Journal of Sports Science and Medicine
Journal of Sports Science and Medicine
ISSN: 1303 - 2968   
Ios-APP Journal of Sports Science and Medicine
Androit-APP Journal of Sports Science and Medicine
©Journal of Sports Science and Medicine (2020) 19, 323 - 336

Research article
Prevalence of Biopsychosocial Factors of Pain in 865 Sports Students of the Dach (Germany, Austria, Switzerland) Region – A Cross-Sectional Survey
Anke Bumann1,2, Winfried Banzer1,3, Johannes Fleckenstein1,   
Author Information
1 Department of Sports Medicine and Exercise Physiology, Goethe University Frankfurt, Frankfurt am Main, Germany
2 Department of Exercise Physiology and Sports Therapy, Justus-Liebig-University Giessen, Giessen, Germany
3 Institute of Occupational, Social and Environmental Medicine, Goethe-University, Frankfurt, Germany

Johannes Fleckenstein
✉ Department of Sports Medicine, Goethe-University Frankfurt, Ginnheimer Landstr. 39, 60487 Frankfurt am Main, Germany
Publish Date
Received: 09-08-2019
Accepted: 01-02-2020
Published (online): 01-05-2020

When sports are part of a person’s profession or education, their careers are often handicapped by pain, a complex physical and mental state that may already occur at lower career stages. This study was designed to assess the occurrence of pain among sports students and the prevalence of relevant contributing psychosocial co-factors. Exploratory cross-sectional study surveying students at 89 sports faculties of universities in the DACH region using the German Sports Pain Questionnaire. It includes several validated surveys related to pain occurrence in different body regions, injuries, pain diagnoses and pain intensity, depression, anxiety, stress, self-compassion, analgesic and alcohol consumption, as well as sleep quality, health-related quality of life and impairments of quality of life by pain. A total of 865 sports students gave consent to participate in the study, and 664 participants (78%; 23.3 ± 2.84 years, 60% female, 40% male) completed the full survey. More than half of the students (53%; n = 403) showed current pain in 2-5 regions of the body, while subjective pain tolerance was enhanced. General injuries or accidents, medically and self-diagnosed pain diagnoses during the last eight weeks were reported by 30%. A current pain intensity ≥ 3 NRS was prevalent in 28% (n = 205), which correlated with increased pain-related biopsychosocial scores. Sports students had increased scores for depression, anxiety and stress, and self-compassion was reduced (compared to age-controlled national reference data, sports students head increased scores). The mean weekly training workload was 5-7 hours. Analgesics and alcohol consumption was increased, 61% reported insomnia. Across sports students, pain and biopsychosocial burden seem significantly increased when compared to other students and age-controlled cohorts. The data implies the need of giving greater importance to pain management at least from the time of sports studies in order to prevent pain and health risks in sports.

Key words: Pain management, elite athlete, pain questionnaire, quality of life, preventive medicine

           Key Points
  • The German Pain Questionnaire, based on validated international questionnaires, has been adapted to the needs and wants of sports students.
  • Young athletes, i.e. sports students, represent an adequate cohort to investigate bio-psycho-social factors of pain at an early stage of their career.
  • The study draws an alarming picture of sports students’ health state.
  • The study highlights key points that may be suitable to develop preventive and rehabilitative instruments.


In an athlete’s life, uncontrolled pain can have a negative effects as it may be source of further and more serious injuries as well as a trigger for -or a consequence of- psychosocial problems and illnesses (Putukian, 2016). Sports students are a special group of athletes, with diverse demands. There are multiple interactions between pain and students' biopsychosocial health (Bailer et al., 2008), an increased stress level due to the double burden of theoretical requirements and performance pressure. In consequence, an impairment of students’ mental and physical health is likely (Putukian, 2016).

Injuries seem to be a key stress factor for sport students (Putukian, 2016), which are more often affected by injuries than other student groups (Dreiskämper et al., 2015). Most recent studies on the psychosocial state of German students point to a concerning development of mental symptoms and fear of failure among the students (Beiter et al., 2015). Studies show that higher resilience and increased resources of athletes, e.g. self-compassion, lead to a better ability to cope with pain and injury (Reis et al., 2015). Beyond that, mental resources, skills for pain management, and coping strategies can affect the healing process of an injury (Kleinert, 2001).

However, little is known about the prevalence of pain in sports students. So far there are only a few studies dealing with this topic, and there is a need for a systematic assessment of biopsychosocial factors in athletes and sports students based on the recommendations of the International Association for the Study of Pain (IASP) for pain assessment and management of pain (IASP, 2018).

The aim of the present survey was to evaluate the prevalence of existing pain and injuries, to obtain a more differentiated understanding of coping with pain and stress in sports, and also to pay adequate attention to mental health and quality of life for sports students.


Study design

We conducted an exploratory cross-sectional electronic survey based on the German Pain Questionnaire, and adapted to sports students’ needs, taking into account demographic particularities of sports students. The study was approved by the Ethics Committee of the Goethe University of Frankfurt am Main (reference number 2017-22), and is in accordance with the Declaration of Helsinki (Version Fortaleza 2013).


Potential participants were all current students at faculties of sports sciences in Germany, Austria, and Switzerland (DACH region), as well as in Luxemburg and Liechtenstein. Faculties were retrieved by online research and according to the list of the German Society of Sport Science (DVS, 2016). All faculties (deans, course directors, student associations) were contacted by mail (in total 321 inquiries) and by announcement in social networks. According to country size and population, the number of contacted universities was highest in Germany (62) and less in Switzerland (21) and Austria (5). Interested candidates could participate online if they met the following inclusion criteria: Participants had to confirm to be a registered student in a sports science course or in a teacher training with the subject of sport at higher education institutions, universities, and colleges. Prior to participation, all candidates provided online consent.

