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AchillesAl part 3: Psychosocial considerations in Achilles pain

7 Dec, 16 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport


By Tom Goom @TomGoom, Sports Physiotherapist at the Physio Rooms and the creator of Running Physio; lead on Running Repairs Course

After a short hiatus we’re back with #AchillesAl part 3. We’ve touched upon training error and how to modify training to find the right level in parts 1 and 2. Next we have a couple of tricky questions from Al and have to consider the psychosocial factors in tendon pain…

“Will continuing to run damage my tendon?”

“Is it likely to lead to a rupture?”

We had some great discussion of this on social media. Check out the hashtag #AchillesAl and once again we invite you to tweet along and share you thoughts on this blog with @BJSM_BMJ and @Physiosinsport. @SportsTherapy56 was in fine form again- sharing some great recent tendon research, follow his thread here.

I think it’s fair to say the focus in tendinopathy research to date has mainly been on building load capacity and on the tendon itself. The role of psychosocial factors such as thoughts, feelings and beliefs around pain are discussed less often despite evidence of their importance in sports injury (Forsdyke et al. 2016). This is beginning to change though with a new systematic review just published in BJSM from Adrian Mallows and colleagues – Mallows et al. (2016). In addition, this excellent review of patellar tendinopathy from Malliaras et al. (2015) covers both psychosocial factors and central sensitisation.

Adrian has kindly shared some insights from his recent research;

“The findings of the review suggest that taken as a whole, there is conflicting evidence as to the significance of psychological variables in tendinopathy. However, specific psychological variables may be associated with tendinopathy and suboptimal outcomes from treatment. Conflicting evidence exists surrounding the significance of the association of anxiety, depression and lateral epicondylalgia. However, strong evidence suggests lateral epicondylalgia is not associated with kinesiophobia. Moderate evidence links catastrophisation and distress with lateral epicondylalgia, with distress being associated with a less than 50% reduction in pain at twelve months. Conflictingly, moderate evidence suggests distress is not associated with rotator cuff tendinopathy, but kinesiophobia and catastrophisation are. However, this may not lead to a suboptimal outcome. Limited evidence exists linking psychological variables and Achilles tendinopathy and patella tendinopathy, but current evidence suggests patella tendinopathy is not associated with anxiety or depression and kinesiophobia may be linked with suboptimal outcomes in Achilles tendinopathy.

Being aware that psychological variables may be associated with tendinopathy could assist the clinician in optimising management by utilising strategies to help overcome or reduce their influence. This may be particularly important when considering more invasive procedures such as surgery, as they are associated with negatively influencing outcomes (Brand and Nyland 2009, Cobo Soriano et al. 2010, Judge et al. 2012). As such, when a person is suspected to have tendinopathy, clinicians should firstly consider using validated screening tools for the presence of psychological variables. Secondly, although future testing by research is required, adopting an individualised management approach which aims to influence hope and positive beliefs (Benedetti et al. 2013) places emphasis on neuroscience education (Louw et al. 2011) or addresses individual cognitive behavioural barriers (Vibe Fersum et al. 2013) whilst maximising working alliance (Ferreira et al. 2012, Fuentes et al. 2014, Hall et al. 2010) are all plausible strategies to adopt in conjunction with a graded loaded programme (Littlewood et al. 2015, Malliaras et al. 2013)”

Follow Adrian on Twitter via @ajmallows1

In a clinical setting concern about damaging or rupturing the tendon appears quite common and emerging research suggests it may be a barrier to rehab. We’ve developed TendonQ, a questionnaire to help screen for factors that might influence tendon health and response to rehab. Many patients, especially with longstanding symptoms, reveal regular concerns about tendon damage, so Al is not alone in this!

Before we try to answer Al’s questions it might help to find out a little more about Al’s beliefs about his pain…

PT, “What do you think is happening within your tendon to make it painful?”

Al, “I’ve read that the tendon develops micro-ruptures that build up over time and these cause pain. If you keep running eventually this can lead to the tendon rupturing altogether.”

Beliefs like Al’s above aren’t that unusual. Sometimes we can even add to them! In insertional tendinopathy clinicians often recommend that people avoid activity that compresses the tendon. This may be sensible initially but can lead to long term patterns of avoidance if patients see these activities as damaging to the tendon. Choose your words carefully!

A positive perception of return to sport is associated with a greater likelihood of returning to your pre-injury level (Ardern et al. 2013) and confidence in the injured area can be an important part of that. It’s hard to have confidence and a positive perception if you see exercise as damaging. It may also increase perceived threat which could influence symptoms.

Perhaps a more positive message would be something like this,

PT, “Tendons are amazing, adaptive tissue. They get stronger with exercise a little bit like muscle does so regular exercise can reduce the risk of rupture rather than increase it. They tend to hurt not because of micro-ruptures or damage as such but simply because they’ve been overworked. Looking back at your training we can see that the achilles load has increased quite quickly. The tendon reacts to this with swelling and discomfort but this settles once the excess load is reduced.”

Al, “So running won’t damage the tendon, providing I don’t do too much?”

PT, “That’s right. We’ve modified your training to a level which should help encourage your tendon to adapt. We can then build up gradually towards your marathon. The tendon thrives with consistent exercise, it struggles if we fluctuate too much, both with big increases AND decreases in activity.”

There’s a good example of this final point from the NFL in 2011. An enforced ‘lockout’ prevented the usual 14 week pre-season training and instead resulted in a period of relative inactivity followed by an intensive training camp to prepare for the season in just 17 days! The results are startling – pre-season achilles tendon ruptures increased 4 fold! Approximately 8 achilles tendon ruptures might be expected in an entire season, in 2011 there were 10 within the first 12 days of training!

Putting this into a simple, positive message for Al, “It’s better for the tendon to keep running at a manageable level and loading the tendon than to stop altogether and start again.”

Every patient will require a different approach to discussing pain and re-framing the injury in a more positive light. Some may become fear-avoidant or concerned about long term implications. It isn’t unusual for some patients to have tried multiple treatment approaches without success. Understandably they can become despondent and deserve our support and empathy. The Pain Catastrophising Scale (PCS) can be a useful assessment tool in those with prolonged or severe symptoms. It helps to appraise a patient’s view of their symptoms and the impact they’re having on their life. Higher PCS scores (typically >30) may indicate a clinically relevant level of catastrophising and suggest treatment focuses more on pain education and self-management at least until this improves.

A pain monitoring approach is favoured in management of tendinopathy (as discussed in part 2) using a pain score out of 10 during activity and assessing symptom response over the following 24 – 48 hours. Such an approach can be very helpful in guiding a gradual progression of tendon loading, however, psychosocial factors may influence pain scores and symptom response. Recent work in DOMS (Delayed Onset Muscle Soreness) suggest that an athlete’s fear avoidance beliefs and trait anxiety before injury may influence reports of their pain intensity after exercise. Might we see a similar impact in tendinopathy? If so what would be the implications for how we use the pain monitoring system in those with evidence of fear avoidance and negative beliefs about pain? Share your thoughts on #AchillesAl.

