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Commonwealth catch up: Interview with Dr Danica Bonello Spiteri, Athlete and Doctor

30 Sep, 14 | by BJSM

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

Interview by Linda Evans

Like the Olympics, the Commonwealth Games only comes along once every four years. Nations that may be omitted from the Olympic pedigree, compete alongside some of the biggest names in sport. For many medics, this summer’s Glasgow Commonwealth Games combined passion and opportunity in Sport and Exercise Medicine. One SEM UK Registrar, also accomplished their dream of competing at the Commonwealth Games. A little over a month ago, Dr Bonello Spiteri finished 15th in the individual triathlon, competing for her home nation Malta. Since passing the finish line, Danica worked in Glasgow as a Sport and Exercise Medicine Doctor. I caught up with Danica to hear about these experiences.

Firstly, congratulations Danica on your brilliant performance in the individual triathlon at the Commonwealth Games. What made you begin triathlon?

I was involved in sports since a young age. I started off as a dancer from the age of 2, but gave this up at the age of 14 as I got into triathlon – which I preferred. Around the age of 14 I won a lot of track and field running medals, and my PE teacher recommended that my mum to send me to athletics training. I also enjoyed venting off energy with swimming and continued through the winter season. One day my swimming coach asked if I knew how to ride a bike, which I did – a BMX bike! He told me what triathlon was all about, and I loved the idea. So my mum managed to borrow a rather large mountain bike and I participated in my first triathlon. I came out of the water 1st lady (and 3rd overall with the men!), faded throughout the bike into 3rd lady, but I ran fast and won my first triathlon at age 14 (first female overall). Then I was hooked.

Danica Spiteri and Etienne Bonello

Danica Spiteri and Etienne Bonello

Triathlon undoubtedly requires a huge commitment in terms of training. How do you manage to balance this around your workload?

My training usually starts with a swim from 7:00-8.15 am and then I rush to get to work by 9am, work all day, and then train again after work. It’s hard to cope with it all. Being a trainee, I had to study for exams, attend courses and keep up to date with my reading. This means I don’t have much free time and getting enough sleep and adequate food intake can suffer! Sometimes I am too tired to go for my evening training, so I skip sessions to get rest. This means that on average I train about 15 hours per week. The positive side to this is that I avoid ‘overtraining’ and injury, so it’s kept me healthy and fit!

Being the Maltese triathlete of the year for the last ten consecutive years, you must have learnt a lot about how you race. Which aspects of triathlon do you excel at and how do you work to these strengths in a race?

I believe that I’m equally strong in all three disciplines and I enjoy the three of them equally well. Each discipline has bits I like and dislike. I probably struggle most in the swim section as I find it hard to make the front pack, but I have improved my swimming greatly over the past two years. I have also worked hard at my running, which has come along nicely too. At present, my favourite bit of the race is crossing the finish line, knowing I have raced to my best ability.

Alongside a very challenging sport, you embarked upon a demanding career. What made you choose medicine?

Two options interested me upon finishing my A levels – becoming a Medical Doctor or a Biology and Physical Education Teacher. When I made the grades, I opted for medicine. However, my desire to teach is still there, and I have lectured at the University of Malta for 5 years. Last year I also lectured at the Leeds University. In 2011, I moved to Leeds, UK, as a Specialist Registrar in Sports & Exercise Medicine. I am currently in my final few months of specialist training. Upon completion I intend to return to Malta and set up Sports & Exercise Medicine services, as this is greatly lacking – both in service provision and in public general knowledge.

What would your advice be to anyone who is interested in a career in medicine?

My Top 3 tips would be:

  1. You must have a passion for what you want to do, as without passion you will not get as far and it may become tedious.
  2. Love what you do and do what you love.
  3. Along the way you will meet many who will try push you down. Ignore them and follow your dreams. You will get there through determination and persistence.

What did you wish you had known at the start of your career that you know now?

I always thought that medicine was ‘just’ a five-year university program. But as soon as you exit you realise that your journey is just beginning! I had no idea that a doctor ‘never stops reading and learning’. But as long as it is related to Sports & Exercise Medicine, I am interested in reading more. My limitation is finding the time to read!

Not only have you had the opportunity to be an athlete at the Commonwealth Games, but you have also worked there. What has been your favourite aspect of working at the games?

The Commonwealth Games is a very friendly atmosphere and I enjoyed meeting new people, as well as working with old friends. It is also a satisfying to help athletes, as I understand what they are going through, andensure they arrive at the start line in their best condition possible.

Finally, what is the best thing about your job?

The best thing about my job is that it combines two things I really enjoy in life – sports and medicine.

I love all the opportunities I have come across. I have managed to meet like-minded colleagues and top athletes, travelled to various places around the world and developed a much deeper understanding of sports medicine. I have also used my medical knowledge to better understand triathlon training and sporting techniques. Best of all are the friendships I have made throughout the years. I now hope to return to my home country in Malta where I can transfer the knowledge to help raise the level of SEM.


Linda Evans BSC (Hons). Is a fourth year medical student at the University of Leeds. Social Media Secretary for USEMS and President and founder of Leeds Sport and Exercise Medical Society.

Twitter: @LindaEvans90 @USEMS and @LeedsSEMSoc

Danica Bonello Spiteri graduated from The Medical School of Malta in 2004. She completed her internship and basic specialist training in acute/general medicine in Malta, whilst completing her MRCP in 2009. She is also a member of the FSEM (UK) and is in the final months of her specialist SEM training. She is married to Malta’s national team cyclist, Etienne Bonello.