Experimental design and outcome assessment

From June to November 2017, the survey was publicly accessible via web-based academic survey system (SoSci Survey GmbH, Munich, Germany) to get a period prevalence. To address the different dimensions of pain, we developed the German Sports Pain Questionnaire (see supplementary data 2), which is a modified version of the German Pain Questionnaire (Nagel et al., 2012) including own questions, not validated yet, of demographic and anthropometric data, sports activity, history of past and present injury and medication, as well as seven validated questionnaires (all in German versions): The Regional Pain Scale (RPS) to determine the localisation of pain (Hauser et al., 2010); The 12-item Short Form Health Survey (SF-12) for physical and mental quality of life; The NRS pain scale to specify the localisation and sensation of pain (10-scaled Numerical Rating Scale NRS, with 0 = no pain and 10 = maximum pain); The Quality of Life Impairment by Pain Inventory (QLIP), showing the intra-individual development of the patient's impairments (Nagel et al., 2012); Two questions of the Patient Health Questionnaire (PHQ) to monitor the quality of sleep (Gräfe et al., 2004); The Depression, Anxiety and Stress Scales (DASS; Depression cut off 10, anxiety cut off 6, stress cut off 10, (Nilges and Essau, 2015)). In addition we assessed the Self-Compassion Scale Short Form (German Version; SCS-D SF) addressing the physical and mental health state (Hupfeld and Ruffieux, 2011). The sequence of all single questionnaires was in a standardised order: RPS, SF-12, NRS, QLIP, DASS, SCS-D SF. All participants could enter free comments concerning their experiences with pain and sports before submitting the survey that will be qualitatively analysed coping strategies for pain and injuries.

The NRS was also used to split the sample according to the World Health Organisation (WHO) and the standard criteria of expert standard Pain Management in care into two subgroups perceiving current pain lower or higher than “3” on the NRS (Schmidt, 2016). In addition, data was analysed for chronic pain, abuse of drugs and alcohol, training loads, and sex differences.

To allow interpretations, all results were compared to age-controlled reference and norm data (see Table 1).

Statistical analysis

Statistical data processing was performed using SPSS (Version 24; IBM Deutschland GmbH, Ehningen). Since all data had a normal distribution (Kolmogoroff-Smirnoff-Lilliefors test), data are expressed as means and standard deviations (95%-CI). For statistical analysis between different subgroups, the T-test for independent samples and the Chi² test for categorised data were applied. The level of statistical significance was set at p < 0.05. The Bonferroni test may be applied to compensate for multiple measurements when comparing the questionnaires (in total n = 9 scores), with . The full dataset was analysed on basis of an intention to participate analysis.

Qualitative Analysis

Free comments were classified into categories, as follows: (i) Performing sports despite pain and injury, (ii) Physiological contexts, (iii) Pain tolerance and pain sensitivity, (iv) Decision-making process concerning injury break, (v) Personal statements and coping strategies, (vi) Conditions for sports studies and (vii) Comments on positive effects of sport. Twenty-nine comments were considered being non-substantial in regard to pain and injury, or contained personal communications as well as positive feedback, and are not reported in this file.


Participants’ characteristics

In total, about 2,500 clicks on the website have been recorded, while 865 sports students (23.35 ± 2.98 years; BMI 22.49 ± 2.41; 526 female, 339 male) gave consent to participate. 664 participants (78%) completed the full survey, 768 students finished at least the main part of pain-related questions. Most of the students were registered at German universities (88%). 12.8 % of the participants studied at Swiss and Austrian universities. The majority planned to graduate as a teacher (state exam 52%) or while receiving a Bachelor degree (44%). The mean progress in terms (2 terms/year) was 5.18 ± 3.02.

Survey’s results

The scores of the different pain items are summarised in Table 1. The RPS reported an average of 3.84 ± 2.98 (rating scala “0” no region of pain to “19” pain in all sites mentioned) sites of current, acute pain or tenderness, with a focus on: Neck (48 %), lower back (45 %), right (38 %) and left (26 %) shoulder, right (24 %) and left thigh (21 %), and knees (21 %; see Table 2). The mean value of the mental component score (MCS-12) was 47.64 ± 9.51 (range: 0-100; 100 = very good health), of the physical component score (PCS-12) 48.88 ± 6.59 (range: 0-100; 100 = very good health). The average current pain intensity was 1.83 ± 1.93 NRS (rating scala “0” no pain to “10” worst pain imaginable), while 91 students (13%) reported ongoing pain (polar question: yes or no). The pain-induced limitations of global quality of life (QLIP) scored 31.98 ± 6.54 (43 = excellent quality of life). The results of the DASS were as follows: Depression 3.20 ± 3.55, anxiety 1.87 ± 2.45, stress 3.79 ± 3.67 (0 = little risk for each subcale). Self-compassion was rated 38.40 ± 7.35 (60 = excel lent self-compassion)). Figure 1A shows an extrapolated spider diagram of all pain-related scores.

Workload, injuries and pain

93% of sports students reported performing sports regularly, and only 2.0 % stated being inactive. The focus of the main training load was in the students’ recreational sports: 29.5 % are five to seven hours active per week, 26.1 % three to five hours per week, while 17.7 % are practicing sports even for nine to twelve hours per week.