Patient’s expectations and our own can be important part of tendon rehab. In particular understanding the timescales involved is key. For the patient, so they can expect 3 to 6 months of rehab, and for us so we don’t abandon a loading programme when we don’t seen changes in a couple of sessions.

Stress and lifestyle

Stress can delay healing (Alford 2006) and impair response to resistance training (Bartholomew et al. 2008). When building strength and load capacity is such a central part to tendon rehab stress could represent a significant barrier.

Chatting to Al about his general health we ask, “How are your stress levels?”

“Not good!” He replies, and explains that he works long hours, gets very little ‘downtime’ to recover, and isn’t sleeping well. He runs his own IT business and says it feels like he’s ‘constantly working’ (sound familiar?!). He uses coffee and sugary snacks to keep him awake during the day only to find he’s then wide awake at night! The dreaded, ‘caffeine cycle’ (courtesy of @Twisteddoodles)…

Al’s has been coping like this for quite some time and the upshot is he now has hypertension and raised cholesterol alongside more stress as he struggles to get by on 5 or 6 hours sleep a night. He uses the running to help manage this stress (and lower his cholesterol) which adds a further level of complexity to his desire to continue running. A purely practical consideration too with such a lifestyle is how will Al fit any rehab in? This may well have an impact on our exercise selection, when we come to it.

These lifestyle factors may have a very direct link on Al’s tendon health. Hypertension has been associated with tendon pain (Abate et al. 2009) and raised cholesterol is thought to impair type I collagen production and reduce tendon strength and energy storage capacity (Scott et al. 2014). Less is known about diet although a diet rich in saturated fat causes significant tendon metabolic and structural alterations in mice (Scott and Nordic 2016).

Stress and lifestyle may well then influence pain, rehab and response to treatment. This highlights how a very tendon focussed approach may miss the important bigger picture in tendinopathy.

What we don’t know yet is how much of an impact these factors have on symptoms and function in tendinopathy. Equally though it isn’t always clear from the research what role biomechanics, muscle strength, flexibility and movement control have in pain. The challenge is to identify which factors are key for each individual patient.

A fascinating study in the Israeli Army reported that sleep can have a significant role in injury prevention (Finestone and Milgrom 2008). Combining a minimal sleep duration of 6 hours per night with a modified training regime helped reduce stress fracture incidence from 31% to less than 10%. This mirrors what we might aim to do in tendinopathy – identify relevant psychosocial factors and address them alongside addressing tissue load and load capacity. Further research is required however to determine the effects of sleep, lifestyle and psychosocial factors on symptoms and outcomes in painful tendinopathy.

These issues raises some interesting questions too and we’d love to hear your thoughts on this;

What is our role in addressing lifestyle factors including mental health? Are we equipped to do this?

Share your views on #AchillesAl.

Hopefully our discussion with Al with have reassured him that exercise has a positive effect on tendon health but we want to ensure this message is understood. Asking open questions like, “how might you describe what’s happened to your tendon to a friend?” Or “what key points have you taken from today’s session?” Might help clarify if we’ve helped change Al’s beliefs.

It may not be within our role to advise on mental health and diet in detail but we can act as a signpost towards the right services and resources such as suggesting Al speaks to his GP or counsellor about his stress or contacts a dietician regarding diet. Free online resources such as the mental health foundation website can be a great help, they also produce a free download to improve sleep.

Sometimes suggesting a subtle attitude change can help, one that moves away from self admonishment and criticism towards self care for both physical and mental wellbeing;

We have to recognise our limitations here though and, ideally, work together for the patient within an integrated multi-disciplinary team wherever indicated.

In part 4 we’ll be discussing exercise selection for Al’s achilles. Until then we’d love to hear your thoughts on some of the questions and issues raised in this piece. Join the discussion on #AchillesAl all views welcome!

USEMS 2016 National Student Sports Medicine Conference – The Highlights!

6 Dec, 16 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog

By Tej Pandya


Manchester SEMSoc Committee – conference organisers.

The 2016 USEMS Student sports medicine conference was held in Manchester on Saturday 12th November. One hundred and fifty keen students attended from all across the UK -representing many different professions. It was fantastic to see such a high level of interest in sports medicine from undergraduates. Below are three of the biggest conference themes,  highlights, & further resources on these key topics – enjoy! ….

Over training syndrome – a condition that we all need to think about

Dr Leon Creaney (@AthleticsDrLeonA) kick started the day with a brilliant talk explaining the concept of over-training in elite athletes. He explained how we can spot over training syndrome (also known as unexplained underperformance syndrome) – having the same training load but recurrent decrease in performance. Causes of this include: rapid increasing in training volume, lack of recovery and training greater than 10% of the day (2.4 hours) in a 24-hour period.1 Careful monitoring is essential to prevent over training. With no specific treatment other than prolonged rest and graduated return to exercise, this can be a frustrating time for both the athlete and the medical team.

Event medical cover is a great way to gain experience in SEM

Dr Clint Gomes (@drclintgomes) fantastically explained what is involved in providing event medical cover at major cycling championship events.2 Getting skilled up- either as a medical student with organisations such as St John Ambulance or as a doctor on courses such as AREA/SCRUMCAPS is key to making yourself flexible. He also gave these tips for success: knowing the sport and type of injuries you may encounter, recognizing and working within the limits of your competence, and not being in “spectator mode” during the event. If working for a smaller club, selecting your own medical kit and asking the club to reimburse your costs will help you to be fully prepared on match days. Finally, after the event, reflect on what went well and what could be better, so that you be even better next time! To hear more about this, listen to the brilliant BJSM podcast by  Prav Mathema.

Motivational interviewing can be useful technique for behavior change 

The brilliant Dr Amal Hassan (@oh_amalhassan) spoke in the afternoon about how we can motivate our patients to be more physically active.  The vicious cycle of: presenting to the doctor, inadequate exercise advice, increasing pain and symptoms leading to the belief that “exercise will make it worse” and then returning to the doctor is a key example of where motivational interviewing can be used to change attitudes. Where possible, using the patients own language, clarifying understanding and asking open questions can help build the collaborative relationship- remember change is not short term!

Be wary of “Female Athlete Triad” in your female athletes

Dr Isobel Heyworth (@IsobelHeyworth) spoke passionately about the importance of recognizing chronically low energy availability, menstrual dysfunction and low bone mineral density in female athletes –  commonly referred to as “The Female Athlete Triad.” 2 Often these symptoms can be difficult to measure in an amateur setting- make sure to ask the difficult questions! Recovery of energy status may well be days or weeks but it can take years to recover bone mineral density so it is important to emphasize this to your patient.

Huge thanks to all organizers, attendees, and presenters!

Thanks to all the fantastic speakers who gave up their time on a Saturday to come to rainy Manchester! Also, thanks to all the sponsors, including our platinum sponsor BASEM, to help keep the costs down and support undergraduate education.