Dr Farrah Jawad coordinates “Sport and Exercise Medicine: The UK Trainee Perspective” monthly blog series.

Are high performing athletes any different from the rest of us? Find out on October 1st, 2014

29 Sep, 14 | by BJSM

edinburgh-mileThe Secrets Behind High Performing Athletes

By Beth Cameron, PR & Communications, Faculty of Sport and Exercise Medicine @FSEM_UK


‘Walk 500 Miles’ Sport and Exercise Medicine Conference 2014, co-hosted by BASEM and the FSEM, will reveal some secrets behind elite performance in sport.

An October 1st conference session will address the question: Are high performing athletes any different from the rest of us?

Yannis Pitsiladis, Professor of Sport and Exercise Science and Director of the Centre for Sport and Exercise Science and Medicine (SESAME) at the University of Brighton, has an established track record of research into the phenomenal success of east African distance runners and sprinters from Jamaica. Professor Pitsiladis will be presenting ‘what we know’ about the Jamaican sprint phenomenon in one of the opening sessions of the conference. The biological mechanisms versus socio-economic and cultural factors affecting the Jamaican athlete’s performance will be a key part of the discussion.

This session is swiftly followed by Dr Calvin Morriss, Head of Speed and Power Sports for the English Institute of Sport, speaking about the upper body requirements of athletes and how detailed biochemical analyses can help provide coaches and athletes with the means to develop highly specific training methods. Dr Morriss will also explore sports where the upper body contribution might appear of a secondary importance to that of the lower body, yet can have a profound effects on performance.

Closing Wednesday’s session will be Dr Mark Gillette, Head of Athletic Performance British Basketball, talking about high performance in Basketball and the strategy British Basketball used to implement a high performance model for its senior squads, in preparation for the London Olympics.

To book your place at Walk 500 miles visit the conference web page at:

World Heart Day: Promote physical activity for cardiovascular health!

26 Sep, 14 | by BJSM

By @exerciseworks

heart dayCardiovascular disease (CVD) is the world’s number one killer. It’s already responsible for 17.3 million deaths per year, and by 2030, expected to rise to 23 million deaths. This year, World Heart Day’s theme on September 29th, 2014 is creating heart-healthy environments. Join us in creating a healthier future for all. Help influence the design of physical activity opportunities that are fun, engaging and most importantly offer better health options for all our patients!

Physical inactivity is the world’s 4th biggest cause of death. Sedentary living has become the norm. We’ve created environments where we are expected to sit and stare. The places in which we live, work and play should not increase our risk of heart disease and stroke. Active transport, active environments, and active spaces can make our lives healthier and more playful (Gates, 2014). We need to actively design heart healthy environments and change those places which encourage sedentary lifestyles. Physical activity and heart healthy exercise is an important part of our daily life. The environments where we live, work, and play hugely effect our ability to make the right choices for our heart health, especially in increasingly urban environments.

So how can health professionals achieve everyone active, every day, within heart healthy environments?

Here are my views:

  • All health professionals have a unique role to promote physical activity and protect the public from sedentary behaviours and the risks of non-communicable diseases (NCDs). They need to promote physical activity within the consult environment. They need to shift the paradigm of a medicalised approach to one that proactively, and engagingly, increases exercise as a medicine in patient care. Patients deserve a choice- and that choice should include a variety of options for exercise prescription.
  • Health professionals need to provide “teachable moments” on heart disease risk within every consult and promote heart healthy exercise and physical activities. Cradle to grave. All cultures. Within all abilities. Every consult.
  • The culture of physical inactivity within a patient’s life and in the communities where they live and work needs to change. Health professionals need to be trained, skilled and capable to influence patients’ heart healthy choices within those environments. Informed patients are our best advocates!
  • In a heart-healthy environment people have the opportunity to make the right choices for their health. So whatever gender, culture, social status, or other determinants of heart health your patients have, isn’t it time to make every contact count for physical activity advice and heart health? Isn’t it time to use your professional influence to change environments within the home, work, school, communities, and in other ‘inactivity generating, life sapping environments’?
  • Let’s use what strategic support we already have. Recent research shows the challenge of national level change. However, Public Health England identified that by moving professionals to mobilize their networks for influence, we can strategically achieve sustained change on physical inactivity. We already know the National Health Service (NHS) and many international health organisations already have the information and clinical networks to advocate for ‘Making Every Contact Count’. Their action is key to getting nations active. All sectors and disciplines can play a role, not just those who already work in health. Professionals and advocates in urban planning, product design, social care, psychology, sport and leisure, media, trade unions, education and business can help bring radical change. But we need to work effectively and collaboratively to ensure long lasting heart health, for everybody. Become disruptive innovators for heart health!
  • Encourage all patients to enjoy variety of heart healthy exercises. For some ideas for patients’ exercises see here and further resources.
  • NHS and health care commissioners should be ‘governed’ to:
    • require training of provider staff on the role of physical activity in the care pathway and opportunities for maximising patient care through its use (NICE PH44 2013)
    • Require brief intervention training in physical activity provider contracts to ensure that all patients access exercise advice and support (NICE PH44 2013)
  • NHS and health care providers should be ‘legally’ required to:
    • ensure all health and social care staff are trained and assessed for their competence in brief interventions and motivational interviewing techniques for lifestyle modification e.g. physical activity and mental wellbeing (such as ensuring this is an essential skill in all health care job descriptions)
    • create an environment which values a ‘making every contact count approach’ to personalised care.

By creating heart healthy environments, collaborating across sectors, and training health care professionals to make every contact count for physical activity we can make the future of heart health better.

