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Management of Pain in Elite Athletes: Identified Gaps in Knowledge and Future Research Directions

Zideman, David A., LVO, BSc, MBBS, FRCA, FRCP, FIMC*; Derman, Wayne, MBChB, PhD†,‡; Hainline, Brian, MD§; Moseley, G. Lorimer, DSc, PhD, BPhty(Hons), FAAHMS, FACP; Orchard, John, MD, PhD, FACSEP, FACSM**; Pluim, Babette M., MD, PhD, MPH††; Siebert, Christian H., MD; Turner, Judith A., PhD‡‡

Clinical Journal of Sport Medicine: September 2018 - Volume 28 - Issue 5 - p 485–489
doi: 10.1097/JSM.0000000000000618
General Review

Objective: For elite athletes to train and compete at peak performance levels, it is necessary to manage their pain efficiently and effectively. A recent consensus meeting on the management of pain in elite athletes concluded that there are many gaps in the current knowledge and that further information and research is required. This article presents the crystallization of these acknowledged gaps in knowledge.

Data sources: Information was gathered from a wide variety of published scientific sources that were reviewed at the consensus meeting and the gaps in knowledge identified.

Main Results: Gaps have been identified in the epidemiology of analgesic use, the management of pain associated with minor injuries, and the field of play management of pain for athletes with major injuries. From a pharmacological perspective, there is a lack of information on the prescribing of opioid medications in elite athletes and more data are required on the use of local anesthetics injections, corticosteroids, and nonsteroidal anti-inflammatory drugs during training and in competition. Pain management strategies for the general population are widely available, but there are few for the elite sporting population and virtually none for elite athletes with a disability. More research is also needed in assessing cognitive-behavior therapies in improving specific outcomes and also into the new process of psychologically informed physiotherapy. A key issue is the paucity of data relating to incidence or prevalence of persistent pain and how this relates to persistent dysfunction, exercise performance, and physiological function in later life.

Conclusions: The identification of the gaps in knowledge in the management of pain in elite athletes will provide a unified direction for the retrieval of information and further research that will provide reassurance, speed return to active sport, and benefit performance.

*Medical & Scientific Department, International Olympic Committee Medical and Scientific Games Group, Lausanne, Switzerland;

Department of Surgical Sciences, Institute of Sport and Exercise Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa;

Institute of Sport and Exercise Medicine, Division of Orthopaedic Surgery, Faculty of Medicine and Health Science Stellenbosch University, IOC Research Center, South Africa;

§National Collegiate Athletic Association (NCAA), Clinical Professor of Neurology, Indiana University School of Medicine, Indianapolis, Indiana;

School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia;

**Medical Department, Koninklijke Nederlandse Lawn Tennis Bond (KNLTB), Amersfoort, The Netherlands;

††Hanover Medical School, Hanover, Germany;

School of Public Health, University of Sydney, Australia; and

‡‡Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington.

Corresponding Author: David A Zideman, Medical & Scientific Department, International Olympic Committee, Chateau de Vidy, 1007 Lausanne, Switzerland;david.zideman@gmail.com.

The authors report no conflicts of interest.

Received March 15, 2018

Accepted May 01, 2018

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INTRODUCTION

The management of pain in elite athletes is of critical importance to immediate and future performance. Pain can lead to loss of training or practice time resulting in poor competitive performance, whereas pain in competition can result in withdrawal from immediate or future events. However, pain is often regarded as part of the elite athlete's life when participating in sport at or near to the physical limits of the human body.

The convening of experts in pain related to sport in Lausanne in November 2016 resulted in long and detailed discussions of the principles and rationale of the management of pain in elite athletes by reviewing current publications and assessing the effectiveness and efficiency of pain-relieving regimens.1 It became apparent that there is a dearth of knowledge based on published research and that many treatments are based on outdated practice and personal preferences, many of which may not be in the long-term interests of the athlete. It was recognized that much of the “low intensity” chronic or persistent pain is managed outside of professional medical practice by the use of self-prescribed or over-the-counter medicines.

