# Overuse injury and affects in competitive sport:
A prospective longitudinal study

Simon Martin, Pascal Edouard, Xavier Sanchez, Andreas Ivarsson

<figure><img src="image_1.png" /></figure>

► To cite this version:

Simon Martin, Pascal Edouard, Xavier Sanchez, Andreas Ivarsson. Overuse injury and affects in
competitive sport: A prospective longitudinal study. Scandinavian Journal of Medicine and Science
in Sports, 2024, 34 (5), pp.e14644. 10.1111/sms.14644. hal-04595100

HAL Id: hal-04595100

https://u-picardie.hal.science/hal-04595100v1

Submitted on 6 Oct 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_3.png" /></figure>

ORIGINAL ARTICLE

WILEY

# Overuse injury and affects in competitive sport:
A prospective longitudinal study

Simon Martin<fnref n="1" />,<fnref n="2" /> ID | Pascal Edouard<fnref n="3" />,<fnref n="4" /> ID | Xavier Sanchez<fnref n="5" />,<fnref n="6" /> ID | Andreas Ivarsson<fnref n="2" />,<fnref n="7" /> ID

Correspondence

Simon Martin, Halmstad University,
School of Health and Welfare,
Halmstad, Sweden.

Email: simon.martin083@gmail.com

Abstract

Overuse injuries, which have a high prevalence in sport, are suggested to result in different affective responses in comparison to traumatic injuries. Affects may also reciprocally act as risk factors for overuse injury. The aim of this study was to examine the associations between overuse injury and affects within a longitudinal follow-up design. Competitive athletes (N=149) of various sports and levels of competition completed the Positive and Negative Affect Schedule (PANAS) and the Oslo Sports Trauma Research Centre Overuse injury questionnaire (OSTRC-O) once a week over 10 consecutive weeks. Bivariate unconditional latent curve model analyses with structured residuals were performed to evaluate the associations within and across weeks between OSTRC-O severity score and affects. Results indicated that OSTRC-O severity score and positive affects (PA) had a statistically significant negative within-week relation (r=-24.51, 95% CI=[-33.9, -15.1], p<0.001). Higher scores of overuse injury were significantly related to lower levels of PA across weeks (β=-0.02, 95% CI=[-0.04, -0.001], p=0.044), while the reciprocal effect of PA on overuse injury was not significant (β=-0.13, 95% CI=[-0.52, 0.26], p=0.51). No statistically significant association was observed between OSTRC-O severity score and negative affects, neither within nor across weeks. Our findings suggest that overuse injury may have adverse psychological consequences on the long run through lessened PA and address the need for providing sustainable psychological support focusing upon such PA when working with athletes experiencing overuse injury.

KEYWORDS

affective states, complex approach, latent curve modeling, micro-trauma injury, person-oriented analysis, recursivity

1 | INTRODUCTION

The epidemiology, risk factors and prevention of overuse
injuries are increasingly examined, and more-developed
methods of data reporting are being implemented (e.g.,
Oslo Sports Trauma Research Centre Overuse injury

questionnaire; [OSTRC-O]); findings show a high prevalence across different sports.<fnref n="1" /> Overuse injuries (e.g., stress fracture or Achilles tendinopathy) are a type of sport-related injuries that result from a mechanism of repetitive micro-trauma accumulating over time.<fnref n="2" /> They are often chronic with periods of remission and exacerbation.<fnref n="3" /> Such

This is an open access article under the terms of the [Creative Commons Attribution License](https://creativecommons.org/licenses/by/4.0/), which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

© 2024 The Author(s). *Scandinavian Journal of Medicine & Science In Sports* published by John Wiley & Sons Ltd.

<footnote n="1">¹APERE, UPJV, Amiens, France</footnote>

<footnote n="2">²Halmstad University, School of Health and Welfare, Halmstad, Sweden</footnote>

<footnote n="3">³Université Jean Monnet, Lyon 1,
Université Savoie Mont-Blanc, Inter-
university Laboratory of Human
Movement Biology, Saint-Etienne,
France</footnote>

<footnote n="4">⁴Department of Clinical and Exercise Physiology, Sports Medicine Unity, University Hospital of Saint-Etienne, Faculty of Medicine, Saint-Etienne, France</footnote>

<footnote n="5">⁵Université d'Orléans, Research Group
SAPRéM, Laboratoire CIAMS, Orleans,
France</footnote>