Seeing patients in your clinic today? Then please provide health healthy exercise choices for every patient. Be world class in heart health- help your adult patients to walk more, sit less and exercise for at least 150 minutes each week. Help children to access at least 60 minutes each day of active play. Together we can beat heart disease and physical inactivity!

Also, watch (and share) this great short video: Make a healthy heart your goal: Get active on World Heart Day

Follow #worldheartday #heartchoices

Ann Gates MRPharmS @exerciseworks

Member of the Emerging Leaders Programme 2014-2015, World Heart Federation.






UK Medical and Sporting Organisations Call for Best Practice Consensus on Concussion

24 Sep, 14 | by BJSM

News Release

23 September 2014

The Faculty of Sport and Exercise Medicine (FSEM) UK has hosted a meeting to discuss the need for consensus in the prevention, assessment and management of concussion in the UK. Concussion is common and can have major implications on quality of life if not recognised early.

stock-footage-woman-brain-anatomyKey influencers and brain injury experts attended the meeting, including representatives from the Medical Royal Colleges and National Governing Bodies of sport.

The overwhelming view of delegates present at the meeting was a common desire to progress the development of consensus as to how sport, health and education bodies in the UK can deliver best practice.

Delegates recognised the work currently being done by multiple governments and key agencies in this area, but felt that greater formal collaboration between the Medical Royal Colleges would facilitate the process.

The following work streams were identified as priority areas: 

  • An updated consensus statement on the prevention, assessment and management of concussion in the United Kingdom
  • The development and dissemination of generic concussion guidance for sports and the education sector, in collaboration with groups and agencies currently working in this area
  • The development of dissemination of appropriate guidance and educational resources for the primary care physician and NHS Emergency Department practitioners
  • Input into the planning of care pathways for concussion and mild traumatic brain injury
  • Consideration of a Cochrane review

The group would like to see consistent best practice, recognition, management guidelines and care pathways adopted from ground level up, across all sectors and by all health and allied professional groups, where concussion is encountered. They also recognised the need for a NICE guideline specifically on concussion.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine, comments: Concussion is recognised to be one of the most challenging of injuries to diagnose assess and manage. Care pathways from concussion to return to play, school, work and every day life are not always easily accessible or understood in the UK.

“I am pleased to say that a broad consensus was established between all the participants of the meeting on the key issues of a medically complex area and we are in a position to take forward the development of a much needed consensus on the management of concussion.”

Dr Simon Kemp, Hon. Secretary of the Faculty of Sport and Exercise Medicine and Chief Medical Officer for the RFU, comments; “Individual sporting bodies recognise the work that they need to do on concussion, however we need to move towards a cross-sports consensus on the recognition and management of concussion with consistency across all sporting bodies and in conjunction with education and healthcare systems.”

Dr Christine Haseler, representing the Royal College of General Practitioners (RCGP), comments: “The RCGP is interested in developing a consensus on the recognition and management of concussion with the group. Out of which, we would like to see a concussion education resource for GPs, which can be applied to the general public as well as those participating in sport.”

Dr Clifford Mann, President of the College of Emergency Medicine (CEM), comments: “One emergency department alone can see upwards of a dozen cases of concussion a week, most of whom are adolescents. There currently exists a large number of differing guidelines out there. Common guidelines, which can be applied across both healthcare and education sectors, are much needed. I am pleased to see that there is already consensus on the need for common guidelines from the meeting attendees and, as this gains momentum, we hope that other key organisations will sign-up.”

Dr Anna-Louise Mackinnon, Jockeys Medical Adviser to the Professional Jockeys Association and Injured Jockeys Fund, comments: “In racing we see more episodes of concussion than in most other sports and we would welcome generic concussion guidelines for UK sport to be used alongside the current British Horseracing Authority Concussion Management Protocol. Consistent advice across all sports, both recreational and professional, is vital to the optimal management of concussion. The development of educational resources available to all those working at the grass roots level will be of great benefit.”

Dr Ian Beasley, Chair of the FA’s Medical Committee and Doctor to the England Men’s Senior Football Team, comments: The advice of medical professionals is key when it comes to the recognition and management of concussion. Whilst sporting bodies have developed processes to deal with many types of injury, including concussion, this is an area that is in need of a set of common guidelines which can be applied across a broad range of sports. All managers, leaders, teachers, players and clubs need to understand the risks associated with head injuries and be equipped with the correct knowledge.”

More to win than the Ryder Cup: the health benefits of golf

22 Sep, 14 | by BJSM

By Steffan Griffen, Andrew Murray (@docAndyMurray) & Roger Hawkes

Golf is played by around 55 million people on 32,000 courses in over 100 countries.¹ With over half a billion homes worldwide tuning in for each day of the Ryder Cup at Gleneagles, a series pitting Europe’s best against the cream of the American crop. We look at the health benefits of playing golf available not only to Rory McIlroy and the game’s elite, but also to those inspired to visit their local course.

McCleery-Golf-Course-Feature-ImageIndeed former British Prime Minister David Lloyd George viewed less talented golfers as reaping more benefits than those bestowed upon the likes of McIlroy:

“Golf is the only game where the worst player gets the best of it. He obtains more out of it as regards both exercise and enjoyment, for the good player gets worried over the slightest mistake, whereas the poor player makes too many mistakes to worry about them.”

But what of the available evidence? Do golfers really live longer happier lives?

A landmark Scandinavian study² of over 300,000 golfers estimated they lived a remarkable 5 years longer than those who do not play golf, regardless of age, gender, or socio-economic status. Evidence also suggests that golf has a role in preventing and treating many chronic diseases, and has positive mental health effects.