After the discussions and the publication of the consensus paper,1 the participants agreed that there was a need for more published information in relation to the management of pain among elite athletes. The experts contributing to the consensus process were asked not only to consider the best evidence and its relevance to current practice but to also identify the gaps in knowledge in the hope of stimulating further evidence gathering and research. This publication represents a synthesis of ideas and outcomes from the above mentioned endeavor.

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GAP AREAS IDENTIFIED

Epidemiology of Analgesic Use

Scientific information regarding the prevalence of analgesic medication use among competitive athletes is scattered and tends to be limited to cross-sectional studies during tournaments,2–4 doping control forms,5 and retrospective surveys.6,7 Most pain relief research has been undertaken in rugby union, football (soccer), and athletics, and has focused mostly on nonsteroidal anti-inflammatory agents.2–6 Although some qualitative data on the use of analgesics by team physicians at the Olympic Games in Rio de Janeiro have been published,1 more quantitative information is needed on the indications for and prevalence of the use of all types of analgesic medications in a wider range of sports throughout the competitive season and out-of-competition, in practice and in training. In addition, qualitative information is needed to understand the how and why of the use, to be able to develop and implement adequate and effective interventions. The collection of epidemiological data would provide knowledge of the risk factors for using analgesics during events so that targeted educational interventions in avoiding or modifying these factors could be understood. The linking of the use of analgesics and the occurrence of serious or life-threatening adverse events [especially heat illness (heat stroke), acute renal failure, and severe muscle cramps occurring during prolonged exercise at mass gathering events] during exercise requires formal evaluation.

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Management of Pain Associated With Minor Injuries

Minor injuries that occur in training or practice can often be managed with physiotherapy and the provision of simple nonopioid analgesia, but little is known as to what interventions are used most commonly and how effective they are. There is published evidence on the use and misuse of nonsteroidal anti-inflammatory drugs (NSAIDs) in elite athletes.8–16 There is no published knowledge of how and when these simple management protocols fail to adequately relieve pain while the injury heals, and whether such failures lead to time out of training or competition or escalation to advanced care, interventions, or medications. In particular, more research is required into to the evidence base of assessing the effect of periodization and timing of treatment and into the effect of overload on the kinetic chain continuum and subsequent injury patterns, including pain.1

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Field of Play Management of Pain for Athletes with Major Injuries

On the field of play, serious injuries may require immediate medical management with or without the provision of analgesic medications. Appropriate management, including pain relief, is essential to the physical and mental well-being of the athlete; poor or inadequate care may lead to a prolonged period out of sport or even premature retirement from active competition.

Much of the current advice and practice is based on extrapolated knowledge from prehospital trauma management, which, considering the immediate response of the field of play medical teams, may be outdated or may not be totally appropriate. Inhalational gases and volatile anesthetic gases are available in some countries but not in others. Intranasal opioids, such as intranasal fentanyl, have a rapid onset, are safe,17 and are now widely used in emergency medicine. However, opioids are severely regulated and their use, even for single-use administration, may not be available to field of play health care professionals. The alternatives are slower in onset and not as effective yet may be all that is available in the acute pharmacopeia.

Research is required into whether adequate pain relief is being provided on the field of play under these circumstances and if emergency field of play treatment is being delayed because of inadequate pain relief. The ethical question of how much acute pain relief can be safely provided while allowing the athlete to return to the field of play to continue training or competition needs comprehensive evaluation. The occurrence of any further tissue injury while under medication and the short- and long-term consequences of administering pain relief medication need urgent consideration.

Formal training of field-side medical teams would improve the appropriate provision of pain relief to athletes and although there are many field-side medical training courses available for field of play medical teams, but there is very little published accumulated experience of the provision of pain relief on or beside the field of play or in the athlete medical room. The development of web-based training and assessment would satisfy the requirement for continuing medical education of these field-side teams to maintain their currency of practice and to gain, where possible information on current practice. Training will also enhance the proper understanding of the use of prohibited drugs named in the World Anti-Doping Agency (WADA) code18 without compromising the athlete's status but still providing the pain relief.

