Authors: Mads Røgen Noesgaard ¹& Stig Arve Sæther²

Corresponding Author:

Stig Arve Sæther
Department of Sociology and Political Science
Norwegian University of Science and Technology, NTNU, Dragvoll, 7491 Trondheim, Norway
E-mail: stigarve@ntnu.no, https://orcid.org/0000-0002-1429-4746

Mads Røgen Noesgaard is educated as a physiotherapist and holds a master’s degree in sport science from the Norwegian University of Science and Technology. He has an extent experience as a physiotherapist from professional sports especially related to football and handball.

Stig Arve Sæther is an associate professor in sport science at the Norwegian University of Science and Technology, with an extensive research portfolio in talent development within sports and especially football. Sæther is head of the sport science staff, head of education at the department of Sociology and Political science and head of the research group Skill and Performance Development in Sports and School (SPDSS).

Decision-making on injury prevention and rehabilitation in professional football – A coach, medical staff, and player perspective

ABSTRACT

Purpose
The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective. Methods: Two professional football players, one physical coach, one physiotherapist and one assistant coach were interviewed in-depth and recruited because of their insight, experience, and expertise from one Norwegian premiere league club. Results: The decision-making process on RTP in the club were partly based on the hierarchy in the club, where the coach was on the top among these actors. Despite that the actor´s describes the process as a natural dynamic, and felt a shared responsibility in the process, their different roles impact on the decisions. The RTP decision was affected by aspects such as the period in the season, earlier injury experience of the player and the medical staff and coach collaboration. Conclusions: Even though the medical staff and the injury prevention could mean that the player could have a longer career, the choices made in the process of RTP is often based on short term player and team performance. Applications in sport: Professional football players have competition as a living and are expected to enjoy and embrace competing against both other teams related to winning trophies and teammates related to a place on the team in matches. This degree of competition was also seen as a part of the RTP process since the competition with teammates gave the players motivation to overcome their injury situation and get back to compete for their “spot” on the team. Even though this study only includes experiences from one professional football club, it gives insight into how the RTP process is done in a professional football context. Future studies should consider recruiting representatives from the club management, which also could give insight on how the macro aspects of a club impact on the RTP decisions in the coaching team of a professional football club.

Keywords: return-to-play, professional sports, communication

INTRODUCTION

The development of professional football player is complex and consist of a myriad of factors, including injury prevention and rehabilitation through the return to play (RTP) (38). Even though the development of injuries in European professional football has decreased over the last two decades (10), the impact of injuries still plays a major role in both team and individual player development and success (7). Time loss in on field training and matches may have a negative impact on the players development, which makes it vital to minimize the duration of rehabilitation and RTP process. The responsibility of injury prevention, treatment and following RTP has in the literature been described as the responsibility of the medical staff, even though a strong coach and player involvement has been recommended (10). Even so, lack of needed authority in this process, have been highlighted as a challenge since both the coaching team and especially the head coach, and the players are expected to be a part of the decision process, hereby creating a dilemma (26). The need for a high performing medical team is thereby indicated crucial for the present success, but also future accomplishments (7).

Knowing that the major predictor in future injury being previous injury (13, 27-28, 35, 45), it has become standard procedure in European professional football clubs to screen and evaluate both in-squad players and potential investments even though research points to a lack of predictive capabilities (29, 46). Hereby the screening process is arguably/potentially increasing the consequences of previous injuries and treatment of such and the importance of injury preventive measures. In the pursuit of securing the best possible squad at all times injury preventive programmes such as FIFA11+, seems common but often adjusted based on either screening results or coaches’ preferences and hereby losing its evidence-based merits (29-30, 34, 46). Another promising preventive strategy is tracking and managing of load and restitution of the individual player and indicated to both increase the “here and now” short-term performance and the long-term performance. The main aim is to reduce the risk of injuries and illness (19, 24, 36), but it also presents a risk of withdrawing players from training and matches unnecessary.

The rehabilitation process of a player must address and manage the psychological and sociological health of the player (12). Though the general plan and goals of the rehabilitation is clear there is a lack of gold-standard and consensus for RTP which complicates the last steps before returning to training and competition (22). The literature advocates a shared-decision-making process to optimize this process. Coaches, medical staff, physical coaches, and the individual player all possess insight about the state of the player seen in a bio-psycho-social framework (5-6, 8, 47). A process as such is nonetheless challenged by the different profession’s confidence in their own decision, but also potentially with a lack of trust in others, hereby creating a dilemma where authority and power becomes more important than teamwork (9-10, 20). To increase the overall medical effort, the literature advocates an SDM-approach to minimize injuries and rehabilitation periods and improve RTP (1). Still, Paul et al. newly published editorial are highlighting that there has been identified concerns surrounding the social complexities of elite sports and the difficulties of truly applying this concept in practice (37).

