Navigating performance and professional duty: UK physiotherapists' experiences of speaking up in elite sport.

OBJECTIVES: To explore perceived barriers and enablers influencing physiotherapists' willingness to speak up about safety and ethical concerns within elite sport environments. DESIGN: Exploratory descriptive qualitative study. SETTING: Fifteen physiotherapists working in UK elite sport participated in semi-structured interviews. PARTICIPANTS: Participants were recruited through purposive and snowball sampling. Interviews were conducted via video conferencing and analysed using reflexive thematic analysis. RESULTS: Four interrelated domains shaped speaking up behaviour: (1) cultural dynamics, including hierarchical structures and performance-driven norms; (2) structural factors, such as employment precarity and unclear reporting systems; (3) interpersonal risk, including fear of reputational damage and not being believed; and (4) enabling conditions, including supportive leadership, trust within multidisciplinary teams and transparent processes. Participants described tension between their professional duty to raise concerns and the realities of working within high-performance systems. Employment insecurity and the interconnected nature of elite sport amplified perceived personal risk. CONCLUSIONS: Despite strong professional and moral commitment to athlete welfare, physiotherapists' willingness to speak up is shaped by organisational culture, leadership behaviours and structural protections. Creating environments that support open dialogue is essential to safeguarding athlete welfare and enabling physiotherapists to fulfil their professional obligations within elite sport systems.