  1. Seene T, Kaasik P, Alev K, Pehme A, Riso EM. Composition and turnover of contractile proteins in volume-overtrained skeletal muscle. International journal of sports medicine. 2004 Aug;25(06):438-45.
  2. De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G, Barrack M. 2014 Female Athlete Triad Coalition Consensus Statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. British Journal of Sports Medicine. 2014 Feb 1;48(4):289-.


Tej Pandya is an intercalating medical student at the University of Manchester and currently President of the Manchester Sports and Exercise Medicine Society (@semsocuk). All enquiries can be directed to

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee.

Please send your blog feedback and ideas to:


Can I get a pound for every time someone says collaboration? Take home messages from the UK Sports Concussion Research Symposium

3 Dec, 16 | by BJSM

By James Murphy

The UK’s first Sports Concussion Research Symposium started with a warm welcome by Velicia Bachtiar (Drake Foundation1) and Dr Simon Kemp (Rugby Football Union (RFU)). Dr Charlotte Cowie (Football Association (FA)) then kicked off official proceedings. This day brought together the concussion and traumatic brain injury communities that in the past have been disconnected. It called for collaboration – a key concept of the day!


Picture credit:

Session 1 – Current UK Sports Concussion Research Landscape

Challenges to Concussion Research (Dr Charlotte Cowie and Professor Keith Stokes)

Factors that hamper research:

  • concussion not a current priority within the sport of your research area
  • funding issues may restrict the size of studies or prevent them from starting in the first place.


Dr Simon Kemp brightly opened by confirming that for the RFU, concussion is the number one medical priority. He confirmed that across sports it is now widely recognised that governing bodies and clubs have a duty to consider the long term health of those playing their game.

To make significant advances in the field, larger projects need to take place, but you:

  • can still ‘do your own thing’
  • should have some commonality with other studies
  • should use common data elements (for comparison and metanalysis purposes).

Opportunities (Academia) – Prof David Menon

We need to ensure we are all talking about the same thing before we start comparing our results. To this end he defined TBI as: “an alteration in brain function, or other evidence of brain pathology, caused by an external force”. (2)

Session 2 – Snapshots of UK Sports Concussion research in progress

In this session researchers presented methodology and some preliminary results from their work.

Results of RECOS programme (Professor Tony Belli, University of Birmingham)

  • Changes in some specific mRNAs may also allow prediction of symptom severity and clinical course.

Football heading produces immediate changes in brain function (Dr Magdalena Letswaart, University of Sterling)

  • Repeated heading of a football affected patient’s cognition and memory over the following 24 hour period – although further work required! (3)

Developing biomarkers for concussion (Dr Etienne Laverse, University College London)

  • Previous research has shown that Neurofibrillation light chain is a marker of subconcussive head injuries – further research planned in rugby players!

Neuroimaging for the evaluation of traumatic brain injury (Professor David Sharp, Imperial College London)

  • David Sharp showed how MRI techniques can show evidence of axonal injury after concussion
  • Do changes in biomarkers precede clinical symptoms?

Investigating the effects of concussion on schoolboy rugby union players: a pilot study of epidemiology and rehabilitation (Dr Éanna Falvey, Sports Surgery Clinic, Dublin)

  • Is exercise below the level at which patients are symptomatic beneficial in their rehabilitation from a concussive injury. This research leads on from studies in America by JJ Leddy et al (4).

The International Concussion and Head Injury Foundation Study LINK (Dr Michael Turner, ICHIRF)

  • This study will compare the incidence and age of onset of depression, suicide and neurodegenerative disorders in retired jockeys versus aged matched controls.

Safer systems for return to play decisions: the promise of integrating neurocognitive testing and neuroimaging (Professor Huw Williams, Univeristy of Exeter)

  • This work by Professor Huw Williams aimed to ensure a safer return to play for athletes. His work is currently looking at the neuroimaging and neurocognitive tests of concussed elite and university rugby players.

Brain health and healthy AgeINg in retired rugby players: The BRAIN study (Valentina Gallo, Queen Mary University London and Professor Neil Pearce, London School of Hygiene and Tropical Medicine)

  • The researchers will compare physical and cognitive capabilities, biomarkers and intermediate neurological endpoints to determine if there are any long term health risks associated with playing rugby.

Session 3 – Breakout

In the middle of the afternoon the delegates split off into groups and discussed many of the key topics in this area: concussion diagnosis, management, surveillance and long term health impacts to name a few. Group facilitators reported back on each group’s discussion.

What were the talking points?

  • A concussion definition could focus on symptoms and signs of the injury as this is what is used in its diagnosis- this should include a reference to traumatic brain injury.
  • For effective concussion surveillance standardised definitions of concussion and methods of diagnosis should be used – we can achieve this through collaboration.
  • We do not yet know the effect of head impacts on long term health.
  • Any head impact could be subconcussive, more work is needed here.
  • Do the physical, cognitive and social benefits of participating in sport outweigh the neurocognitive risk? It is up to each individual to decide and for healthcare professionals to inform players as best as they can.

Symposium summary

Professor Mark Batt closed the day with a summary of key points. His call to action was for research groups to pull together and collaborate! Is it possible to create vast research networks such as ARUK’s Centre for Sport, Exercise and OA, focused purely on concussion? (5) He underlined the amount of funding there is for concussion research in America, and that researchers need access to similar sums in the UK.

A great day, if you have any of the answers to the questions above, feel free to pen a blog on them, and get in touch with those currently undertaking this important research!


The Drake Foundation – ‘About us’ – Accessed 24/11/16

Position statement: definition of traumatic brain injury. Menon DK, Schwab K, Wright DW, Maas AI Arch Phys Med Rehabil 2010;91: 1637-40.

Thomas G. Di Virgilio, Angus Hunter, Lindsay Wilson, William Stewart, Stuart Goodall, Glyn Howatson, David I. Donaldson, Magdalena Ietswaart, Evidence for Acute Electrophysiological and Cognitive Changes Following Routine Soccer Heading, EBioMedicine, Volume 13, November 2016, Pages 66-71, ISSN 2352-3964,

John J. Leddy, John G. Baker, Barry Willer, Active Rehabilitation of Concussion and Post-concussion Syndrome, Physical Medicine and Rehabilitation Clinics of North America, Volume 27, Issue 2, May 2016, Pages 437-454, ISSN 1047-9651,


James Murphy has completed four years of medicine at Newcastle University and is currently intercalating on the MSc Sports and Exercise Medicine course at the University of Nottingham. 

Will training load modification reduce the incidence of anterior cruciate ligament ruptures in netball?

30 Nov, 16 | by BJSM

By Zoe Rippon

Netball is the most common female team sport played in Australia and New Zealand. The elite professional netball league (ANZ championship) includes 10 teams across Australia and New Zealand. The high physical demands of the sport from sprinting, maximal jump landing (often with contact), change of direction and the rules only allowing one step after landing with the ball causes a significant risk of knee injuries to athletes. Between 2008 and 2015 Stuelcken et al, [1] found 21 athletes tore their anterior cruciate ligament (ACL) despite multiple screening tools and prevention measures in place to reduce the risk of these injuries. These injuries were sustained by either indirect contact (landing following a collision), non-contact (landing with no contact) or changing directions. ACL ruptures are still happening at an alarming rate with five female athletes nameable from the 2015/2016 campaign requiring ACL reconstructive surgery.