<footnote n="6">⁶Université Paris Saclay, Orsay, France</footnote>

<footnote n="7">⁷Department of Sport Science and
Physical Education, University of
Agder, Kristiansand, Norway</footnote>
temporality can explain the presence of particular psycho-
logical responses in athletes sustaining overuse injury that
may differ from those following sudden-onset traumatic
injury.⁴,⁵ Psychological responses to injury are suggested to
involve cognitive, affective, and behavioral processes that
are inter-related, which dynamically influence short- and
long-term outcomes through biopsychosocial pathways.⁵,⁶
Reciprocally, psychological factors predisposing to over-
use injuries are also well documented.⁷ This suggests the
existence of a bi-directional influence, which is supported
by complex approaches of sport injuries that refer to the
principle of recursivity.⁸

Affects, which are thought to act as a pivotal mecha-
nism in this complex process,⁶ refer to the mental states
involving evaluative feelings.⁹ Unlike emotional episodes,
affective feelings are not necessarily directed at specific
objects per se,¹⁰ but are consciously accessible as the sim-
plest raw—nonreflective—feelings.¹¹ Affects are primar-
ily characterized by the combination of two dimensions,¹¹
pleasure–displeasure (pleasure or valence) and activa-
tion–deactivation (arousal or energy). Based on these
two dimensions, conceptualisations of affects have been
proposed (for a review, see¹²). One of these approaches
considers that activated affects account for most of the ev-
eryday life experiences and represent the subjective com-
ponents of two broader biobehavioural systems.¹³ Hence,
focusing on positive and negative activated affects can pro-
vide a “highly parsimonious explanation of certain affect-
related phenomena”,¹³ p. 828, including sport injury.¹⁴
These two largely independent categories of affects can be
labeled as positive affects (PA), that is the “extent to which
individuals feel enthusiastic, active, and alert”,¹⁵ p. 1063,
and negative affects (NA), that is “a general dimension of
subjective distress” subsuming a variety of aversive states
such as anger and anxiety,¹⁵ p. 1063.

In line with this conceptual stance, research examin-
ing the links between overuse injury and affects indicate
that such relationship might be, indeed, recursive. Firstly,
NA such as frustration, fear or anger were reported as psy-
chological responses to overuse injury.¹⁶ In relation to the
progressive onset and chronicity of most overuse injuries,
athletes may particularly experience prolonged episodes
of emotional distress, whereas sudden-onset traumatic in-
juries may elicit more prominent, but less durable NA.⁵,¹⁶
Other research dovetails this suggestion, as shown in
athletes with chronic-overuse injury who appeared to
be suffering from a type of prolonged stress-response
syndrome.¹⁷ However, athletes' affective responses that
are specific to overuse injury must be further clarified.¹⁶
Secondly, affects are suggested to act, in turn, as predispos-
ing factors for overuse injury.¹⁸ More specifically, Messier
et al.¹⁹ reported that NA such as being jittery, irritable and
nervous predicted overuse injury in recreational runners.

Thus, a dynamic interplay may develop between overuse
injury and affects, creating a downward spiral that would
contribute to explain the persistence of overuse symptoms.
However, this hypothesis of a recursive relation has yet to
be empirically tested; to date, no studies have attempted to
capture the bidirectional relations between overuse injury
and affects as time unfolds.

In addition, affects are likely to change rapidly over
time,²⁰ especially if resulting from the perception of
fluctuating overuse symptoms. Consequently, their asso-
ciations require to be investigated by using intensive re-
peated measures at the within-person level and through
a longitudinal research design, thus allowing “to exam-
ine how people change over time, not just in relation to
other people but also in relation to themselves” (,²¹ p. 235).
Importantly, this type of analysis examining how two dif-
ferent variables fluctuate rapidly in relation to themselves
and to each other over time was described as a first step in
a causal analysis of change, assuming that the variables
are ordered in time.²¹,²² More precisely, the use of within-
person analyses where both autoregressive (i.e., within-
construct) and cross-lagged (i.e., between-constructs)
effects are specified in the same model has been recently
deemed as necessary;²² it should be considered when
studying the bidirectional relation affects-overuse injury.

Based upon the abovementioned conceptual and meth-
odological considerations, the aim of the present study
was to examine whether: (1) overuse injury severity at
the within-person level was related to PA within the same
week; (2) changes in overuse injury severity predicted
subsequent changes in PA, and vice-versa (i.e., across-
week relations); (3) overuse injury severity at the within-
person level was related to NA within the same week; and
(4) changes in overuse injury severity predicted subse-
quent changes in NA, and vice-versa. More precisely, we
hypothesized that there would be: (H1) a negative associa-
tion between weekly overuse injury severity and PA; (H2)
a negative bi-directional relation between overuse injury
severity and PA across weeks; (H3) a positive association
between weekly overuse injury severity and NA; and (H4)
a positive bi-directional relation between overuse injury
severity and NA across weeks.