Nevertheless, looking at the training load in preparation for practical tests at university, 25.8 % stated one to three hours per week, 18.2 % five to seven hours, 10.3 % five to seven hours while 34.3 % reported not preparing actively for university tests. Neither training load nor adherence to a youth league revealed significant differences between scores (p > 0.05). Most rated disciplines in recreational sports were weight training and fitness (21.07 %), running (16.71 %), ball games (18.52 %) water sports (11.02 %) and mountain sports (10.29 %). Being in a club or practicing on a competitive level was found mostly for these disciplines: Soccer (23.88 %), handball (13.06 %), beach-/volleyball (8.77 %), gymnastics (8.58 %) and water sports (5.41 %). Still, 69% of the students had one or more practical sports courses. Within the previous eight weeks, almost three of four students suffered an accident or injury (of any kind), received a medical diagnosis related to pain, or perceived some form of pain that was not medically diagnosed. Every third participant (33%) had to postpone practical tests at university in the past due to injury and pain. This result is supported by the willingness to endure pain in sports studies (59.10 ± 29.54) (0 = no tolerance, 100 = complete tolerance; Figure 2) while pain tolerance seems greatest in competitive sports (81.09 ± 21.94) and is estimated to be the lowest in mass sports (41.29 ± 29.04). These three statements differ significantly (<0.001). In this question, we did not predefine pain tolerance, as we wanted the students to answer according to the IASP pain being the subjective experience of the individual (IASP, 2017).

Other co-factors of pain included problems to sleep through the night in the last two weeks (61%). Participants specified a constrained well-being due to a higher need to sleep as well as caused by a lack of energy and fatigue (81%).

Coping strategies: Qualitative assessment

Students describe a mental condition, which is characterised by considerable pressure, fear, passion, as well as physical and spiritual pain, in the context of pain and injury. Diverse reasons, voluntary or not, push the students into doing sports despite pain (see supplementary data 1). The students describe, that they get used to it or even manage to ignore the pain, which accompanies you during sports (supplementary data 1, 1.4, 1.11, 3.4). “I think it is completely normal for an athlete to have to endure pain, to some extent” (supplementary data 1, 1.4) - pain as an experience which teaches you to cope better with pain and to regulate your threshold for pain intensity. “Overcoming it [pain] is also a strong part [of contact sports] and I have experienced that it makes you mentally stronger, at least for the game” (supplementary data 1, 1.12). ”In competitive sports, pain (…) was part of everyday life. Without them, one almost felt as if something was wrong” (supplementary data 1, 1.11). The pressure to cope with pain may also turn into suffering and force: “I have already taken practical exams with torn cruciate ligaments and pain, only not to lose a semester” (supplementary data 1, 6.5); “The pressure to perform in exams then leads to the fact that one goes through the training or practical exams despite intensive pain, (…) Personally it happened to me that I only experienced intensively fun and joy to do sports again after I had passed all exams” (supplementary data 1, 6.7). Health seems to be of secondary importance, and injury breaks are taken only when the body refuses to work. “In my sports studies I have the feeling that pain is not taken seriously and you are expected to continue, regardless of symptoms.” (supplementary data 1, 6.4). For more comments, see supplementary data 1.

Abuse and consumption of stimulating substances and analgesics

Every third participant reported drinking alcohol at least once a week, and 9% of students mentioned being a smoker. Stimulating substances were rarely consumed.

The most common analgesics among sports students in painful situations were ibuprofen (56%), paracetamol (27%), and aspirin (25%). Table 3 gives an overview of detailed abuse and consumption.

Subgroup analysis revealed no effects of alcohol (n = 242; 32,9 %), caffeine (n = 67; 9,1 %), or cannabis (n = 15; 2 %) on pain scores (p > 0.05). Still, smokers reported higher pain intensities (mean difference 0.856 cm VAS, p = 0.001) and stress scores (1.02 DASS-S, p = 0.043). The use of muscle relaxants (n = 28; 3,8 %), ibuprofen (n = 408; 55,4 %) and paracetamol (n = 191; 26,0 %) was associated with elevated pain intensities, and the latter two with increased stress and a decrease in QLIP (all p < 0.05). The intake of aspirin (n = 185; 25,1 %), metamizole (n = 29; 3,9 %), and tramadol (n = 9; 1,2 %) was not associated with altered scores (n = 8).

Subgroup analysis: Pain intensity NRS </≥ 3

According to the WHO and the standard criteria of expert standard Pain Management in care (Schmidt, 2016), pain intensity of the participants was divided into subgroups < 3 NRS (n = 531) and ≥ 3 NRS (n = 205). All pain scores significantly differed between both groups (p < 0.001; Table 4; Figure 1B). The willingness to endure pain in mass sports and the study of sports was significantly increased among participants with an increased intensity of pain.

Gender differences

Splitting the data for gender did not reveal significant differences for the subgroup analysis (p > 0.05).


Major findings

This representative survey reports comprehensive data on pain prevalence and the presence of biopsychosocial cofactors among 865 students in sports sciences in the DACH region. The data show that almost one out of four students is impaired by pain to an extent that requires treatment according to the WHO (Nagel et al., 2012). These students report a current pain intensity of ≥3 NRS. About half of all participants (51.44%) show 2-5 body regions with acute pain, with three out of four students having suffered injuries during the last eight weeks, and an increased consumption of painkillers and alcohol. Students with a higher pain intensity show a significantly higher probability to suffer from depression, anxiety and stress as well as lower self-compassion. Of all sports students, 80.54% complain of fatigue and lack of energy, 60.61% report of sleep disorders. Students report the belief, that participating in sports, depending on the competitive level, is invariably linked to the occurrence of pain and injury.