Laura Geitz jumping. Photo: Matt King / Getty Images

Could this be a training load issue? [2]

Training load is important to consider due to the competitive mentality of athletes to be the best; training harder and longer will enable them to perform better. This training mentality often pushes athletes  to extreme physical limits. Overloading does not only cause overuse injuries; it is thought to contribute to acute soft tissue injuries as well. [2] Gabbett 2016, [2] describes the ‘Training-Injury Prevention Paradox’ established from current evidence that non-contact soft tissues injuries are a result of an incorrect training regimes. His research states that consistent loading from training has a reduced risk of injury of less than 10% (based on extrinsic factors (GPS) or intrinsic factors (rateable perceived value)) if training load was 5% less or 10% more than the previous week. Injury risk increased rapidly to between 21% and 49% If the load increased by 15% or more.

Figure 1: Ratio of acute:chronic training load. Acute = is recent training load. Chronic = moderate-term training load. Green area where reduced injury risk where acute training load is graduated at 0.8-1.3 of the chronic training load. [2]

Figure 1: Ratio of acute:chronic training load. Acute = is recent training load. Chronic = moderate-term training load. Green area where reduced injury risk where acute training load is graduated at 0.8-1.3 of the chronic training load. [2]

The non-contact nature of these injuries leads to the questions: does overloading of the ACL in netball via the sudden deceleration mechanism during a running, jump, land and stop add to the high incident of ACL ruptures? Is there micro trauma/weakening or even previous partial tears that are undetected that make individuals prone to the ACL rupture?  Does inappropriate loading lead to fatigue of the hip muscles, trunk muscles and/or hamstrings and then cause a high strain on the ACL? [1,3,4] Does mental fatigue have an effect on neuromuscular control? [5] It’s not as if we can pre-scan the ACL or do testing just before the injury to answer our questions and therefore we rely on documentation of the injuries including their mechanism. There are plenty of questions and not many clear answers. What we can establish from the literature is that the contributing factors are multifactorial. [1]

For minimising ACL injury risk we also need to take into account other factors that affect load on the netball athletes: [6]

  • Age of the athlete
  • Individual factors – biomechanics, neuromuscular control, BMI, physiological systems, psychological factors (confidence, determination)
  • Equipment – netball shoes, floor surface (grip and shock absorption)
  • Position on the netball court – requires different amounts of jumping, landing and running
  • Level of the athlete e.g. development, experienced, length of time in team
  • Athletes who play more than one sport
  • Nutrition and recovery methods

The million-dollar question – what is the optimal training load for our netball athletes?

Optimal training loads are challenging to research and compare. Athletes or Coaches at the elite level do not want to share their information as possibly this is what gives them the edge over their competitors. Getting the load of training right not only reduces the athlete’s injury risk it also maximises their ability to perform. Reduction in injuries allows for maximal training and game time and more athletes available for competition. [2]

ACL injuries don’t just happen at the elite level, this is right through from juniors, recreational players, up (but aren’t well documented at these other levels). From my experience playing at a premier club level, the focus is on movement patterns and strength, but based on the Training-Injury Prevention Paradox model we need to start educating coaches and players on load management and appropriate training principles if we want to minimise non-contact injury risk further. [2] This training principle not only applies to preseason training and in season training and games, we can also use it to guide rehabilitation and a safe return to sport.


Zoe Rippon is a Postgraduate student in sports physiotherapy at the University of Otago. She has an interest in netball injuries and prevention being a player herself. She also works in Private Practice at Muscle People Physiotherapy, Christchurch, New Zealand.


1 Stuelcken M, Mellifont D, Gorman A, et al. Mechanisms of anterior cruciate ligament injuries in elite women’s netball: a systematic video analysis. J Sports Sci 2016;34:1516-1522. doi: 10.1080/02640414.2015.11211285 [published Online First: 8 December 2015].

2 Gabbett T. The training-injury prevention paradox: should athletes be training smarter and harder? Br J Sports Med 2016;50:273-280. Doi:10.1136/bjsports-2-15-095788 [published Online First: 12 January 2016].

3 Guelich D, Xu D, Koh J, et al. Different roles of the medial and lateral hamstrings in unloading the anterior cruciate ligament. The Knee 2016;23:97-101. doi: 10.1016/j.knee.2015.07.007 [published Online First: 6 August 2015].

4 Bossuyt F, Garcia-Pinillos F, Raja Azidin R, et al. The utility of a high intensity exercise protocol to prospectively assess ACL injury risk. Int J Sports Med 2016;37:125-133 doi: 10.1055/s-0035-1555930 [published Online First: 28 October 2015].

5 Halson S. Monitoring training load to understand fatigue in athletes. Sports Med 2014;44:S139-S147 doi: 10.1007/s40279-014-0253-z [published Online First: 9 September 2014].

6 McGrath A, Ozanne-Smith J. Attacking the goal of netball injury prevention: a review of the literature. Monash University Accident Research Centre 1998:1-105 (assessed: 24 September 2016).



Five pearls from the first Swiss Sports and Exercise Medicine Student’s Day – for future doctors

26 Nov, 16 | by BJSM

Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine Blog Series

By Justin Carrard, @Carrard.Justin

I am very honored to launch the new Swiss Junior Doctors and Undergraduate Perspective blog series. This series will help amplify Sport and Exercise Medicine (SEM) as a medical specialty in our country. It will also encourage dialogue and raise awareness about SEM issues, both unique to Switzerland, and global. Topics of interest will likely include: (i) access to ‘hands-on’ learning opportunities (ii) strategies to raise awareness about and implement physical activity in the daily care of patients, (iii) the integration of research and practice.


The Swiss Society for Sports and Exercise Medicine (SGSM) recently held its first Student’s Day in Interlaken1. A diverse lineup of Swiss SEM experts shared their insights. Presenters included: Dr. André Leumann (sports orthopaedic surgeon), Dr. Boris Gojanovic (sports physician), Dr. Patrik Noack (sports physician) and Prof. Matthias Wilhelm (sports cardiologist).

The goal of the conference was to introduce students to key aspects of SEM. I greatly enjoyed the day, and share my 5 take home messages.

Which postgraduate training is the most appropriate to become a sports doctor in a country that does not have SEM speciality?

As explained in the editorial of the recent Swiss BJSM edition1, Switzerland is one of the European countries in which SEM is not yet a speciality. Thus, it could be a bit tricky for medical students to find their way to become a sports doctor. In our country, about 60% of all sports doctors have a general medicine postgraduate training: about 15-20% are orthopaedic surgeons, 10-15% are physiatrists and 10% have another specialty (e.g., paediatrics, cardiology and respiratory medicine). Medical students should then basically decide whether they prefer to work in a practice, in an operating theatre or in a rehabilitation setting. As Dr. Patrik Noack highlighted through fascinating clinical cases, a broad clinical training base (such as the one of a general practitioner) is suitable for somebody who is keen to become a team doctor and work on the sporting fields. While the Swiss training for general medicine enables a lot of rotations in different specialties (additionally to the core training in internal and general medicine), the following areas are recommended: orthopaedics and traumatology, emergency medicine, cardiology, paediatrics or physical medicine and rehabilitation.

