Determinants of Intention to Disclose Musculoskeletal Injury in Adolescent Athletes

This study used a cross-sectional survey administered via an online platform (Qualtrics, Inc) as part of a larger study to assess the intention to disclose both the symptoms of MSK injury and the symptoms of concussion. In this article, we report the results of only the MSK injury components. Specifically, the survey included items designed to evaluate proposed determinants of intention to disclose symptoms of MSK injury. Proposed determinants were age, gender, race, socioeconomic status, presence of an athletic trainer, and MSK injury-specific behavioral factors (MSK injury history, MSK injury-related knowledge, attitudes, perceived social norms, and perceived control). The study was approved by the institutional review board at the University of Texas at San Antonio before participant recruitment.

Because the study was conducted with minors in high school and middle school settings, permission was given for the research team to provide the survey link to administrators at the selected schools, but no direct interaction with the participants was authorized. Potential participants were approached by administrators at their respective schools and invited to complete the survey via email. Select schools also made additional announcements; however, this was site dependent as we were not allowed to have any contact with the surveyed population. An estimated 1300 high school and 750 middle school student-athletes were eligible to participate in the study. The survey was distributed on the campuses of 4 high schools and 3 middle schools that were strategically identified as representing the diverse characteristics of student-athletes. Each school was located in a large metropolitan city in the southern portion of the United States. Three of the 4 high schools and 2 of the 3 middle schools were located in largely affluent, predominately White school districts, whereas the fourth high school and third middle school were located in an intercity school district. All students had access to athletic trainers on an as-needed basis, but only the 3 suburban high schools employed full-time athletic trainers. Of the estimated 2050 eligible individuals, a total of 564 (27.5%) consented to participate and completed all aspects of the survey. A detailed description of the survey was provided to participants on the first page, and they were asked to indicate that their parents consented to their involvement and that they had read the description and provided assent to participate before beginning the survey. Only those individuals who clicked to consent, moved to the second page of the survey, and indicated that they had read the instructions were allowed to proceed with the survey.

The survey instrument was based on previously validated items and included questions concerning participant demographics, the presence of an athletic trainer, MSK injury history, and sport participation. In addition, MSK injury knowledge, attitudes toward disclosure of MSK injury, and perceived social norms surrounding MSK injury disclosure were assessed using modified existing scales to predict MSK injury disclosure behavior.^17,18,22  Additionally, single-item measures of perceived control over disclosure and intention to disclose future MSK injury were included.

The MSK injury history and disclosure were evaluated by first giving participants the following definition of MSK injury: “Musculoskeletal injuries are ANY injury to the muscles, tendons, ligaments, cartilage, and/or bones. They can include, but are not limited to, sprains, strains, dislocations, tears, ruptures, and fractures.” After reading the definition, participants were asked, “Given the definition above, have you ever had an MSK injury related to sport or other activities (Yes/No)?” Those who answered yes were asked follow-up questions: “How many MSK injuries have you had?” and “How many of these injuries did you report/disclose to a medical professional or someone in authority at the time of injury?” Lastly, all participants were asked, “How many injuries have you purposefully hidden or not reported?”

Their MSK injury knowledge was assessed using 41 yes, no, or maybe items concerning symptom recognition, potential signs and symptoms, potential long-term side effects, effects of premature return to play, and consequences of incurring multiple MSK injuries. Correct answers were scored as 2 points, and incorrect answers were scored as 0 points; participants who selected maybe were given 1 point. Potential scores ranged from 0 to 82, with a maximum composite score of 82 (higher scores meant better MSK injury knowledge).

The MSK attitude questions were adapted from previously used and validated concussion attitude questions.^18,20,22  Eight validated items scored on a 7-point scale reflect attitudes toward and perceptions of MSK injury disclosure. Answers to all 8 items were summed, resulting in a composite attitude score ranging from 1 to 56, with higher scores representing more favorable disclosure attitudes toward MSK injury disclosure. For example, the previously validated concussion attitude question read, “Disclosing possible concussive symptoms to a medical professional or someone in authority during physical activity is …,” whereas the MSK attitude question replaced the phrase “concussive symptoms” with “musculoskeletal symptoms,” followed by the same 8 items. Athletes were asked to rate their attitudes to each item on a 7-point scale: cowardly (1) to brave (7), shameful (1) to prideful (7), harmful (1) to beneficial (7), extremely difficult (1) to extremely easy (7), bad (1) to good (7), unimportant (1) to important (7), a waste of time (1) to worthwhile (7), and weak (1) to strong (7).

