You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Imaging in Sports-Specific Musculoskeletal Injuries

29 Sep, 16 | by BJSM

By Karim Khan (@BJSM_BMJ) and Hakim Chalabi

(This blog is based on the published preface for the book – it’s not a new piece of writing. Think of BJSM going green – re-use, refresh, re-edit (a bit)).

Wow!!! Wow!!! Wow!! As experienced sports physicians we have seen most of the injuries, we have listened to very many lectures and we own many books. We have perused a zillion sports medicine books at conferences, academic bookstores and among our friends/colleagues’ collections. So when we heard that Professor Guermazi and Doctors Roemer and Crema were writing a sports medicine radiology book we were pleased but we were not expecting to be surprised.


Comprehensive!! We were not expecting 776 pages. This is encyclopedic but also very friendly to access. With 27 chapters, all the common sports are, of course, included but you can also learn about the imaging of rodeo and climbing sports injuries, for example.

Sporting focus!! The first wave of sports medicine books were anatomically-oriented and very surgical. The next generation was symptom-oriented and much more multidisciplinary. There have been very few ‘sport-focused’ books and no single book springs to mind as a ‘must have’. The International Olympic Committee has published a comprehensive series of encyclopedias and manuals on a sport-by-sport basis and that makes a good collection. But the set is not cheap.

In Imaging in Sports-Specific Musculoskeletal Injuries, the world experts such as Mark Anderson, Philip Robinson, Hollis Potter, Adam Zoga, Ronald Adler, Mario Maas, Anne Cotten and others provide insights sport by sport. Even if one were not interested in radiology J, but just sports medicine, then this book provides remarkable value because it details the mechanisms of sporting injuries and the pathologies that result. The skiing and snowboard chapter is just one example. Twenty years of dogma relating to potential mechanisms has recently been overturned and the new paradigm is captured in this sports imaging book!

We are both very experienced. Despite that, some chapters took us on a steep learning curve. Kudos to the authors. In other chapters, those where we have worked a great deal, we can confirm the quality of the evidence. Which reminds me that the referencing in this book is also outstanding. So it’s also a remarkable guide to the broader sports medicine. There are 2177 references. In chapter 5 alone there are over 260 references! Did we mention ‘comprehensive’?

Images! Just one exclamation mark for the 876 outstanding figures (1690 parts, 104 in color). We had a very, very high bar for images. We expected Professor Guermazi and Doctors Roemer and Crema to provide immaculate images and they did. This sports imaging book has no competitor for the quality and the number of images for sports medicine.

In Imaging in Sports-Specific Musculoskeletal Injuries, the authors provide customized color art (ie, “line drawings” in the older nomenclature) to illustrate anatomy, injury mechanisms, or pathology, where this is complicated. Images from MRI and ultrasound are overdrawn in color to help the reader. Pedagogy applied to help the reader.

One major take home message from this book is that radiologists with a real interest in sports medicine can add great value to the treatment team and ultimately for the patient. This book, although focused on the patient and clinical care, essentially provides a curriculum for the discipline of sports radiology. There is the potential for these authors to now share their knowledge via in person and online channels.

We like it! For the serious clinician who uses imaging – who aims to understand his or her clinical work, this book is a wonderful investment. This is an essential part of the libraries of specialist sport and exercise medicine physicians, sports physiotherapists and sports surgeons.


Karim Khan, MD, PhD, FACSEP, Professor, University of British Columbia; Editor in Chief, BJSM

Hakim Chalabi, MD, Sports Medicine International Expert; Former Medical Doctor of Paris Saint-Germain Football Club

Work It. Make It. Do It. Sports injuries at the Olympics: an overview from past games and future directions

27 Sep, 16 | by BJSM

 Engagement, Evidence, & Practice Blog Series

By Nirmala Perera (@Nim_Perera)

Examining the changing profiles of injuries provides opportunity for insight, and potential to better embed innovative injury prevention strategies and advances in sports medicine.


Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Athletes from over 200 nations gather every four years for the Olympic and Paralympic Games to celebrate sport, culture, fair play and international cooperation on sport’s biggest stage. I like many of you BJSM blog readers who watched the Rio Olympic (#Rio2016) coverage saw the myriad of injuries and illness captured and broadcast by the media, from fractures and dislocations to diarrhoea and subsequent collapse. At elite level, top players and teams are separated by a very small margin. Injuries and illness affect athletes’ ability to train, complete and can even shatter their dreams of gold. Injury prevention therefore, could be considered ‘legal’ performance enhancement.1 2

Work It. Make It. Do It. Makes Us: Faster. Higher. Stronger.

The Olympic motto Citius, Altius, Fortius (Latin for “Faster, Higher, Stronger”) inspires athletes to reach new heights, changing the nature of the sport over time. The Olympic Games are the pinnacle of many athletes’ careers. They aspire to successfully compete at the games. Injuries and illness can be the cost of striving for athletic greatness. Protecting athletes’ health is therefore, important to maximise performance and chances of success. Current profile of injuries in a sport might be different to injuries suffered by athletes participating the same sports in the past as rules, techniques and equipment evolve. Additionally, elite athletes enter sports much earlier and some continue to compete for longer. Consequently, sports medicine and injury prevention has to evolve with the athlete and their sport.

Injury and illness surveillance of Olympic athletes

The number one priority for the IOC and its Medical and Scientific Commission is protecting the health of the athletes3. Injury surveillance therefore, was initially established by the IOC during the 2004 summer games in Athens and was limited to team sports4. In 2008  injury surveillance was expanded to include all athletes participating in the  Beijing Summer Olympics5 and subsequently the 2010 Winter Olympics in Vancouver6; 2012 London Summer Olympics7, and 2014 Sochi Winter Olympics8. For the first time, injuries in 2012 London Paralympics were reported9 10.

The overall injury rate has remained similar over the last two summer Olympics (9.6% in Beijing5, 11.0% in London7). In addition, 7.2% athletes suffered an illness such as infections to respiratory and gastrointestinal tract during London Olympics. Female athletes were 1.6 times more likely to be ill than their male counterparts7. It is likely that these figures will remain comparable in #Rio2016.

Olympic pains:  the most common injuries by sport, nature and mechanism of the injury

Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Football, taekwondo and handball topped the injury list in both Beijing and London. Field hockey and weightlifting, also in the top 5 sports with the most frequent injuries in Beijing5 were ousted by BMX and mountain biking in London7.

Fractures, ligament ruptures and dislocations were the most common types of injury during the Beijing games5. The most common injuries for the London games were ligament sprains, muscle strains, fractures7. Head/neck/face, hand/wrist/fingers and lower back were the most frequently injured regions at #London2012. Interestingly, most of the diagnosis examinations performed at  #Rio2016 Polyclinic at the Athletes Village were to the knee, lumber region and ankles.

Overuse was the second common cause of  injuries in Beijing5. And, it was the most common injury mechanism in London. However, 68% of the reported overuse injuries did not require time-loss from the sport7.  High prevalence of overuse injuries signals to the repetitive nature of elite sport. Elite players are selected on the strength of the key sports specific skill. Many hours of practice are required for athletes to achieve mastery, which necessitate repetitive activities potentially associated with overuse and recurrent injuries. Particularly if training regimes are poorly managed.

Cupping: why athletes use it?

Techniques to manage pain of overexertion such as myofascial decompression (i.e. cupping) to improve healing and release muscle stress attracted a heightened media coverage in #Rio2016. Cupping has shown to provide effective pain management but the evidence is of poor quality and subject to bias. Exact mechanism of cupping is unclear; it may work by ‘counter irritation’ or by ‘placebo effect’. Yet, athletes turn to drug-free methods such as cupping as an alternative to medications possibly because the anti-doping regulations.

Injury prevention research into practice

Nine IOC research centres of excellence work alongside sporting organisations and key stake holders, striving to develop and implement effective preventive and treatment measures for injuries 3. For example, in Beijing5 49.6% of the injuries resulted in an inability to compete, this was reduced to 35.0% in London7. This might be due to advancement in sports medicine where management strategies such as activity modifications/restrictions and analgesia may have delay treatment or prolong recovery until the end of the games, particularly for overuse injuries. The latest research innovations developed by preeminent international authorities in sport injury and illness prevention will be showcased at the IOC World Conference on Prevention of Injury and Illness in Sport in Monaco (#IOCprev2017). In addition, the IOC supports the #BJSM Injury Prevention and Health Protection issues to further enhance knowledge translation to protect the health of both professional and amateur athletes.



