Behind the performance: How cultural and system-level factors shape injury experiences in track and field athletes in low-middle-income settings

Track and field athletes experience a high injury burden affecting physical health, psychological wellbeing, and career progression. While quantitative studies have documented injury incidence and risk factors, limited qualitative research explains how cultural norms, communication practices, and system-level constraints shape injury experiences, particularly in low- and middle-income country (LMIC) settings. This study aimed to explore how cultural expectations, social relationships, communication networks, and structural conditions influence injury reporting, training behaviours, and recovery experiences among Sri Lankan track and field athletes. This qualitative analysis drew on in-depth, semi-structured interviews with elite and highly trained track and field athletes and key stakeholders, including coaches, physiotherapists, sports medicine practitioners, sports administrators, and parents. All interviews were conducted face-to-face or online, audio-recorded, and transcribed verbatim. Data were analysed using reflexive thematic analysis and interpreted within the socio-ecological model (SEM). SEM mapping revealed that injury experiences were shaped by influences across individual, interpersonal, organisational, community, and system levels, captured in five interrelated themes: (I) social and cultural pressures shaping injury behaviour; (II) injury underreporting and overtraining; (III) barriers and facilitators to injury prevention; (IV) quality of athlete support and communication networks; and (V) system-level challenges in injury management. Athletes described a performance-oriented culture that normalised pain, leading to injury concealment and continued training despite inadequate recovery. Coach-centred and fragmented communication, financial insecurity, limited access to specialised care, and weak organisational infrastructure further constrained prevention and rehabilitation. Effective injury prevention in LMIC contexts requires context-sensitive, multidisciplinary strategies that strengthen communication, address structural barriers, and prioritise athlete health alongside performance.