Comparability to other student peer groups Pain

According to the results on pain mentioned above, there are significantly higher restrictions of quality of life in the subjects with pain intensity ≥ 3 NRS (28%), between the two groups (≥ 3 NRS; < 3 NRS). This score of NRS is interesting in so far as this pain level, light to moderate, is assigned to Step 1 of the pain ladder according to the standard criteria of expert standard Pain Management in care of the WHO (Schmidt, 2016). This pain level implies the need for at least non-opioid analgesics, in particular nonsteroidal anti-inflammatory drugs (NSAID) in pain therapy. This result is an alarming fact in that every third sports student is experiencing a pain level in need of treatment.

A survey among 2443 German students, dating from 2017, reinforces this observation: Schlarb et al. (2017) showed the prevalence of any functional somatic disorder - including the occurrence of pain- is 13%. This is less than we found among sports students in our study (33%). This can be underlined by a study comparing Chinese to German students (Chu et al., 2015), which suggests higher prevalence of pain among German students. Regarding symptomatic pain in German students, it has been reported that the most frequent complaints were different kinds of pain, comparable to Spanish and Lithuanian students (Stock et al., 2003).

Looking at results from colleagues Fett et al. (2017) we have comparable groups regarding pain in competitive sports as well as in sports students. Their recent study investigated the occurrence of back pain in 1114 elite athletes and 166 sports students as active controls (Fett et al., 2017). Authors report 7-day-prevalence of low back pain in 34.0% of the elite athletes compared to 29.0% in the control group. This is not in line with our results suggesting a 7-day-prevalence of 45.4% in sports students. Regarding neck pain, authors report a prevalence of 23% in elite athletes (Fett et al., 2017), 22% in sports students, which is again remarkably less than observed in students we interviewed (47.5%). Still, the comparison of results differs as pain in sports may vary between disciplines, ethnicity or gender (Fett et al., 2017). For example, light differences in sex distribution between our survey (m/f 60.1/39.2%) and Fett and colleagues can be found (elite athletes m/f 46.5/53.1 %; control m/f 74.7/24.1 %), as well as variances in age (sports students 23.35 ± 2.98y; elite athletes 20.9 ± 4.8 y; active controls: 21.2 ± 2.0 y). Another, potentially important reason for the different pain prevalence might be the difference in sports disciplines: Elite athletes and active controls in Fett et al. were active in Hockey, Track and Field, Rowing, Skiing and Swimming, while the top 5 disciplines in our study were soccer, handball, beach-/volleyball, gymnastics and water sports.

Further painful body regions (as reported in Table 2) were both shoulders (left 25.7%, right 38.0%), both thighs (left 20.8%, right 23.7%), and the knees (21%). Various studies show these joints and regions to be typically prone to pain in sports (Askling et al., 2006; Gerhardt and Scheibel, 2016; Salati et al., 2017).

Biopsychosocial symptoms

Cut-off scores categorising the QLIP suggest a suspicious score at ≤ 20 (Uberall et al., 2015), and an acceptable score with minor/no impairment at ≥ 32 in the context of back pain patients (Uberall et al., 2017). The sports students in our study varied around the acceptable score cut-off (31.98 ± 6.54). However, students with higher pain intensities (NRS ≥ 3) report a significant lower QLIP score (27.48 ± 7.41; p < 0.001). They feel particularly restricted in their activities and needs by pain, see their mood impaired by the pain, and doubt that they can influence their pain in a soothing way. This group also names more additional complaints such as gastrointestinal problems, concentration problems, depression, sleep disorders, sweating, and listlessness.

Today, students in general seem increasingly suffering from poor mental health (Kohls et al., 2012; Pedrelli et al., 2015). Bailer et al. (2008) describe their results on psychological symptoms of 1130 students at the University of Mannheim, Germany, being alarming, and point to a great need for psychological care for students at German universities. 22.7% of the students are meeting at least the PHQ criteria for one psychological disorder. Apart from the alcohol syndrome (30.2%), three are somatoform (9.1%) and other depressive syndromes (8.1%). Performance and success pressure, as well as later career plans, are described as the most important concerns and worries among students (Beiter et al., 2015). These results, together with the fact that sports students also report a deterioration in sleep quality, sharpen the possible link between sleep, and both physical and psychological impairments (Schlarb et al., 2017).

Still, sports students seem to be even more likely affected by biopsychosocial factors of pain then matched age controls when comparing our results to reference data. Physical and mental health (PCS 48.88 ± 6.59; MCS 47.64 ± 9.51) are decreased by 7.7 and 2.4 points, respectively (Socio-Economic Panel 2004; PCS 56.62 ± 6.20; MCS 50.03 ± 9.37; (Moegling, 2006)). However, these differences are not clinically meaningful, according to problematical cut offs values mentioned in the German Pain Questionnaire (PCS < 29; MCS < 44; (Nagel et al., 2012)). We could not detect pathologies assessing the DASS. The values of the students (DASS-D 3.20 ± 3.55; DASS-A 1.87 ± 2.45; DASS-S 3.79 ± 3.67) are clearly below the cut-off values of the manual of the German Pain Questionnaire (cut off DASS-D 10; cut off DASS-A 6; cut off DASS-S 10; (Nagel et al., 2012)). However, sports students show a lower likelihood of depressive disorders, a reduced stress level, but an increased score for an anxiety disorder when compared to a DASS validation study among unspecified students (Nilges and Essau, 2015). Pain tolerance as rated by the sports students /see Figure 2) is likely to be influenced by self-experiences (IASP, 2017). In the case of studying sports this may contribute to the fact, that doing sports is not only leisure but also stressful, e.g. when passing competitive exams.