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Opioid Medication and Its Risks

There are occasions when athletes suffer severe acute pain from injuries, such as fractures and dislocations, or when they undergo surgical procedures. In such situations, opioid medication may provide great pain relief. There is very little published on the use of opioid medication in elite athletes, either short term for acute injuries or longer term for more serious injuries with chronic pain. Data are available from controlled drugs prescribing records and from therapeutic use exemption forms, and this information needs extraction, correlation, and publication so that the use of opioids can be understood and rationalized. Further research, with long-term follow-up, is urgently required to better understand the long-term risks of such use of opioids, and strategies to mitigate these risks (for example, limiting the duration of opioid use). It is unclear whether guidance for the general population applies to elite athletes.19,20 Furthermore, there are no epidemiologic studies on postcareer drug abuse or addiction among elite athletes.

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Use of Corticosteroids and Nonsteroidal Anti-inflammatory Drugs

There is a gap in knowledge regarding whether the administration of a short course of NSAIDs delays tissue healing in the various types of injured tissue. Furthermore, the timing of ingestion of an NSAID in relation to the effects on tissue healing of an acute injury needs further evaluation. Information is also needed regarding the effect of multiple corticosteroid injections on long-term tissue damage, other risks, and patient outcomes.

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Use of Local Anesthetic Injections

Research on local anesthetic injections has, through case series with long-term follow-up, identified that some types of injections are associated with high or low risk of long-term subsequent injury.21 Some local anesthetic injections can therefore be determined to be relatively benign, whereas others could be considered high risk.21 To date, there have been no studies that have compared the short- and long-term safety of local anesthetic injections compared with other treatment options, and that provide the best relative safety in situations where pain relief is required to continue in elite sporting competition.

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Epidemiology of Persistent Pain in Elite Athletes

Although there are numerous accounts of the incidence of certain injury types in elite sport—for example, tendinopathy or ankle sprains—there are no clear epidemiological data relating to incidence or prevalence of persistent pain and how this relates to persistent dysfunction and to exercise performance and the simple collection of this information would add greatly to the future management of these athletes. Anecdotally, many athletes report pain that persists beyond tissue healing times,22 sometimes accompanying the athlete throughout most of his or her career and beyond. However, how common this situation truly is remains unknown and there is an urgent need for information collection across all elite sports. The consensus committee identified this gap in knowledge as a fundamental one because it forms the platform on which other questions are asked.

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Moderators and Mediators of Persistent Pain in Elite Athletes

There is a significant body of literature regarding the role of cognitive and affective variables in pain and its relationship to functional limitations in nonsporting populations. Fear of reinjury, self-efficacy for managing pain, and catastrophic interpretations of pain have all been shown to be associated with levels of pain and disability in nonsporting populations. However, aside from primarily theoretical reviews,23 and with very few exceptions,24 there is little mention in the literature of how these issues pertain to athletes, let alone rigorous scientific inquiry. There are therefore vast gaps in our knowledge about how cognitive or psychosocial issues relate to pain and performance limitations in elite athletes.

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Interactions Between Pain and Performance in Elite Athletes

Many studies have investigated the effect of noxious stimuli on motor output and compared motor output between those with and without painful conditions. There are some studies in recreational athletes25 but very few in elite athletes. Again, although theoretical models have been presented,23 an important gap exists in empirical data relating to the interactions between noxious stimuli, pain, and performance in elite athletes. Moreover, we do not have detailed understanding of the effect of interventions aimed at providing pain relief on performance. Indeed, it is important that the effects of the various analgesic agents used in pain management are evaluated with respect to their influence on physiological function during high-intensity exercise, so that their complete effect on the athlete may be understood.

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Management Strategies for Persistent Pain in Elite Athletes

This is another area where there is significant available literature from clinical, nonathletic populations, but almost nothing from elite sporting populations. Anecdotally, cognitive and behavioral treatments, for example, pain neuroscience education, psychologically informed physiotherapy, acceptance commitment therapy, and cortically targeted motor imagery strategies26 have achieved positive effects in the sporting context, but empirical data are lacking. This constitutes another critical gap in knowledge because as long as empirical data are absent, decisions regarding clinical care and load modification will be based on anecdote, personal preferences, and extrapolation from clearly different populations.