Golf & Walking

A 2006 study³ found a mean of 11,948 steps are taken per 18-hole round, exceeding the commonly recommended daily amount of steps for health.  With technological advances coming into the game, calls have been made to reduce the use and availability of motorised carts to transport players around the course. Cart use reduces walking distance from an average 8+km to 3.86km per round.⁴

Another study⁵ found that walking 18-holes was the equivalent of moderate-high intensity exercise for the elderly, moderate for the middle-aged, and low for the young. A 1998 study⁶ determined that golf should be classified as a form of aerobic training for middle-aged people.

An Inclusive Sport

Golf suits participants of all ages, with people of mixed ability, sex, and age able to play together.  The Walker Research Group concludes: “golf is well suited for the development of social capital” with designated social spaces and natural breaks providing unparalleled socialisation opportunities and thus potential psychosocial benefit to participants of all ages⁷.

A 2006 study⁸ engaged children in non-traditional sports such as golf during extra-curricular time and found that such an intervention coupled with lifestyle activities such as walking, significantly increased physical activity in primary school aged children. This also slowed unhealthy weight gain.

In regards to gender inclusion, the recent news of women winning the right to R&A membership at St. Andrews after a 260-year wait, exhibits a positive step by the game’s administrators to quash these barriers and see more women playing and staying in the game9.

Was David Lloyd George right?

There is clear evidence that regular physical activity, in the form of golf, increases life expectancy.  And although Lloyd George was correct that the benefits can be accrued by players of all abilities, research suggests that low handicap players tend to play more often and have the lowest mortality rates.  Encouraging friends, family, and patients to take part in regular physical activity is time well invested, and golf can offer significant benefit to Joe and Jane Public and Rory McIlroy alike.  Just don’t hire a buggy!


  1. Wilson B. Golf industry facing challenges: BBC News Online:, 2011:Online News Article.
  2. Farahmand B, Broman G, de Faire U, Vagero D, Ahlbom A. Golf: a game of life and death–reduced mortality in Swedish golf players. Scand J Med Sci Sports 2009;19(3):419-24.
  3. Kobriger, S. L., Smith, J., Hollman, J. H., & Smith, A. M. (2006). The contribution of golf to daily physical activity recommendations: How many steps does it take to complete a round of golf? May Clinic Proceedings, 81(8), 1041-1043
  4. Sell, T. C, Abt, J. P., Lephart, S, M. (2008) Physical activity-related benefits of walking during golf. Science and Gold V: Proceedings of the World Scientific Congress of Golf. 128-132
  5. Broman, G., Johnsson, L., & kaijser, L. (2004) Golf: a high intensity interval activity for elderly men. Aging – Clinical and Experimental Research, 16(5), 375-381
  6. Magnussen, G. (1998). Science and golf III: Proceedings of the 1998 World Scientific Congress of Golf. (eds.) Martin R. Farrally, Alastair J. Cochran. Human Kinetics
  7. Walker Research Group. The Health & Wellness Benefits of Golf Participation & Involvement. Review of Academic Literature. Golf 20/20 & World Golf Foundation. (2011)
  8. Taylor, R., Mculey, K., Williams, S., Barbezat, W., Nielsen, G., & Mann, J. (2006). Reducing weight gain in children through enhancing physical activity and nutrition: The APPLE project. International Journal of Pediatric Obesity, 1(3), 146-152
  9. Women win right to R&A membership after 260-year wait as other clubs are told to remove barriers. The Telegraph. Online news article.


Steffan Griffin University of Birmingham @lifestylemedic

AndrewMurray University of Edinburgh, European and Challenge Tour Golf. @docandrewmurray

Roger Hawkes. CMO European Tour and European Ryder Cup @dochawkes

Can a 15-mintue warm up programme prevent ACL injury? Study results

19 Sep, 14 | by BJSM

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

By Kate Markland, Clinic Director, The Markland Clinic @MarklandClinic

The anterior cruciate ligament (ACL) is one of the most commonly disrupted knee ligaments with a high incidence amongst young athletes and the physically active. To address this, we recently examined whether the “Prevention Injury and Enhance Performance” (PEP) 15- minute exercise program can reduce ACL injury risk factors and increase jump height.


Female athletes have an almost staggering 7-fold increased risk of an ACL injury compared to males. ACL tear is often associated with injuries to the articular cartilage, the menisci and other ligaments: this will accelerate the onset of arthritis. Although the injury is treated with surgery and long-term rehab, the high costs associated with the management of ACL injury, both personally for the athlete and from a financial standpoint, means that prevention is a crucial priority.


The study consisted of 33 participants which included:

  • A men’s basketball team consisting of 9 players all aged 16-18,
  • A women’s netball team consisting of 10 players age 16-18 and;
  • A women’s netball team with 14 players ages 14-18.

Baseline assessment

We used the landing error scoring system (LESS) which evaluates 17 jump-landing characteristics that may predispose an individual to lower extremity injuries. A high LESS score was associated with a higher risk of sustaining non-contact ACL injury.

We made an initial drop jump landing video assessment: athletes jumped off a 30cm step and then asked to immediately jump again. To monitor the jumps, two video cameras recorded the landing form the front and from the side. We also assessed the basketball players’ jump height; each athlete jumped as high as possible three times on each leg, and we recorded the highest jump on each leg.


Within one week, we explained the purpose of the programme to the players, emphasizing the importance of movement and form quality. We also showed a video of an ideal drop jump landing. With assistance from the physiotherapists, players scored their own drop jump landing using the LESS scoring system.

