the exam. The athlete might believe exam stress caused the injury. A closer examination may, however, show that it was the way the coach had changed behaviour towards the athlete that affected the injury aetiology. When applying a complex systems approach to injury research, the focus moves from identifying single risk factors for injuries to recognising patterns of interaction among multilevel components, acknowledging that these components interact in unpredictable ways and may be moderated by a number of individual and contextual factors. 4 6 8

Researchers are currently discussing how the implementation of complex systems thinking can advance sport injury research, specifically through statistical mathematical models and computer-based simulations guided by equations, rules and laws. Complex models 4 and statistical procedures such as the Agent-Based Modelling (ABM) and Systems Dynamics (SD) modelling 9 are recent examples. According to Bekker 6  (p. 80), however, this development represents an “overemphasis on the epistemological question of how multifactorialism is accounted for in research and a corresponding underemphasis on the ontological considerations and assumptions we make about the world”, which reflects a dissonance in how complexity is understood and applied to sport injury research. The current argument for complexity assumes a reductionist positivist/postpositivist view where complexity is understood as emerging from the rule-based interactions of simple agents/elements and explored through agent-based modelling. 56 Consequently, it tends to ignore that there is more to emergence than the product of interactions of agents; athletes are themselves complex systems, and more complex than agents in agent-based simulations. 56 Thus, the current argument for complexity is limited in recognising the importance of understanding athletes’ interactions with and in a certain context; hence, it is ignoring the significance of incorporating sociocultural conditions that researchers from the interpretivist paradigm have identified as relevant. Bekker further argues that injury researchers’ focus should not be on methodological preferences, but rather on ‘understanding system goal behaviour using methodological pluralism’ 6 (p. 81). We agree. A complexity approach requires alternative research methodologies. One such approach, which we have found to have potential in the FIT project to account for the multiple dimensions of injury aetiology, is an interdisciplinary research process that includes scientific disciplines from different paradigms and integrates qualitative and quantitative research methods.

The potential of interdisciplinary sport injury research

Drawing on research by Klein and Newell, 57 we understand interdisciplinarity as a research process aiming to address a topic that is too broad or complex to be dealt with adequately by a single discipline. Furthermore, an interdisciplinary research process integrates disciplinary perspectives through construction of a more comprehensive perspective. 57 Both Newell 55 and sports researchers such as Buekers et al 58 argue that complex systems and phenomena are a necessary condition for interdisciplinary studies. The rationale for this argument lies in the way complex phenomena can be understood and studied. If an injury is to be understood as complex, then this would mean, as argued earlier, that the phenomenon is multidimensional. Seeing it from one single angle, such as from biomedicine or sociology, only, the phenomenon appears different than from another angle. Since the overall pattern of behaviour is non-linear and dynamic, an effective method for modelling such a phenomenon must offer insight into the separate parts as well as the complex pattern produced by their overall interactions. 55 An interdisciplinary research process, which draws insights from relevant disciplines and integrates these insights into a more comprehensive understanding, is thus proposed to have potential to study sport injury aetiology. 1

The benefits of interdisciplinarity have been pointed out in a recent Nature editorial. 59 The editor specifically endorsed the incorporation of social sciences, cautioning that ‘[i]f social, economic and/or cultural factors are not included in the framing of the questions’ then ‘a great deal of creativity can be wasted’. Recently, sports sociologists Pringle and Falcous 60 have also advocated a collaboration between the social and natural sciences. They argue that a collaboration between biomedical researchers and sport sociologists, which they refer to as methodological border crossing, could improve the political impact of research from the sociology of sport. Regarding sport injury research, Burwitz et al 1 argued for the benefits of interdisciplinarity over two decades ago. Despite their call, however, very little empirical work has been conducted to this end. Reasons provided for this reservation have been related to various obstacles that prevent high quality, truly integrated interdisciplinary work, as well as practical difficulties relating to gaining funding and publishing. 1 58 Philosophical obstacles relating to paradigmatic differences may also result in a lack of shared understandings, research approaches and methods, 61–63 preventing researchers from adopting such an approach. Nevertheless, our research in the FIT project has demonstrated that interdisciplinarity has potential for sport injury research.

The interdisciplinary research process of the FIT project

The interdisciplinary research process of the FIT project consisted of five phases depicted in figure 1 . The five-phase research process was developed based on key interdisciplinary research steps outlined by interdisciplinary researchers such as Alan Repko, Rick Szostak and William H. Newell. 55 64 While presented sequentially, the five-phase research process is an iterative and non-linear process. At times it was necessary to move back to an earlier phase or forward towards later phases, which is common and reflects the complexity of the interdisciplinary research process. 55 64

The interdisciplinary research process of the FIT project. The figure illustrates the five-phase interdisciplinary research process adopted for the study of youth football injury aetiology. 10 The blue boxes present the main theme of each of the five phases of the process. The green boxes entail research actions. The interdisciplinary research process was not linear, but involved the researchers moving back to an earlier phase or forward towards later phases during the process.

In the first phase of the process, the FIT project research group came together from multiple scientific disciplines and agreed on researching injury aetiology in youth football using an interdisciplinary approach. In the second phase, the project team members decided which scientific disciplines to draw on to study the problem, a process that took place through meetings, discussions, reviewing literature and presentations of research within and outside of the project group. In phase III, we conducted research applying the following research methods to study youth football injury aetiology: questionnaire; measures of weight and height; injury diagnostics; clinical examinations; strength testing; running analyses; knee laxity measurements; examination of training protocols; field observations and interviews. Research methods were chosen based on knowledge gained from project team members’ disciplinary expertise, existing literature, internal meetings and discussions with experts outside of the research group. Additionally, phase III entailed recruitment of research participants.

In the final two phases, data were analysed through measurement-specific analyses (eg, three-dimensional kinematics to analyse movement-specific characteristics; isometric strength to analyse muscle weakness and/or muscle imbalance; content analysis of field notes and interview transcripts) and an analytic procedure was prepared that makes integrated analysis of measurement-specific analysis possible.

During the FIT project’s five-phase interdisciplinary research process, the research group encountered paradigmatic challenges typical of working interdisciplinarily. 61 One example is sample size and recruitment. Where positivist paradigmatic distinctions require a statistically powerful sample size, the interpretivist paradigm demands possibilities for in-depth and detailed examination of one or a few cases. A further challenge was the lack of an integrated data analysis procedure that would allow us to integrate the measurement-specific analysis referred to above. As we could not locate a suitable analytical procedure, we needed to spend time and effort to develop and test such a procedure. Finally, we have found that presenting the FIT project research in multiple cases resulted in misunderstanding and scientific criticism. As a result, we had to place extra effort in considering the communication of the FIT project’s scientific rationale, methodology and results. Indeed, while we have not struggled to respect our different paradigmatic worldviews and demands, it has been challenging to find and communicate what interdisciplinary researchers like Repko and Szostak 64 and Welch 65 call the ‘space in between’ scientific paradigms and disciplines we have been trying to create. The key measure that helped us to move forward in the interdisciplinary research process was a negotiation process that entailed regular meetings.