Who is consulting a sports doctor practice and why are they doing it?

As Dr. Gojanovic explained, most patients currently consulting a sports physician are active ones suffering from musculoskeletal disorders (MSK) or less frequently sedentary people who want to become active and look for counselling. Typically, each sports doctor has some elite athletes among their practice. It is not common in Switzerland that ill patients consult a SEM physician even if mounting scientific evidence points to physical activity’s key role in the treatment of non-communicable diseases (NCDs)2. As pictured in figure 1, SEM is much more than musculoskeletal medicine. SEM  offers a great opportunity as a modern way to prevent and treat NCDs.


Is only endurance training useful in reducing the overall mortality?

Health care practitioners often think that endurance training only is the only type of regular physical activity that reduces the overall mortality3. However, as Ruiz et al. showed: “muscular strength is inversely and independently associated with death from all causes and cancer in men”4. Thus, the World Health Organization recommends at least 150 minutes of moderate-intensity aerobic or 75 minutes of vigorous-intensity of aerobic physical activity and muscle-strengthening activities at least twice a week5.

Do elite athletes recover faster from injury than standard patients?

Elite athletes do not heal faster per se compared to standard patients. As young and fit patients, they belong to the left side of a normal (or gaussian) distribution of the needed healing time. Dr. Leumann highlighted that some factors, like nutrition, could be optimized in order to support the healing process. Clinical controls will then be performed more frequently in order to detect as soon as possible a consolidation/healing state compatible with intensive physiotherapy. Thus, although the healing process of elite athletes might not be faster, the injury management is more timely and sophisticated.

Is a left ventricular wall thicker than 12 mm always pathological?

Twelve millimeters thickness is a commonly accepted definition to diagnose left ventricular hypertrophy and consequently suspect hypertrophic cardiomyopathy (HCM) among athletes6,7. However, this criteria was established within white athletes and should be critically reviewed among black athletes, “in whom deaths attributed to HCM are more common”8. Basavarajaiah et al. found that 18% and 3% of black athletes shown left ventricular wall thickness greater than 12mm and 15mm respectively without other cardiac abnormalities9. To conclude, there is potential for false positive HCM diagnosis if physician use the criteria derived from studies among white athletes.

“Together, we reach new heights”1

Forty students participated in this free teaching day around SEM. We heard directly from some of the leading physicians in the country about the many facets and perspectives in the field. The SGSM wishes to engage students and junior doctors to share ideas and motivations to develop the SEM field in a relevant way. In that way, the SGSM invites engagement with its new Swiss Junior Doctors and Undergraduate Sports and Exercise Medicine Society.


Justin Carrard (@Carrard.Justin) is a first year internal medicine resident based in Biel/Bienne (Switzerland). He is the newly appointed Swiss Correspondent for the brand new BJSM Swiss Junior Doctors and Undergraduate Perspective Blog Series. He is currently implementing the new Swiss Junior Doctors und Undergraduate Sports and Exercice Medicine Society. Justin aims to raise SEM awareness among Swiss medical students and modern solutions it provides to big public health issues like non-communicable diseases. As an ex-competitive swimmer, Justin has a keen interest for endurance sports and regularly practices them with passion.

Email:                                  Twitter: @Carrard.Justin

If you would like to contribute to the “Swiss Junior Doctors and Undergraduate Perspective on Sport and Exercise Medicine” Blog Series please email for further information.


  • Kriemler, A. Leumann, B. Gojanovic. Together, we reach new heights: Swiss Sports Medicine Society (SGSM/SSMS) joins BJSM Br J Sports Med 2016; 50:1099
  • Derman W, Schwellnus M, Hope F, Jordaan E, Padayachee T. Description and implementation of U-Turn Medical, a comprehensive lifestyle intervention programme for chronic disease in the sport and exercise medicine setting: pre-post observations in 210 consecutive patients. Br J Sports Med. 2014 Sep; 48(17): 1316-21.
  • Wen CP, Wai JP, Tsai MK, Yang YC, Cheng TY, Lee MC et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. 2011 Oct 1; 378 (9798): 1244-53.
  • Ruiz JR, Sui X, Lobelo F, Morrow JR Jr, Jackson AW, Sjöström M et al. Association between muscular strength and mortality in men: prospective cohort study. 2008 Jul 1; 337: a439
  • Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med 1991; 324:295–301.
  • Sharma S, Maron BJ, Whyte G, Firoozi S, Elliott PM, McKenna WJ. Physiologic limits of left ventricular hypertrophy in elite junior athletes: relevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am Coll Cardiol 2002; 40:1431–6.
  • Maron BJ, Carney KP, Lever HM, Barac I, Casey SA, Sherrid MV. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol 2003; 41:974–80.
  • Basavarajaiah S, Boraita A, Whyte G, Wilson M, Carby L, Shah A et al. Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol. 2008 Jun 10; 51(23): 2256-62




Vote now for your favorite BJSM cover of 2016! #Round2preliminaries

24 Nov, 16 | by BJSM

Vote now to advance your favourite cover into the sudden victory (or death) final round. Want more details about potential prizes? Read the first blog of the 2016 cover competition HERE.

The poll will be open for one week. Rally your friends and colleagues.

April-50-7: High performance on the Pacific Rim

April-50-7: High performance on the Pacific Rim


April-50-8: Training-load-and-injury-running-biomechanics

April-50-8: Training-load-and-injury-running-biomechanics

May-50-9: Anterior-cruciate-ligament-rupture-and-osteoarthritis

May-50-9: Anterior cruciate ligament rupture and osteoarthritis


May-50-10: IOC Exercise & Pregnancy in Athletes Expert Group

May-50-10: IOC Exercise & Pregnancy in Athletes Expert Group

June-50-11: Injury prevention health protection in olympic sports

June-50-11: Injury prevention health protection in Olympic sports

June-50-12: UEFA elite teams study 14 years of commitment to uefa players

June-50-12: UEFA elite teams study 14 years of commitment to uefa players





Tendinopathy – State of Play Orthopaedic Research UK – Conference Highlights

21 Nov, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr Farrah Jawad

Orthopaedic Research UK arranged a one-day Tendinopathy conference in London last week – Tendinopathy: state of play. The event brought together field leaders from sports and exercise medicine, physiotherapy and surgery “to address tendinopathy from the cellular level to the sporting arena.” It aimed to share the latest research and encourage discussion among clinicians.

tendonopathy-runHere are some key findings, highlighted in the speaker presentations.