Most of the research on this subject and in professional football have used a quantitative approach (7) and there seems to be a need of qualitative insight on how this process unfolds in practice, and how and by whom the decisions are made. An exception is Law and Bloyce (25) who interviewed professional football managers behavior towards injured players. The results indicated that managers at the lower levels felt more constrained to take certain risks related to injured players. The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective.

METHODS

Participants 

Two professional football players, one physical coach, one physiotherapist and one assistant coach were interviewed in-depth and chosen based on strategic selection because of their insight, experience, and expertise in the field and their long-term involvement within one Norwegian premiere league club. The two players have in total more than 15 years in the club, while the physiotherapist and the physical coach has been in the club’s medical team for more than five years and altogether more than 20 years of experience in the field. The assistant coach has more than seven years of coaching experience. The participants are described in table 1.

All interviews were conducted in person and the location chosen by the interviewee. The length of each interview varied from 50 to 90 minutes with a mean at 70 minutes. Each interview was initiated with general questions to start the conversation and to get more background information on each participant. Prior to the interviews the questions were largely prepared to facilitate the conversation into different themes and topics of interest, with prepared follow up questions when depth and more context was needed. The questions varied specificity from general questions about the interviewee’s thoughts on the injury-period (e.g. “How do you think a player can develop while injured”) to more defined questions about the different actors’ actual role in the decision-making process about RTP (e.g. What role does the player has in the RTP-decisions). With these types of specific questions, the former mentioned extensive experience and expertise in the field was highly prioritized in the selection of participants. This made the insight in the specific club more extensive and gave the answers more depth. In addition, all participants were giving the opportunity to read through the transcript and afterwards able to withdraw parts or the interview in full, which none of the participants did. None of the participants neither wanted to alter the transcription. All interviews were audio-recorded and transcribed verbatim. By using pseudonyms for each participant, the transcriptions ensured the interviewee’ confidentiality and furthermore, ethical approval was in accordance with and approved by the Norwegian Social Sciences Data Services (number: 678375).          

Analysis
The analysis of data was done with the six steps of theme-centred approach as described by Braun and Clarke (2-3). The process was initiated by the transcription by the first author who afterwards read and reread the data twice. This was followed by initial coding, phase two of the chosen method. In this process the transcription was revisited multiple times until the final codes were discovered and presented to the second writer for discussion. The total of 47 codes were structed using a mind-map, which visualised the third phase of the process and used to structure the data into nine higher-order themes. Phase four was a back-and-forth process rereading the transcript, revising the raw material for clarifying questions, reviewing the codes all in all to elaborate the emerged themes. Through dialog and discussion within the research group the final three/four themes were identified, and subgroups reviewed and hereby phase five concluded. Finally, phase 6 was a detailed process and highly interwoven with the analysis of data. To present the findings in an argumentation related to research question and to illustrate the story of the data it was important to revise the extracts and go back to the both the higher order themes and the final themes in the writing of the report to ensure that the essence of the data was captured and presented. The final report presents the experienced everyday life of the participants in this specific Norwegian Premier League football club, how they perceive the decision-making process in the context of both development and performance and how the structure and reality of modern football plays and important role in both injury prevention and RTP after injury.

RESULTS

The actors in the RTP process – the club hierarchy
According to the actors (medical staff, coach and players), the prevention of injury and RTP practice has changed throughout the last decades, from a collective focus to a more specific and individual practice, described as a positive change by all the actors. RTP was described as a process, with benchmarks which was considered a motivational factor in the overall rehabilitation process. The decision-making process in the professional football club related to decisions on injured players and their capacity to play were affected to some degree by a hierarchy in the club. Even though the actor´s in the present study describes the process as a natural dynamic, and that they agree on their shared responsibility of the process, the different roles impact on the decisions.

Highest in the hierarchy are the coaches, and even though they highlight that the medical staff has an impact on their decision, the coaches seem to be the final decision maker in the process. This is indicated as a natural order because the coach is the one to take the ”fall” when the decisions shows to be wrong or more precisely have a negative output and also the final responsibility for the team performance. The coach described therefor a need to keep the medical staff on their toes, which the medical staff described as a challenge of their decisions, often based on what they considered external pressure on performance and results. This again meant that the medical staff had to make the “right” decision to keep their authority in the collaboration with the coaches.