The MSK injury perceived social norms consisted of 7 validated 7-point scale items measuring each participant’s perceptions of their organization’s expectations, social referent expectations, and their peers’ actions concerning MSK injury disclosure. Answers were summed, resulting in an MSK composite social norm score ranging from 1 to 49, with higher scores representing more favorable perceived social norms surrounding MSK injury.

Perceived behavioral control over disclosing an MSK injury was explored using a single 7-point scale question regarding how much control student-athletes believed that they had over disclosing MSK injury. A perceived control score was categorized as higher (score of 6 or 7), indicating agreement regarding having control over MSK injury disclosure, or lower (score of 1 to 5), indicating some agreement to strong disagreement regarding having control over MSK injury disclosure.

Intention to disclose an MSK injury consisted of a single 7-point scale question on a student-athlete’s intention to disclose the symptoms of an MSK injury. Intention scores were categorized as higher (score of 6 or 7), reflecting agree or strongly agree with intentions of disclosing symptoms of MSK injury, or lower (score of 1 to 5), reflecting somewhat disagree to strongly disagree with intention to disclose symptoms of MSK injury. In addition to the intention to disclose future MSK injury, prior MSK injury disclosure behavior was also measured by asking the following question to anyone who reported having had an MSK injury: “How many of these musculoskeletal injuries did you report/disclose to a medical professional or someone in authority at the time of injury?” Subsequently, these data were transformed into a disclosure percentage ([number of injuries participant reported disclosing at the time of injury/total MSK injuries participant disclosed having sustained previously] × 100).

General descriptive statistics were used to describe the demographic information of participants (age, gender, race, academic grade, primary sport, estimated household income, and MSK injury history; Table 1). We conducted Cronbach α tests to determine the internal consistency for each of the summative domains in the survey (MSK knowledge, MSK attitudes, and MSK social norms). Before running models, variables were examined for multicollinearity. The disclosure percentage was defined as the number of previous MSK injuries disclosed by each athlete divided by the total number of previous injuries the athlete recalled having sustained. Intention to disclose an MSK injury was converted into a categorical variable and dichotomized as high (6 or 7) or low (0 to 5) to explore differences between those who reported a higher intention to disclose an injury and those who reported a lower intention to disclose, in accordance with previous literature.²²  Last, a multivariate binomial regression mode including gender, race, ethnicity, knowledge of injury signs and symptoms and consequences of injury, attitudes toward disclosure, perceived social norms, and perceived control over disclosure was used to identify which of the hypothesized determinants influenced higher intentionality for MSK injury disclosure.

When asked to select all the reasons that apply to when an MSK injury should be revealed, 54% of athletes chose when the pain was initially felt but only if the injury seemed serious. In contrast, 37% of respondents reported that an MSK injury should be disclosed at the first sign of pain if it was not thought to be too serious. Last, 17.4% of participants believed that an MSK injury should be reported if it only hurt a little and was not affecting their game play (Table 2).

Athlete knowledge total scores ranged from 4 to 72 out of a possible 82 (mean = 44.8 ± 10.03; Table 3). Higher scores indicated greater knowledge of MSK injury symptoms and consequences of injury. Respondents’ attitude scores toward disclosure of MSK injury ranged from 8 to 56 out of a possible 56 (mean = 34.9 ± 6.6), with higher attitude scores representing more favorable attitudes (Table 4, Figure 1). Participants’ social norms received scores ranging from 12 to 42 out of a possible 49 (mean = 27.8 ± 6.8), and higher scores represented greater perceived support and social acceptance for MSK injury disclosure (Table 5). Last, respondents endorsed an average of 4.5 ± 1.7 (range = 1–7) related to perceived control over MSK injury reporting, with higher scores indicating more control, which would be equivalent to somewhat agree (Figure 2).

In total, 457 (80.2%) of the athletes described having sustained ≥1 MSK injury related to sport; the mean number of MSK injuries was 3.32 ± 2.2 (range = 1–10). When asked how many of those injuries were not reported to a coach or a health care provider, respondents noted having not reported or purposefully hidden 77%.