Epidemiology of Achilles Tendinopathy in UK runners and the role of soleus in tendinopathy and rehabilitation – Mr Seth O’Neill, Physiotherapy Lecturer, Department of Medical and Social Care Education, University of Leicester

  • Calf stretching may make the tendon-muscle unit more pliable
  • Healthy controls seem to have less pliable tendons (cause or effect?)
  • Soleus is very important in the running population as it contributes a large force during this activity. Its strength can reduce with age, which may be implicated in the onset of tendinopathy.
  • Plantarflexor weakness has been demonstrated in Achilles tendinopathy patients
  • Plantarflexion function and mechanistic studies may be targets for interventional studies.
  • The contralateral limb should not be used in studies as a comparison to the tendinopathic side, as it is not an adequate control.

Tendon Loading and Implications for Injury – Dr Steve Pearson, Senior Lecturer in Human and Applied Physiology, University of Salford

  • Potential mechanisms of tendinopathy may include: tendon overload or underload (these terms are difficult to define as they mean different things to different individuals), poor mechanics, insufficient recovery
  • The superficial region of the Achilles tendon tends to undergo greater strain compared to the deep region – could this result in tendon maladaptation?
  • It is possible that the increased water in tendinopathic tendons has a protective effect.
  • Time under tension may be the most important factor in rehabilitation.
  • Eccentric loading has shown benefits over other tendon loading protocols for clinical outcomes but not necessarily tendon structure.

Can new ultrasound imaging modalities influence the management of Achilles Tendinopathy? – Dr Bhavesh Kumar, Consultant in Sport and Exercise Medicine, Institute of Sport, Exercise and Health, University College London

  • The limitations of ultrasound for tendons are that: hypoechoic areas can be difficult to delineate, ultrasound may be operator dependent and distinguishing between tears and tendinosis can be difficult.
  • This is where Ultrasound Tissue Characterisation (UTC) can have a role
  • There may not be value in monitoring structural changes compared with monitoring clinical severity, as pain symptoms may resolve earlier.
  • UTC appears to detect pre-symptomatic Achilles tendon changes; there may be value in screening certain cohorts.
  • UTC may be able to detect occult tendinopathic changes within clinically normal tendons that are not visible on ultrasound imaging.
  • There is a poor correlation between pain and structural pathology.

Plantaris – Its role in the athlete – assessment and management – Mr James Calder, Consultant Orthopaedic Surgeon, Fortius Clinic, London

  • Medially located Achilles tendon pain may be due to plantaris
  • Plantaris tendon is present in around 98%1
  • The insertion of plantaris may be slightly varied among different individuals2
  • Plantaris effect may be compressive, related to neuroinflammatory mediation or result in less capacity for elongation.
  • Excising the plantaris tendon in elite athletes with non-insertional Achilles tendinopathy may have a role3
  • Plantaris should be investigated as a possible cause of Achilles pain.
  • Heavy slow resistance may help when plantaris is involved, and surgery may be considered if conservative treatment fails.

Neural Aspects of Achilles Tendinopathy – Dr Polly Baker, Consultant in Sport and Exercise Medicine and Honorary Research Fellow, University of Brighton

  • Hypoxic tissue produces vascular endothelial growth factor (VEGF) which leads to neovascularisation and stimulates axonal outgrowth.
  • There seems to be an upregulation in pain in Achilles tendinopathy
  • Ongoing pain may be due to nociception or persistent inflammation, or psychological factors
  • Nerve injury may also cause neovascularisation
  • Neural assessment gives an understanding of the aetiology, and should be an essential part of examining patients with Achilles tendinopathy.

Is Tendinopathy and Inflammatory Condition? – Professor Andy Carr, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford

  • Immune cells are players in tendon repair – inflammation is an important contributor in tendinopathy
  • Perhaps clinicians should avoid using emotive terms such as “degeneration” to describe tendon changes
  • Tendon cells do not turn over; the tendon we make in adolescence stays with us for life.
  • Tendon cells may behave in a semi-inflammatory fashion
  • Neurosensitisation may be an important factor in nociception
  • Central sensitisation is implicated by both upregulation of glutamate and increased sensitisation to glutamate.
  • Steroid injections switch off “good” and “bad” inflammation.
  • In the future, there may be anti-inflammatory medications which may be available for tendinopathy
  • Platelet-rich plasma (PRP) may be bad for tissues – apoptosis has been observed in histological tendon samples.

How do our models of tendinopathy help us treat patients? – Dr Jonathan Rees, Consultant in Rheumatology and Sports Medicine, Honorary Senior Lecturer, Addenbrooke’s Hospital

  • Cook and Purdam’s continuity model4,5 and Fu’s failed healing response model6 are easy to understand
  • Modulation of the inflammatory response may be a potential option
  • Neovascularisation is described in osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, diabetic neuropathy, malignancy, ischaemia. To say that tendon degeneration alone is causing neovascularisation without an inflammatory mechanism does not make sense
  • Macrophages, T and B lymphocytes are seen in chronic Achilles tendinopathy using monoclonal antibodies to CD68, CD3 and CD20 – inflammation is implicated7,8.
  • Current models may not have the complete story.

Tendinopathy: physiotherapy and rehabilitation – Dr Bruce Paton, Clinical Specialist Physiotherapist, Lower Limb Extended Scope Practitioner, University College Hospital

Optimum rehabilitation goals are to restore:

  • the load function of the tendon
  • adequate tendon stiffness
  • adequate stretch-shortening behaviour
  • load dissipation
  • an effective kinetic chain
  • a pain-free state.

Loading programmes:

  • Concentric – some evidence that this may be effective9
  • Eccentric – best treatment available.10,11 Clears majority of midsubstance but not all
  • Isometrics – give some short-term pain relief and cortical inhibition, and may be good for reactive/compressive tendinopathy12
  • Heavy slow resistance – seems to be effective in patellar tendinopathy,13 now also evidence in Achilles tendinopathy.

Other rehabilitation considerations:

  • Possibly the kinetic chain
  • Neurodynamics have a role
  • Address psychosocial factors such as fear avoidance
  • Mixed evidence for pushing through pain
  • Address metabolic factors such as obesity.

What evidence do we need to translate into practice to better manage tendinopathy – and how? – Dr Dylan Morrissey, Consultant Physiotherapist and Clinical Reader, National Institute for Health Research

  • Need to consider evidence based on physical activity vs exercise vs sport – there may be differing evidence for the elite level athletes vs weekend warriors vs the sedentary.
  • A case study illustrating the importance of thinking around the problem and expecting the unexpected.


The Orthopaedic Research UK’s Tendinopathy conference was informative and thought-provoking.   Tendinopathy is a frequently encountered clinical problem which can prove challenging to manage.  Hopefully the conference will become a regular event in the sport and exercise medicine calendar.