The purpose of this paper was to consider and outline an interdisciplinary research process to research the complex nature of youth sport injury aetiology. To facilitate this proposal, our narrative review of existing biomedical, sport psychological and sociological literature summarised youth football and youth sport injury research and demonstrated paradigmatic distinctions and methodological assumptions, research approaches, research methods and data analysis procedures. The narrative review has shown a paucity on youth football injury research in the sociological discipline as well as a dominance of monodisciplinary research and a lack of integration across research disciplines and paradigms.

Our paper has further shown that to advance youth sport injury research, specifically considering complexity, an interdisciplinary research process, such as proposed in figure 1 , has potential to integrate disciplinary knowledge and measurement-specific data across research paradigms. The integrated potential is particularly promising for research aiming to examine the interactions of components proposed vital to understand the complexity of injury aetiology. We recognise, however, that to advance this potential, additional research is necessary. We particularly see a need to develop and trial analytical procedures that integrate qualitative and quantitative injury aetiology data to produce complex injury aetiology findings, and to explore interdisciplinary research teams’ pragmatic negotiation of the challenges of melding seemingly opposing paradigms in the interests of better understanding the complexities of sport injury processes.

Contributors: NB-R and SG conceptualised the FIT project, which is the basis for this paper. NB-R acquired the funding. AS, NB-R, SG and SEH-S contributed with the preparation of tools and data production for the FIT project. SEH-S is the PhD student in the FIT project. NB-R and SEH-S were responsible for the initial preparation and writing of the manuscript. RP, AS and SG contributed to the accurate and critical revision of the manuscript as well as approval of the final version. All authors were involved in the preparation and editing of the manuscript.

Funding: This study was funded by The Swedish Research Council for Sport Science.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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A sport injury is a type of injury which can be defined as any kind of injury, pain or physical damage that occurs during sports, exercise, or any physical activity. Sports medicine helps people in improving their performance in sports, fast recovery from injury and prevent future injuries. Ayurveda being the oldest science to serve mankind can prove to be the best science in management of the sport injuries. Various methods mentioned in Ayurveda classics like Vyayama (physical exercise), Abhyanga (an-ointment), Rasayana (rejuvenation) Therapy, Marma (vi- tal points) Therapy, yogic practices, Pranayamas (meditation technique) etc. proves to be a boon for a sports person for his performance as well as to overcome the physical and mental trauma suffered during the sport. Keywords: sport injury, sport medicine, Vyayama, Marma INTRODUCTION A sport injury is a type of injury which can be defined as any kind of injury, pain or physical damage that oc- curs during sports, exercise, or any physical activity. It is most commonly the musculoskeletal injuries which include muscle, bones, cartilage and associated tissue. Sports injuries can be caused by an accident, impact,

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Abstract Context: Sport specialization during adolescence may affect future injury risk. This association has been demonstrated in some professional sports athletes. Objective: Determine the association between adolescent sport specialization levels in high school and injuries sustained during collegiate club sports. Design: Cross-sectional study. Setting: Paper and online surveys. Patients: Collegiate club sport athletes. Intervention: An anonymous survey was administered from September 2019–May 2020. The survey included sport specialization classification via commonly used 3-point scale (Low, Moderate, High) for each high school year (9th–12th), high school sports participation, and collegiate club sport injury history. The number of years an individual was highly specialized in high school was calculated (0–4 years). Individuals who participated in the same sport in high school and college were compared to individuals who were playing a different sport in college than their high school sports. Main Outcome Measures: An injury related to sport club activities and classified as arising from a contact, non-contact, or overuse mechanism that required the individual to seek medical treatment or diagnosis. Injuries were classified into overuse and acute injury mechanisms for the upper and lower extremity, (UE and LE respectively) and head/neck. Results: Single sport participation or number of years highly specialized in high school sport were not associated with college club sport injuries (p>0.1). Individuals who played a different collegiate club sport than their high school sports were more likely to report a LE and head/neck acute injury compared to athletes who played the same collegiate and high school sport (LE=20% vs 8%, χ2=7.4 p=0.006; head/neck=16% vs 3%, χ2=19.4 p<0.001). Conclusions: Adolescent sport specialization was not associated with reported club sport injuries in collegiate club sport athletes. Collegiate club sport athletic trainers should be aware that incoming students exploring a new sport may be at risk for LE and head/neck acute injuries.

Psychological Profile in Female Cyclists and Its Relationship with Age, Training Parameters, Sport Performance, and Injury Incidence

Previous studies have highlighted the importance of psychology on sports performance and its relationship with the incidence of sport injuries. The objectives of the present investigation were: (1) to analyze the psychological profile of female cyclists as a function of age, training parameters, sport performance, and injuries suffered and (2) to design a model to predict their psychological profile. Sixty-one female cyclists participated in the study. Differences were found as a function of a competitive category for team cohesion (F = 5.035; p = 0.002), sport level effect on performance evaluation (F = 5.030; p = 0.004) and team cohesion (F = 64.706; p = 0.000), the effect of having reached the podium in the last competition on performance evaluation (t = 2.087; p = 0.041) and motivation (t = 4.035; p = 0.000), and injury severity on stress management (F = 6.204; p = 0.008). The factors that affected the psychological profile of the female cyclists the most, in addition to the independent psychological parameters, were the number of podiums in the last year and the years of cycling experience. In conclusion, there is an interaction between the psychological profile, sociodemographic variables, training, performance, and injuries suffered in female cyclists.

Personal and Situational Factors Affecting Psychological Response to Sport Injuries

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Specialty grand challenge article, great challenges toward sports injury prevention and rehabilitation.