2 | METHODS

2.1 | Study design

This study used a prospective longitudinal design with
self-reported weekly measurements of overuse injury and
affects over 10 consecutive weeks. The study gained ethi-
cal approval (Dnr 2017/1052). No financial compensation
was offered for participation.
## 2.2 | Participants

For recruitment purposes, coaches of 37 different clubs were approached by the research team. Following coaches' agreement, email addresses of athletes meeting the inclusion criteria were collected (i.e., eligible athletes; see below). Across the 37 different clubs approached, a total of 493 athletes were identified as eligible to participate. More precisely, of the original 168 athletes who started the weekly follow-up, eight decided to withdraw from the study and 11 were excluded due to insufficient data. These non-respondents, 13 men and six females with a mean age of 28.2 years (SD = 13.3), were competing in athletics (n = 7), in volleyball (n = 5), rugby (n = 3), handball (n = 2), basketball (n = 1), and football (n = 1).

Participation inclusion criteria were: (1) being an active competitive athlete, that is participating in official competitions in either of the countries where data was collected (France and Sweden), and (2) being at least 16 years old. Ultimately, a total of 149 athletes (89%) from 16 different clubs were included in the analysis. Participants were 44 females and 105 males competitive athletes aged between 16 and 60 (M = 27.9, SD = 12.8), and participating in eight different sports: athletics (n = 74), handball (n = 27), rugby (n = 19), football (n = 18), volleyball (n = 9), basketball (n = 4), triathlon (n = 1) and weightlifting (n = 1); some athletes were involved in different sports. At the time of the study, they were actively participating in official competitions that ranged from regional level to international level; competitions were official and held by either of the national federations in France or Sweden.

## 2.3 | Data collection

### 2.3.1 | Overall procedure and recording methods

A short video presenting the study aim and protocol was sent to each eligible athlete by email. Athletes were redirected to a first questionnaire including informed consent to participate and demographics. Athletes who agreed to participate were then enrolled into a longitudinal follow-up of 10 consecutive weeks. Data were self-reported through a weekly questionnaire. For most of the participants (72%, based in France), we used Briteback®, which is a research tool developed for intensive longitudinal designs available both online and as a mobile application (allowing notifications to be sent). Every Sunday at 4 p.m., participants were contacted to complete three questionnaires (see below) on affects, overuse injury,

and sports exposures experienced during the past week. The overall survey necessitated approximately 3 min to be completed. Non-respondents were automatically sent a reminder one, and if needed again 2 days after the first request. If participants failed to answer the weekly questionnaire for two consecutive weeks, they were contacted individually by the first author and encouraged to carry on with participation. For the remaining participants (28%, located in Sweden), data were self-reported manually before the first training session of the following week, and collected by the first author at their respective training sites.

### 2.3.2 | Measure of affects

Affects were measured through the French and Swedish validated versions of the Positive and Negative Affect Schedule (PANAS).<sup>15,23,24</sup> This self-reported questionnaire consists of a 20-item checklist with a 10-item subscale aiming to measure PA (e.g., active, determined, inspired), and a 10-item subscale aiming to measure NA (e.g., afraid, guilty, jittery). Participants were asked to indicate to what extent they felt a certain way during the past week by using a five-point Likert scale ranging from 1 (very slightly or not at all) to 5 (extremely). The scores for the PA and NA scales were obtained by adding the individual scores for the 10 PA, and for the 10 NA, respectively. A high score on the PA scale reflects an optimal state of energy, concentration, and pleasurable engagement whereas a low score indicates a state of sadness and lethargy. A high score on the NA scale denotes a state of distress and unpleasant engagement whereas a low score suggests a state of calmness and serenity.<sup>15</sup> It should be reminded that PANAS subscales “do not measure all pleasant and unpleasant affective states, but rather measure only high-activation states”<sup>10</sup>. The French and Swedish versions of the PANAS have been previously tested and exhibited adequate psychometric properties.<sup>23,24</sup> In the present sample, internal consistency was found to be adequate both for the positive affect subscale and the negative affect subscale (Cronbach's α week to week range between 0.84 and 0.87).

### 2.3.3 | Measure of overuse injury

The first version of the OSTRC-O<sup>25</sup> was used to record overuse injuries. For this study, the instructions, which were originally made to target specific body regions (e.g., knee problems), were reformulated so that information were asked irrespective of the body area. A numerical value ranging from 0 to 25 was allocated to the different
answer propositions of the four questions that required information on how potential “physical problems” affected training participation, training volume, performance, and elicited pain, respectively. This allowed to calculate a severity score ranging from 0 to 100 for each week, and represented an ordinal-scale variable. We used two translated versions of the OSTRC-O: the Swedish version,²⁶ and the French version (Martin et al., 2021).²⁷