The effect of self-compassion on depressive symptoms has been investigated in 347 psychology students aged 17-36. (Raes, 2011) Sports students (38.40 ± 7.35) undercut their values considerably (46.76 ± 11.64). Self-compassion is an important variable among others for well-being in students (Gunnell et al., 2017), and emotional regulation in difficult sport situations in female athletes (Reis et al., 2015). In consequence, preventive possibilities to strengthen the self-compassion in sports students need to be discussed, and implemented as this skill is also a potential protective factor for depression (Raes, 2011).

As a final point, the remarkably high participation of female students needs to be highlighted: In the last years, women have clearly been underrepresented in sports studies (Statistisches_Bundesamt, 2014), gender differences in communicating pain (Strong et al., 2009). Female adolescents tend to be more cooperative and emotional in conversational contexts (Goldshmidt and Weller, 2000).

The role of psychosocial factors among sports students

Sporting ambitions have been described being a double burden for students as they are linked to associated stress and the potential risk factor for injuries (Putukian, 2016). In general, sport and activity are supposed to have a positive impact on health. Besides having the focus of the survey on the negative and impairing consequences of sports, there were also only 5 % of the personal comments on health and pain addressing a positive mind-set towards the topic. Stress is an important factor influencing the athletes' psychological resources concerning return-to-play, healing, and mental strain from injuries. The author identifies an increased risk of mental health problems such as depression, eating disorders, and substance abuse (Dannecker and Koltyn, 2014), which cannot be confirmed for the sports students in this survey. Our data is in line with previous studies analysing social structures and norms that affect the individual assessment and coping with pain. The term “sports-specific pain culture” describes the paradoxical way of thinking and behaving in sports (Richartz, 2001). While knowing the risks and consequences of continuing sports despite pain and injury, athletes report that they accept a loss of health in exchange for improved performance and potential success. In this survey, students strongly agree with the hypothesis that competitive sports is only achievable when tolerating pain. Sports seem to be a field in which pain is sought out voluntarily (Moegling, 2006). Mayer and Tiehl (2011) specify this daily phenomenon as the “playing hurt” in elite sports: The conscious suppression of enormous risks of injury, long-term consequences as well as the integration of pain and injury as a normal part of everyday sports life. This philosophy can be impressively confirmed by the personal comments the students made at the end of the survey: "Pain is part of my sport. Among other things, it is a confirmation and sign that I have trained hard", “You should admit your pain and learn to deal with it as well as possible”. This phenomenon has been named the “risk-pain-injury-paradox” (Nixon, 1994). Peer pressure from coaches, teammates, family, social environment, but also fans and media paired with simultaneously communicated concern for the athlete and the warning of overload. In consequence, the athlete finds himself in an ambivalent situation, in which her or his decision depends on how good and consolidated the relations to important persons of her or his sports network are. The topic of social influence in elite sports can be summed up into a problem of compatibility of all expectations with is well transferable into the group of sports students.

Protective resources

Empathy can be a potential protective factor for emotional problems such as depression (Raes, 2011). This is in line with a study suggesting athletes with a higher level of self-passion to deal better with emotionally difficult situations in a sporting context (Reis et al., 2015). In addition, increased self-passion can increase the well-being of students (Gunnell et al., 2017). Taking the results of our MCS-12, DASS, and SCS-D scores together, a mental constellation is likely reflecting the possible influence of pain and injury on students’ psychological aspects.

Out of this perspective, there is the need to focus on various programs and findings supporting the thesis, that strengthening mental health in sports can have a protecting effect: Interventions to increase self-efficacy seem to have positive effects on sports performance among athletes (Zagorska and Guszkowska, 2014), but also during injury rehabilitation (Clement et al., 2015; Wesch et al., 2012). In addition to the multifactorial effects of sports resilience (Galli and Vealey, 2008), hardiness is positively associated with good performance and psychological well-being in athletes, while negatively linked with psychological distress (Nezhad and Besharat, 2010). Psychological strategies can decrease stress among athletes (Dawson et al., 2014; Reed and Giacobbi, 2004), as well as strengthen coping strategies and pain management skills (Deroche et al., 2011; Ghazaie et al., 2015). Consequently, there is a wide range of measures and possibilities that could be applied protectively to the sports students to strengthen resources.

Implications for daily life

Parallels can be seen between sports students and competitive athletes with regard to the performance mentality, health-related ways of thinking, but also multifactorial strains. Pain is part of everyday sports life in top athletes, occurring through injury but also independently of injuries, and being influenced by a variety of factors (Hainline et al., 2017b). A review on health in elite sports clearly shows that the health status of athletes at performance level is evaluated differently (Thiel et al., 2010): You are healthy when you are able to train and to take part in competitions. Pressure to perform and psychophysical stress are part of everyday life in top-class sport in order to exercise at a certain level, and pain is already taken into account in training recommendations (Dannecker and Koltyn, 2014).

