Speaker: Caroline Bolling, PT, PhD, University Medical Center, Amsterdam, The Netherlands
Congress: Sport & Exercise Medicine Switzerland and Swiss Sport Physiotherapy Association joint conference: “Structure & Function”, Lausanne, October 30th and 31st 2025
Scan to access presentation on Sportfisio YouTube channel
Introduction
Contemporary sports medicine emphasizes measurable structure and quantifiable function as primary determinants of injury management and return-to-sport decision-making. However, this clinician-centric paradigm may fundamentally misalign with athlete experience and contextual realities of elite performance. This article presents a provocative reconceptualization of injury, prevention, and rehabilitation that centers athlete perspective and acknowledges the complex ecosystems within which clinical interventions exist, drawing from research presented by Caroline Bolling, sports physiotherapist and researcher from Amsterdam UMC.
The expert paradox: clinical knowledge versus lived experience
Traditional hierarchies position clinicians as experts who determine how athletes should feel and function based on biomechanical analysis and pathophysiological knowledge. However, this paradigm overlooks a fundamental truth: athletes possess irreplaceable expertise regarding their own bodies, performance contexts, and career trajectories. As expressed by English footballer Beth Mead regarding her ACL injury, athletes develop profound understanding of their conditions through lived experience that cannot be replicated through clinical examination or imaging.
This creates an expert paradox—while clinicians possess technical knowledge of tissue pathology and healing timelines, athletes possess contextual knowledge of performance demands, symptom-function relationships, and career implications. Optimal outcomes require integration of both knowledge domains rather than hierarchical imposition of clinical judgment.
Injury definition: the subjectivity problem
Consensus Definitions Versus Athlete Reality
The International Olympic Committee consensus injury definition emphasizes tissue damage and altered physical function—constructs measurable by clinicians. However, epidemiological surveillance tools like the Oslo Sports Trauma Research Centre (OSTRC) Questionnaire measure perceived complaint, perceived need for medical attention, and perceived time loss—inherently subjective constructs requiring athlete acknowledgment of injury status.
Performance as Diagnostic Criterion
Research with elite athletes reveals that injury definition centers primarily on a single question: «Does it hamper my performance?» Symptom presence alone is insufficient for self-classification as injured. Athletes employ secondary considerations including: Can I manage symptoms through training modification? Can I adapt technique? Can I still compete effectively despite performance compromise?
This performance-based definition fundamentally differs from clinical tissue-damage models and explains discrepancies between clinical assessment and athlete injury reporting.
Contextual and Cultural Determinants
Injury reporting demonstrates profound context-dependency. Research with Malta’s national football team revealed that during important matches, athletes do not report injuries regardless of symptoms or functional limitations—»I don’t care if I’m injured, I will give everything.» Team culture, competition importance, and perceived replaceability all influence whether athletes acknowledge and report injury status.
Inclusivity Failures
The inadequacy of universal injury definitions becomes starkly apparent in adapted sports. Research with blind footballers revealed athletes receiving concussion protocols warning them to «watch out for double vision»—highlighting how standardized definitions fail to accommodate diverse athlete populations. Injury represents a dynamic, context-dependent concept rather than a binary clinical state.
The efficacy-effectiveness GAP in prevention
Evidence Without Context
Injury prevention trials demonstrate impressive efficacy: some hamstring protocols achieve 70% injury reduction, certain ACL programs exceed 60% reduction. However, this evidence exists within specific contexts. Systematic review of football non-contact injury prevention reveals nearly exclusive representation of European and North American populations, creating substantial knowledge gaps for other geographical, cultural, and sporting contexts.
Prevention research establishes causal claims under specific conditions—»it works somewhere»—but clinical application requires answering a different question: «Does it work here, for this population, in this context?»
Implementation Reality: The Knee Control Study
The Knee Control program exemplifies the efficacy-effectiveness gap. Randomized controlled trial demonstrated 64% injury reduction; real-world implementation achieved 12% reduction. Qualitative investigation revealed contextual barriers: cold Swedish climate, artificial turf conditions, time constraints (75-minute training windows), resulting in selective exercise implementation and compromised quality.
This disparity demonstrates that efficacy trials, while establishing biological plausibility, cannot predict real-world outcomes without understanding implementation contexts.
The prevention ecosystem
Beyond Single-Exercise Reductionism
Cirque du Soleil artist perspectives reveal prevention complexity: “It’s not about one exercise… if you are healthy, if you eat healthy, your body will be healthy, it’s mindset… an exercise will not change your life, it’s a lot of stuff.” Qualitative research identified multiple interacting factors: physical load, mental load, social load, sleep, nutrition, psychological well-being—all influenced by numerous stakeholders including coaches, performance staff, medical teams, management, and family.
This ecosystem perspective explains why isolated interventions demonstrate limited effectiveness—injury prevention requires systemic approaches addressing multiple determinants and coordinating multiple stakeholders.
Risk Management Versus Prevention
Snow sports athletes rejected the concept of “injury prevention” entirely, reframing their approach as “risk management”—a continuous mental negotiation between performance ambition and safety concerns, metaphorically described as an “angel and devil” debate. This reconceptualization acknowledges that certain athletic contexts involve inherent risk that cannot be “prevented,” only managed through informed decision-making.
Career Stage and Context Evolution
Women’s football research revealed that identical athletes require different prevention strategies across career stages. Early-career athletes training from 9:30 PM to 1:00 AM before working 8:00 AM jobs require fundamentally different approaches than professional athletes with optimal training environments. Prevention strategies must adapt to evolving contexts rather than applying static protocols.
Return-to-sport: Communication and complexity
Fragmented Decision-Making
Return-to-sport processes typically involve multiple professionals (surgeons, physiotherapists, strength coaches, sport psychologists) each focusing on discrete outcome domains—the surgeon monitors structural healing, the physiotherapist assesses functional capacity, the coach evaluates sport-specific performance. Athletes frequently serve as mediators between disconnected professionals, receiving contradictory guidance and assuming coordination responsibilities without appropriate support.
One athlete described: “I was practically in tears because I had a lot of mixed messages… Who is coordinating everything? We need to make sure that everyone knows the work of everyone.” This fragmentation creates confusion, anxiety, and suboptimal decision-making.
The Decision Not to Return
Clinical paradigms emphasize successful return-to-sport as the optimal outcome, potentially dismissing athlete decisions to retire or reduce participation. However, athletes possess legitimate reasons for not returning despite meeting clinical milestones: chronic pain concerns, psychological readiness, team dynamics, career-life balance considerations. One athlete’s decision exemplifies this complexity: “I know in my heart I don’t want to stop, but I know in my mind that it’s the best for my body. I don’t want to feel pain in my life anymore.”
Additionally, athletes nine months post-ACL reconstruction meeting all clinical criteria may face contextual barriers: media pressure, fan expectations, team performance dynamics, perceived replaceability. Clinical readiness does not ensure contextual readiness.
Conclusion: Decengering clinical vanity
While structure and function assessment provide valuable information, they represent incomplete frameworks for injury management. Optimal outcomes require acknowledging that «the song is not about us»—clinical expertise must serve athlete needs rather than imposing clinician-defined success criteria. This requires fundamental shifts: listening to athlete perspectives, involving athletes in decision-making, respecting athlete autonomy regarding career decisions, acknowledging implementation contexts, coordinating multidisciplinary care, and recognizing the complex ecosystems within which athletes exist. The athlete remains the real expert on their body, performance, and career—clinical expertise should support, not supplant, athlete agency.
References
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