After receiving instruction by a Physiotherapist on the PEP programme, the basketball players performed the programme 5 times per week, and the netball players performed the session 1-2 times per week.

Follow-up Assessment

Assessments and data collection were repeated at a 6-8 week follow up. Our preliminary analysis showed positive results. In line with our theory, there were no recorded ACL injuries. Two players sustained injuries that were not associated with the knee and were not related to using this programme. However at the 8 week follow up, the remaining 31 athletes significantly improved in their LESS score. The basketball team’s LESS score average improved from 8.89 (poor), to 3 (excellent). The netball team’s LESS score average improved from 7.8 (poor) to 4.6 (good). Lastly in the final netball team there was an improvement from a poor 10.5 to a good 4.75. The results are positive, proving that a modified 15-minute warm up programme can improve the LESS score in young athletes. In addition, we found that there was an overall increase in the average, percentage hop height in the basketball players of 5.8% in the left leg and 10.5% in the right leg.


Despite sample size and study length limitations, our study suggests that following a 15-minute warm up programme may lead to a reduced risk of sustaining ACL injury. This in turn, may reduce and/or prevent the emotional and financial burden of treating such career threatening injury.

Jump Leaflet women

Tickets still available! Welsh Exercise Medicine Symposium on 19th September, 2014

17 Sep, 14 | by BJSM

exerciselogoThe Welsh Exercise Medicine Symposium on 19th September, 2014 will have a fantastic array of world leaders speaking on physical activity, its benefits, controversies, and promotion. There will also be masterclasses on exercise prescription, motivational interviewing, and advances in physical activity measurement (including the launch of the new Welsh Physical Activity Report Card).

Aside from the interactive seminars, keynote speakers will include:

  • Dr Ruth Hussey (Chief Medical Officer for Wales),
  • Prof Flemming Dela (Professor of SEM, University of Copenhagen, Co-Chair of the Scientific Board for the European College of Sports Science (ECSS); and
  • Prof Mats Borjeson (Professor of Sports and Consultant Cardiologist at the Swedish School of Sport and Health Sciences, Stockholm. Chairman of the European Society of Cardiology and Scientific Secretary of the Swedish Society of Sports Medicine).

Building on the success of last year’s inaugural symposium, the congress will appeal to those in Medicine, Physiotherapy, Sports Therapy and Sports and Exercise Science. With over a hundred delegates, the conference also provides exceptional networking potential with future employers and/or options for work experience.

The one day event is on Friday, 19th September, at Swansea University. Attendance is only £15, which includes lunch, refreshments, and a certificate of attendance.

Tickets available:

Plantar fasciitis – important new research by Michael Rathleff

15 Sep, 14 | by BJSM

Blog by @MichaelRathleff 

Introduction by Tom Goom @TomGoom

Originally posted on the Running Physio blog

Plantar fasciitis can be a nuisance to treat and, to date, we’ve had little high quality evidence to guide us. Today’s blog represents an exciting new direction in treating this stubborn condition. For some time we’ve noted the similarities between plantar fascial problems and tendinopathy. Back in 2006 Scott Wearing wrote an excellent paper on how the two structures shared similar pathology and similar response to load. However, no one has tested whether we might be able to treat plantar fasciitis like a tendinopathy, that is until now… Michael Rathleff and colleagues have just published an exciting new paper that is the first of its kind and represents a new treatment approach for plantar fasciitis, so I was delighted when Michael very kindly agreed to share his findings with us in a guest blog. Michael’s work includes excellent papers on hip strength and patellofemoral pain and patellofemoral pain in adolescents. To find out more about Michael’s research check out his Google Scholar Profile and follow him on Twitter via @MichaelRathleff.

Most of us who have experienced plantar fasciitis know first hand how debilitating and frustrating it can be. Every morning resembles being forced to walk on broken glass and you quickly become grumpy and dissatisfied. The prevalence in the general population is estimated to range from 3.6% to 7% [1 2], and may account for as much as 8% of all running-related injuries [3 4]. The life time prevalence may be as high as 10% which means that quite a big proportion of us will at some point be affected by plantar fasciitis or see these patients in the clinic.

Most previous treatment studies on plantar fasciitis have used a combination of orthotics, plantar specific stretching or similar non-exercise intervention. These interventions have proven successful to some degree and we know they are superior to placebo treatment. However a large proportion of patients still have symptoms two years after the initial diagnosis. Most clinicians who see these patients in the clinic will agree that they can be quite the challenge – especially if they have a long symptom duration. So we definitely need to start thinking about new effective treatments. An interesting thing is that we are starting to realise that there are some similarities between plantar fasciitis and tendinopathy. We know from the literature that high-load strength training appears to be effective in the treatment of tendinopathy [5]. A similar approach to plantar fasciitis therefore seems to be relevant to test. We recently completed a study where we investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis.[6]

Our main question before initiating the trial was how we could induce high tensile forces across the plantar fascia to resemble the loads induced to the patella tendon during e.g. single leg squat. Our approach was to exploit the windlass mechanism during single-leg calf-raises by using a towel to dorsal flex the toes. In theory, the windlass-mechanism would cause a tightening of the plantar fascia during dorsal flexion of the metatarsophalangeal joints while high-loading of the Achilles tendon is transferred to the plantar fascia because of their close anatomical connection [7-9].

We recruited 48 patients with ultrasonography verified plantar fasciitis. They were randomised to either high-load strength training or plantar specific stretching. In addition both groups received a short patient information sheet and gel heel-inserts. The patient information sheet covered information on plantar fasciitis, advice on pain management; information on how to modify physical activity; how to return slowly to sports and information on how to use the gel heel-inserts. On a side note, I think that one of the key things in successful management of plantar fasciitis is to educate the patient. The advice we used can be seen below in table 1.