• 1 Inter-university Laboratory of Human Movement Science (LIBM EA 7424), University of Lyon, University Jean Monnet, Saint Etienne, France
• 2 Faculty of Medicine, Department of Clinical and Exercise Physiology, Sports Medicine Unit, University Hospital of Saint-Etienne, Saint-Etienne, France
• 3 Department of Physical Therapy, Congdon School of Health Sciences, High Point University, High Point, NC, United States

Introduction

While the positive benefits of sport participation are numerous, unfortunately this is balanced by the negative effects of injury ( Engebretsen and Bahr, 2005 ; Merkel, 2013 ; Malm et al., 2019 ). Sports injury prevalence and incidence vary according to sports and population. And unfortunately, short- and long-term negative consequences can impact a variety of different domains (e.g., physical, psychological, sport, professional, financial, or social). Whatever these impacts, there is a need to reduce the occurrence and consequences of sports injury in order to allow a healthy and sustainable sports participation ( Engebretsen and Bahr, 2005 ). This is the important challenge of injury prevention and rehabilitation! This challenge includes primary prevention (i.e., to reduce the occurrence of the first injury event), secondary prevention (i.e., to reduce the occurrence of reinjury after a first injury event) and tertiary prevention (i.e., to reduce the occurrence of sequalae) ( Commission on Chronic Illness, 1957 ).

The popular saying, “prevention is better than cure,” has been known for quite some time. While large efforts have launched to continue to engage in this challenging goal of injury prevention, it still remains a real problem in sports. This could be due to the complex and multifactorial nature of sports injury ( Meeuwisse, 1994 ; Bittencourt et al., 2016 ; Pol et al., 2019 ), which makes its “prevention” / “reduction” difficult. It seems that sports injury is not the result of one unique cause but likely the combination and interactions of several factors (including among others intrinsic and extrinsic risk factors and injury mechanism) ( Meeuwisse, 1994 ; Bahr and Krosshaug, 2005 ; Bittencourt et al., 2016 ).

In order to face this challenging problem of sports injury, there is thus even more of a need to understand sports injury: How to monitor sports injury? What are the risk factors? How these factors interact? What is the healing process injured tissue? How can we optimize the process of healing, functional recovery, and safe return to sports? Then, there is a need to continue to reflect and develop strategies that can help to reduce the occurrence and recurrence of sports injuries: How can we play on/modify these factors to reduce the occurrence and/or recurrence of sports injuries? Which strategy or combination of strategies can reduce the occurrence and/or recurrence of sports injuries? Are these strategies efficient to reduce the occurrence and/or recurrence of sports injuries, in the context of scientific studies and in real life? How can we implement these strategies? How can athletes be compliant with these strategies? To answer these questions and reach this great challenge of injury prevention and rehabilitation, we believe that there is not one way, we believe that approaches should be comprehensive, multidisciplinary and holistic, including contributors from different fields, with communication between them and by embracing new fields.

Prevent or Reduce?

Before going to concrete aspects, there is maybe a need to improve knowledge and accuracy on some conceptual and terminological aspects.

“Prevention” is a widely used term, however, this is likely not the most appropriate or feasible term within sports. This term is well-known and recognized as a banner of work which aims to protect the health of athletes, especially injuries and illnesses, perhaps thanks to the important efforts of the Oslo Sports Trauma Research Center and the IOC toward injury and illness prevention ( Engebretsen and Bahr, 2005 ; Ljungqvist, 2008 ; Engebretsen et al., 2014 ). Although this term could be useful to describe the field (as we use for the name of our section Injury Prevention and Rehabilitation ), it is maybe not the most appropriate when we want to accurately discuss about the concrete goals. Indeed, “prevention” means no occurrence of injuries, which is probably not possible. So, most appropriate terms would probably be “injury control” or “injury risk management” or “injury risk reduction” ( Avery, 1995 ; Webster and Hewett, 2018 ). Other terms are also used on our field that deserve to have clear definitions for proper use, such as for instance “efficacy,” “effectiveness,” “compliance,” “prediction,” “prognostic.” Therefore, we believe that some discussions, researches and/or consensus should clarify these aspects.

In addition, sports injury prevention research is often modeled around the classic four-step sequence presented by van Mechelen et al. (1992) nearly 30 years ago. This model has provided a conceptual framework to monitor progress and effectiveness of decreasing the incidence of a variety of sport injuries ( Edouard et al., 2015 ; Hewett et al., 2016 ). The “sequence of prevention” conceptual framework was extended in 2006 by Finch (2006) to phases related to the implementation of prevention measures and evaluation of real-world impact. Recently, Bolling et al. (2018) revised the four-steps sequence by improving the first step of the sequence extended to exploration of the context of the sports injury. Other frameworks have been developed to detail some steps of the sequence or some specific aspects, for instance, concept of sports injury ( Timpka et al., 2014b ), etiology of sports injury ( Meeuwisse, 1994 ), understanding injury mechanisms ( Bahr and Krosshaug, 2005 ), a biomechanics-focused model ( Hewett and Bates, 2017 ), complex systems approach ( Bittencourt et al., 2016 ; Pol et al., 2019 ), risk factor-based categorization of the prevention ( Jacobsson and Timpka, 2015 ), prevention measure implementation ( Tee et al., 2020 ), and individualized approach ( Roe et al., 2017 ). These conceptual frameworks of sports injury prevention research can continue to benefit from improvements or details to help researchers and/or practitioners.

Primary and Secondary Prevention = Same Fight!

Methodology used in primary prevention could seamlessly assist secondary prevention and vice versa ( Hewett and Bates, 2017 ; Cools et al., 2020 ). In addition, given the high prevalence of sports injury, a large percentage of athletes will participate in sport with history of previous injury. Therefore, the need for secondary prevention is ongoing and increasingly more important as athletes age. However, primary and secondary approaches are sometimes compartmentalized; sports scientists and coaches may be more involved with primary prevention, while health professionals involved with secondary prevention. Consequently, scientific literature may also be compartmentalized. Therefore, we strongly support that all knowledge regarding both primary and secondary prevention should be directly translated to all stakeholders (applied, clinical). In addition, we suggest increased communication and collaboration between professionals and community to reach success in this challenge.

Specificity of Sports Rehabilitation

Secondary prevention can be addressed through rehabilitation ( Hewett and Bates, 2017 ; Cools et al., 2020 ). This particular phase of the sports injury management has some specificities. It aims to orient/guide the injured tissue healing process, restore the function, and help the patient/athlete return to sporting activities while at the same time minimizing the risk of reinjury. This multi-goal management is currently approached mainly through biological/physical aspects (e.g., physiological, biomechanical…). However, psychological, social and contextual factors play a critical role in the recovery of patients/athletes after sports injury, and should be taken into account in this phase of the sports injury management.

Sports rehabilitation should thus be done in a multifactorial biopsychosocial approach, bringing the patient/athlete from injury to return to his desired activity, by taking into account the consequences of the sports injury at these different levels ( Ardern et al., 2016 ; Van Melick et al., 2016 ; Cools et al., 2020 ).