  1. Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the incidence of plantaris tendon.   Foot Ankle Int. 2000 Jul;21(7):570-2.
  2. van Sterkenburg MN1, Kerkhoffs GM, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study.  J Anat. 2011 Mar;218(3):336-41.
  3. James D F Calder Richard Freeman Noel Pollock.  Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes.  Br J Sports Med 2015;49:1532-1534.
  4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.  Br J Sports Med. 2009 Jun;43(6):409-16.
  5. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?  Br J Sports Med. 2016 Oct;50(19):1187-91.
  6. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process.  Sports Med Arthrosc Rehabil Ther Technol. 2010 Dec 13;2:30.
  7. Rees JD, Stride M, Scott A. Tendons–time to revisit inflammation.  Br J Sports Med. 2014 Nov;48(21):1553-7.
  8. Rees JD. The role of inflammatory cells in tendinopathy: is the picture getting any clearer?  Br J Sports Med. 2016 Feb;50(4):201-2.
  9. Wetke E, Johannsen F, Langberg H. Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting.  Scand J Med Sci Sports. 2015 Aug;25(4):e392-9.
  10. Frohm A, Saartok T, Halvorsen K, Renström P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols.  Br J Sports Med. 2007 Jul;41(7):e7. Epub 2007 Feb 8.
  11. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols.  Scand J Med Sci Sports. 2015 Feb;25(1):3-15.
  12. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.  Br J Sports Med. 2015 Oct;49(19):1277-83.
  13. Kongsgaard M1, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Magnusson SP. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training.  Am J Sports Med. 2010 Apr;38(4):749-56.

Dr Farrah Jawad is a registrar in Sport and Exercise Medicine in London.  She has previously worked in the Tendinopathy clinic at the Institute of Sport, Exercise and Health in London and currently works at Homerton University Hospital.  She has recently completed her MSc in Performing Arts Medicine at UCL, for which she has been nominated for the Dean’s Prize.  Farrah co-ordinates the BJSM Trainee Perspective blog.

Exercise medicine resources launched for health and social care students

18 Nov, 16 | by BJSM

*Media Release*

Working with the Council of Deans of Health, Exercise Works! has launched the latest update of its physical activity and health resources designed specifically to support teaching in undergraduate health programmes. The “Movement for Movement” resources equip health and social care students to promote physical activity in the prevention and treatment of disease.

The resources on exercise medicine and health for undergraduate education were endorsed by the Council of Deans of Health when they were first launched in 2015. The revised version contains the latest evidence for future health professionals to use in discussing lifestyle medicine with their patients and deliver safe and effective exercise advice.

Ann Gates, Director of Exercise Works! said:

“I’m delighted to be able to launch these updated resources that address one of the most pressing public health challenges of our time. I look forward to seeing how universities use them to strengthen teaching about exercise in their programmes.”

Read more about Movement for Movement in this:

BJSM blog: A Movement for Movement: what’s art got to do with it? A lot. and;

BJSM Editorial: Movement for movement: exercise as everybody’s business?


For more information: Contact Ann Gates @exerciseworks


Counselling athletes with cardiac arrhythmias and conduction abnormalities based on the AHA/ACC recommendations.

16 Nov, 16 | by BJSM

Implementing black and white guidelines on a grey clinical field.

By Wouter van Everdingen, MD, Prabath Lodewijks, MD, and Tijmen van Assen, MD PhD

Recently the American Heart Association and American College of Cardiology (AHA/ACC) created a combined taskforce to define eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities.1 Recommendations were given for several cardiovascular topics. Albeit comprehensive, the AHA/ACC recommendations on cardiac arrhythmias and conduction abnormalities are quite limiting for a sports physician when used in clinical practice. The recommendations are based on competitive athletes, it is therefore debatable whether they are applicable to recreational athletes. Applying the recommendations to recreational sports might exclude athletes too quickly from all sports-related activities. Moreover, the recommendations lack advice on participation with well-defined limitations. Limitations and alternatives for participation in sports are perhaps beyond the scope of the recommendations, however a sports physician deals with these issues on daily basis. Strict adherence to these guidelines may exclude a large proportion of athletes from healthy physical activity and exercise. A specific set of guidelines for recreational athletes is therefore warranted.

The incidence of events due to cardiovascular disease is relatively low compared the number needed to exclude.2 Athletes with cardiac arrhythmias and conduction abnormalities are therefore specifically suited for sports participation with certain boundaries. These electrophysiological diseases are more ‘grey’ than black and white. As McCartney et al. recently stated on the application of guidelines in clinical practice, these are: “guidelines, not tramlines”.3  Nevertheless, the focus of the recommendations lies on preventing cardiovascular morbidity and mortality caused by extreme conditions of competitive sports. At least the prevention of cardiovascular events is more likely when athletes are excluded. Although the level of evidence on which athletes are excluded is questionable.

The AHA/ACC statements are mainly accompanied with Class I recommendations, with level of evidence C.1 A class I recommendation may leave no doubt on the matter at hand (table 1). However, doubt is justified when scientific backing is meagre, as level C is the lowest level of evidence (table 2). One might wonder whether ‘consensus of opinion of the experts and/or small studies, retrospective studies, or registries’ justify the highest class of recommendation. Although the percentage of evidence based medicine is improving, sports medicine has much to gain on proper scientific backing.4

Table 1. Classes of recommendations for guidelines

Table 1. Classes of recommendations for guidelines

In some cases obtaining scientific backing can be difficult, as randomized clinical trials on sports medicine and cardiovascular risks can be unethical. For example, it is relatively unethical to implement randomized clinical trials on the danger of patients with an implantable cardioverter defibrillator (ICD) participating in contact sports. Nevertheless, observational studies on these subjects may be an alternative. There are currently several athletes with an ICD performing in high level activity, such as professional football. Excluding athletes with an ICD may therefore be too restrictive.5 Observational studies can improve acceptance of (recreational) athletes with an implantable cardiac devices (ICD) currently performing in sports. Some surveys already prove the acceptance of ICDs in clinical practice.6 Indeed, approximately 40-60% of electrophysiologists/cardiologists already allow their patients with ICDs to compete. Injury to the athlete or ICD system, reported in a survey, were relatively low (<1% and below 5%, respectively).6 A recent publication by Lampert et al. on athletes with an ICD has already led to a more lenient approach.7 They concluded that athletes with ICDs can participate in competitive sports without health risks despite the occurrence of both inappropriate and appropriate shocks. As stated above, the pros and cons of participation of athletes with an ICD should be weighed on an individual basis.8 The specific sport, level of competition and accompanied dangers should be considered and discussed with the athlete, leading to a patient specific (shared) decision.

Table 2. Levels of evidence

Table 2. Levels of evidence

Conclusions: can we be more adaptable, inclusive and evidence-based?

The recent statements by the AHH/ACC on eligibility and disqualification of athletes for competitive sports include a thorough set of guidelines. However, these guidelines underscore the absence of an individual approach when implementing guidelines, the absence of guidelines for recreational athletes, and the problem of applying consensus opinion without adequate evidence as a Class I recommendation. Moreover, these guidelines indicate a gap in the evidence based approach in treating cardiovascular diseases in sports medicine. While this might seem a drawback, it offers a wide field of opportunities for future research. A careful and open minded approach is advised to prevent (recreational) athletes sitting at home, possibly succumbing to the negative effects of inactivity.