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Pain Management Strategies for Elite Athletes with Impairment

The symptom of pain in the athlete with impairment is more common (as compared to the able-body athlete) and may be either impairment or injury related. During the literature search for evidence regarding pain management in professional athletes, the IOC consensus group noted that the data regarding Paralympians and athletes with impairment were even more difficult to obtain, if not nonexistent. Indeed, most studies documenting clinical use of analgesic agents in the populations with impairment is derived from sedentary or nonsporting patients.26 There could be an interesting comparison between the use of analgesics by elite athletes and by the general population with the same or similar impairments. Some research regarding the epidemiology of injury in individual impairment types, and different sports, document higher injury rates and different profiles compared with able-bodied counterparts yet have not established or described pain relief protocols for their management.26–28 In disability sport, pain management seems to be an individualized decision process as standardized pain management protocols do not exist.29 The reason for this is based on the fact that most athletes with impairment have over time adapted their pain control strategies to their individual needs with specific regard to the respective underlying impairment or injury. It is also noteworthy that Paralympic athletes perceive their sports-related injuries and therefore the resulting pain differently compared with able-bodied athletes.30,31 The use of a therapeutic use exemption process is therefore more common in the athlete with impairment. Pain assessment and monitoring in these impaired athletes can be challenging. Although specific, internationally recognized scores are available for pain and dysfunction, (for example, the Wheelchair User's Shoulder Pain Index), standardized pain management protocols and pain measurement tools are still difficult to implement, even in such subgroups.32

The use of an adapted Sports-Medical Assessment Protocol for athletes with a disability may help identify medical problems and provide a baseline of pain measurement for future studies, while allowing for an evaluation of the individual form of pain management.33 More widespread use of longitudinal self-reporting systems such as the Sports-Related Injuries and Illnesses in Paralympic Sport Study (SRIIPSS) may also provide valuable data for this group of athletes.34 Further longitudinal research is necessary to develop treatment strategies in various impairment categories and monitoring and measurement tools targeted to this special population of elite athletes.

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Psychosocial Interventions for Athletes with Pain

Cognitive-behavioral therapies (CBTs) are the prevailing psychosocial treatment for chronic pain, with demonstrated effectiveness in improving pain, pain-related disability, and associated problems such as anxiety, depression, and insomnia.35–38 However, research on CBT for athletes with pain is lacking. One study found that a cognitive-behavioral intervention reduced athletes' anxiety, pain, and days to recovery after arthroscopic surgery for meniscus injury.39

Most acute pain conditions will resolve, and psychosocial intervention is not needed. However, when pain continues and risk of chronicity increases, psychosocial intervention may offer an important opportunity to prevent chronic pain. Given that fear of reinjury/pain and low self-confidence are associated with worse return-to-sport outcomes,40–46 CBT targeting these factors offers promise in improving outcomes. Methodologically rigorous randomized controlled trials are needed to evaluate effects of cognitive-behavioral interventions in improving specific outcomes (eg, pain, function, sport participation, and psychological distress) among athletes with pain problems. Randomized controlled trials are also needed to evaluate which cognitive-behavioral interventions are most effective for specific outcomes for key subgroups of athletes with pain (eg, those with subacute vs chronic pain and those with vs without mental health comorbidities).

Research is also indicated to evaluate a promising new approach, psychologically informed physical therapy.47,48 This type of physical therapy incorporates psychoeducational interventions and cognitive and behavioral psychological principles and strategies (eg, techniques to reduce fear-avoidance, use of graded activity, and exposure techniques) during physical rehabilitation. Randomized controlled trials are needed to evaluate its benefits for improving pain and function outcomes among athletes with acute, subacute, and chronic pain.