Unity is Strength: Need of Multidisciplinary Teamwork!

To face the problem of sports injury, everyone is needed! Each person has a different experience, expertise, and view of the problem. So, it is important to encourage and act on the input from all parties involved. This implies a multidisciplinary approach, with inputs from several fields (e.g., sports medicine, sports and exercise science, physical conditioning and training, biomechanics, nutrition, physiology, psychology, sociology, data science…). This implies for instance at a field level that health professionals and coaching staffs, who are facing the same problem of sports injury, share their points of view, arguments, proposals of management in order to find the optimal solution for athletes. Likewise, this should be extended to other fields working with athletes in order to create a cohesive multidisciplinary team. This approach should be favored at the field/clinical and research levels.

Such an approach implies communication to go beyond discussions simply within a field and extend to discussions between diverse fields of interest. This also means for athletes' monitoring or research purpose collecting data from different fields, and probably makes choice or compromise given the amount of data this can represent. These discussions or choices are probably not easy because of some conceptual or language barriers, potential for competition, or perceived skepticism. There will maybe a need to structure discussion / choice, and there is a need to clarify the responsibility of each other, especially when coming the decision. But we believe that this is a relevant orientation to overcome the great challenge of sports injury prevention and rehabilitation. We suggest this would be a win-win approach for all stakeholders. The resulting benefits of discussion, exchange, and collaboration would be greater than the sum of each individual input.

Need for a Holistic and Individual Approach

Recent evidence supports that several factors of varying types can play a role in the occurrence of injury or reinjury ( Kerkhoffs et al., 2012 ; Hewett et al., 2016 ; Green et al., 2020 ). In addition, each athlete will respond differently to these factors and combination of factors; each will not have an injury for the same reasons. Hence, patients will respond differently to the injury and its consequences. This is supported in contemporary sports injury management which should utilize a bio-psycho-social approach at an individual level and grounded in evidenced-based practice. Thus, efforts should be made in sports injury research to provide knowledge and evidence in each of these different fields, and if possible, combining all these fields.

Given the complexity of sports injury, the research approach currently simplifies the problem, but there will need to go deeper in complex multifactorial individualized approach to better meet the “reality” of sports injury ( Meeuwisse, 1994 ; Bittencourt et al., 2016 ; Pol et al., 2019 ).

There is thus a need for a more complex approach, a comprehensive holistic and individual approach, as for understanding the determinants of the sports injury as for the development of strategies that aim to reduce the occurrence of injury or reinjury. Examples are proposed through conceptual or perspective articles ( Mendiguchia and Brughelli, 2011 ; Mendiguchia et al., 2017 ; Buckthorpe et al., 2019 ), and there is now a need to provide supporting evidence of the theses approaches.

Improve Methodological and Analytical Approaches

One of the challenges in injury prevention research is to capture the outcome, i.e., sports injury. Efforts have been done to develop and improve methodology for recording and reporting injuries ( Hagglund et al., 2005 ; Fuller et al., 2006 ; Junge et al., 2008 ; Timpka et al., 2014a ; Bahr et al., 2020 ) and should continue to most accurately capture injuries and their complexities.

Alternative analytical approaches of effectiveness of injury prevention measures can use as outcome the consequences of the sports injury at physical, psychological, social or financial levels. Injury prevention is of course useful to reduce the occurrence or reoccurrence of injuries, but also that of sequelae ( Engebretsen and Bahr, 2005 ) or of the financial impact ( Krist et al., 2013 ). Taking into account the economical burden of sports injuries ( Hickey et al., 2014 ; Hespanhol Junior et al., 2017 ) could also be a way to improve stakeholders adherence to prevention and increase means for sports injury prevention and rehabilitation at the practical and research levels.

The multifactorial biopsychosocial approach leads to the need of adding in the measurements, data collection or monitoring, information related to the sports injury and the injured athletes, taking into account their multifactorial and complex nature, as well as about the context including individual, socio-cultural and environmental/policy levels ( Bolling et al., 2018 ).

The multifactorial approach leads to multimodal methodological approaches. Traditionally quantitative analyses are used in sports injury prevention and rehabilitation research. There is thus a need to improve knowledge through qualitative approach ( Bolling et al., 2018 , 2019a , b ). There is also a need for more behavioral approach when it comes to actual sports injury prevention ( Verhagen et al., 2010 ) and when we aim increase compliance to prevention measures.

The multifactorial approach leads to analytical challenges. Indeed, this implies increasing the magnitude and type of data, which is of interest to fit the complex nature of sports injury, but can be difficult to managed by traditional analytical approaches, and for sure imply the collaboration with statistical and data science community ( Casals and Finch, 2018 ; Nielsen et al., 2020b ). To analyse complex interactions between factors and/or between sports injury and factors, there is a need for new analytical advances ( Bittencourt et al., 2016 ; Nielsen et al., 2020b ). As a consequence, other fields of data analyses, such as for instance machine learning, will continually be embraced in the future ( Bittencourt et al., 2016 ; Ruddy et al., 2019 ). These analytical approaches may help analyse complex interactions as well as estimating the risk of sports injury occurrence, with application to understand the sports injury as well as to reduce their occurrence or recurrence ( Bittencourt et al., 2016 ; Ruddy et al., 2019 ).

In addition, there is a need to use appropriate methodologies to analyse the efficacy of each of these strategies. Randomized Controlled Trial is currently the gold standard to analyse the efficacy of an intervention ( Philipps et al., 2009 ), it is the design that should allow the highest level of evidence by minimizing the risk of bias. However, such design may not be the most relevant to reflect the reality of sports given, among others, the risk of low compliance ( Nielsen et al., 2020a ). We could benefit from improvement in methodological design inspired from other research fields. In addition, usual analytical approaches, such as intention-to-treat, per protocol or as treated analyses, can lead to bias, especially in the context of low compliance (Edouard et al., in revision). Therefore, there is a need to explore other analytical approaches, as IV analysis, or other G-estimation, which can address some of the problems that arise from low compliance without losing the value of randomization and can also be helpful in observational studies (Edouard et al., in revision).