  1. Raysmith BP DM. Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study. J Sci Med Sport 2016;19(10):778-83. doi: 10.1016/j.jsams.2015.12.515
  2. Hägglund M WM, Magnusson H, et al. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 2013;47(12):738-42. doi: 10.1136/bjsports-2013-092215
  3. Engebretsen L BR, Cook JL, et al. . The IOC Centres of Excellence bring prevention to Sports Medicine. Br J Sports Med 2014;48(17):1270-75. doi: 10.1136/bjsports-2014-093992
  4. Junge A LG, Pipe A, et al. . Injuries in Team Sport Tournaments During the 2004 Olympic Games. Am J Sports Med 2006;34(4):565-76. doi: 10.1177/0363546505281807
  5. Junge A EL, Mountjoy ML, et al. . Sports injuries during the summer Olympic games 2008. Am J Sports Med 2009;37(11):2165-72.
  6. Engebretsen L SK, Alonso JM, et al. . Sports injuries and illnesses during the Winter Olympic Games 2010. Br J Sports Med 2010;44(11):772-80.
  7. Engebretsen L ST, Steffen K, et al. . Sports injuries and illnesses during the London Summer Olympic Games 2012. Br J Sports Med 2013;47(7):407-14.
  8. Soligard T SK, Palmer-Green D, et al. . Sports injuries and illnesses in the Sochi 2014 Olympic Winter Games. Br J Sports Med 2015;49(7):441-47.
  9. Willick SE WN, Emery C, et al. The epidemiology of injuries at the London 2012 Paralympic Games. Br J Sports Med 2013;47(7):426-32. doi: 10.1136/bjsports-2013-092374
  10. Derman W SM, Jordaan E, et al. . Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff. Br J Sports Med 2013;47(7):420-25. doi: 10.1136/bjsports-2013-092375


Nirmala Perera (@Nim_Perera) is a health practitioner, an epidemiologist and a PhD scholar at the Australian Centre for Research into Injury in Sport and its Prevention (@ACRISPFedUni). She is the @IOCprev2017 #SoMe campaign coordinator.


PS: Image credit info as per

copy this link to your blog or website  <a href=’’>Designed by Freepik</a>

School Games: great introduction to a multi-sport experience

24 Sep, 16 | by BJSM

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

By Dr Philippa Turner

If anyone is looking for an introduction to the multi-sport experience, look no further than the School Games! Previous medical team alumni (and athletes, of course) have gone on to World University Games, Commonwealth Games, Olympic and Paralympic Games success.

About the games

Developed and organised by the Youth Sport Trust, Sport England and the Department of Culture, Media and Sport, the School Games creates an inspirational and motivational setting. It provides elite young sports people with the opportunity to perform at the highest level. It also encourages more young people to take part in sport. Over 1,600 young athletes competed across three days this September at Loughborough University, England.

The Games currently includes twelve sports: Fencing, Rugby Sevens, Gymnastics, Hockey, Athletics, Cycling, Judo, Swimming, Table Tennis, Volleyball, Wheelchair Basketball and Wheelchair Tennis; disability athletes compete in seven sports: Athletics, Fencing, Swimming, Table Tennis, Cycling, Wheelchair Basketball and Wheelchair Tennis.

Organisers make the School Games as similar to the Olympics and Paralympics as possible. This includes an Opening and Closing Ceremony to participate in and enjoy, shared flats as accommodation, communal food halls, accreditation procedures, volunteer support staff, and a central medical clinic alongside pitch-side support.

SEM takeaways – ‘court-side’ lessons learned

This was my first experience of working at the School Games. It made me realise the massive logistical planning which goes into providing medical cover at such an event compared to a single one off fixture. A day of introduction and CPD was put on prior to the competitions’ start. This included sessions on safeguarding, anti-doping, dental injuries and venue familiarisation. It also allowed the medical team to get to know each other and practise moulages. This was a great opportunity to learn from both more experienced colleagues in a supervised setting, and other health professionals who work in a wide range of sporting environments.