The medical staff of each club was responsible for collecting data regarding traumatic injuries. Indeed, as suggested by Clarsen et al.,¹ the OSTRC-O was used to gather information on all types of ‘physical problems’ (i.e., irrespective of the type of injury). Hence, to differentiate overuse from traumatic injuries, medical staff referred to the definition and criteria of traumatic injuries, described by Fuller et al.,²⁸ which were clarified by the first author prior to the initiation of the study. Participants were asked to record any new traumatic injury that required medical attention occurring over the data collection period and to report corresponding time-loss when the athlete was unable to train.²⁸ At the end of data collection, injury data from self-reported and medical staff sources were compared. Any injury self-reported by the athlete that matched the data provided by the medical staff was considered as a traumatic injury and removed from the final data set (i.e., not considered as an overuse injury). If data were insufficient to determine the nature of the injury mechanism, athletes were asked by phone at the end of the collection period to make the necessary amendments (i.e., to correctly label the injury as either overuse or traumatic).

### 2.3.4 | Measure of exposures

Training and competition exposures were also self-reported by athletes using the definitions provided by Fuller et al.²⁸; that is, by recording the amount of time spent in both conditions each week.

### 2.3.5 | Procedure used to increase adherence of participants

Following guidelines to improve athletes' response rate and adherence to the study protocol,³,²⁹ a feedback procedure was implemented with regular reports about overuse injury data sent to the coach or athletic trainers of each club. This procedure was approved by athletes beforehand, as part of the initial consent. To minimize response

bias due to social desirability, individual data regarding overuse injuries were pooled and presented as average values of each team/group.

## 2.4 | Analyses

In line with the suggestion of Clarsen et al,²⁵ we decided to exclude the data of the first week, which seemed to present an artificially high rate of overuse injuries. Also, following these previous recommendations, participants who failed to answer the questionnaire over four consecutive weeks at some point of the study, were excluded from the final data set. The prevalence of athletes reporting overuse injuries and the average severity score (with a 95% CI) were calculated for each week.

We used the Mplus software (version 8.0) to perform all statistical analyses, applying the robust maximum likelihood estimator (MLR). A *p*-value below 0.05 was used as cut-off for statistical significance in all analyses. As the PANAS consists of two highly independent subscales¹⁰, two separate bivariate unconditional latent curve models with structured residuals LCM-SR³⁰ were estimated, one for PA, and one for NA. The LCM-SR has recently been described as a favorable method allowing to estimate more rigorously both between-person and within-person processes of the over-time relations between two constructs simultaneously.³⁰ In other words, this method allows to model the complex (i.e., bidirectional) dynamic relations that link overuse injury and affects over time, and how these relations vary dynamically both within and across individuals in a way that is consistent with our hypotheses. More particularly, as compared to traditional multi-level modeling approaches (e.g., multivariate LCM), the LCM-SR is better suited to specify cross-lagged relationships between the two variables at the within-person level while controlling for the autoregressive effects within each construct, and allow a pure disaggregation of between-person and within-person effects (see,³⁰ for more information on LCMs-SR).

To obtain our two bivariate LCMs-SR (i.e., one for PA and one for NA), we combined the univariate LCM-SR for OSTRC-O severity score with the univariate LCMs-SR for the two PANAS subscales separately. The following goodness-of-fit indices were used to assess the model: root mean square error of approximation (RMSEA) with 90% confidence interval (CI), the comparative fit index (CFI)/Tucker-Lewis index (TLI), and the standardized root mean squared residual (SRMR). The following cut-off criteria were applied to indicate acceptable fit (Marsh, 2007): CFI/TLI >0.90, SRMR and RMSEA <0.08.
3 | RESULTS

**3.1 | Survey response rate**

The average individual weekly response rate to the PANAS, OSTRC-O and exposure questionnaire was 81.6% (SD = 7.3), ranging between 71.8% and 91.9%. In total, 91% of the athletes (n = 135) reported at least one overuse injury, with an average weekly OSTRC-O severity score over the 9 weeks of 23/100 (95% CI = [22, 25]). Detailed data regarding the prevalence of overuse injuries in this cohort were published elsewhere.

**3.2 | Associations between overuse
injury and PA**

The model using LCM-SR for PA demonstrated adequate fit to the data ($\chi^2$=193.82), *p*=0.04, CFI/TLI=0.96, SRMR=0.11, RMSEA=0.038 (90% CI=[0.011, 0.055]).

3.2.1 | (H1) Within-week relation

A statistically significant cross-sectional within-person correlation between OSTRC-O severity score and PA was observed (r = -24.51, 95% CI = [-33.9, -15.1], p < 0.001), indicating a negative within-week relation between the two constructs.