Conclusions

Although injury prevention and rehabilitation are not new disciplines, there is still an unmet need to improve knowledge toward theoretical understanding on epidemiology, risk factors, and injury mechanisms, as well as on practical strategies that can reduce the risk of sports injury or reinjury and of sequalae after injuries. Given the complex nature of injury, a holistic multifactorial biopsychosocial approach is needed through comprehensive, multidisciplinary and individualized approach to reach this great challenge. We therefore hope that this new section Injury Prevention and Rehabilitation of the Frontiers in Sports and Active Living can contribute to this improvement of knowledge, but also positively impact the sustainable and safe participation and short and long-term health of athletes.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

This work was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number R21AR069873 (to KF).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: health protection, sports injury prevention, injury risk, sports rehabilitation, multidisciplinary approach, multifactorial approach

Citation: Edouard P and Ford KR (2020) Great Challenges Toward Sports Injury Prevention and Rehabilitation. Front. Sports Act. Living 2:80. doi: 10.3389/fspor.2020.00080

Received: 26 May 2020; Accepted: 28 May 2020; Published: 03 July 2020.

Edited and reviewed by: Gregoire P. Millet , University of Lausanne, Switzerland

Copyright © 2020 Edouard and Ford. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Pascal Edouard, Pascal.Edouard42@gmail.com ; Kevin R. Ford, kford@highpoint.edu

• Open access
• Published: 03 May 2023

Interdisciplinary sport injury research and the integration of qualitative and quantitative data

• S.E Hausken-Sutter 1 ,
• K Boije af Gennäs 2 ,
• A Schubring 1 , 3 ,
• J Jungmalm 1 &
• N Barker-Ruchti 1 , 4  

BMC Medical Research Methodology volume  23 , Article number:  110 ( 2023 ) Cite this article

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To understand and prevent sport injuries, scholars have employed different scientific approaches and research methods. Traditionally, this research has been monodisciplinary, relying on one subdiscipline of sport science and applying qualitative or quantitative research methods. Recently, scholars have argued that traditional approaches fail to address contextual components of sport and the nonlinear interactions between different aspects in and around the athlete, and, as a way forward, called for alternative approaches to sport injury research. Discussion of alternative approaches are today taking place, however, practical examples that demonstrate what such approaches entails are rare. Therefore, the purpose of this paper is to draw on an interdisciplinary research approach to (1) outline an interdisciplinary case analysis procedure (ICAP); and (2) provide an example for future interdisciplinary sport injury research.

We adopt an established definition and application of interdisciplinary research to develop and pilot the ICAP for interdisciplinary sport injury teams aiming to integrate qualitative and quantitative sport injury data. The development and piloting of ICAP was possible by drawing on work conducted in the interdisciplinary research project “Injury-free children and adolescents: Towards better practice in Swedish football” (the FIT project).

The ICAP guides interdisciplinary sport injury teams through three stages: 1. Create a more comprehensive understanding of sport injury aetiology by drawing on existing knowledge from multiple scientific perspectives; 2. Collate analysed qualitative and quantitative sport injury data into a multilevel data catalogue; and 3. Engage in an integrated discussion of the collated data in the interdisciplinary research team.

The ICAP is a practical example of how an interdisciplinary team of sport injury scholars can approach the complex problem of sport injury aetiology and work to integrate qualitative and quantitative data through three stages. The ICAP is a step towards overcoming the obstacles of integrating qualitative and quantitative methods and data that scholars have identified.

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Introduction

Traditionally, sport injury researchers study injury aetiology in youth athletes from the perspective of one scientific discipline (e.g., exercise physiology, biomechanics; sport psychology; sport sociology). Broadly speaking, researchers of these disciplines follow distinctive assumptions of what an injury is and what research questions, ethical stances, research methods and interpretations and explanations of results are most appropriate to researching injury aetiology in youth athletes [ 1 , 2 , 3 ]. Biomedical scholars, for instance, often regard an injury to be related to identifiable individual physical factors and apply quantitative methods to test if components such as muscle strength previous injury, and growth and maturation are related to injury aetiology [ 4 , 5 , 6 ]. Sport sociologists often understand sport injury as a socially constructed phenomenon and apply qualitative methods to interview youth athletes about the coach-athlete relationship and/or observe contextual aspects such as the training environment [ 7 , 8 ]. To study aspects such as injury experiences, consequences and perceptions, sport psychology researchers oftentimes use either quantitative [ 9 ], qualitative [ 10 ] or mix qualitative and quantitative methods [ 11 ].

The predominant monodisciplinary approach to sport injury research has provided extensive knowledge on injury aetiology in youth athletes. In recent years, however, several sport injury scholars have critiqued the traditional monodisciplinary approach and suggested a turn to complexity approaches to account for the multifaceted nature of sport injury aetiology [ 12 , 13 , 14 , 15 , 16 , 17 ]. The key argument is that contemporary research has not been accounting for the nonlinear interactions between different components across different dimensions, such as interactions between people and the physical and social environments, and thus, does not consider the unpredictable, fluid, and flux nature of sport injuries. Instead, the scholars suggest a framework away from risk factors towards identifying risk patterns and looking deeper into the complex nature of sport injury aetiology [ 12 , 13 , 15 , 16 , 17 ]. To achieve this goal, however, scholars consider how to best address complexity differently, and best practice examples are a work in progress for sport injury research. To address this gap and to contribute to the current discussion on alternative approaches we propose that interdisciplinarity offers potential. We have adapted and applied the definition of interdisciplinarity based on Julie Klein and William H. Newell [ 18 ], who have significantly influenced the field of interdisciplinary research in the past 40 years. These scholars define interdisciplinarity as a research process that addresses a complex phenomenon that cannot be dealt with adequately by a single scientific discipline. To fit Klein and Newell’s definition to the team context within which we conducted interdisciplinary research, we adapted Klein and Newell’s [ 18 ] definition which in this article involves collaboration of researchers specialising in different scientific disciplines and methodological approaches, and the application of both qualitative and quantitative methods.

The need for interdisciplinarity in sport injury research was first called for by Burwitz et al. [ 19 ] in the 1990s. Since then, several sport science scholars have argued that research on athlete health and wellbeing requires a holistic and multidimensional approach, where scholars from different disciplines collaborate [ 20 , 21 , 22 ]. The rationale is that different scientific perspectives and research methods have established important insight into sport injury aetiology and can thus address a greater range of components that influence sport injury aetiology. The different disciplinary insights offer a means to facilitate an integrated understanding and discussion of sport injuries in relation to individual players’ context and situation, which has the potential to extend existing insights [ 19 , 22 , 23 ]. For example, and as demonstrated by sport science scholars Schofield, Thorpe, and Sims [ 24 ], their bringing of qualitative sociological data into dialogue with quantitative physiological data helped the team to draw novel conclusions as to which athletes were struggling with health problems, which eventually led to new insight and a return to the empirical data for a second stage of analysis. Such new and integrated insight into athlete health is necessary to develop prevention strategies that are more effective in addressing the components of sport injury aetiology. To that end, this paper contributes with a piloted procedure on how to work in an interdisciplinary team with qualitative and quantitative data in sport injury research. Specifically, the purpose of this paper is to draw on an interdisciplinary research approach to (1). outline an interdisciplinary case analysis procedure (ICAP); and (2). provide an example for future interdisciplinary sport injury research.

