"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.

Elite athletes with persistent low back pain experience significant burden including disruption to identity, self-confidence, and perceived worth.

• 17 elite national and international athletes competing in 10 Summer Olympic sports were included
• Mean symptom duration was 18 months with current pain of 3.5/10 (SD±2.1)
• Athletes described that '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'
• Burden of persistent LBP was identified as the first major theme from reflexive thematic analysis
• Participants reported disruption not only to athletic performance but to quality of life more broadly

Athlete agency in managing persistent low back pain was fostered through validation of their pain experience, enhanced by education, diagnostic labelling, and a culture of openness.

• Validation, agency, and feeling empowered to manage pain was identified as the second major theme
• Diagnostic labelling was reported by athletes as contributing to their sense of agency and empowerment
• Education about pain was identified as a key mechanism for fostering agency
• A culture of openness around pain was perceived as enabling athletes to better manage their condition
• Clinicians were identified as playing a key role in facilitating athlete agency and contextualising pain

The culture of elite sport magnifies psychosocial determinants of pain and recovery for athletes with persistent low back pain.

• Culture and interpersonal relationships for managing persisting low back pain was identified as the fourth major theme
• Elite sport culture was described as amplifying psychosocial factors that influence pain experience and recovery
• Relationships within and beyond sport were found to influence recovery outcomes
• The study used a biopsychosocial framework to explore factors influencing recovery
• Athletes were partnered with throughout the research process including study design and data analysis

Perceived barriers to recovery and coping strategies were a distinct theme in elite athletes' lived experience of persistent low back pain.

• Perceived barriers and coping strategies in recovery was identified as the third major theme
• Mental health was identified as influencing recovery from persistent LBP
• Athletes described both internal and external barriers to recovery within the elite sport context
• Coping strategies were developed by athletes to manage the ongoing challenges of persistent LBP
• Clinicians were identified as having a key role in supporting psychological and social well-being alongside physical management

The study used qualitative reflexive thematic analysis with athlete partnership throughout the research process to explore lived experiences of persistent low back pain.

• Australian elite athletes with persistent LBP (>3 months) participated in semi-structured interviews
• Recordings were transcribed verbatim and data were analysed using Braun and Clarke's reflexive thematic analysis
• Athletes were partnered with throughout the research process including study design and data analysis
• 17 participants competed across 10 Summer Olympic sports at national and international level
• Interviews focused on the biopsychosocial factors that influence recovery from persistent LBP