Ask me how I am,not only how much it hurts: Narratives of injured recreational runners

1 Introduction

Running-related injuries (RRI) are common among recreational runners, and evidence indicates that a musculoskeletal injury often extends beyond a biological aspect [1–4]. Published research regarding the psychosocial consequences of a RRI is limited in a recreational running population. Using questionnaires to collect data, a study by Chan et al. [5] found increased psychological symptoms in injured runners', such as depression, anxiety, mood disturbance, and lower self-esteem, consistent with psychological symptoms found during experimental exercise withdrawal [6]. More recently, Verhagen et al. [7] explored recreational runners perception of RRI and the occurrence and prevention of RRI and identified that by providing information, advice, and programs to injured recreational runners, self-regulation of RRI could be recommended. Other studies within this field have not included injured runners, and the data collection is primarily based on questionnaires [8–10].

Chan et al. [5] suggest that loss of consistent running due to a RRI may result in psychological distress when running is used as a coping strategy to reduce stress or to induce psychological reinforcement. The loss of frequent running may reduce the quality of life and make daily living less manageable [11]. Therefore, an injury may increase the risk of sick leave, as stress is one of the most typical reasons for absenteeism from work [12]. A prolonged RRI may also reduce overall physical activity or result in the discontinuation of running, thereby increasing the risk of lifestyle diseases [13–17]. Considering the number of adults participating in running worldwide and the risk of RRI, increased knowledge of the psychosocial consequences in injured runners is pertinent [2, 18].

Available knowledge primarily stems from other athletic populations [4, 19]. However, from a management and rehabilitation point of view, population-specific insight and knowledge of experiences and reactions resulting from a RRI are important. Otherwise, physiotherapists may not explore psychosocial issues relevant to rehabilitation when treating an injured recreational runner [20, 21]. One way of strengthening the competencies of physiotherapists working with injured recreational runners would be to increase the accessible knowledge concerning the psychosocial consequences resulting from a RRI.

Therefore, this study aimed to explore the psychosocial aspects experienced by injured recreational runners hindered in usual running because of RRI. A phenomenological approach was used to explore injured recreational runners’ experiences, reactions, thoughts, and feelings [22].

2 Methods

Three main codes were identified: 1) Reasons for running, 2) Daily life during an injury - besides running, 3) Running while injured. Figure 1 shows examples of participant quotes related to each main code. Subgroups were highlighted within each code.

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Fig. 1a

Participant quotes related to main codes. 1b. Alt text: An illustration of the three main codes; Reasons for running, Running while injured, Daily life during an injury, and their interacting with running-related injury. Each code is accompanied by quotes from the participants.

4 Discussion

This study aimed to explore the psychosocial aspects experienced by injured recreational runners hindered in usual running because of RRI.

In 1979 JE Nash argued that running has two functions; promoting individual health and giving meaning to runners life [30]. The participants in the current study describe individual health as an important reason for running, a finding which resonates with the literature on reasons for running [7, 31]. Two perspectives on individual health are described, mental and physical. Running is for all the participants included in a healthy lifestyle as the preferred type of exercise. Running also provided participants with a meaningful social aspect, providing a way to stay in touch with friends while physically active. To all participants, running is also a way to gain mental calmness and relaxation in an otherwise sometimes chaotic and ever-changing daily life.

From the study findings, it became clear that all participants' greatly value participation in running and that RRI, on a psychosocial level, negatively impacts the participants everyday lives and their lives as recreational runners. The participants experienced a feeling of turmoil and a negative mood change, increased inactive everyday life, and a feeling of being less attractive because of bodily changes, which influenced their self-image by threatening the “running body” and a loss of social connectivity to the running community [32, 33]. These findings provide contemporary insight into injured recreational runners’ experiences, which may have important implications for clinical practice and physiotherapists managing injured runners. All participants consult a physiotherapist because of their injury. The physiotherapists provide recommendations regarding exercise therapy and modification of running habits, which provide confidence. However, the feeling of turmoil is present in all participants and is described as dominant. So, despite ongoing physiotherapeutic management of the participants RRI, potential psychosocial aspects of the injury are left unresolved. Therefore, it may be crucial to the injured runner that the physiotherapist not only acknowledges the psychosocial aspects of being injured but also explores how the injured runners manage these [34]. The biological part of physiotherapeutic management is still of great importance and relevance. Still, the following discussion will address the importance of a concurrent focus on the psychosocial aspect when working with alternatives to running, load modification, self-management strategies, and prognosis [35–37].