  1. Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NA, 3rd. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 9: Arrhythmias and Conduction Defects: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2412-23.
  2. Bessem B, Groot FP, Nieuwland W. The Lausanne recommendations: a Dutch experience. Br J Sports Med 2009;43:708-15.
  3. McCartney M, Treadwell J, Maskrey N, Lehman R. Making evidence based medicine work for individual patients. BMJ 2016;353:i2452.
  4. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med 2014;42:1738-42.
  5. Heidbuchel H, Carre F. Exercise and competitive sports in patients with an implantable cardioverter-defibrillator. Eur Heart J 2014;35:3097-102.
  6. Lampert R, Cannom D, Olshansky B. Safety of sports participation in patients with implantable cardioverter defibrillators: a survey of heart rhythm society members. J Cardiovasc Electrophysiol 2006;17:11-5.
  7. Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation 2013;127:2021-30.
  8. Lampert R, Cannom D. Sports participation for athletes with implantable cardioverter-defibrillators should be an individualized risk-benefit decision. Heart Rhythm 2008;5:861-3.






Table 2. Levels of evidence

Level of Evidence A Data derived from multiple randomized clinical trials or meta-analysis
Level of Evidence B Data derived from a single randomized clinical trial or large non-randomized studies
Level of Evidence C Consensus of opinion of the experts and/or small studies, retrospective studies or registries



Wouter van Everdingen, MD, is resident in sports medicine and PhD-student at the department of cardiology, both in the University Medical Centre (UMC) Utrecht, Utrecht, The Netherlands. As an amateur endurance athlete, he is enthusiastic on aiding competitive and recreational athletes in the department of sports medicine in Utrecht. His research at the department of cardiology focusses on electrophysiology, specifically the optimization of cardiac resynchronisation therapy.

Prabath Lodewijks, MD, is a sports physician in the University Medical Centre (UMC) in Utrecht. He is also the team physician of FC Utrecht, a professional football team playing in the Dutch Eredivisie, the highest league of The Netherlands.

Tijmen van Assen, MD PhD is a resident in sports medicine at the University Medical Centre (UMC) in Utrecht. Before the start of his residency, he conducted his PhD studies on the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES).




The Undergraduate Perspective blog series revitalized – an invitation to all

14 Nov, 16 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog

By Jonathan Shurlock and Manroy Sahni

Are you an undergraduate interested in a career in Sports and Exercise Medicine? Or a sportsperson keen on injury surveillance, prevention, and rehabilitation? Do you have a role in healthcare and are passionate about physical activity for your patients, clients, and community of practice?

Then we may have the perfect opportunity for you. Share your experiences and interests, while you build your skills and networks.

sprinter-on-the-blocks-sunHere at the BJSM we have been working hard to revamp our blog series: ‘The Undergraduate Perspective on Sport and Exercise Medicine.’

We are looking for undergraduates motivated to curate a blog on the SEM topic of your choice!

Traditionally our blogs have been 500-750 word research or story based submissions, with at least 2 references. We invite you to submit your ideas and/or drafts to either of the emails below. BUT we are also looking for innovative formats! Why not send in a video blog, or a virtual interview, or anything else you can think of! Surprise us!

Drop us an email if you want to discuss an idea for a blog or want a bit of advice with the process.

Please send draft submissions to the blog coordinators at and

Still have questions? Let us summarize.

What do we want from you?

  • Enthusiasm for the world of SEM
  • Honesty: we want to hear about all of your SEM experiences, good or bad
  • Motivation to obtain new experiences and skills
  • Passion and commitment to write clearly and share innovative ideas with our audiences

What do we want from the content?

  • Engaging: exploring current hot topics in SEM
  • Accurate: grounded in a reliable evidence base (at least one BJSM reference)
  • Relatable: we want YOUR perspective on SEM as an undergraduate

What’s in it for you?

  • Development of your knowledge, skills and experience relevant to SEM
  • Online publishing of your writing, free to share
  • Exposure of your work to our global SEM network (our blog has 200, 000 views per year)
  • Networking opportunities with the professional SEM community
  • Mentorship, support and feedback on your writing

Previous writing experience is not required; we will support you through the processes of formulation, draft revision, formatting, and submission. If this opportunity is of interest to you, we welcome you to the team.

For some final inspiration, here are some examples of previous blogs:

Exercise Addiction – too much of a good thing? By Daniel Taylor-Sweet (@dtaylorsweet)

Aspiring to get ahead? Sports Physio tips from the UK to Qatar. By Johnathon King (@Jonny_King_PT) & Liam West (@Liam_West)

Doctor’s role in physical activity adherence: how can we keep patients on the road to better health? By Steffan Griffin (@lifestylemedic)


  1. Taylor-Sweet. Exercise Addiction – too much of a good thing? BJSM Undergraduate Perspective on Sport & Exercise Medicine blog series. Online. [Available from:]
  1. King, West. Aspiring to get ahead? Sports Physio tips from the UK to Qatar. Undergraduate Perspective on Sport & Exercise Medicine blog series. Online. [Available from:]
  1. Doctors role in physical activity adherence: how can we keep patients on the road to better health? Undergraduate Perspective on Sport & Exercise Medicine blog series. Online. [Available from: ]

Get to know our new undergrad series coordinators:

Manroy Sahni (@manroysahni) is a final year medical student at the University of Birmingham and a newly appointed Lead Coordinator for the BJSM Undergraduate Perspective blog series. He is currently Co-President of Birmingham University Sports and Exercise Medicine Society (BUSEMS). As a key part of his role, Manroy organises seminars and practical sessions to raise awareness of the specialty and facilitate networking. He also serves as the Education Officer for the national Undergraduate Sports and Exercise Medicine Society (USEMS) committee. Manroy’s avid interest for research is demonstrated by his successful completion of an intercalated degree, clinical research elective in New Zealand and Tom Donaldson award for best poster presentation at the 2016 BASEM / FSEM conference. As a Move Eat Treat ambassador he promotes a healthy and active lifestyle and pushes for increased incorporation of lifestyle issues into medical education. Outside of medicine he enjoys football, tennis and running.

Email:     Twitter:@manroysahni

Jonathan Shurlock (@J_Shurlock) is an academic foundation year 1 doctor based in Sheffield and a newly appointed Lead Coordinator for the BJSM Undergraduate Perspective blog series. He is an advocate for clean sport, and works as a Research Assistant the FIMS Reference Collaborating Centre of Sports Medicine for Anti-Doping Research. He was awarded the BASEM Undergraduate Research Prize on the basis of this World Anti-doping Agency funded work. Jonathan is member of the USEMS committee, and Football Association Medical Society (SE) Social Media Officer. In his last year as medical student, he successfully introduced and delivered physical activity teaching into the Brighton and Sussex medical school undergraduate curriculum. Jonathan spends his spare time running in circles (around a track) and climbing any nearby boulders.

Email:    Twitter:@J_Shurlock


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