Interdisciplinary research and implications for data analysis

Interdisciplinary scholars Klein and Newell [ 18 ] define interdisciplinary research as:

a process of answering a question, solving a problem, or addressing a topic that is too broad or complex to be dealt with adequately by a single discipline or profession … [interdisciplinary research] draws on disciplinary perspectives and integrates their insights through construction of a more comprehensive perspective [ 18 p3].

Interdisciplinarity thus constitutes both a research approach and a process that is developed for the study of complex systems [ 23 ]. A key aspect of interdisciplinary research is integration: “…crafting an integrated synthesis of the separate parts that provide a larger, more holistic understanding of the question, problem or issue at hand” [ 18  p12; emphasis in original]. Detailing this definition, interdisciplinarians Repko, Szostak and Buchberger [ 25 ] outline that integration is a cognitive process, where the researcher(s) evaluate disciplinary knowledge from multiple scientific perspectives and create a more comprehensive understanding of the problem under study based on the disciplinary knowledge. The common ground is, according to several interdisciplinary scholars, necessary for integration of disciplinary insight to be possible [ 25 , 26 ]. For interdisciplinary sport injury research, we took this to mean that a team of disciplinarians, could collaborate, share, and integrate disciplinary knowledge, and engage in a discussion during which qualitative and quantitative data could be integrated.

The interdisciplinary research approach outlined above may seem familiar to scholars conducting mixed methods research in, for example, health research and sport psychology [ 27 , 28 ]. Mixed methods research does indeed often aim to integrate qualitative and quantitative methods and data to gain broad and deep understanding and to generate unique insight into multifaceted phenomena [ 27 , 29 , 30 ]. However, the type of interdisciplinarity proposed in this paper differs from the mixed methods research approach by involving strategies for dealing with an array of ontological, epistemological, and contextual challenges that often exist or emerge when a team of disciplinarians collaborate. For example, interdisciplinary teams in sport science research can experience, and have experienced problematic power relationships, language barriers, and misunderstandings that complicate the integration of qualitative and quantitative data if these issues are not dealt with in the team [ 22 , 24 , 31 ]. Such teamwork and related onto-epistemological differences have received sparse attention in mixed methods research [ 32 , 33 , 34 ]. Therefore, to account for these differences, interdisciplinarity does not only involve strategies for integrating methods and data, but also for integrating disciplinary knowledge to create a more comprehensive understanding of the problem under study, which is necessary for integration to be successful [ 26 ].

With the potential and challenges of interdisciplinary research in mind, how can qualitative and quantitative data be integrated in an interdisciplinary research team context? As we could not locate established procedures for interdisciplinarity in sport science and sport injury research, we draw on suggestions of an applied interdisciplinary process developed by Newell and colleagues [ 26 , 35 ], which constitutes integrative steps to guide researchers through the decisions made in the interdisciplinary process. According to these scholars, integration cannot follow an algorithm; rather, integration requires analytical reasoning and creative thinking as the interdisciplinary research process and its steps are iterative and complex [ 26 , 35 ]. Moreover, being humble, respectful of, and acknowledging each other’s perspectives has been recognised as valuable cognitive skills when aiming to integrate knowledge and data across disciplinary borders [ 22 , 36 ]. To successfully conduct integrated research, then, efforts beyond those associated with conducting high-quality disciplinary research and mixed methods approaches are necessary [ 26 ]. First, researchers need to understand a problem from different perspectives and disciplines. Second, researchers need to consider different disciplinary views and the methodological toolkits that the disciplines constitute. Finally, it is important that researchers embrace a holistic approach – an understanding of how disciplinary ideas and information relate to a problem and to each other. In sum, as the holistic thinking involved in interdisciplinary research opposes the traditional reductionist disciplinary strategy, interdisciplinary research is not “business as usual” [ 26 p262].

To develop an interdisciplinary case analysis procedure, which became the ICAP, we draw on research conducted in the interdisciplinary research project “Injury-free children and adolescents: Towards better practice in Swedish football (the FIT project) [ 37 ]. The purpose of the FIT project was to provide evidence-based interdisciplinary injury prevention strategies. The project aimed to produce a comprehensive and integrated picture of injury aetiology in a sample of male and female Swedish football players aged 10 to 19. The research team consisted of scholars from four scientific disciplines—biomechanics, sport medicine, sport sociology, and sport coaching. Based on the four scholars’ respective scientific expertise, qualitative data was generated through interview and observation-studies and quantitative data through biomedical measurements (kinematics/movement; strength; joint range of motion/flexibility; Peak Height Velocity (PHV)) and a longitudinal questionnaire study implementing an adapted version of the OSTRC-H questionnaire [ 38 ]. Upon completion of the studies, qualitative and quantitative data were analysed according to their respective disciplinary data analysis methods and quality standards (e.g., thematic analysis for qualitative interview and observation-data; statistical procedures for biomedical data). The next step was to perform integrated data analysis, which led us to the development of the ICAP.

The Interdisciplinary Case Analysis Procedure (ICAP)

The ICAP is a flexible, circular, and iterative procedure entailing three stages (see Fig.  1 ). The stages reflect the research process of a team of disciplinary researchers aiming to integrate data through an interdisciplinary data analysis procedure. In stage 1 and taking seriously the need for integration of disciplinary insights early in the research process, the aim is to create a comprehensive understanding of the phenomenon/a that the project team aims to study based on the scientific disciplines included in a project. In stage 2, qualitative and quantitative data, analysed according to their respective disciplinary standards, are brought together. Finally, in stage 3, the collated data is discussed through a team meeting consisting of the researchers representing the data included in step 2.

The three stages of the Interdisciplinary Case Analysis Procedure (ICAP)

Stage 1: Creation of comprehensive understanding

In stage 1, the aim is to create a comprehensive understanding of the problem that the project team intends to study based on the scientific disciplines included in the project [ 23 ]. To create comprehensive understanding, it is necessary that the team members find a common language, recognise conflicts and their unique strengths, and the disciplinary knowledge each member brings to the study [ 23 ]. In this stage, the either/or disciplinary thinking is replaced by both/and thinking requiring the disciplinarians to “think outside of the box” [ 26  p260].