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The Future

The development of effective pain management strategies based on published clinical evidence can only be of benefit to all sport. For those in elite sport, it will provide reassurance that when in pain or injured, the pain relief athletes are offered is not only approved and effective but will provide such relief with minimal short- or long-term risks and will allow for a rapid return to their sport. It is our hope that this article will stimulate further research to shed more knowledge in the areas identified, as well as dissemination of that knowledge to health care professionals providing medical care for elite athletes.

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References

1. Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51:1245–1258.
2. Pedrinelli A, Ejnisman L, Fagotti L, et al. Medications and nutritional supplements in athletes during the 2000, 2004, 2008, and 2012 FIFA Futsal World Cups. Biomed Res Int. 2015;2015:870308.
3. Vaso M, Weber A, Tscholl PM, et al. Use and abuse of medication during 2014 FIFA World Cup Brazil: a retrospective survey. BMJ Open. 2015;5:e007608.
4. Tscholl PM, Vaso M, Weber A, et al. High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. Br J Sports Med. 2015;49:580–582.
5. Tscholl P, Alonso JM, Dollé G, et al. The use of drugs and nutritional supplements in top-level track and field athletes. J Am J Sports Med. 2010;38:133–140.
6. Fernando ADA, Bandara LMH, Bandara HMST, et al. A descriptive study of self-medication practices among Sri Lankan national level athletes. BMC Res Notes. 2017;10:257.
7. Harle C, Danielson E, Derman W, et al. Analgesic management of pain in elite athletes: a systematic review. Clin Sports Med. 2018;35:227–243.
8. Warner DC, Schnepf G, Barrett MS, et al. Prevalence, attitudes, and behaviours related to the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in student athletes. J Adolesc Health. 2002;30:150–153.
9. Derman EW. Medical care of the South African Olympic team—the Sydney 2000 experience. S Afr J Sports Med. 2003;15:22–25.
10. Virchenko O, Skoglund B, Aspenberg P. Parecoxib impairs early tendon repair but improves later remodelling. Am J Sports Med. 2004;32:1743–1747.
11. Cohen DB, Kawamura S, Ehteshami JR, et al. Indomethacin and celecoxib impair rotator cuff tendon-to- bone healing. Am J Sports Med. 2006;34:362–369.
12. Da Silva ER, De Rose EH, Ribeiro JP, et al. Non-steroidal anti-inflammatory use in the XV Pan-American Games (2007). Br J Sports Med. 2011;45:91–94.
13. Alaranta A, Alaranta H, Helenius I. Use of prescription drugs in athletes. Sports Med. 2008;38:449–463.
14. Paoloni JA, Milne C, Orchard J, et al. Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use. Br J Sports Med. 2009;43:863–865.
15. Derman EW, Schwellnus MP. Pain management in sports medicine: use and abuse of anti-inflammatory and other agents. South Afr Fam Pract. 2010;52:27–32.
16. Warden SJ. Prophylactic use of NSAIDs by Athletes: a risk/benefit assessment. Phys Sportsmed. 2010;38:132–138.
17. Karlsen APH, Pedersen DMB, Trautner S, et al. Safety of intranasal fentanyl in the out-of-hospital Setting: a prospective observational study. Ann Emerg Med. 2014;63:699–703.
18. World Anti-Doping Agency. The World Anti-Doping Code International Standard Prohibited list. 2018. Available at: https://www.wada-ama.org/sites/default/files/prohibited_list_2018_en.pdf. Accessed May 18, 2018.
19. Franklin GM, Stover BD, Turner JA, et al. Early opioid prescription and subsequent disability among workers with back injuries: the disability risk identification study cohort. Spine. 2008;33:199–204.
20. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015. Morb Mortal Wkly Rep. 2017;66:265–269.
21. Orchard JW. Is it safe to use local anaesthetic painkilling injections in professional football? Sports Med. 2004;34:209–219.
22. Hainline B, Turner JA, Caneiro JP. Pain in elite athletes—neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Med. 2017;51:1259–1264.