Table 1: Advice given to the patients

The plantar-specific stretching protocol was identical to that of Digiovanni (2003) [10]. Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].

Figure 1: Plantar-specific stretching

High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.

A key clinical point is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.

Figure 2: High-load strength training

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

There are still lots of unanswered questions about why high-load strength training may work in the treatment of plantar fasciitis. One explanation could be that high-load strength training may stimulate increased collagen synthesis which help normalise tendon structure, increase load tolerability of the plantar fascia and thereby improve patient outcomes. Another explanation may be that the exercise help improve ankle dorsal flexion range of motion as well as improving intrinsic foot strength and ankle dorsal flexion strength. When I completed the high-load strength training program as part of our pilot studies I developed good DOMS in the intrinsics which suggest they are active during the exercise. The questions are many and hopefully other researchers will take a critical look at our findings and confirm or contradict our findings.

The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis. The key message to the patients is that they need to perform the exercises (otherwise they are unlikely to work) and they need to be performed slowly (3s up, 2s pause at the top and 3s down) to decrease risk of symptom flaring and with enough load starting by 12RM for three sets and working their way down to 8RM for five sets.


1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1(1):2 doi: 10.1186/1757-1146-1-2[published Online First: Epub Date]|.

2. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159(5):491-8

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36(2):95-101

4. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71

5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z[published Online First: Epub Date]|.

6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313[published Online First: Epub Date]|.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy 2013;223(6):665-76 doi: 10.1111/joa.12111[published Online First: Epub Date]|.

8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194-203 doi: 10.1016/j.clinbiomech.2005.09.016[published Online First: Epub Date]|.

9. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 2000;21(1):18-25

10. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(7):1270-7

11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19(6):790-802 doi: 10.1111/j.1600-0838.2009.00949.x[published Online First: Epub Date]|.

Football Medicine in England: A personal perspective on protocols, standards, and moving the field forward

13 Sep, 14 | by BJSM

By Dr. Michael Stone, Chief Medical Officer, Birmingham City Football Club

I am fortunate to have worked within elite sport since 1994 – the majority of this time within football. Experiences and observations from my longstanding involvement in football influence my personal views on the practice of Sports Medicine both within football, and comparatively to other sports.

soccer-ball in netSports Medicine within football in England remains a specialty in development. It still has an awfully long way to go to be considered a  secure path for the new sport and exercise medicine consultants reaching the end of their training programmes. Jan Ekstrand1 has expressed  how doctors may influence injury rates in elite professional football and hence show their value to a football club. In England at the present time, professional football in general is a long way from realising these ideals.

Current Climate for Premier League Club Doctors

Premier League Clubs employed full time doctors since the end of the 1990’s. This is still not a general finding and all Clubs in the football league still employ doctors on a part time basis. Only since the 2003-04 season have the Football Association (FA), Premier and Football League regulations stipulated that newly appointed Club doctors in the premier and football leagues possess a diploma in sport and exercise medicine (SEM) or have a “similar qualification” prior to their appointment. Due to the relatively small number of appropriately qualified doctors interested in pursuing even a part time football related sports medicine career, it Clubs in the lower leagues may struggle to appoint a suitably qualified doctor.

It is not unusual for doctors within English football to be appointed by the Club manager and be “recommended” to the Board / Chief Executive (Club) without a full and robust interview process. They hence answer to the manager and not the Club. This is a main reason that within SEM the job of Club Doctor is deemed insecure. If the manager falls out with the doctor for whatever reason the doctor is likely to lose his job. If the manager leaves the Club, the new manager may decide he wants to install his own doctor and medical team. Until this situation changes and the Club assumes responsibility for the appointment, contracts, actions and regular appraisal of the medical team and withstands pressure from a manager to change the doctor (unless they have failed in their medical duty) a secure career path is impossible.

The benefit of research and relationships

The excellent work done by F Marc2 in relation to injury rates at major football events and Jan Ekstrand and his group’s work in the UEFA Champions League Audit3 are but two examples of how information / research may benefit football. Although the FA published an audit of injuries in 20044, there is little other collaborative research from within English football. Perhaps as a consequence of job insecurity there is very little incentive for Club Doctors to embark on long-term research projects or cultivate links with local or regional centers of excellence. The unwillingness of some Clubs to be protectionist with medical information (to limit potential for others’ ‘competitive advantage’) is another barrier for collaborative research.

The FA has established audits of injuries sustained by Clubs in the Premier League and from the 2013-14 season in the Championship. These audits continue and I trust the data from them will be published on a regular basis. It is a matter of regret that only thirteen of twenty-four clubs participated fully in the initial Championship audit. Why? Reasons given include appointment of new medical staff, not enough medical staff to do the work and lack of interest. These are not good reasons but they are understandable and unless addressed, the collection of statistically significant data from within English football will be much more difficult to achieve.

Medical Professionals’ Qualifications and FA Standards

The FA oversees the regulation of football in England, and to my mind, ensures the qualifications of all medical professionals. From a medical perspective, I see no difference between a professional footballer in the premier league and one in football league two. The qualifications needed to care for someone earning their living from football should be the same.

It is my view that the medical committee of the Football Association should oversee:

  1. the basic medical qualifications,
  2. the continued professional development and,
  3. the satisfactory appraisal of doctors (and other medical staff) working within football.