3.2.2 | (H2) Across-week relations

A statistically significant autoregressive effect was observed for OSTRC-O severity score ($\beta$=0.43, 95% CI=[0.33, 0.54], *p*<0.001) and for PA ($\beta$=0.26, 95% CI=[0.14, 0.39], *p*<0.001). Namely, the OSTRC-O severity score 1 week was positively related to the OSTRC-O severity score the following week. Similarly, the level of PA 1 week was positively related to the level of PA the following week. At the within-person level, a statistically significant cross-lagged effect of OSTRC-O severity score on PA was observed ($\beta$ = -0.02, 95% CI = [-0.04, -0.001], *p*=0.044). Namely, individuals having reported higher OSTRC-O severity scores relative to their underlying level of OSTRC-O severity score at one point in time were more likely to experience lower levels of PA relative to their underlying level of PA at a subsequent point in time. No statistically significant cross-lagged effect of PA on OSTRC-O severity score was observed ($\beta$ = -0.13, 95% CI = [-0.52, 0.26], *p*=0.51).

3.3 | Associations between overuse
injury and NA

The model using LCM-SR for NA demonstrated adequate fit to the data ($\chi^2$=212.01), *p*=0.004, CFI/TLI=0.94, SRMR=0.09, RMSEA=0.047 (90% CI=[0.028, 0.063]).

3.3.1 | (H3) Within-week relation

No statistically significant cross-sectional within-person correlation between OSTRC-O severity score and NA was observed (r = 6.84, 95% CI = [-0.25, 13.9], *p*=0.058).

3.3.2 | (H4) Across-week relations

A statistically significant autoregressive effect was observed for NA ($\beta$=0.18, 95% CI=[0.09, 0.27], *p*<0.001). Namely, the level of NA 1 week was positively related to the level of NA the following week. At the within-person level, no statistically significant cross-lagged effect of OSTRC-O severity score on NA ($\beta$=0.004, 95% CI=[-0.01, 0.02], *p*=0.063) and of NA on OSTRC-O severity score ($\beta$=0.22, 95% CI=[-0.17, 0.60], *p*=0.27) was observed.

4 | DISCUSSION

The present study examined the associations between over-
use injury and affects over time. Findings showed support
for the first (H1) hypothesis; that is, higher OSTRC-O sever-
ity scores were related to lower levels of PA within the same
week. Furthermore, findings also showed partial support for
the second (H2) hypothesis; that is, an increase in OSTRC-O
severity score was related to a subsequent decrease in the
level of PA, but no reciprocal effect of the level of PA on
OSTRC-O severity score was reported across weeks. Lastly,
neither the third (H3) nor the fourth (H4) hypotheses were
supported by findings; OSTRC-O severity score and NA
were not related, neither within nor across weeks.

Our results of lessened PA in the presence of a worsen-
ing overuse injury suggest that overuse injuries may have
adverse psychological consequences on the short-term,
but also on the long-term run. Our findings corroborate
previous results indicating that athletes with chronic-
overuse injury were suffering from a form of general and
prolonged stress-response¹⁶,¹⁷; long-term psychological
response to overuse injury might be characterized by a
decrease in PA more than by the presence of NA. This
finding might be of clinical relevance because even minor
reductions in the level of PA may cumulatively have a sig-
nificant effect on mental health, including a higher vul-
nerability to depressive symptoms.³¹ Therefore, it seems
critical to pay a careful attention to the level of PA over the
course of an overuse injury, and to implement strategies
allowing to maintain a significant level of PA, to prevent
more severe psychological consequences.

One potential explanation for this observation is that different types of injuries may elicit different emotional responses.⁴,⁵ More specifically, the mode of onset and chronicity of injury was suggested to influence short- and long-term affective responses.⁴ It is therefore possible that athletes experiencing progressive onset overuse injuries might be more susceptible to long-term psychological disorders such as depressive mood, frustration, and sadness,⁴ whereas the depressive symptoms following traumatic injuries were found to decrease rapidly over time.³² This suggestion is supported by previous research in health psychology, which highlighted that daily hassles (the chronic strains of everyday life) are more predictive of health problems than isolated major stressful life events.³³ Indeed, it can be more difficult to cope with daily episodes of stress (e.g., when experiencing a long-term overuse injury) in comparison to coping with a more prominent, but less durable stressful episode (e.g., experiencing a traumatic injury). Overuse injury, thus, deserve attention in relation to the prevention of mental health issues in athletes.³⁴

Findings from the present suty, however, showed no
week-to-week influence of PA on overuse injury. The fact
that this negative relation was observed within the same
week but not across weeks suggests that the temporality
of these interactions may be important. More precisely,
results suggest that the decrease in PA experienced as a
prolonged response to overuse injury becomes, with time,
too sparse to act as a subsequent risk factor for overuse
injury. Notwithstanding, this result might also be due
to the strong autoregressive effect obtained for overuse
injury, which is a limiting factor for observing a statis-
tically significant cross-lagged effect.³⁰ Similarly, the au-
toregressive effects for both PA and NA were statistically
significant. Because affects, to some extent, are related to
personality traits,¹³ it is not surprising that a proportion
of affects remain somewhat stable over time. This may
also explain why no statistically significant cross-lagged
effect of overuse injury severity on NA, and vice-versa,
were observed.