23. Wallwork SB, Bellan V, Catley MJ, et al. Neural representations and the cortical body matrix: implications for sports medicine and future directions. Br J Sports Med. 2016;50:990–996.
24. Wiese-Bjornstal DM. Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement. Scand J Med Sci Sports. 2010;20:103–111.
25. Rio E, Moseley L, Purdam C, et al. The pain of tendinopathy: physiological or pathophysiological? Sports Med. 2014;44:9–23.
26. Kromer P, Roecker K, Sommer A, et al. Acute and overuse injuries in elite paracycling –an epidemiological study. Sportverletz-Sportschaden. 2011;25:167–172.
27. Derman W, Schwellnus MP, Jordaan E, et al. High incidence of injury at the Sochi 2014 Winter Paralympic Games: a prospective cohort study of 6564 athlete days. Br J Sports Med. 2016;50:1069–1074.
28. Derman W, Runciman P, Schwellnus M, et al. High precompetition injury rate dominates the injury profile at the Rio 2016 Summer Paralympic Games: a prospective cohort study of 51 198 athlete days. Br J Sports Med. 2018;52:24–31.
29. Hirschmueller A. Personal communication. 2016.
30. Fagher K, Forsberg A, Jacobsson J, et al. Paralympic athletes´ perceptions of their experiences of sports-related injuries, risk factors and preventive possibilities. Eur J Sport Sci. 2016;16:1240–1249.
31. Derman EW, Ferreira S, Subban K, et al. Transcendence of musculoskeletal injury in athletes with disability during major competition. South Afr J Sports Med. 2011;23:3–5.
32. Yildrim NU, Comert E, Ozengin N. Shoulder pain: a comparison of wheelchair basketball players with trunk control and without trunk control. J Back Muskuloskeletal Rehabil. 2010;23:56–61.
33. Jacob T, Hutzler Y. Sports-medical assessment for athletes with a disability. Disabil Rehabil. 1998;20:116–119.
34. Fagher K, Jacobsson J, Timpka T, et al. The sports-related injuries and Illnesses in Paralympic Sport Study. BMC Sports Sci. 2016;8:19–28.
35. Williams A, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407.
36. Brasure M, Fuchs E, MacDonald R, et al. Psychological and behavioral interventions for managing insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians. Ann Intern Med. 2016;165:113–124.
37. Linde K, Sigterman K, Kriston L, et al. Effectiveness of psychological treatments for depressive disorders in primary care: systematic review and meta-analysis. Ann Fam Med. 2015;13:56–68.
38. Hofmann SG, Asnaani A, Vonk IJJ, et al. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cogn Ther Res. 2012;36:427–440.
39. Ross MJ, Berger RS. Effects of stress inoculation training on athletes' postsurgical pain and rehabilitation after orthopedic injury. J Consult Clin Psychol. 1996;64:406–410.
40. Ardern CL, Webster KE, Taylor NF, et al. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596–606.
41. Forsdyke D, Smith A, Jones M, et al. Psychosocial factors associated with outcomes of sports injury rehabilitation in competitive athletes: a mixed studies systematic review. Br J Sports Med. 2016;50:537–544.
42. Ardern CL, Taylor NF, Feller JA, et al. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2013;41:1549–1558.
43. te Wierike SCM, van der Sluis A, van den Akker-Scheek I, et al. Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review. Scand J Med Sci Sports. 2013;23:527–540.
44. Lentz TA, Zeppieri G, George SZ, et al. Comparison of physical impairment, functional, and psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status after ACL reconstruction. Am J Sports Med. 2015;43:345–353.
45. Czuppon S, Racette BA, Klein SE, et al. Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med. 2014;48:356–364.
46. Hsu CJ, Meierbachtol A, George SZ, et al. Fear of reinjury in athletes. Sports Health. 2017;9:162–167.
47. Nicholas MK, George SZ. Psychologically informed interventions for low back pain: an update for physical therapists. Phys Ther. 2011;91:765–776.
48. Main CJ, George SZ. Psychologically informed practice for management of low back pain: future directions in practice and research. Phys Ther. 2011;91:820–824.
Keywords:

Elite athletes; analgesia; pain management; gaps in knowledge

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