The committee must ensure appropriate medical governance for English football. The FA publishes their medical criteria in the annual regulations and it is these that should define – in a simple unambiguous way - the absolute minimal requirements for all medical staff working within football. The premier league and football league may stipulate further medical requirements but, the FA rule-book should be the accepted enforceable benchmark. All Clubs at the start of a season need to meet these openly published standards or they should risk having their games postponed until they have complied.

The difference in current acceptable qualifications within professional football is probably best illustrated with reference to pitch side care. In the FA guidelines for season 2013-14 there is no mention of pitch side care qualifications. Since the 2008-09 season the Premier League  requires that both the physiotherapist and doctor attending a first team premier league game must have an AREA (Advanced resuscitation and emergency aid) qualification. This is a fully medically accredited pitch side care course. In the Football League, it is only the doctor that must have this qualification (since the 2014-15 season). Physiotherapists in the championship and below need only the Intermediate First Aid in Sport qualification. The reason given by the FA for this difference in standards relates to the cost of the courses and is deemed”pragmatic”. The AREA course is recognized as a more advanced qualification. With the recommendation to undertake a regular yearly revision course and the necessity to undertake a three yearly full re examination the cost to the individual or Club of the AREA course is not inconsiderable.

With the amount of money available in football it seems a very lame excuse that football can’t afford to educate its medical staff to an agreed standard. One per cent of the money football obtains for television rights would probably pay for pitch side care courses for all medical staff caring for professional players. The FA and the professional footballers association should insist that all professional players are treated by medical staff qualified to the same standard. Suppose a Patrice Muamba incident happened during training in a player of a league two team where the physiotherapist did not have the higher qualification and the outcome was not as good? Could the FA defend the different qualification requirements for the medical staff?

Especially in the Premier League, Club doctors are under increasing scrutiny from the media and public. It is important that they know that their appropriate medical decisions  will be supported by the Club and will not be interfered with by the manager. Confident in their value to their Club, with a secure job, provided they perform to satisfactory standards, can only help cope with this not insignificant pressure.

In Closing

There are examples of excellent practice within football. The Premier League Doctors Group strives to increase standards of medical care within the premier league and the recently established Football Medical Association is also working to improve standards and support across all medical personnel working in football. However, football medicine in England will not become an attractive career prospect for sport and exercise physicians, until we collectively address these basic problems.


1Ekstrand J. Br J Sports Med 2013;47:723-724

2Junge A, Dvorak J. Br J Sports Med 2013;47:782-788

3Br J Sports Med 2013;47:723-768

4Price RJ, Hawkins RD, Hulse MA, et al. Br J Sports Med 2004;38:466-471

Top 10 Clinical Pearls from #Tendons2014 / ISTS: Beginning the Long Walk to (tendon) Freedom

10 Sep, 14 | by BJSM

By Paul Dijkstra @DrPaulDijkstra & Jill Cook @ProfJillCook

Micrograph of tendon insertion 'tide line'.

Micrograph of tendon insertion ‘tide line’.







Before we delve into evidence based medicine as it relates to tendons, here are the top 10 short (clinical) pearls from the 3rd International Scientific Tendinopathy Symposium (ISTS) or #Tendons2014:

  1. Tendinopathy is still not clearly defined
  2. Do not treat all tendons with the same recipe – what works for the upper limb tendons might not be good for lower limb weight bearing tendons
  3. Pain is complex – consider central sensitization; psychosocial factors contributing
  4. Do not rely on (expensive) special investigations – they are often not helpful in diagnosis or follow up
  5. UTC – (the imaging tool Ultrasound Tissue Characterization) too early to use in private practice or isolation; research setting / big team perhaps OK
  6. No good evidence for injections into or around tendons yet
  7. Inflammation poorly defined and not part of the (clinical) equation – no evidence to suggest otherwise
  8. Load, Load, Load – adjust; sensibly progress; role of isometrics
  9. Each patient is an individual – own special genetic make-up. Treat them as individuals, do not fall into the trap of ‘individual genetic profiling’ and reject the direct to consumer genetic ‘profiling’ for whatever tendon reason!
  10. We’re giving the early steps on a long and complex road to understand tendons better!

We don’t have an agreed, consensus definition for tendinopathy; we’re all thinking about tendons and tendon injuries from a biased personal framework, including our interpretation of ‘evidence’.

A question of concern for all clinicians is how effective (and efficient) our approach is to a specific, individual patient with a certain clinical problem. With the best of intentions, we can still do harm. An evidence-based approach helps minimise the potential for harm.

Time for a quick recap on EBM – because folks are overlooking elements. The term ‘evidence-based medicine’ (EBM) was coined by the David Sackett and colleagues at McMaster University in Ontario, Canada in the early 1990s. EBM gained significant ground worldwide since the inception in 1993 of the Cochrane Collaboration, a non-profit body which systematically organizes research information. The central role of the Cochrane Collaboration has been ‘to liberate the results of unpublished clinical trials from their neglect, with the aim of pulling together separate strands of research into a coherent, useful and reliable guide to best outcomes’. (1)

4 pillars of the evidence-based medicine approach in the tendon context

In its broadest form, EBM integrates the best research evidence with clinical expertise and patient values to achieve the best possible patient management.