Moreover, no statistically significant within-week rela-
tion between NA and overuse injury was reported. This
finding is contrary to previous research findings highlight-
ing that NA may increase the risk of injury through in-
creased autonomic nervous system activation.¹⁸ However,
according to a recent systematic review of the psychosocial

risk factors for overuse injuries in competitive athletes,⁷
no other study has investigated the potential contribu-
tion of NA in the risk of sustaining overuse injury specif-
ically. Messier et al.¹⁹ found that athletes reporting more
NA were more likely to sustain overuse running injuries;
however, these athletes were recreational runners and af-
fects were not measured repeatedly with an adequate fre-
quency – as we did in the present study. In a meta-analysis
of the psychological factors of traumatic injuries, Ivarsson
et al.³⁵ discussed the potential mediating role of affect and
cognition that might explain how stress can generate poor
decision-making and reaction-time, which in turn can
create a higher vulnerability for injury.³⁶ A potential ex-
planation of a contradictory finding in our study is that
this mechanism is only relevant to explain the occurrence
of sudden-onset injuries, whereas gradual-onset overuse
injuries were suggested to be less dependent on this type
of cognitive processing and more likely related to physio-
logical processes affecting training adaptation and recov-
ery.⁶ Moreover, other findings suggest that overuse injury
may elicit avoidance, denial and escape behaviors pre-
dominantly.¹⁷ This type of cognitive-behavioral reactions
allows athletes to reframe the meaning of the problem, for
instance by using ‘magical thinking’ (i.e. meaning that the
problem will resolve by itself⁷);). Consequently, because
the meaning that is attached to an experience determine,
to a large extent, the threat posed by such experience,³⁷
athletes using these coping strategies may not report NA
in the presence of overuse injury.

## 4.1 | Limitations and future research directions

A first limitation of this study is related to the temporal-
ity of measurements of the variables examined. Because
affects can fluctuate rapidly over time,²⁰ their weekly
measurement may have overlooked some of their varia-
tion. In addition, the relatively short data collection pe-
riod (10 weeks) may be a limitation as it is certainly not
sufficient to fully capture the suggested long-term affec-
tive response associated to overuse injury. Future studies
are therefore encouraged to implement more frequent
measurement points over a longer extended period (e.g.,
twice a week across several months). A second limitation
relates to the fact that information regarding overuse in-
juries and affects were recorded at the same time every
week. More specifically, affects may have been over re-
ported because of the necessary focus on overuse symp-
toms, and vice-versa, which may not be fully indicative of
what has really been experienced over the week. A third
limitation is related to the use of PANAS, which does not
allow to measure the full spectrum of affective states, as
deactivated affects are excluded from its structure.¹⁰ Other methods that allow both activated and deactivated affects to be captured, such as the list of 20 items proposed by Hyde et al.,³⁸ deserve attention. In line with the Multilevel Model of Sport Injury,³⁹ which encourage to embrace a more interpersonal approach of sport injury, future studies are finally suggested to investigate the influence of overuse injuries sustained by athletes on the affects experienced by their coaches. Also, it would be of interest to use a similar design in more specific populations (e.g., a given sport in a given country) on the importance of socio-cultural factors in sport injury (e.g., the normalization of pain), which were not considered in this study.

## 4.2 | Perspective

Athletes experiencing overuse injury certainly need to be both supported over extended periods of time and screened for potential mental health disorders. Coaches are at the frontline of this process and should be trained to identify early affective signals of overuse injury such as reduced PA, and associated behavioral manifestations. This might be done by spotting athletes' body language or by monitoring the level of PA, for instance weekly. In line with Wadey et al.,³⁹ we also emphasize that enhanced coach-athlete communication (e.g., allowing time for conversation on the sideline, in training sessions) and social support at all stages of the overuse injury are important to consider. Policy makers (especially those setting coaching education programs) should also ensure that coaches know how to help athletes understand what happens to them, and that overuse injuries can have serious adverse physical and psychological consequences in the long run. Similarly, coaches and psychology consultants should strive to promote a multidimensional self in athletes, and to offer sustainable narratives that allow to reduce the affective burden of injuries.⁴⁰

## CONFLICT OF INTEREST STATEMENT

No conflict of interest to declare.

## DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

## ORCID

Simon Martin https://orcid.org/0000-0003-0882-383X

Pascal Edouard https://orcid.org/0000-0003-1969-3612

Xavier Sanchez https://orcid.org/0000-0002-3498-0276

Andreas Ivarsson https://orcid.org/0000-0002-8987-5975

## REFERENCES

1. Clarsen B, Bahr R, Myklebust G, et al. Improved reporting of overuse injuries and health problems in sport: an update of the Oslo sport trauma research center questionnaires. *British J sport med*. 2020;54:390-396. doi:10.1136/bjsports-2019-101337

2. Neil ER, Winkelmann ZK, Edler JR. Defining the term “overuse”: an evidence-based review of sports epidemiology literature. *J Athl Train*. 2018;53(3):279-281. doi:10.4085/1062-6050-84-16

3. Bahr R, Clarsen B, Derman W, et al. International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020 (including STROBE extension for sport injury and illness surveillance (STROBE-SIIS)). *Br J Sports Med*. 2020;54(7):372-389. doi:10.1136/bjsports-2019-101969

4. Flint FA. Integrating sport psychology and sports medicine in research: the dilemmas. *J Appl Sport Psychol*. 1998;10(1):83-102. doi:10.1080/10413209808406379

5. Wiese-Bjornstal DM. Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement: sport injury psychology consensus statement. *Scand J Med Sci Sports*. 2010;20:103-111. doi:10.1111/j.1600-0838.2010.01195.x

6. Appaneal RN, Perna FM. Biopsychosocial model of injury. *Encyclopedia of Sport and Exercise Psychology*. Vol 1-2. SAGE Publications, Inc.; 2014:74-76. doi:10.4135/9781483332222

7. Tranaeus U, Martin S, Ivarsson A. Psychosocial risk factors for overuse injuries in competitive athletes: a mixed-studies systematic review. *Sports Med*. 2021;52:773-788. doi:10.1007/s40279-021-01597-5

8. Pol R, Hristovski R, Medina D, Balague N. From microscopic to macroscopic sports injuries. Applying the complex dynamic systems approach to sports medicine: a narrative review. *Br J Sports Med*. 2018;53:1214-1220. doi:10.1136/bjsports-2016-097395

9. Parkinson, B., Totterdell, P., Briner, R. B., & Reynolds, S., *Changing Moods: The Psychology Of Mood And Mood Regulation*. Longman; 1996.

10. Barrett LF, Russell JA. The structure of current affect: controversies and emerging consensus. *Curr Dir Psychol Sci*. 1999;8(1):5-14.

11. Russell JA. Core affect and the psychological construction of emotion. *Psychol Rev*. 2003;110(1):145-172. doi:10.1037/0033-295X.110.1.145

12. Watson D, Clark LA. Measurement and mismeasurement of mood: recurrent and emergent issues. *J Pers Assess*. 1997;68(2):267-296. doi:10.1207/s15327752jpa6802_4

13. Watson D, Wiese D, Vaidya J, Tellegen A. The two general activation systems of affect: structural findings, evolutionary considerations, and psychobiological evidence. *J Pers Soc Psychol*. 1999;76:820-838.

14. Wiese-bjornstal DM, Smith AM, Shaffer SM, Morrey MA. An integrated model of response to sport injury: psychological and sociological dynamics. *J Appl Sport Psychol*. 1998;10(1):46-69. doi:10.1080/10413209808406377

15. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. *J Pers Soc Psychol*. 1988;54(6):1063-1070.

16. Russell H, Wiese-Bjornstal D. Narratives of psychosocial response to microtrauma injury among long-distance runners. *Sports*. 2015;3(3):159-177. doi:10.3390/sports3030159
17. Shuer ML, Dietrich MS. Psychological effects of chronic injury in elite athletes. *West J Med*. 1997;166(2):104-109.

18. Perna FM, Antoni MH, Baum A, Gordon P, Schneiderman N. Cognitive behavioral stress management effects on injury and illness among competitive athletes: a randomized clinical trial. *Ann Behav Med*. 2003;25(1):66-73. doi:10.1207/S15324796ABM2501_09

19. Messier SP, Martin DF, Mihalko SL, et al. A 2-year prospective cohort study of overuse running injuries: the runners and injury longitudinal study (TRAILS). *Am J Sports Med*. 2018;46(9):2211-2221. doi:10.1177/0363546518773755

20. Knutson B, Katovich K, Suri G. Inferring affect from fMRI data. *Trends Cogn Sci*. 2014;18(8):422-428. doi:10.1016/j.tics.2014.04.006

21. Stenling A, Ivarsson A, Lindwall M. The only constant is change: Analysing and understanding change in sport and exercise psychology research. *Int Rev Sport Exerc Psychol*. 2017;10(1):230-251. doi:10.1080/1750984X.2016.1216150

22. Ivarsson A, Stenling A, Weman Josefsson K, Höglind S, Lindwall M. Associations between physical activity and core affects within and across days: a daily diary study. *Psychol Health*. 2021;36(1):43-58. doi:10.1080/08870446.2020.1745801

23. Archer T, Adolfsson B, Karlsson E. Affective personality as cognitive-emotional presymptom profiles regulatory for self-reported health predispositions. *Neurotox Res*. 2008;14(1):1. doi:10.1007/BF03033573

24. Gaudreau P, Sanchez X, Blondin J-P. Positive and negative affective states in a performance-related setting. *Eur J Psychol Assess*. 2006;22:10-249.

