Authors: Trease, L for all authors – Foley, G; Kemp, JL; Hancock, MJ; Wilson, F; Makdissi, M; Morrison, J; Mosler, A
Why is this study important?
Low back pain (LBP) is common in elite sport, affecting around half of all athletes each year (1). Currently, most research focuses on risk factors, anatomy and biomechanics (2, 3), with treatment studies largely centred on biological interventions (4, 5). This approach is disconnected from the broader community LBP literature where a biopsychosocial approach is considered best practice (6).
Our study explored how elite athletes experience pLBP and the biopsychosocial factors that shape their recovery.
How did the study go about this?
We conducted in-depth, semi-structured interviews with 17 Australian elite athletes competing across 10 Olympic sports. All had LBP lasting longer than three months. Using reflexive thematic analysis, we explored their lived experiences: what pain meant to them, what shaped their recovery, and how their sporting environment influenced both. Importantly, athletes were involved throughout the research process, ensuring the findings remained grounded in real-world elite sport.
What did the study find?
Four themes captured how athletes experienced and navigated pLBP.
- The burden of pLBP extends beyond pain
Athletes described pLBP as intrusive, with impacts extending well beyond physical symptoms. Unlike training pain, which is expected and chosen, pLBP was unpredictable and disruptive. It eroded confidence, challenged identity and created a sense of losing control over the body, “an alien presence”. For many, the hardest part was not the pain itself, but what it meant for their ability to train, compete and maintain a sense of self.
- Validation drives agency—and agency drives recovery
Validation was central to recovery. When clinicians validated an athlete’s pain, and helped them understand it, athletes felt more in control. In contrast, uncertainty or dismissal eroded confidence and trust. Diagnostic labelling and clear explanations often acted as a turning point, reducing fear and increasing engagement in rehab. This validation appeared to underpin agency.
- Mental health and pain are tightly intertwined
Athletes described a bidirectional relationship between pain and psychological distress. Periods of high pain often coincided with low mood, anxiety, and fear of re-injury. But those who could reframe pain as manageable—not threatening—were better able to stay engaged in training and recovery.
- Culture and relationships shape recovery
Pain was experienced within, and shaped by, the elite sporting environment. Athletes described pressure to continue training, fear of being perceived as weak or replaceable, and reluctance to disclose symptoms. Relationships with coaches, clinicians and teammates strongly influenced these experiences. Support outside sport, particularly from family and partners, was often positive for pain experience.
What are the key take-home points?
Elite sport is a unique environment where self-worth, selection, and income are closely tied to health and performance. When pain persists, it doesn’t just affect training, it can threaten athlete identity, belonging and career trajectory.
For clinicians, this means it’s not enough to prescribe exercises or interpret scans. We must:
- Communicate clearly and contextually
- Validate the athlete’s pain experience
- Facilitate shared decision-making
- Recognise the pressures of elite sport
- Advocate for environments where athletes feel safe to disclose pain
In elite sport, recovery is not just about getting athletes back to performance—it’s about protecting their autonomy, identity, and well-being along the way. Because, as our athletes told us, the pain itself is only part of the story.
Illustration credit
Illustrations are by Jessica Morrison OLY, dual Olympic medalist in Rowing, co-author and illustrator.
References
- Wilson F, Ardern CL, Hartvigsen J, et al. Prevalence and risk factors for back pain in sports: a systematic review with meta-analysis. Br J Sports Med 2020 doi: 10.1136/bjsports-2020-102537 [published Online First: 20201019]
- Hides JA, Stanton WR, McMahon S, et al. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports Phys Ther 2008;38(3):101-8. doi: 10.2519/jospt.2008.2658 [published Online First: 20071207]
- Takemitsu M, El Rassi G, Woratanarat P, et al. Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography. Spine (Phila Pa 1976) 2006;31(8):909-14. doi: 10.1097/01.brs.0000209308.19642.96 [published Online First: 2006/04/20]
- d’Hemecourt PA, Gerbino PG, 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19(4):663-79. doi: 10.1016/s0278-5919(05)70231-3
- George SZ, Delitto A. Management of the athlete with low back pain. Clin Sports Med 2002;21(1):105-20. doi: 10.1016/s0278-5919(03)00060-7
- National Institute for Health and Care Excellence: Guidelines. Low back pain and sciatica in over 16s: assessment and management. London: National Institute for Health and Care Excellence (NICE) Copyright © NICE 2020. 2020.