Their assessment of acceptance and handling with pain in competitive sports confirms that sports students can be compared with top athletes with respect to pain problems as well as regarding performance, success pressure, and multifactorial physical and mental strain. However, a comparison of health care in top athletes and sports students reveals differences: Psycho-regulatory training methods, biofeedback, and psychological training are one of the central conditions for top performance (Heaney et al., 2015; Wiese-Bjornstal, 2010), there are even current statements on pain management in elite sports (Hainline et al., 2017a). Medical care, especially psychological support, has already reached a high level in the field of competitive sports, while the pain management for sports students indicates a high need for development.


Data acquisition in large cohorts is a common limitation in survey studies. We belief that the choice of an online-based survey and its distribution via contact persons at the universities and social networks can be considered as a strength of this data acquisition. We achieved a high responder rate and a large case number, and included students from other German-speaking countries (DACH). However, we cannot exclude that non-responders would have altered the results. In addition, we cannot rule out that some students participated twice.

The survey was compiled in accordance with DSF guidelines and expert opinions, and is based on validated questionnaires (Nagel et al., 2012). The questionnaires have been validated in age-controlled but not sports-controlled cohorts, and included questionnaires that present standard instruments in investigating pain for many years. However, this is the first time this questionnaire was implemented in its full version in a large sports cohort, and future confirmatory studies are necessary to eliminate systematic errors.

Reporting and interpretation of the results is based on the guidelines for cross-sectional studies of the STROBE initiative (ISPM - University of Bern 2009). We assume our sample size to be adequately robust to represent the chosen cohort.

Finally, the comparison of pain experienced by sports students to athletes in other disciplines is limited. Reasons for this focus on the special multifactorial demands in sports studies. In addition, students between universities could differ due to different degrees of physical strain.


We can confirm a high period prevalence of pain (28%) among sports students, noting a relationship between pain and various factors in the context of a multifactorial biopsychosocial overload problem. It seems like the students feel left alone with their problems concerning various health and career aspects.

Therefore, the role of pain needs to be on increased focus in the public discussion. As the results of the survey emphasise development needs regarding pain management, the communication between students, lecturers, and universities need to be optimised. This re-evaluation of the treatment of injuries, pain, and health restrictions can be an initial step of preventing pain and health risks among sports students.


The experiments comply with the current laws of the country in which they were performed. Parts of this study constitute the Master Thesis (MA) of Anke Bumann. We thank Dr. Christian Koelbl, MD, PhD, Assistant Professor at Columbia University Division at Mount Sinai Medical Center, Miami Beach, USA to revise our manuscript. No funding was achieved for this study. The authors have no conflict of interest to declare.


Journal of Sports Science and Medicine Anke Bumann
Employment: PhD student and scientific researcher in exercise physiology and sports therapy at the Justus-Liebig-University Giessen.
Degree: M.A.
Research interests: The relationship between pain, injury and performance in sports, as well as coping strategies and sport psychological coaching.

Journal of Sports Science and Medicine Winfried Banzer
Employment: Professor, Institute of Occupational, Social and Environmental Medicine, Goethe-University, Frankfurt, Germany
Degree: Prof. Dr. med. Dr. phil. (MD PhD)
Research interests: Professor of sports medicine with a clinical and scientific focus on health prevention by means of physical activity.