The players felt in this regard that the medical staff had a two-sided role or responsibility both towards the coaches and the players, but that they still according to the players weigh the perspective of the player the heaviest. This double role was considered challenging and could mean lack of support in cases of doubt, while the medical staff considered that the final decision was taken by the coaches and the player. From the player perspective the trust was described as essential in this process. So even though trust, communication and collaboration are fundamental elements to keep a squad of players performing, there is also a need for a trust in the actors’ competencies and loyalty, both highlighted by the coach Lars: “Despite thinking about the result, first and foremost, we of course think: “The best for the player”. Because the player performs best when he is 100% healthy, both physically and mentally.” The physical coach Thomas stated this on the matter:

Thomas: “Because the vast majority of players understand deep down what the point is. They know when they shouldn’t go out there. They want to have hope, that: “yeah, it’s allright” and so sometimes our job is actually just to say: “Yes, it’s actually allright”, even if it’s 50/50, if it’s the last match on the season and they wanna take the chance anyways. Okay, then we have to see that and then just say: “This is allright”.

Thomas argued that their role in the process was to inform the coaches and even though the decision was not always in line with their suggestions, they felt that their opinions was considered vital for the final decision-making.

The factors that impact the decision process

Because of the complexity and uncertainty of who decides which players could play, the medical staff experience situations where at times they felt pressured to clear a player for playing, which in their experience often leads to a longer injury period. And despite the open communication, the pressure got more intense especially before important matches and at the end of the season, as this conversation and the following quotes indicates: Physiotherapist Hans: “You get a player who runs at 60%?”, Coach Lars: “Yes, but he is so important for us in set-pieces, so we have to have him”. This becomes even more prominent at the end of the season as physical coach Thomas highlights: “The fewer matches left, the greater chances you are willing to take with the athlete’s health”.

The decision to deny a player to train or play a match based on the risk of injury, was considered difficult for the medical staff because of uncertainty of the outcome. The coach describes how they in some cases start the player and see how it goes. Even though this was described as happening seldom and especially since this could be considered treating the players differently, which potentially could impact the team dynamic:

Lars: “If you and I play in the same position, and you train 3 times a week but you are a little better than me. I’m training every single day, and then you get to play matches. I train more than you, twice a week, and then arrangements will be made for you to play. That could become a conflict.”

The medical staff points out how this load-management strategy is potentially positive for RTP, the coach argument furthermore how this might add pressure for the next matches both for the player and the medical staff. If the team loses, one could consider that being in minus and that means that the next match must be won. This adds on to the earlier statement that an injury might be a heavy process for a player:

David: “From the moment you feel that you are a part of something, then you will show up the day after you have been injured, then you show up for work. You eat breakfast, you go to the locker room and then the rest of the team go out on field and do what you love the most, they play football. But you wander into a dark gym alone and do what all footballers think is the most boring job, cycling and doing rehab training. As boring as it gets. But you have to do it. You go into such a lonely and confined, empty mental phase, it’s really hard.”

What was considered the “right” decision depended on the perspective, even though obviously the most impacted part is the player:

Niels: “Perhaps I have been lucky in that I have not had so many major injuries, but at the same time the one injury I have had, where it was done the way it was done, that was enough for me to think: “yes, I lost some good matches that year”, then you can think of those who have been injured longer and have had more injuries, how much it has affected them.”

Injuries are however also described by all actors as a natural part of professional football, and that this often means taking risks to be able to perform on the highest level. One of the players, David, describes it as following:

David: “At the top level, you are balancing on a knife’s edge much more often, because you are pushing boundaries all the time and then the need for medical help is all the greater than when you operate at a not so fully professional level.”

It could seem from a professional players perspective that the players consider their everyday life as a footballer as finding the optimal balance to be able to stay fit and avoid injuries, and that this situation is difficult and that they need help from the medical staff to be able to keep staying “in the game”. Even so, the physical coach Lars highlights the difference between pain and injury:

Lars: “I think when you play football and it’s one-on-one, it’s dueling, you can get a knee in the side, you can get hit by an elbow, so after a football match, you might have a bruise here and a little bit of swelling there and you can have, stiffness in generel. That doesn’t mean you need 2-3 days to recover because that pain you feel”.