  1. The best research evidence (systematic reviews of randomized clinical trials as the top level of evidence). It is important that we all agree on the fact that ‘the plural of anecdote is NOT evidence’.
  2. Patient expectation, values, concerns:
    • elite high jump athlete with an acute flare of PT one week before the Olympics;
    • 62yr-old with acute Achilles tendinopathy following a course of quinolone antibiotics for prostatitis going on a cruise with his new wife in 5 days;
    • 12yr old keen swimmer with signs of supraspinatus tendinopathy, multi-directional instability and scapula-humeral dysfunction and ‘female tenocytes’…she’s the daughter of a colleague;
    • 32yr old national team volleyball player with longstanding anterior knee pain misdiagnosed as patella tendinopathy and a brother who ruptured both Achilles tendons
  3. Clinician experience and expertise:
    • a practitioner with a tool… a junior doctor in a NHS ward with a stethoscope and a pair of hands;
    • a private orthopaedic surgeon with a knife and shares in the clinic;
    • a radiologist with an expensive 3T MRI… and shares in the clinic;
    • a SEM physician with a (brand new) portable US scanner;
    • a keen clinician who jumped on the UTC bandwagon;
    • A scientist who just bought shares in / founded Genetics4U (and he didn’t hear Malcolm Collins at the ISTS 2014…) and has a multi-million-pound-strong elite footballer with a painful tendon in front of him)
  4. Environment including concern about litigation:
    • school rugby team – parents begging to inject Johnny’s sore knee (patellar tendinopathy) in the change room before the interschool semi-final;
    • warm-up track before the Olympic 1500m final;
    • NHS GP practice with 5 patients waiting – you only have 6 minutes for this consultation;
    • physio room of Queens Diamond Royal Premiership Football Club – manager banging on the door;
    • hotel room clinic in Nairobi before the African Games opening ceremony

It’s NEVER simple!

The dilemma is often (falling back to our own ‘framework’) the media (or coaches / colleagues… patients) creating unreasonable expectations around certain miracle (guru-juice) treatments; treatments that got celebrity player Z back on the track in no time… No evidence, just the report on ‘News at 6’.

Here are some critical reflections on a clinical approach – remembering that tendons are complex and different; patients are individuals with their own unique expectations.

  1. Always take a thorough and detailed history with particular attention to the onset of symptoms, the type of symptoms, the location of the symptoms, functional deficits and performance goals (‘get to my apartment on the 1st floor’; ‘run in the Olympic final’; ‘go with my new wife on a boat cruise without crutches’ etc.);
  2. Perform a thorough and tendon-specific examination (make sure the pain is truly a tendon-pain – example patella tendinopathy and not anterior knee pain; red flags include fever, weight loss, signs of inflammatory arthropathy – Sacroiliitis, night pain etc; bilateral thickened Achilles tendons – cholesterol etc; PLANTARIS – medial Achilles / musculotendinous junction calf pain, recurrent soleus strains / failed rehabilitation, don’t like dorsi-flexion – ‘push-off’
  3. Assess pain and function – perhaps without exception patients want to have less pain and better function. There is good evidence that specific targeted tendon loading (isometrics for instance in PT) reduces pain.
  4. Consider special investigations. The vast majority of patients around the world will not have access to special imaging – ultrasound, MRI and now UTC. Fear of litigation (missing a partial tendon rupture in an elite Olympic athlete, patient expectation and finances etc. will influence decision). UTC has limited clinical value – perhaps only in a research setting and as part of the toolbox used by medical teams looking after elite athlete teams. Make sure however that you know how to interpret the scan and perhaps how not to react to abnormal findings… especially important is how you communicate these to the patient. Blood tests won’t contribute anything unless of course the tendinopathy is part of a possible inflammatory / rheumatologic disease.
  5. Management tools. Load, load, load. Load adjustment (when overload in the elite athlete is a problem), load introduction if a sedentary lifestyle is part of the equation and specific loading programs as part of a physiotherapy program. Footwear, including heel raises; technique and functional rehabilitation (the swimmer with rotator cuff tendinopathy dropping her elbow… Scapula Humeral Dysfunction etc); address the psychosocial aspects of pain perception – stress, sleepless nights (just had a baby), long working hours (paying the mortgage), sitting in the car in the London-traffic for 2 hours before a training session – no wonder high hamstring tendinopathy is a problem…); pharmacological agents – inflammation is not part of the tendinopathy equation.
  6. No evidence for injecting anything into or around the tendon. However high volume injections / hyaluronic acid in sheaths and soft tissue interfaces, dextrose or Platelet Rich Plasma (PRP) for intra-substance ruptures are all being done on a regular basis by clinicians all around the world. Especially practitioners looking after elite athletes might feel pressured ‘to do something’. This is complex and decisions should be made after careful thinking and thorough risk-benefit discussions between performance health and coaching teams. For the purpose of this blog the fact remains that we have no conclusive evidence to suggest that injecting anything into or around a tendon is of any clinical benefit. We only have anecdote, low quality or small epidemiological trials in support. There are however very well conducted Randomised Controlled Clinical Trials against for instance PRP.
  7. Monitor – discuss with the patient one or two symptoms / loading tests to perform at home or in the gym / rehab room on a regular basis as some objective indicator of progress.
  8. Follow up – re-asses; discuss progress and set new goals. Tendon palpation has very little value.


Prof Jill Cook is a Physiotherapist, Tendon Clinician-Scientist, Deputy Editor of BJSM @ProfJillCook

Dr. Paul Dijkstra is a Specialist Sport & Exercise Medicine Physician ASPETAR, DOHA, QATAR. UK Athletics Chief Medical Officer Beijing & London Olympic Games. Views are my own. @DrPaulDijkstra

BJSM was an official sponsor of the 3rd International Scientific Tendinopathy Symposium - #Tendons2014. The next conference will be in 2016 at a venue to be determined. BJSM will aim to break the news! “And the winner is….!”

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