For the FIT project to create comprehensive understanding of sport injury, we held several team meetings to discuss and reflect upon our different research approaches and understandings of sport injury aetiology. The meetings were carefully planned and led by the project leader, who aimed to be inclusive in type of language and making room for all disciplinary perspectives. We also reviewed diverse disciplinary literature relevant to sport injury, with a particular focus on youth football, to critically reflect upon onto-epistemological differences in sport injury research for the narrative review article we published together [ 39 ]. Through reviewing literature, we also considered the basic assumptions of complexity thinking, especially in relation to nonlinear interactions between different components in the athlete’s context. Moreover, the project was presented within and outside of academia to gain additional knowledge on disciplinary research approaches and sport injury aetiology in youth athletes. The planning and implementation of the FIT project’s four sub-studies also taught us more about the differences in qualitative and quantitative methods in relation to concepts such as recruitment, validity, and reliability. Finally, all researchers had the opportunity to participate in the respective studies, where, for example, the sport coaching researchers participated in the biomedical testing.

Stage 2: Collation of qualitative and quantitative data

The aim of Stage 2 is to bring together qualitative and quantitative data in preparation for stage 3’s integrated discussion of injury aetiology.

For the FIT project, we focused on one single case of a female player aged 14 that had participated in all four studies included in the FIT project. This entailed two steps: First, individual analysis of the different datasets using suitable data analysis methods (i.e., thematic analysis for qualitative interview and observation-data; statistical procedures for biomedical data). Second, collation of the analysed data per research participant in a multilevel data catalogue in the form of an Excel document (see supplemental online file ). The idea of this catalogue is to visualise and collate in a common “space” qualitative and quantitative data to provide a foundation for the integrated discussion in stage 3. The multilevel data catalogue entails six levels of information (see Table 1 for a simplified overview; for a more comprehensive description of the six levels, see the supplementary file ).

In level 1, to demonstrate the FIT project’s disciplinary perspectives, the multilevel data catalogue is divided into one biomedical (biomechanics, sport medicine) and one sociological (sociology, sport coaching) section. The purpose of level 2 is to show the different types of measurement and research methods employed under each disciplinary perspective. The columns in level 2 are divided into different biomedical- and sociology-themes (e.g., strength measurements; observation, interview). Level 3 specifies the type of data measured and generated for each of the themes. For example, for the strength theme, the hip abduction/adduction ratio is listed in separate columns. For the interview theme, topics such as “knowledge about injury and injury prevention” are listed. Level 4 contains data excerpts to demonstrate the type of qualitative and quantitative data from the individual analyses of the injured football player. Quantitative data is represented in numeric form (for example results from the strength measurements) while qualitative data is represented in textual form (for example quotes from the interview). Level 5 shows the reference value for qualitative and quantitative data. For the former, codes were given through a qualitative thematic analysis procedure [ 41 ]. For the latter, individual biomedical data was calculated and compared to the mean values of one reference group “females aged 14–19”. Finally, level 6 contains interpretation and evaluation of the qualitative and quantitative data in relation to reference values and literature. This level lays the most important groundwork for the team discussion and continuation of data integration for stage 3.

Stage 3: Team meeting and discussion

In stage 3, the aim is for the researchers from the different disciplines included in the interdisciplinary project to meet and discuss the collated qualitative and quantitative data. According to Newell [ 26 p261], the goal of this interdisciplinary stage is to “achieve a balance among disciplinary influences on the more comprehensive understanding”, i.e., no disciplinary perspective should dominate the discussion. The qualitative and quantitative data about the complex problem (i.e., sport injury) is in this stage examined to “identify patterns of behaviour” [ 26 p261], or relationships (interactions) between different components in the system that influence injury aetiology.

For the FIT project, stage 3 was conducted through a team meeting consisting of researchers representing the scientific disciplines included in the project. The discussion was moderated by one of the researchers in the team, who had experience from the FIT project’s four sub-studies and knowledge of interdisciplinary research. The data catalogue containing analysed data served as the basis for the two-step discussion: First, each researcher presented interpretations of the analysis of data relevant to their disciplinary expertise. Their interpretations were related to the FIT project’s overarching aim and were not yet specific to a specific case/research participant. During each researcher’s statement of the analysed data, the other team members were invited to ask questions, which is argued to enable a deeper understanding of the problem at hand [ 42 ]. Second the different perspectives and data were related to the 14-year-old female player’s injury in a joint discussion. The integrated discussion was also a way to identify different patterns in the empirical data.

Implications for interdisciplinary injury data analysis

As part of the process of developing and piloting the ICAP, we have encountered four issues that have implications for the use of the procedure and future research.

First, to facilitate the collation of qualitative and quantitative sport injury data in interdisciplinary research, we experienced that the different assumptions regarding disciplinary perspectives and qualitative and quantitative data require consideration early in the interdisciplinary research process. We propose that this consideration is vital as underlying ontological, epistemological, and methodological assumptions can complicate interdisciplinary research and integration due to misunderstandings and difficulties in reflecting and verbalizing these assumptions among members of interdisciplinary research teams. Therefore, the ICAP was, and needs to be part of a purpose-driven interdisciplinary research process that focuses on integration of disciplinary perspectives and research methods already in the planning and designing-phase of a project.

Second, as differences in assumptions influence how researchers define and research a phenomenon, it is necessary to facilitate collation through three circular, iterative, and pragmatic stages that enable teamwork across disciplinary borders. Indeed, working interdisciplinarily requires spaces, or “a community of research practice” [ 3 p56] within and through which the team can explore, negotiate, and reflect upon their commonalities and differences in scientific perspectives [ 43 ]. We have therefore found that it was of great importance that the team followed a procedure through which we met on a regular basis and had a team leader that supported methodological flexibility throughout the process. Such regular team meetings have indeed been found to facilitate the development of strategies that can help bring qualitative and quantitative materials together [ 24 ]. Following such a procedure does not, however, mean that working interdisciplinary is a strict and linear process. On the contrary, we did, for example, experience that we had to go back to stage 1 and learn more about concepts such as reliability, validity, credibility, generalisability, and transferability in relation to qualitative and quantitative methods [ 44 ] when interpreting the data in stage 3.

