No Pain, No Gain?

No Pain, No Gain?

Elite sport – risks and side effects

What inspires elite athletes to keep competing despite injury? Is a medal or making it to a final worth the pain? Which health related consequences may such behaviour entail?

It is the 6th of August 2016. The gym in Rio de Janeiro is well filled with 8000 spectators that are waiting to admire the best gymnasts in the world that are competing in the men’s team event. The 25-year-old German champion and medal hope Andreas Toba prepares for his floor routine. He doesn’t know yet that he is about to go down as ‘Hero de Janeiro’ in the history of the Olympic Games.

It is the qualification round, and every point counts to reach the team finale. However at the start of his floor routine, Toba injures his knee and has to limp off the floor fighting back tears. Preliminary diagnosis: ACL tear. Already crossed off from further competitions, Toba decides to enter the pommel horse event: strap up my knee, I have to get up there”. The judges award him an incredible 14,233 points for his routine, the highest German score, which enables his team to reach the finals. Toba explains in an interview:

“I just knew, if I don´t compete, we will be missing a point and in the end, every half point, every tenth, is important to reach the finals.”
The media celebrate him as a hero, his team mates as well as his opponents express their respect. However, the physicians shake their heads. What was Andreas Toba thinking this morning?
“I would have blamed myself for the rest of my life if I hadn´t tried,” he told a reporter.

One would think that only unparalleled events, such as the Olympic Games, lead elite athletes to risk their long-term health for short-term success. Toba is no isolated case. Even in less well-known and media effective sports, there are numerous reports of elite athletes who continue despite serious injuries. One example is Ultimate Frisbee player Peter Woodside, who broke both of his arms in the course of an MLU playoff game and still kept playing.

In sports science this phenomenon is known as the Risk-Pain-Injury Paradox. It describes the drive of athletes to push physical limits to achieve peak performance, which simultaneously increases the risk of injury. This ‘culture of risk’ is often nurtured by the athletes’ environment that encourages participation in competitions despite physical complaints. According to the GOAL study, the suppression of injury risks and the acceptance of health consequences is an inherent part of elite sport. Prof. Dr Ansgar Thiel wrote in the German Journal of Sports Medicine:

Elite athletes are socialized into this culture of risk very early. The dealing with pain and disease in elite sports is therefore the result of a long-term learning process.

In the case of Toba, those responsible had to make a difficult decision within a very short time. The team physician, Dr Hans-Peter Boschwert says in retrospect: “if you really tape the knee very tight, you can account for him doing his pommel horse routine. And we did not have a lot of time to think about it. Andi made his decision and I supported it”. This demonstrates the conflict of interest, which both the athlete and the physician are exposed to.

A single serious injury may end an elite athlete’s career. In Andreas Toba´s case, it was his last participation at the Olympic Games. From this point of view, the decision of an athlete to continue despite injury is quite understandable. Whether Andreas Toba will suffer from long-term health consequences due to his effort, is unclear. Among others, this is one of the questions we hope to answer through the Head in the Game project. We want to know: Do injuries and training with physical complaints lead to long-term sequelae? Or do athletes only suffer from acute consequences like pain? Which injuries are especially prognostic for potential long-term consequences such as osteoarthritis? Through the results of the Head in the Game project we aim to support athletes, physicians, and coaches to make responsible and well-informed decisions with regards to long-term health in elite sport.

By the way, the team around Andreas Toba recently received the “Sportler mit Herz” (sportsman with heart) award for their touching commitment and team spirit. We congratulate and wish them all the best!


The goal of the Head in the Game project is to evaluate and improve long-term health in elite men's and women's football. The main question we seek to answer is: does a professional football career have any consequences for the musculoskeletal or neurocognitive health of former players?

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