I was placed at Volleyball with three physiotherapists, a paramedic and technician. I had no prior experience of covering Volleyball. It was quickly evident that the crowd was enthusiastic and loud! The competition was tight at the top of the tables in both the girls’ and boys’ groups. This made for some aggressive warm ups causing bloody noses, but also some great games to watch.

The main issues we saw included shoulder, knee and lower back pain. The athletes’ long levers with little muscle bulk to control movement patterns were clearly causing issues. Many of the boys were over 6’5” tall and did not fit on our examination plinths. Many also appeared to rely on K-Tape to get them through matches. So as a medical team, we tried to educate our patients as much as possible about activation and strengthening exercises they could perform in order to improve their performance both in the short and long term.

I also became more aware that, when working with young athletes, their overall wellbeing is paramount. We were not there simply to treat an injury or illness. When the competition started the pressure from coaches, parents and the athletes themselves was also a critical thing to manage. This was further intensified by the fact that this was many of the athletes’ first time away from home, and/or their first experience with a team of professional medical support.

A great opportunity


Philippa Turner, Phillip Harris, Jude Coe, and Leanne Simoncelli

I thoroughly enjoyed getting to know and learning from the medical team.  Working at the School Games lets you see first-hand young athletes gaining invaluable multi-sport experience. They performed at their best even if the results didn’t go their way. I would certainly encourage any doctor or physiotherapist who is interested in Sport and Exercise Medicine to look out for the job adverts on the UK Sport website early next year and do their homework before the interviews! You never know – you might look after the next Max Whitlock, Ellie Simmonds or Adam Peaty!

For more information about the 2016 School Games you can visit

Dr Philippa Turner, ST5 in the East Midlands Deanery. She works as the match day doctor for Aston Villa Ladies Football Team, Team Physician to England Cricket Disability Squads and the Women’s Performance Programme. She is also the Trainee Representative on the SEM Speciality Advisory Committee (SAC).

Dr Farrah Jawad is a registrar in London and co-ordinates the BJSM Trainee Perspective blog.



Bewertung von Personen als Risikopatienten – eminenzbasierte Willkür?

22 Sep, 16 | by BJSM

Original article in English/ Original Artikel: (BJSM open Access, Editorial)

German translation by Isi Schneider @isi69schneider

Original article by Järvinen, Teppo LN

Zuerst online veröffentlicht am 16. November 2015

Wenn ein Arzt nicht in der Lage ist Gutes zu tun, dann muss man ihn davon abhalten Schaden anzurichten.


In der heutigen Zeit kann das „hohe Risiko“ eine Krankheit zu erleiden beinahe schon als eine eigene Krankheit betrachtet werden. Umfassende Bildungsprogramme in allen Bereichen von Gesundheit und Pflege machen aus dem „hohen“ Blutdruck, den erhöhten Blutfettwerten oder der geringen Knochendichte ansonsten gesunder Patienten chronische Zustände mit einem zunehmenden Risiko möglicher schlimmer Ereignisse1. Aber was bedeutet „hohes Risiko“ überhaupt? Diese Frage bildet den Kern der modernen Medizin in Bezug auf die primäre medikamentöse Prävention.


Befürworter dieser Entwicklung argumentieren schlicht, dass Primärprävention Leben rettet. Allerdings muss die freizügige Definition bestimmter Zustände als Krankheit nicht zwingend harmlos sein. Auf der individuellen Patientenebene bestehen mögliche Nachteile unter anderem darin, dass relativ gesunde Individuen sich selber als „krank“ empfinden. Dabei beinhaltet beinahe jede Behandlungsform gewisse Risiken2. Auf der gesellschaftlichen Ebene können wir uns sicherlich noch alle an die entmutigenden Ergebnisse der neuen europäischen Richtlinien für Herz-Kreislauf-Erkrankungen erinnern, auf deren Grundlage die meisten Norwegischen Erwachsenen – mit eine der gesündesten Populationen weltweit! – als Hochrisikogruppe für kardiovaskuläre Erkrankungen3 betrachtet werden müssten. Würden diese Richtlinien im norwegischen Gesundheitssystem tatsächlich angewendet, dann würde allein der Fokus auf Bluthochdruck den jährlichen Gesundheitsetat vollständig erschöpfen.