25. Clarsen B, Myklebust G, Bahr R. Development and validation of a new method for the registration of overuse injuries in sports injury epidemiology: The Oslo Sports Trauma Research Centre (OSTRC) Overuse Injury Questionnaire. *Br J Sports Med*. 2013;47(8):495-502.

26. Ekman E, Frohm A, Ek P, Hagberg J, Wirén C, Heijne A. Swedish translation and validation of a web-based questionnaire for registration of overuse problems. *Scand J Med Sci Sports*. 2015;25(1):104-109. doi:10.1111/sms.12157

27. Martin S, Johnson U, McCall A, Ivarsson A. Psychological risk profile for overuse injuries in sport: An exploratory study. *J. Sports Sci*. 2021;39(17):1926-1935. doi:10.1080/02640414.2021.1907904

28. Fuller CW, Ekstrand J, Junge A, et al. Consensus statement on injury definitions and data collection procedures in studies of football (soccer) injuries. *Scand J Med Sci Sports*. 2006;16(2):83-92. doi:10.1111/j.1600-0838.2006.00528.x

29. Barboza SD, Bolling CS, Nauta J, Mechelen WV, Verhagen E. Acceptability and perceptions of end-users towards an online sports-health surveillance system. *BMJ Open Sport Exerc Med*. 2017;3(1):e000275. doi:10.1136/bmjsem-2017-000275

30. Curran PJ, Howard AL, Baster S, Lane ST, McGinley JS. The separation of between-person and within-person components of individual change over time: a latent curve model with structured residuals. *J Consult Clin Psychol*. 2014;82(5):Art. 5-Art. 894. doi:10.1037/a0035297

31. Wichers M, Wigman JTW, Myin-Gemeys I. Micro-level affect dynamics in psychopathology viewed from complex dynamical system theory. *Emot Rev*. 2015;7(4):362-367. doi:10.1177/1754073915590623

32. Appaneal RN, Levine BR, Perna FM, Roh JL. Measuring Postinjury depression among male and female competitive athletes. *J Sport Exerc Psychol*. 2009;31(1):1-76. doi:10.1123/jsep.31.1.60

33. Chamberlain K, Zika S. The minor events approach to stress: support for the use of daily hassles. *Br J Psychol*. 1990;81(4):469-481. doi:10.1111/j.2044-8295.1990.tb02373.x

34. Reardon CL, Hainline B, Aron CM, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). *Br J Sports Med*. 2019;53(11):667-699. doi:10.1136/bjsports-2019-100715

35. Ivarsson A, Johnson U, Andersen MB, Tranaeus U, Stenling A, Lindwall M. Psychosocial factors and sport injuries: meta-analyses for prediction and prevention. *Sports Med*. 2017;47(2):353-365.

36. Wilkerson GB. Neurocognitive reaction time predicts lower extremity sprains and strains. *Int J Athl Ther Train*. 2012;17(6):4-9. doi:10.1123/ijatt.17.6.4

37. Pearlin LI, Schooler C. The structure of coping. *J Health Soc Behav*. 1978;19(1):2. doi:10.2307/2136319

38. Hyde AL, Conroy DE, Pincus AL, Ram N. Unpacking the feel-good effect of free-time physical activity: between- and within-person associations with pleasant-activated feeling states. *J Sport Exerc Psychol*. 2011;33(6):884-902. doi:10.1123/jsep.33.6.884

39. Wadey R, Day M, Cavallerio F, Martinelli L. Multilevel Model of Sport Injury (MMSI): Can coaches impact and be impacted by injury. *Professional Advances in Sports Coaching*. Routledge; 2018.

40. Everard C, Wadey R, Howells K. Storying sports injury experiences of elite track athletes: a narrative analysis. *Psychol Sport Exerc*. 2021;56:102007. doi:10.1016/j.psychsport.2021.102007

**How to cite this article:** Martin S, Edouard P, Sanchez X, Ivarsson A. Overuse injury and affects in competitive sport: A prospective longitudinal study. *Scand J Med Sci Sports*. 2024;34:e14644. doi:10.1111/sms.14644