Student-estimated household income, knowledge of MSK injury symptoms and consequences, attitudes toward MSK injury disclosure, and perceived social norms surrounding the disclosure of an MSK injury were significant predictors of a high intention to disclose MSK injuries (Table 6). Specifically, for each unit increase in total MSK injury knowledge (Exp[β] = 1.061, β=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[β] = 1.070, β = 0.064, P < .001, 95% CI = 1.027, 1.115) scores, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[β] = 1.178, β=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was seen. However, gender (Exp[β] = 1.116, β=0.066, P = .54, 95% CI = 0.776, 1.606), race (Exp[β] = 0.848, β=0.059, P = .091, 95% CI = 0.700, 1.028), presence of an athletic trainer (Exp[β] = 0.912, β=0.042, P = .615, 95% CI = 0.637, 1.306), and MSK injury history (Exp[β] = 1.544, β=0.641, P = .187, 95% CI = 0.810, 2.943) were not significant predictors of a high intention to disclose future MSK injury.

We demonstrated 3 primary findings. First, most participants reported a low level of knowledge regarding MSK symptoms and consequences. Second, fewer than one-quarter of athletes believed it was necessary to disclose an injury, even if it was bothering them, as long as they could still play. Third, several previously identified determinants of high intention to disclose signs or symptoms of a concussion, such as knowledge of signs and symptoms, injury consequences, attitudes toward disclosure, and perceived social norms surrounding disclosure, were significant predictors of a high intention to disclose an MSK injury.

When asked about the consequences of MSK injury, more than 70% of participants answered either yes or maybe to whether “no bad things” could happen if someone continued playing “through the pain,” returned to sport or physical activity too soon, or had multiple MSK injuries during their lifetime. This finding suggests that MSK injuries may not be perceived as significant or meaningful unless they cause significant disability or pain sufficient to substantially restrict an athlete’s ability to participate. This idea is in direct conflict with the idea that early disclosure and early treatment of injury could help reduce the overall burden of MSK injury.²³  Therefore, adolescent athletes may benefit from education related to the potential side effects and consequences of “playing through the pain,” returning too early, or sustaining multiple MSK injuries over time without proper recovery.^7,11 

In addition to a lack of understanding regarding the consequences of MSK injury, respondents lacked a clear understanding of MSK injury symptoms, such that no single listed symptom was correctly identified as an indicator of MSK injury by >50%. Although many of the listed symptoms may also reflect another condition and might have elicited a maybe answer, early evidence of a general lack of knowledge concerning MSK injury symptoms among adolescent athletes was present.

A lack of knowledge of the symptoms and consequences of MSK injury may also play a role in the prevention, treatment, and risk of reinjury. For example, certain injuries, such as ankle sprains, medial tibial stress syndrome, shoulder impingement, and many more, have several early signs and symptoms. If these symptoms are recognized by the athlete and reported in a timely fashion, the total injury burden, such as time loss and economic expense, associated with the treatment of chronic injuries, such as chronic ankle instability, shoulder impingement, and low back pain, could be dramatically reduced. For each unit increase in total MSK injury knowledge, there was a 6% increase in the likelihood of a high intention to report MSK injuries. Incremental increases in knowledge could be addressed through proper educational efforts and may serve as a starting point for targeted intervention programs geared at promoting and encouraging early disclosure of MSK injury.

Overall, 77% of MSK injuries that participants sustained were either not reported or were purposefully hidden at the time of injury, suggesting a generalized perception of not needing to disclose most MSK injuries. Previous researchers in the concussion space have demonstrated the effectiveness of simple educational programing to improve the prevalence of injury disclosure. For example, up to a 40% difference was evident in the disclosure of concussion among individuals who had received educational programing compared with those who had not.¹⁹  Documented success from educational programing designed to increase concussion reporting behavior indicates that practitioners interested in increasing the disclosure of MSK injury can start by mirroring these interventions.