„Hohes Risiko“ – wie tief können wir ansetzen?

Die derzeitige Diskussion über „Risiko als Krankheit“ dreht sich um die angemessene Schwelle, ab der ein Zustand als Krankheit definiert wird. Der kürzlich von Medizinexperten der Nationalen Osteoporosestiftung (NOF, USA) verabschiedete Osteoporoseleitfaden empfiehlt eine medikamentöse Osteoporosebehandlung wenn die Wahrscheinlichkeit eines Patienten, innerhalb von 10 Jahren eine Schenkelhalsfraktur zu erleiden, bei mindestens 3% liegt. Würden diese Ratschläge der NOF in einer breit angelegten prospektiven Studie Anwendung finden, müsste in den USA mindestens 72% weißer Frauen über 65 und sogar 93% der über 75-jährigen eine Medikamententherapie nahegelegt werden4. Parallel dazu steckt die neue Cholesterinrichtlinie praktisch die gesamte ältere Bevölkerung in die Schublade mit dem Etikett „krank“.

Risikoverständnis: leiten hier die Blinden die Blinden?

Aber wer sind dann die richtigen Leute, um die Grenze zum „hohen Risiko“ festzulegen? Fürsprecher der Hegemonie medizinischer Experten argumentieren dass Ärzte – als Sachverständige – Krankheiten als solche definieren sollten5. Aber wenn wir davon ausgehen, dass Mediziner in Sachen Beurteilung der Perspektive von Patienten die ihnen gegenübersitzen wirklich kompetenter sind als die Patienten selber, sollten wir dann nicht in der Lage sein zu belegen, dass ein Arzt diese Aufgabe auch wirklich erfüllen kann? Traurigerweise scheinen Ärzte trotz eines Medizinstudiums und klinischer Erfahrung dafür nicht die erforderlichen Qualitäten aufzuweisen6.

Schlimmer noch, es kann gut sein dass Patienten diese Wahrnehmung nicht vollständig teilen. So liegt beispielsweise die oben erwähnte Schwelle der NOF mehr als 15-mal tiefer als der Wert, den Patienten in Bezug auf das 10-Jahres Risiko einer Schenkelhalsfraktur zur Legitimierung einer knochenspezifischen Pharmakotherapie befürworten würden (50%).7

Damit einhergehend existiert eine fundamentale Lücke zwischen dem, was beide Seiten als „effektive Behandlungsmethode“ betrachten. Allgemein würden Patienten bei einer absoluten Risikoreduktion (für Herzinfarkte) von >20% mittels präventiver Pharmakotherapie eine entsprechende Behandlung befürworten.8 Dagegen haben Ärzte in der ganzen Welt damit begonnen begeistert Rezepte auszustellen, als sich gezeigt hat, dass ein neues Osteoporosemedikament in der Lage ist, die Wahrscheinlichkeit der Vermeidung einer Schenkelhalsfraktur von 97.9% auf 98.9% zu erhöhen. Tatsächlich hat also ein 1%iger absoluter Vorteil die Kollegen überzeugt. Allerdings – und das soll nicht unerwähnt bleiben – nachdem ihnen dies als 50%ige relative Risikoreduktion verkauft wurde.

Verpflichtet uns der Hippokratische Eid zum Eingreifen?

Man mag sich fragen, warum wir überhaupt noch eingreifen, obwohl nicht nur unsere Patienten unsere Ansichten nicht teilen, wenn es um die Frage geht worin ein nachvollziehbares und behandlungsbedürftiges Risiko besteht, bzw. wie sich eine effektive Behandlung überhaupt definiert. Vor allem dann, wenn die eingesetzten präventiven Maßnahmen 10-mal kostspieliger sind als die eigentliche Behandlung des Ereignisses dem dadurch vorgebeugt werden soll? Die meisten Mediziner vertreten die Ansicht, dass wir keine andere Option haben wenn es um Leben und Tod geht. Allerdings tun wir uns in anderen Disziplinen, die ebenfalls Auswirkungen auf Gesundheit und Wohlergehen der Bevölkerung haben, wesentlich leichter, kostenbasierte Entscheidungen zu treffen. Grundschullehrer sind sich beispielsweise durchaus bewusst dass es in jeder Klasse eine Anzahl von Kindern mit Lernschwierigkeiten gibt, weil sie vielleicht aus Problemfamilien kommen und daher logischerweise einem „hohen Risiko“ ausgesetzt sind, auf einem niedrigen Bildungsniveau zu verharren. Aber veranlasst uns die erhöhte Gefahr der sich daraus ergebenen sozialen Benachteiligung dazu, in großem Umfang spezielle Lernprogramme für alle „Risikokinder“ zu veranlassen und zu finanzieren?