A drop in the level of physical activity has been reported among injured runners, and the participants in the current study also described an experienced increased level of inactivity [38]. This influences the physical aspect of individual health but may also be closely related to the psychosocial aspects [39]. Participants engage in alternative forms of exercise on their own initiative when unable to run. However, they do not experience the desired acute mental calmness and relaxation when participating in alternative exercise instead of running [40]. The combination of running and being out in the environment, by yourself or with others, seems important for the runners to experience the mental state they strive for. Reductions in running or discontinuation from running during a specified period of time is often part of the physiotherapeutic management of RRI. However, a relationship has been found between running and increases in good mood and decreases in bad mood [33]. Injured runners prevented from running experienced both negative mood changes and increased symptoms of psychological distress compared to injured runners who, despite injury, continued to run [5]. Therefore, physiotherapeutic management could possibly also be a source of a negative mood change when advising against running as part of a load management strategy. This is crucial for the healthcare provider to understand and consider in a patient-therapist relationship [41].

Further, the participants experience a change in their attention to bodily signals. Due to the RRI, they become increasingly aware of their body, perceiving bodily signals with increased caution. When running, the participants experience an internal conflict between the reasons for running and the perceived bodily signals. This may be another enabling part of the dominating feeling of turmoil. To positively influence the feeling of turmoil, physiotherapists could help injured runners understand their perceived bodily signals and provide strategies for self-regulation related to running and running-related injury symptoms [7].

Thoughts and attitudes among runners related to developing and preventing RRI are plentiful. Participants in the current study may have shared some of these thoughts and attitudes [8, 9]. Because when in need of treatment, they engaged in different strategies in an attempt to self-manage their RRI by changing running shoes or applying tape to support the injured tissue. But, most often, a feeling of insecurity accompanied these choices related to self-management strategies. In the clinical setting, this may be addressed by providing accounts for the clinical actions and relating these accounts to the runners’ concerns, as accounts have been shown to foster mutuality and may enhance the therapeutic relationship [42]. Therefore, engaging in an open-minded conversation about the embodied experience of injury, instead of a singular biological approach, providing the runner with the opportunity to express how they feel, and using timely produced accounts can be of great importance [42, 43]. The experiences of a lack of success with alternative exercise forms and the insecurity related to the different strategies for self-management may enable the dominating feeling of turmoil. As a physiotherapist, attention to these experiences is important. By providing acknowledgment and accounts during the exploration of these experiences, the physiotherapist may strengthen the therapeutic relationship and educate by including runners in the reasoning process and increasing self-confidence [42]. A because-account, defined as causes or needs related to existing matters, may be provided as a reason why the physiotherapist asks for insecurities related to strategies for self-management. An in-order-to-account, defined as aims, aspirations, purposes, and things that will be achieved or avoided as a result of the action, may address the importance of exploring multiple aspects in relation to the physiotherapeutic examination and treatment. During the exploration, adjustments to the runners, self-management strategies can be proposed, and potential concerns can be addressed within the interaction [42].