Journal of Sports Science and Medicine Johannes Fleckenstein
Employment: Specialist anaesthesiologist, acupuncturist and sports physician.
Degree: Priv.-Doz. Dr. med. (MD)
Research interests: Electrophysiology of peripheral nerves and the functioning of neural ion channels to the somatosensory description of different types of pain.
Journal of Sports Science and Medicine Askling C., Saartok T., Thorstensson A. (2006) Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. British Journal of Sports Medicine 40, 40-44.
Journal of Sports Science and Medicine Überall M.l.A., Müller-Schwefe G.H.H., Nolte T., Kletzko H. (2015) Das integrierte Versorgungskonzept Rückenschmerz (IV-R) der IMC – Ergebnisse der ersten 10.000 Patienten. Schmerzmedizin 31, 28-41.
Journal of Sports Science and Medicine Bailer J., Schwarz D., Witthoft M., Stubinger C., Rist F. (2008) [Prevalence of mental disorders among college students at a German university]. Psychotherapie Psychosomatik Medizinische Psychologie 58, 423-429.
Journal of Sports Science and Medicine Beiter R., Nash R., McCrady M., Rhoades D., Linscomb M., Clarahan M., Sammut S. (2015) The prevalence and correlates of depression, anxiety, and stress in a sample of college students. Journal of Affective Disorders 173, 90-96.
Journal of Sports Science and Medicine Chu J.J., Khan M.H., Jahn H.J., Kraemer A. (2015) Comparison of Subjective Health Complaints between Chinese and German University Students: A Cross-Sectional Study. International Journal of Environmental Research and Public Health 12, 15794-15806.
Journal of Sports Science and Medicine Clement D., Arvinen-Barrow M., Fetty T. (2015) Psychosocial responses during different phases of sport-injury rehabilitation: a qualitative study. Journal of Athletic Training 50, 95-104.
Journal of Sports Science and Medicine Dannecker E.A., Koltyn K.F. (2014) Pain During and Within Hours After Exercise in Healthy Adults. Sports Medicine 44, 921-942.
Journal of Sports Science and Medicine Dawson M.A., Hamson-Utley J.J., Hansen R., Olpin M. (2014) Examining the effectiveness of psychological strategies on physiologic markers: evidence-based suggestions for holistic care of the athlete. Journal of Athletic Training 49, 331-337.
Journal of Sports Science and Medicine Deroche T., Woodman T., Stephan Y., Brewer B.W., Le Scanff C. (2011) Athletes' inclination to play through pain: a coping perspective. Anxiety Stress Coping 24, 579-587.
Journal of Sports Science and Medicine Dreiskämper, D., Tietjens, M. and Strauß, B. (2015) Sicherheit im Sportstudium: Empirische Studien zu Ursachen und Wirkungen von Unfällen im Sportstudium in NRW [Safety in sports studies: empirical studies on causes and effects of accidents in sports studies in North-Rhine Westphalia]. In German. Schriften zur Körperkultur 68. LIT Verlag Münster.
Journal of Sports Science and Medicine DVS (2016) German.
Journal of Sports Science and Medicine Fett D., Trompeter K., Platen P. (2017) Back pain in elite sports: A cross-sectional study on 1114 athletes. Plos One 12, e0180130.
Journal of Sports Science and Medicine Galli N., Vealey R. (2008) “Bouncing Back” from Adversity: Athletes’ Experiences of Resilience. The Sport Psychologist 22, 316-335.
Journal of Sports Science and Medicine Gerhardt C., Scheibel M. (2016) Schulterverletzungen im Leistungssport. Sport-Orthopädie - Sport-Traumatologie [Sports Orthopaedics and Traumatology] 32, 54-59.
Journal of Sports Science and Medicine Ghazaie M., Tajikzadeh F., Sadeghi R., Saatchi L.R. (2015) The comparison of pain perception, coping strategies with pain and self-efficacy of pain in athlete and non-athlete women. Journal of Fundamentals of Mental Health 17, 159-163.
Journal of Sports Science and Medicine Goldshmidt O.T., Weller L. (2000) "Talking emotions": Gender differences in a variety of conversational contexts. Symbolic Interaction 23, 117-134.
Journal of Sports Science and Medicine Gräfe K., Zipfel S., Herzog W., Löwe B. (2004) Screening psychischer Störungen mit dem “Gesundheitsfragebogen für Patienten (PHQ-D)“ [Screening of mental disorders with the "Patient Health Questionnaire (PHQ-D)"]. Diagnostica 50, 171-181.
Journal of Sports Science and Medicine Gunnell K.E., Mosewich A.D., McEwen C.E., Eklund R.C., Crocker P.R.E. (2017) Don't be so hard on yourself! Changes in self-compassion during the first year of university are associated with changes in well-being. Personality and Individual Differences 107, 43-48.
Journal of Sports Science and Medicine Hainline B., Derman W., Vernec A., Budgett R., Deie M., Dvorak J., Harle C., Herring S.A., McNamee M., Meeuwisse W., Lorimer Moseley G., Omololu B., Orchard J., Pipe A., Pluim B.M., Raeder J., Siebert C., Stewart M., Stuart M., Turner J.A., Ware M., Zideman D., Engebretsen L. (2017a) International Olympic Committee consensus statement on pain management in elite athletes. British Journal of Sports Medicine 51, 1245-1258.
Journal of Sports Science and Medicine Hainline B., Turner J.A., Caneiro J.P., Stewart M., Lorimer Moseley G. (2017b) Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. British Journal of Sports Medicine 51, 1259-1264.
Journal of Sports Science and Medicine Hauser W., Schild S., Kosseva M., Hayo S., von Wilmowski H., Alten R., Langhorst J., Hofmann W., Maus J., Glaesmer H. (2010) Validation of the German version of the Regional Pain Scale for the diagnosis of fibromyalgia syndrome. Schmerz 24, 226-235.
Journal of Sports Science and Medicine Heaney C.A., Walker N.C., Green A.J., Rostron C.L. (2015) Sport psychology education for sport injury rehabilitation professionals: a systematic review. Physical Therapy in Sport 16, 72-79.
Journal of Sports Science and Medicine Hupfeld J., Ruffieux N. (2011) Validation of a german version of the self-compassion scale (SCS-D) [Validierung einer deutschen version der self-compassion scale (SCS-D)]. Zeitschrift für Klinische Psychologie und Psychotherapie 40, 115-123.
Journal of Sports Science and Medicine IASP (2017) IASP Terminology. International Association for the Study of Pain.
Journal of Sports Science and Medicine IASP (2018) International Association for the Study of Pain.