Die Behandlung von „hohem Risiko“ – zum Hohn der Patientenmitbestimmung?

Kehren wir zurück zur entscheidenden Frage: ist die Behandlung von „hohem Risiko“ ein praktikables Konzept? Die Strategie, über eine einfache Einschätzung des Risikos eines Patienten dieses auch effektiv zu minimieren wirkt verführerisch. Allerdings suggerieren Ergebnisse aus der Verhaltensforschung, dass wir uns in der Regel schwertun, Wahrscheinlichkeiten korrekt einzuschätzen.9 Und trotz ehrbarer Bemühungen die Kommunikation und das Verständnis sowohl in Sachen Risikobewertung, als auch bezüglich zu erwartender Behandlungserfolge zu verbessern, sind sowohl Ärzte als auch Patienten von einer exorbitanten Unfähigkeit befallen, Risiken korrekt einzuschätzen (Abb.1)6. Aber ohne ein genaues und übereinstimmendes Begreifen dieser Schlüsselaspekte existiert keinerlei Basis für gemeinsame Lösungsansätze10. Und ohne solch gemeinsame Lösungsansätze wird eine pharmakologische Primärprävention zur Tyrannei der Eminenz.

größere Version öffnen:       in einem neuen Fenster       Download als PowerPoint Folie

Abbildung 1

Der Begriff Risiko bezeichnet die Wahrscheinlichkeit dass etwas Schlechtes oder Unangenehmes passiert. Intuitiv erscheint dies als ein sehr einfaches Konzept. Allerdings gibt es starke Anzeichen dafür, dass das Begreifen des Risikokonzeptes sowohl bei Ärzten als auch bei Patienten nur schwach ausgeprägt ist.


An Alan Cassels, für seine Hilfe beim Editieren und das Einfügen zusätzlicher Argumente.


  1. Moynihan R; Surrogates under scrutiny: fallible correlations, fatal consequences. BMJ 2011;343:d5160.
  2. Tikkinen KA, Leinonen JS, Guyatt GH, et al; What is a disease? Perspectives of the public, health professionals and legislators. BMJ Open 2012;2:pii: e001632. doi:10.1136/bmjopen-2012-001632
  3. Getz L, Sigurdsson JA, Hetlevik I, et al; Estimating the high risk group for cardiovascular disease in the Norwegian HUNT 2 population according to the 2003 European guidelines: modelling study. BMJ 2005;331:551. doi:10.1136/bmj.38555.648623.8F
  4. Donaldson MG, Cawthon PM, Lui LY, et al; Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines. J Bone Miner Res 2009;24:675–80. doi:10.1359/jbmr.081203
  5. Moynihan R; A new deal on disease definition. BMJ 2011;342:d2548. doi:10.1136/bmj.d2548
  6. Martyn C; Risky business: doctors’ understanding of statistics. BMJ 2014;349:g5619. doi:10.1136/bmj.g5619
  7. Douglas F, Petrie KJ, Cundy T, et al; Differing perceptions of intervention thresholds for fracture risk: a survey of patients and doctors. Osteoporosis Int 2012;23:2135–40. doi:10.1007/s00198-011-1823-7
  8. Trewby PN, Reddy AV, Trewby CS, et al; Are preventive drugs preventive enough? A study of patients’ expectation of benefit from preventive drugs. Clin Med 2002;2:527–33.
  9. Kahneman D, Tversky A; Prospect theory—analysis of decision under risk. Econometrica 1979;47:263–91.
  10. Hoffmann TC, Montori VM, Del Mar C; The connection between evidence-based medicine and shared decision making. JAMA 2014;312:1295–6.



