Health research has been increasingly concerned with the phenomenon of attending work while ill. In the sports context, keeping up social functioning despite health concerns is a common phenomenon as well. However, social practices referred to as ‘playing hurt’, ‘playing through pain’, or ‘competing injured’ have only recently been linked to general presenteeism discourses in the health sciences. Considering findings from other work settings, we argue that presenteeism in sports (and beyond) is a highly complex phenomenon that can take on different forms; is caused by multiple, interrelated factors; and is associated with observer-dependent consequences. To capture these complexities, we developed a holistic decision-based framework for understanding athlete presenteeism in sport organisations. On the basis of systems theory considerations, the presented process–structure model about competing hurt decision-making integrates empirical findings about health and injury management in elite sports and refers to relevant knowledge from general presenteeism research. As the appropriate management of presence and absence is a delicate balancing act, further efforts are necessary to differentiate the generative mechanisms leading to presenteeism and to clarify the multidimensional consequences on the premise that athletes’ rights and welfare should be given priority.