In general, when participants were asked to rate their attitudes toward MSK injury disclosure, their scores were relatively low (34.8 ± 7.9 out of a possible 56) and similar to early observed attitude scores related to concussion.^19,20  However, many recent studies reflect improvements after educational programing and increased global awareness surrounding and supporting the disclosure of concussion symptoms to a health care provider.^24–27  Such attitude scores pertaining to MSK injury in the present population are close to the preliminary scores of concussion patients approximately 10 years ago before widespread educational efforts were implemented.^17,18  Our respondents’ average score for each question in the attitude subcomponent was 4.4. Multiple interventional studies have shown the positive effect of educational interventions that not only target athlete knowledge of signs and symptoms but also focus on a socioecological framework incorporating interpersonal relationships between athletes and their coaches and peers, societal and community acceptance, and intrapersonal components surrounding athlete concerns about disclosing an injury.^19,28  For each unit increase in attitude score, the likelihood of a high intention to disclose an MSK injury increased 7%. Based on the concussion literature, attitudes toward MSK injury may be similarly improved by applying a socioecological educational framework that targets multiple levels of injury disclosure, such as policy and societal, community, and interpersonal and intrapersonal considerations.

In the same way, low perceived social norm scores in our adolescent athletes surrounding the disclosure of MSK injury were consistent with perceived social norm scores in the early concussion symptom reporting literature.^17,29,30  However, if we again look back across the past decade, we see several successful examples of reducing barriers to concussion symptom reporting through educational programing that seeks to improve the social context of accepting concussion disclosure as a positive factor.^29,30  For each unit increase in social norms, the likelihood of patients endorsing a high intention to disclose a future MSK injury increased 18%. Recent findings in the concussion literature support the theory that targeted educational programing aimed at improving the social context of injury disclosure may also benefit efforts to improve the early reporting of MSK injuries.

Despite a general lack of investigation into determinants of MSK injury disclosure, a few elements, such as age and gender, have been implicated in influencing MSK injury disclosure.^7,31  Moreover, the authors of 1 study identified correlations in collegiate sport athletes between determinants of intention to disclose concussion injury, such as knowledge of injury symptoms and consequences, attitudes toward injury disclosure, perceived social norms, perceived behavior control, and a high intention to disclose an MSK injury.²² 

We found that knowledge of MSK injury, attitudes toward MSK injury disclosure, and social norms surrounding the disclosure of MSK injury were all significant predictors of a high intention to disclose an MSK injury among adolescent athletes. Moreover, household income determined the MSK injury disclosure intention. With each unit increase in household income, the likelihood of endorsing a high intention to disclose future MSK injuries increased 34%. In contrast, other hypothesized predictors, such as gender, race, presence of an athletic trainer, and MSK injury history, were not significant predictors of a high intention to report an MSK injury. To our knowledge, this is the first examination of predictors of adolescent intentions to disclose an MSK injury. These results identify key starting points for researchers, coaches, parents, and relevant health care professionals interested in reducing the economic and social burden of MSK injury in adolescents: the development of educational programs pertaining to the symptoms of MSK injury, helping athletes understand the context in which MSK injury should be disclosed, and what type of information should be shared with a health care provider. Moreover, perceived social norms influenced MSK injury disclosure decisions. Thus, it is important to consider the entire socioecological framework targeting multiple levels of injury disclosure, such as policy and societal, community, interpersonal, and intrapersonal considerations.

Although we worked with the school staffs who disseminated the survey, we did not have direct access to the participants, and therefore, do not know if each site promoted and distributed the survey in a similar fashion. Several other biases, such as response, social desirability, recall, and selection bias, may have also played roles in the outcomes. Every effort was made to reduce such biases by recruiting each student in the same manner and not targeting particular students or groups of students. Furthermore, participants were instructed that their individual responses would not be shared or linked to their identifiable information, and the results would be shared only as aggregate data to decrease the likelihood of their answers being biased out of fear of what others might think.

Adolescent athletes reported a low level of knowledge of the symptoms and consequences of MSK injury, with most (77%) of their past MSK injuries either going undisclosed or being purposely hidden. Also, several identified determinants of intention to disclose concussive injuries, including knowledge, attitudes, and perceived social norms, accounted for the intentionality of participants to report MSK injuries. Previous researchers demonstrated the success of multifactorial interventional educational programs targeted at improving the social context surrounding concussion disclosure and enhancing the knowledge of potential signs, symptoms, and consequences. These studies highlighted the significance of interventions designed to expand knowledge of an injury while improving the social environment, attitudes, and perceptions of injury disclosure and the context of sport participation to make disclosure of injury more socially acceptable.^21,32  Investigators who want to better understand the barriers and social context surrounding the disclosure of MSK injuries can learn from the interventional models applied to encourage concussion symptom disclosure. These models could serve as a starting point to enhance MSK injury disclosure behavior and reduce the social and economic burden of MSK injury.