Protecting the players

The coach stated that it was important to protect the players and not introduce them for unnecessary risk, even though he pointed out that there is a limit in terms of how much consideration one could do for each player. In this regard did the physical coach acknowledges that there had not been a reduction in the number of injuries despite the heavy number of added resources to prevent them. The injuries have changed but one has not been able to eliminate the incident rate:

Thomas: “There is much less ankel rolls, but there are more hamstring injuries and groin injuries because there is more sprinting in the matches and the matches are closer schedueled. And you can’t quite solve that. Even with sufficient sleep, enough nutrition, tablets in the fusion of plasma, i.e. “you name it”, game ready – the player still breaks down and then you see that if you train very well, then maybe you will go through the season with very little damage.”

This was also something the players describes as problematic in certain situations, as stated by Niels: “Coach, physio and they, they really push you back in and then it’s difficult as a player to sit there and say: “I’m not healthy”, it’s difficult!”

The physical coach recons it is all about the time spent on the pitch to improve RTP and the high amount of matches impact on the possibilities for the medical staff to schedule and complete the injury preventions and rehabilitation. One example mentioned are an away match where the travel time is the reason for the player not attending enough training sessions, even though he is ready to train.  Furthermore, the game importance is an important factor because of the impact on the results sportingly and economically and has been found to be the reason as to why players play partly injured, or at least adding on to the pressure on the medical staff and their decision on every player potentially injured.

          Also, one of the players described how he perceived that the players are at their best when the get to train and play matches as much as possible:

David: “All footballers perform at their best when they get the opportunity to play football every day. Play every match. That’s when you get into a rhythm, where you act on intuition in battle and in that moment. In order to do that, you have to have continuity in your training and to have that, you have to be good at taking care of your body, to manage and last through a tough week of training, to perform in every match. So it’s definitely important. You profit from doing a good job (ed. injury prevention) in order to be able to perform in the best possible way. It is absolutely indisputable.”

Both the players and the medical staff highlights that the injury prevention is important for the players to be able to train more.  The physical coach highlights that this injury prevention training has a direct impact on the player opportunity to run faster and develop more power.

One of the players mentions how each club and their culture try to maximise the development and that the club culture is impacting the performance. This was also mentioned by the coach who stated that building the club is one of the most important tasks for the club, which is considered difficult since both players and coaches comes and goes. Another challenge is the impact the head coaches have on how the club perceive injury and development. The physiotherapist describes how the many changes also impact on the medical staff and their way of working:

Hans: “I think that, the biggest challenge in all of this is the constant change in player material, the constant change, at least as it has been in X, that coaches change, and therefore you constantly have different routines. It is natural that a coach who comes in and is boss wants to have it his way, and then a new coach comes in who wants it his way. Then there will always be changes and that means that what you tested on last year will be tested in a different way this year.”

Both players and the physical coach add on to this position, even though they also see positive outputs when new people are trying to collaborate:

Thomas: “Things that work well can also be diluted by poor execution. I think we make it work. I think so. that’s how it is when you bring new things to the table. Basically, it should be a good thing and if you manage to get best out of it, then it will be beneficial.”

The injury situation as an opportunity for development

All the actors thought of the injury period as a period for potential development of performance level of the player. So even though the players considered it as a tough and challenging period, it also contains opportunities. The coach highlighted that this motivation and opportunity had to come from within, and that he medical staff and the coach’s role was to facilitate and further motivate. In that way the injury period can be effective and also an opportunity, which could be considered a win-win situation both for the player and the team. 

Still, at times the players felt pressured to play, and sometimes felt alone and “naked” in the discussion between them, the medical staff and the coaches. This was partly confirmed by the physiotherapist, who described football as being black or white at times, and that he felt the need to protect the player:

Hans: “A player who is out several times and often… It can very quickly become black and white in a football club, “This player is always injured. No, we’ll give up on him a little”, and then it’s challenging to say: “You mustn’t give up on him, even if he’s a bit injured now. There are several factors that cause him to be injured and we have to look at ourselves as well, all of us.” What we have often done is to look at the coach and say: “If we are going to get him out of this, we’ll have to make a change. What we are doing now is not good enough. So we have to take him out of training and have to do this instead of that. He can’t play every game and at the moment”.

However, at other times the medical staff also feel the need to push the players to return to ordinary training or playing matches. They feel the need to be careful since they might misstep. Some players might get pushed back to soon, while others need a push.