Professor Teppo LN Järvinen, Klinische Medizin/Abteilung für Orthopädie und Traumatologie, Universität Helsinki, Zentrale Uniklinik Helsinki, Töölö Klinik/Topeliuksenkatu 5, Helsinki 00014, Finnland;

Übersetzt von

Isabel Schneider, M.A. Englisch als Fremdsprache, MA Sportwissenschaften, Dozent an der H:G Hochschule für Gesundheit und Sport, Technik und Kunst

Physio-Motion – Beratung und Dienstleistungen rund um Sport, Bewegung und Gesundheit


Safety in youth rugby: education is not the answer to the concussion crisis

19 Sep, 16 | by BJSM

By Adam White @AdJWhite, Dr. Tim Gamble, and John Batten @JBatz85 

Injury worries

Despite the potential health benefits from participating in the sport, rugby is under increasing scrutiny as a result of the high number of injuries experienced by youth participants. We know, for example, that injury rates in rugby union for participants under 21 years of age can be as high as 128.9 injuries per 1000 playing hours, with a mean injury incidence rate of 26.7 per 1000 playing hours. The tackle is often to blame, causing sixty-three per cent of all injuries in one study on school rugby.


Concussion has received particular attention due to the potential long-term impacts (e.g., chronic traumatic encephalopathy) it may have upon brain functioning. Indeed, a systematic review of concussion in youth sport, stated that rugby had the highest risk of concussion compared to sports such as Field Hockey and American Football. In fact, one recently published study in Sweden shows many of the damaging social outcomes of concussion. Concerned about the potential damage the tackle may be having on children, we and the Sport Collision Injury Collective recently wrote to the British government urging them to ban tackling in rugby in school sport.

The HEADCASE programme

The Rugby Football Union’s response to safety concerns in their sport is through the delivery of educational initiatives. Specifically, the online HEADCASE programme provides key stakeholders with information about recognising concussion and managing injured players (i.e., secondary prevention). Delivered through an online, interactive web platform, it is freely available for players, coaches, officials, parents, teachers, first-aiders and spectators to complete. This potentially represents an improvement to player-safety, with the rugby authorities (the Rugby Football Union, World Rugby etc.) leaders in the management of brain trauma in sport. However, the following sections highlight some concerns about the effectiveness and delivery of this health-focused educational programme.

Voluntary participation

Globally, some rugby authorities require their coaches and teachers take either annual or biannual training to coach the sport. The Rugby Football Union, however, has no mandate for coaches to have undertaken HEADCASE training – although any individuals seeking to undertake a new coaching or refereeing qualification (which is also not mandatory to coach or officiate) are required to complete the programme before attending a course. Yet, this neglects the vast population of coaches who have completed their qualifications before the introduction of the HEADCASE programme, or those coaches and officials who do not seek qualifications at all. Furthermore, coaches and officials in England who have completed the training will only have to do so once, with no immediate plans to make it a yearly requirement like rugby governing bodies in the southern hemisphere.

Lack of evaluation

There is poor evaluation of educational initiatives aimed at reducing injury in sport. Only two rugby programmes (BokSmart and RugbySmart) complete all four elements of Van Mechelen’s Model of Injury Prevention (i.e., establishing the extent of the injury problem, establishing the aetiology and mechanisms of sports injury, introducing a preventative measure, assessing its effectiveness by repeating the process) to establish intervention effectiveness. Subsequently, researchers have asserted: ‘There is a dearth of evidence to support the effectiveness of such programmes’. Additionally, a recent BJSM systematic review found the concussion prevention benefits of technique training and practice time restrictions may be limited to a specific sub-set (i.e., 11-15 year olds) of the at-risk athletic population.