A prolonged injury period made some participants experience their injury period as both frustrating and unmanageable. Participants express fear of being unable to run as they did pre-injury, and some are afraid that it may affect their work capabilities in the future. Among injured participants from different sports and activities with a specific musculoskeletal injury, feelings of frustration and fear of the future are common findings [44, 45]. These findings highlight a need for strategies to manage the psychosocial aspects of a RRI among recreational runners and prevent the development of a misdirected problem-solving approach or fear avoidance of running [46, 47]. If not managed, the psychosocial aspect of a RRI may result in discontinuation of running despite biological recovery. Findings from the present study highlight the importance of physiotherapists making time to listen and engage with the injured runner beyond a biological perspective. An experienced lack of understanding from their surroundings, including physiotherapists, resulted in frustration among the participants, which Turner et al. [45] also describe among recreational runners with Achilles tendinopathy. Clement et al. [48] found that a health professional’s diagnosis made injured athletes situation more manageable and reduced their frustration. Likewise, a study by Wadey et al. [49] found the utilization of goal setting to be an effective coping strategy in athletes with high hardiness. Therefore, physiotherapists treatment may benefit from communicating the examination and treatment process to align expectations and by making time for conversation in consultations [50, 51].

The findings discussed were based on phenomenological reduction, non-value-based inquiry, and a search for descriptions instead of explanations. However, some methodological choices should be considered as they may have influenced the findings. The convenience sampling method may have increased participant diversity and reduced the risk of selection bias introduced by authors’ sampling based on specific characteristics [52]. Nevertheless, selection bias might have been unintentionally introduced by including more resourceful recreational runners, as participants had to contact the authors themselves.

Theoretical saturation was not sought because of the phenomenological nature of the study. Instead, data saturation was sought on an individual level – per interview – in accordance with Giorgi's focus on rich, descriptive data and the unique and subjective nature of individual experiences. In practice, this meant that interviews were completed when the interview team (M. K. Festersen and A. M. Kloosterman) felt they had fully understood the participant's perspective [53]. However, data saturation was not achieved on the level of the data set as a whole. Ideally, the recruitment would have continued until data saturation to explore the psychosocial aspects experienced by injured recreational runners hindered in usual running because of RRI [29, 54].

Both interviewers were inexperienced in qualitative research but had conducted several interviews related to their clinical practice as physiotherapists. However, being novices in the field may have limited the exploration of relevant aspects and their descriptions and left narratives unspoken. To increase the credibility and trustworthiness of the study, participant validation could have been used. The method used did, however, manage to create confidence and an informal, relaxed setting in the interview situation as participants, when evaluating their experience participating, expressed it as a safe and comfortable experience.

STC by Malterud was used as a strategy for analysis and was inspired by Giorgi’s Descriptive Psychological Phenomenology method. STC’s deviation from its inspiration might have conflicted with the descriptive phenomenological approach as junking meaning units during analysis may have disrupted the phenomenological reduction and a preconception-free approach to the empirical material. According to Giorgi, the analysis is not phenomenological if the phenomenological reduction is not maintained [23]. However, the STC strategy is described in more detail and has a more systematic approach to the empirical material, which the authors view as increased transparency. During the data preparation and analysis, dialogical validation through reflective dialogue and a between-authors independent transcription of interviews followed by cross-validation of transcriptions were used to ensure validity. However, the risk of disruption of the phenomenological reduction existed. The authors worked methodically with preunderstandings to increase awareness of potential preconceptions, as described by Tufford & Newman [55]. This was complemented by including authors, both present and not present, at the interviews in all parts of the study, including the transcription and analysis process [56].

This study does not show the development of phenomena over time. The injury duration differentiated between the participants, and this study made no attempt to separate or focus on rehabilitation phases. The responses to the phenomena present may be linked to different rehabilitation phases, as described by Clement et al. [48] he prominence of the phenomena present may vary between injury phases, time spent injured, and the influence of injury on physical ability [48]. In conclusion, the recreational runner's experiences explored in this study support the importance of bio-psycho-social awareness when physiotherapists meet runners hindered in usual running because of RRI. RRI negatively impacts everyday life on both a psychological and social level. The most influential phenomena were an experienced lack of mental calmness, increased body awareness, a feeling of lack of social connectivity, and a general frustration with the situation. Attempts to substitute activity do not negate these experiences, highlighting a need for strategies to manage the psychosocial aspects of a RRI among recreational runners to increase the quality of patient-centered rehabilitation.