Lars: “Sometimes where you have to push a little, and we really do that for the sake of the player, not because we absolutely have to. We don’t take any chances with players, that is. But if we see that he has done what he is supposed to and at the same time it is a player who is a bit more careful with himself. Because that too, you have to know the group, you have to know the player, because there are some who can be too tough too early, and then there are some who are actually ready, but holding back. So you can say that sometimes we have to try and push them in a positive way too, I think. Without us doing anything wrong.”

One of the players Niels stated that for some of the players, they need to be more included in the decision-making-process. One example mentioned by one of the players was the importance to get into the pre-season together with the squad, to be able to compete about his playing position.

The medical staff clearly stated that they did not consider themselves having the definitive solution in every case. They also mentioned the fact that holding a player back from a match based on the fear of being injured might deprive the player from development and potentially economic gain (e.g. club transfer, bonuses etc.) or the team’s performance or the club’s economic gains. Many of the actors highlighted that if the player felt ready to play, and the coaches meant that he would have an impact on the game, the medical staff would take that into consideration. This position of taking a decision which is good for all the actors both in a short-term and long-term perspective was considered a difficult dilemma for the medical staff, since they feel an extra responsibility related to the players health.

Keeping the players on their toes but still together

The coach also highlighted that the competition between players could challenge the individuals in the club. Internal competition is essential and when a player is injured, that could create an opportunity for other players. This competition was also highlighted by the two players, however as a stressor for the injured player. The coach however stated that this type of competition must be present and that it makes the players push each other, and fight for a place on the team. This type of pressure, trying to withhold your place on the team, having the right attitudes, frequent changes in the coaching staff, and short-term results, was describes from all the actors as impacting the medical staff’s opportunity to impact the decision for players to play matches and their development. Both the coach and the medical staff highlighted that this might impact the decision, but never determined the RTP, while the players could consider this as a weighty stressor

The players point out a potential isolation of the injured players by dividing the players into two groups: those who are injured and those who are not, but this division is described differently based on the perspective. They also describe the rehabilitation as lonely, heavy, and boring, especially the acute phase, and experience that the injured players not to be a part of the community in the club, which the player Niels described in the following: “But I want to put it this way, you are down in hell and then you start the ascent from there, and then it becomes a bit like tunnel vision. You don’t see the light at the start, but you see it eventually”. The coach, however, does not describe this as an isolation or division of the team, but rather a natural part of the everyday life in a club, but highlight the importance of joint meals and meeting schedules. The medical staff have another nuance of this division, since an injury might be challenging and create a sense of exclusion, while this could also be good for the team, since the negativity which often comes with an injury does not get spread among the other team members. The physical coach highlights the same and furthermore that it should be attractive not to be injured.

All the actors describe the deprivation from matches in times of doubt about a player’s availability have both sportingly and economic negative impact on the player’s career:

David: “Football can be so simpel that if you, how should I put it , score a hat-trick in the right match against the right team, you can be like… And the salaries are so high, so if you end up in the right place then you, then you can in a way support the whole family for the rest of your life. So it’s quite clear that injuries affect the course of a career.”

Injuries means less time to train, and the actors agree that the time for the specific football training and matches are essential for a player’s individual development. Both the coach and the physiotherapist highlighted however the importance of making the most of the injury period, which could be considered as a window of opportunity to focus on individual skill development, which normally one does not have time for. The physical coach stated however that it might be difficult for a player to develop largely during the rehabilitation process. And this could be related to the somewhat black-white perspective the medical staff and the coach has on injuries. The physiotherapist meant that this approach might have a positive consequence for a player who have experienced an injury. They often work harder than before to be able to get back to football. At the same time Hans also pointed to the fact that the players could be “forgotten” by the coaches if they achieve a “bad” reputation: “But if you first get a reputation of being.. that the coach gets the feeling that he is not available, then it can often be difficult. A fight really. That is my experience”. The coach Lars partly confirmed this by stating that the coaches are aware of players who have a history of injuries, which often mean that they cannot play all matches during a season:

Lars: “In other words, injury follows injury. It’s a bit like that. So there are certain players that you know more or less that he is not going to play 100% of the games. Let’s say there is an exclusive player who often gets hamstring issues, then you know that during the season he will play 70% of the games. It may happen that we have players, who we know are like that.”