Journal of Sports Science and Medicine Kleinert J. (2001) Clinical findings, emotional mood and pain-management as predictive variables of thehealing process at patients with supination trauma of the ankle joints [Klinischer Befund, emotionale Stimmung und Schmerzbewältigung als Prädiktoren des Heilungsverlaufs bei Patienten mit Sprunggelenktraumen: Eine Erkundungssstudie]. Deutsche Zeitschrift für Sportmedizin 52, 57-62.
Journal of Sports Science and Medicine Kohls N., Bussing A., Sauer S., Riess J., Ulrich C., Vetter A., Jurkat H.B. (2012) Psychological distress in medical students - a comparison of the Universities of Munich and Witten/Herdecke. Zeitschrift für Klinische Psychologie und Psychotherapie 58, 409-416.
Journal of Sports Science and Medicine Mayer J., Thiel A. (2011) Verletzungen im Leistungssport aus soziologischer Perspektive. Sportwissenschaft 41, 124-136.
Journal of Sports Science and Medicine Moegling, K. (2006) Über die Grenzen des Körpers hinaus: Überforderungen, Verletzungen und Schmerz im Leistungssport [Beyond the physiological limits: overload, injuries and pain in elite athletes]. Immenhausen bei Kassel: Prolog Verlag. In German.
Journal of Sports Science and Medicine Morfeld, M., Kirchberger, I. and Bullinger, M. (2011). Fragebogen zum Gesundheitszustand: SF-36, deutsche Version des Short Form36 Health Survey, Manual [SF-36 Health Survey, German Version]. Göttingen: Hogrefe. In German.
Journal of Sports Science and Medicine Nübling, M., Andersen, H.H. and Mühlbacher, A. (2006) Entwicklung eines Verfahrens zur Berechnung der körperlichen und psychischen Summenskala auf Basis der SOEP-Version des SF 12 (Algorithmus) [Development of a method for the calculation of the physical and psychological sum scale based on the SOEP version of the SF 12]. In German. DIW Data Documentation 16, Deutsches Institut für Wirtschaftsforschung (DIW), Berlin.
Journal of Sports Science and Medicine Nagel B., Pfingsten M., Lindena G., Nilges P. (2012) Deutsche Schmerzgesellschaft e.V. Version 2015.
Journal of Sports Science and Medicine Nezhad M.A.S., Besharat M.A. (2010) Relations of resilience and hardiness with sport achievement and mental health in a sample of athletes. Procedia - Social and Behavioral Sciences 5, 757-763.
Journal of Sports Science and Medicine Nilges P., Essau C. (2015) Depression, anxiety and stress scales: DASS--A screening procedure not only for pain patient. Schmerz 29, 649-657.
Journal of Sports Science and Medicine Nixon H.L. (1994) Coaches’ Views of Risk, Pain, and Injury in Sport, with Special Reference to Gender Differences. Sociology of Sport Journal 11, 79-87.
Journal of Sports Science and Medicine Pedrelli P., Nyer M., Yeung A., Zulauf C., Wilens T. (2015) College Students: Mental Health Problems and Treatment Considerations. Academic Psychiatry 39, 503-511.
Journal of Sports Science and Medicine Putukian M. (2016) The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine 50, 145-148.
Journal of Sports Science and Medicine Raes F. (2011) The Effect of Self-Compassion on the Development of Depression Symptoms in a Non-clinical Sample. Mindfulness 2, 33-36.
Journal of Sports Science and Medicine Reed S., Giacobbi P.R. (2004) The Stress and Coping Responses of Certified Graduate Athletic Training Students. Journal of Athletic Training 39, 193-200.
Journal of Sports Science and Medicine Reis N.A., Kowalski K.C., Ferguson L.J., Sabiston C.M., Sedgwick W.A., Crocker P.R.E. (2015) Self-compassion and women athletes' responses to emotionally difficult sport situations: An evaluation of a brief induction. Psychology of Sport and Exercise 16, 18-25.
Journal of Sports Science and Medicine Richartz A. (2001) "Alles halb so schlimm!" Wie junge Athletinnen und Athleten Schmerzen und Verletzungen bewältigen. Leistungssport 31, 47-52.
Journal of Sports Science and Medicine Salati U., Doody O., Munk P.L., Torreggiani W. (2017) Evaluation of Knee Pain in Athletes: A Radiologist's Perspective. Canadian Association of Radiologists Journal 68, 27-40.
Journal of Sports Science and Medicine Schlarb A.A., Classen M., Hellmann S.M., Vogele C., Gulewitsch M.D. (2017) Sleep and somatic complaints in university students. Journal of Pain Research 10, 1189-1199.
Journal of Sports Science and Medicine Schmidt, S. (2016) Expertenstandards in der Pflege - eine Gebrauchsanleitung [Expert Standards in Nursing]. 3., aktualisierte u. erw. Aufl. 2016 edition. Berlin, Heidelberg: Springer Berlin Heidelberg. In German.
Journal of Sports Science and Medicine Statistisches_Bundesamt. (2014) Bildung und Kultur-Studierende an Hochschulen [Education and culture - Students at universities]. Available from URL:
Journal of Sports Science and Medicine Stock C., Kucuk N., Miseviciene I., Habil Guillen-Grima F., Petkeviciene J., Aguinaga-Ontoso I., Kramer A. (2003) Differences in health complaints among university students from three European countries. Preventive Medicine 37, 535-543.
Journal of Sports Science and Medicine Strong J., Mathews T., Sussex R., New F., Hoey S., Mitchell G. (2009) Pain language and gender differences when describing a past pain event. Pain 145, 86-95.
Journal of Sports Science and Medicine Thiel, A., Digel, H. and Mayer, J. (2010) Gesundheit im Spitzensport: Eine sozialwissenschaftliche Analyse [Health and elite sports: a social science analysis]. Schorndorf: Hofmann. In German.
Journal of Sports Science and Medicine Uberall M.A., Emrich O.M.D., Muller-Schwefe G.H.H. (2017) Real-life efficacy and tolerability of methocarbamol in patients suffering from refractory muscle-related low/back pain - Results of a health care research project based on data from the German pain practice registry. MMW Fortschritte der Medizin 159, 6-17.
Journal of Sports Science and Medicine Wesch N., Hall C., Prapavessis H., Maddison R., Bassett S., Foley L., Brooks S., Forwell L. (2012) Self-efficacy, imagery use, and adherence during injury rehabilitation. Scandinavian Journal of Medicine & Science in Sports 22, 695-703.
Journal of Sports Science and Medicine Wiese-Bjornstal D.M. (2010) Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement. Scandinavian Journal of Medicine & Science in Sports 20, 103-111.
Journal of Sports Science and Medicine Zagorska A., Guszkowska M. (2014) A program to support self-efficacy among athletes. Scandinavian Journal of Medicine & Science in Sports 24, e121-128.
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