Third, and to further facilitate collation of qualitative and quantitative data in an interdisciplinary research team context, we noticed that the team benefitted from including a researcher with knowledge of interdisciplinary research and the different disciplines included in the project. We found this particularly important in stage 3 of the ICAP, when the team discussed the compiled data in relation to the injured player. When the discussion reached a dead-end, or when the disciplinarians misunderstood each other or the data, the interdisciplinary researcher moderator could clear up misunderstandings by, for example, pointing out how the different disciplines understand and interpret concepts differently and helping the team to find a common language. It occurs, for instance that qualitative and quantitative data contradict, which can be seen as a problem and an obstacle for integration [ 31 ]. Including an interdisciplinarian in the integration phase can, however, help the team use the contradictions in data to create new insight into the problem under study [ 31 ], which is key in Newell’s interdisciplinary process [ 26 ]. The idea of the interdisciplinarian , [ 26 ] or interlocutor , [ 30 ] as someone in the middle, who takes part in dialogue and conversation with the disciplinarians, can help the team see beyond their disciplinary borders, create unity, and refocus the team’s efforts towards constructive engagement in knowledge production [ 43 ]. Although the interdisciplinarian might not be able to eliminate possible power inequalities between the disciplinarians, paying attention to these boundaries and engaging the team in conversation can facilitate a common and interdisciplinary understanding of sport injury aetiology. For the FIT project, the interdisciplinarian helped the team to establish several aspects that needed further development, such as a need for a larger quantitative data set to be able to finalise the quantitative analysis as well as a need for additional cases to find patterns between cases. The team also realised the need for discussing the qualitative data in relation to findings and interpretations from similar qualitative research.

Fourth, we have noticed that successful integration requires a common understanding of what integration means in the team and where in the research process integration should take place. For the FIT project, integration involved a comprehensive understanding of sport injury aetiology in stage 1 [ 39 ], the collation of qualitative and quantitative data in one common space in stage 2 (the multilevel data catalogue), and an integrated discussion in stage 3 which together facilitated our interdisciplinary understanding of sport injury aetiology. There are, however, differences in degrees of integration [ 45 ]. Sometimes, for example, integration of knowledge and the collaborative process includes actors outside of academia and can lead to the creation of a new framework, which can generate a fundamental epistemological shift [ 36 , 43 ]. Being clear in the beginning of a project on what, when, and how to integrate is key for sucessful collaboration across disciplinary boarders.

Finally, some methodological limitations need to be considered before conducting an integrated analysis procedure such as the ICAP. First, the ICAP is a complex procedure to carry out and requires more time, resources, and expertise than traditional analysis procedures. Second, there is a lack of research on the integration of qualitative and quantitative data in the interdisciplinary research context, and more research is needed on the integrated potential of such an approach and process. Finally, in the interest of better understanding the complexity of sport injury aetiology, there is a need to explore the pragmatic negotiations that an interdisciplinary research team needs to make when integrating seemingly opposing worldviews, methods, and data.

The purpose of this paper was to draw on an interdisciplinary research approach to (1) outline an interdisciplinary case analysis procedure (ICAP); and (2) provide an example for future interdisciplinary sport injury research. The Interdisciplinary Case Analysis Procedure (ICAP) consists of a three-stage process that allowed us to create a more comprehensive understanding of sport injury aetiology, collate qualitative and quantitative data in a multilevel data catalogue and engage in an integrated discussion to identify patterns in the empirical data. Working interdisciplinarity is not business as usual and requires researchers to adopt certain cognitive skills that might be outside of their disciplinary comfort-zone. Creativity, flexibility, and openness are key such skills.

While we have developed the ICAP specifically for an interdisciplinary youth sport injury research project, the procedure is generic and can be applied in interdisciplinary research addressing other complex phenomena. For researchers who aim to adopt (and adapt) the ICAP, it is important to keep in mind that the procedure is not “just” about mixing or integrating qualitative and quantitative data, it includes strategies to integrate disciplinary knowledge and consider onto-epistemological differences throughout the whole research process. In so doing, the ICAP is a step towards overcoming the obstacles of integrating qualitative and quantitative methods and data that scholars have identified. It is our hope that sport science and other researchers will consider and apply ICAP in the interest of better understanding the complexities of a phenomenon under study.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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Open access funding provided by University of Gothenburg. The Swedish Research Council for Sport Science (CIF) has been funding the FIT project since 2016 through partial funding of a PhD studentship (F2016-0017; FO2021-0016; FO2017-0004; FO2018-0007; FO2020-0005; FO2021-0016) and partial project funding for one year (P2017-0090). The FIT project application was developed for a specific 2014 CIF call for interdisciplinary research on health and performance in child and adolescent sport. CIF funds research in the field of sports, which are defined to include everything from club sports to exercise, physical activity, performance and training for children, young people, adults, and the elderly.

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Department of Food and Nutrition, and Sport Science, University of Gothenburg, Box 300, 405 30, Gothenburg, Sweden

S.E Hausken-Sutter, A Schubring, S Grau, J Jungmalm & N Barker-Ruchti

Department of Sport Science, Malmö University, Malmö, Sweden

K Boije af Gennäs

Institute of Sociology and Gender Studies, German Sport University Cologne, Cologne, Germany

A Schubring

School of Health Sciences, Örebro University, Örebro, Sweden

N Barker-Ruchti

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Contributions

NBR initiated and designed the FIT project with SG. SEHS and NBR led the drafting of the manuscript. All authors collected and analysed the data. KBaG, AS, SG, JJ and NBR contributed to the writing of the manuscript. All authors read and revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to S.E Hausken-Sutter .

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Ethical approval was obtained from the Central Ethical Review Board in Gothenburg on 18 October 2017 (Dnr 815–17). In accordance with the Swedish Ethics Review Law, participants over the age of 16 gave their own written consent. For participants below 16 years of age, written informed consent was obtained from a parent or a guardian. All methods were carried out in accordance with relevant guidelines and regulations.

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Hausken-Sutter, S., Boije af Gennäs, K., Schubring, A. et al. Interdisciplinary sport injury research and the integration of qualitative and quantitative data. BMC Med Res Methodol 23 , 110 (2023). https://doi.org/10.1186/s12874-023-01929-1

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Received : 20 October 2022

Accepted : 21 April 2023

Published : 03 May 2023

DOI : https://doi.org/10.1186/s12874-023-01929-1

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Sports Injury Research

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With the increasing focus on tackling obesity and other lifestyle-related illnesses and conditions, participation in sports and physical activity is growing. The consequences are that injuries and unwanted side-effects of healthy activity are becoming major health problems. Prevention is crucial to health gain, both in the short-term (preventing immediate injury), and in the longer term (reducing the risk of recurrence and prolonged periods of impairment). Prevention follows four main steps: 1) the sports injury problem must be described in incidence and severity; 2) the etiological risk factors and mechanisms underlying the occurrence of injury are identified; 3) preventive methods that are likely to work can be developed and introduced; and 4) the effectiveness and cost-effectiveness of such measures are evaluated.

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