In a long-term perspective and focusing on the players career, the coach also highlighted that the players are screened and assessed by clubs if a club transfer is in motion, that a player with a large injury history would be considered as less interesting to recruit:

Lars: “[…] But the more players who don’t have an injury history.. So if you’re going to build a team then you have to get as few players as possible with an injury history, because often you see that those type of issues, especially if it’s the groin or hamstring or those types of injuries, they often come back.”

The coach described players’ injury history as essential when clubs assess which player they could recruit, and that injured players must convince the coaches to become relevant for a club transfer. These types of assessment are important for coaches in their process of building a squad both in a short-term and long-term perspective.

Discussion

The aim of this study is to research how the decision-making on RTP from the medical staff impact on the perceived short- and long-term performance of the player and the team, from a coach, medical staff, and player perspective. The decision-making process on RTP in this professional football club were partly based on the hierarchy in the club (40). So, despite that the actor´s in the present study describes the process as a natural dynamic, and felt a shared responsibility in the process, their different roles impact on the decisions. The coaches were described highest in the hierarchy and related to them being responsible for the sportingly results and the performance of the team. The players were described as having a say in the decision of his availability, even though they often highlighted an experience of being pressured to play in certain situations (9). The medical staff was considered to have a two-sided role, since they were employed and a part of the coaching team and naturally felt a responsibility on behalf of the coaches and the club, they also felt the need to protect the players and their health as professional health workers (20). Their decisions would often mean that they had to “disappoint” the coaches or the player, by denying the player to play or the availability of a player in a match.

Responsibility was a term especially the medical staff used to describe how they felt about their role, but also when taking part in the final decision in the RTP process. This responsibility became important in the process of making “the right” call based on the information available while trying to account for the interests of all the actors. This might mean that they let a player play, with a “let´s see how it goes” approach, and that the outcome of the decision was described as “right” if the player played the whole game. A dilemma in the process was also related to the natural part of pain and injury as part of professional football described by all the actors in the process (31). So even if protecting the players was important, time spent on the pitch is the main goal for both the individual players and the team’s development and performance. Even so, earlier research (41) has indicated that elite sports have a pain culture where pain is a natural and expected part of elite sports, which could have a negative impact on the players development, if this means that the players do not communicate when feeling injured or unavailable for training and matches.

Professional football is all about results and performance (32). So, a characteristic off successful environments is their constant search of areas to develop further (14). This seemed to be the case in this club as well since a period of injury was considered an opportunity for the player to develop. The players are competing about a place in the starting line-up and need to pick up the glow to get back into the team. Still, there was also a mutual understanding that each RTP case might be different and had to be considered individually. So, in some cases both the medical staff and the coaches felt that some players needed a push to get back. This may in many cases also be in the best interest of the player since it could mean that they in example get identified by scouts, impacting their career by a club transfer. Furthermore, this pressure could mean that the players are willing to take a higher risk by playing while injured. The players in this study described being injured as lonely and feeling isolated from the team, as found in earlier studies (32), which could be perceived as an increased motivation to RTP potentially even before the mind or body are ready.

In accordance with the focus on results and performance in professional football are also the high degree of uncertainty in this professional context (15). This could be related to the small margins between success and failure. This is also related to the RTP process, since all actors in the process of RTP must make the best decision for both the individual and teams’ performance. Still, there is a lack of knowledge related to the potential outcome of the decision. This means that the actors must “take risks” to be able to maximize the opportunity to succeed. While it was not a part of the study, the obvious economically benefits of decreasing time loss in training and competition on both an individually (players, medical team, and coaching team) and club level (potential sale of players), also makes both the rehabilitation and preventive strategies important. The club perspective might conflict with the individual actors in the RTP process, with the example of the club winning the league, while a player got injured because of the overload and hereby potentially ending his career.

CONCLUSIONS

All the actors in this study highlight that football is a sport where you must expect to feel pain regularly and that injury is a part of being a professional football player. So even though the medical staff and the injury prevention could mean that the player could have a longer career, the choices made in the process of RTP is often based on short term player and team performance. Professional football players have competition as a living and are expected to enjoy and embrace competing against both other teams related to winning trophies and teammates related to a place on the team in matches. This degree of competition was also seen as a part of the RTP process since the competition with teammates gave the players motivation to overcome their injury situation and get back to compete for their “spot” on the team. Even though this study only includes experiences from one professional football club, it gives insight into howe the RTP process is done in a professional football context. Future studies should consider recruiting representatives from the club management, which also could give insight on how the macro aspects of a club impact on the RTP decisions in the coaching team of a professional football club.

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