"The pain isn't the hardest challenge... it's the frustration at how much it affects my day-to-day life, my mental health and my ability to train": A qualitative thematic analysis of elite athletes' lived experiences of persisting low back pain

Objective Low back pain (LBP) impacts the performance and quality of life of elite athletes during and beyond their career. Our aim was to explore the lived experiences of elite athletes with persistent LBP (pLBP) with a focus on understanding the biopsychosocial factors that influence their recovery. Methods Australian elite athletes with pLBP (>3 months) participated in semistructured interviews which focused on their pLBP experience. Recordings were transcribed verbatim, and data were analysed using Braun and Clarke's reflexive thematic analysis. We partnered with athletes throughout the research process, including study design and data analysis. Results 17 elite national and international athletes who competed in 10 Summer Olympic sports were included (mean symptom duration 18 months and current pain of 3.5/10 (SD+/-2.1)). Four themes were generated to represent participants' experiences: (1) the burden of pLBP, (2) validation, agency and feeling empowered to manage pain, (3) perceived barriers and coping strategies in recovery and (4) culture and interpersonal relationships for managing persisting low back pain. Conclusions Elite athletes with pLBP report disruption to identity, self-confidence and perceived worth. The culture of elite sport magnifies psychosocial determinants of pain and recovery. Agency was fostered through validation of their pain experience, enhanced by education, diagnostic labelling and a culture of openness. Recovery was influenced by mental health and relationships within and beyond sport. Clinicians play a key role in facilitating athlete agency, contextualising pain and supporting psychological and social well-being.