Education and injury prevention

Unless sporting bodies evaluate the effectiveness of their training, the impact upon injury prevention is unknown. However, evidence from the health and safety literature suggests that when implementing controls to manage risk, educational interventions are somewhat limited in effectiveness. Specifically, the Hierarchy of Control asserts that elimination of a risk is the most effective way of management, with personal protective equipment being the least effective, and administrative controls (i.e. education) the second least effective. Thus, altering the structure of an activity (substitution) or eliminating the mechanism – in this case tackling –  are likely to be much more effective interventions for the prevention of injuries than educational initiatives. Exemplifying this, law amendments in youth Ice Hockey (i.e., removing the body check) resulted in a reduction of injuries and concussions.

The way forward

Injury prevention must be the priority when considering the current concussion crisis in sport.  However, if the Rugby Football Union is committed to education about tertiary care of brain trauma at this stage, programmes should specify mandatory annual participation for the rugby workforce, with comprehensive evaluations of their effectiveness simultaneously undertaken. Although unlikely to be as effective as altering the structure of the sport (e.g., moving from contact rugby to touch rugby in schools), such changes may help to reduce the risk of concussion in youth rugby, while maintaining the cardiovascular and psychosocial health benefits offered by participation.

Conflicts of interest: None to be declared.


Adam White [] @AdJWhite, is a doctoral researcher at the University of Winchester and founding member of the Sport Collision Injury Collective. He also sits on the committee of the England Rugby Football Schools Union.

Dr. Tim Gamble [] is a Senior Lecturer in Psychology at the University of Winchester. His main research interest is investigating risk and protective equipment, specifically the unintended consequences of safety equipment provision.

John Batten [] @JBatz85 is a senior lecturer in the Department of Sport and Exercise at The University of Winchester where he is currently programme leader for the BSc/MSci (Hons) Sport and Exercise Science.

The International Sports Physical Therapy Specialist: reflections on the UK situation (what we may take for granted)

16 Sep, 16 | by BJSM

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

By Colin Paterson ,MSc PGCert (Ed) MCSP SFHEA RISPT

I recently presented at the Japanese Physical Therapy Congress in Saporro on the development of the International Federation of Sports Physical Therapy (IFSPT) competencies. Specifically, how we use them in the UK in relation to our Continuous Professional Development (CPD) pathway. I met with a variety of sports physical therapists in Japan, national committee members, the Lead Physical Therapist for TOCOG/Tokyo 2020 games to share knowledge and learn more about the professional context in Japan. These experiences spurred me to reflect on the specialty in the UK. Notably, the status and skill level of the profession and opportunities that exist in the UK- that others may take for granted.

Selfie at the top of the ski jump used for the Winter Olympics in Saporro 1972.

At the top of the ski jump used for the Winter Olympics in Saporro 1972.

Broad and enriching scope of practice

In the UK, physiotherapists are autonomous, first contact health care professionals able to work in a number of environments: hospitals, private clinics, the community and the sports field. With extending skills and scope of practice, physiotherapists with appropriate training adopt skills and roles previously only undertaken by doctors. In sport these skills and experiences continually grow and develop. Sports physiotherapists work at all levels from aiding the patient with a chronic long term condition to exercise, to recreational weekend warrior athletes, to high level elite athletes. In the UK they are the ‘go to’ practitioner for sports injury management advice, rehabilitation and advice to optimise sporting performance unlike other countries where athletic trainers have a greater presence.

This scope of practice isn’t the case in other countries where physical therapists are not always licensed to be a first contact practitioner, or work pitch side. They may not be able to use advanced skills or perform the trauma management role. UK sports (and exercise medicine) physiotherapists must not take this for granted. They must maintain the high reputation of the profession. Experienced physiotherapists also need to ensure a legacy by supporting new physiotherapists to work within the specialty to maintain its strong presence and reputation.

Organizational support networks

The UK sports Physiotherapy group, the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), has always maintained strong UK links with other sporting bodies and also internationally with IFSPT and WFATT (athletic training group). This facilitates UK physios involvement in discussions, debates and information exchange – positioning us well to influence and implement best practice. The ACPSEM/UK was one of the first countries worldwide to have a sports physiotherapy CPD pathway based on the IFSPT competencies (IFSPT 2016. See Figure 1) when they were developed in 2004 (Bulley et al 2004). Only 8 countries now have an approved pathway for members to call themselves a Registered International Sports Physical Therapists, again something we shouldn’t take for granted in the UK.


Figure 1. IFSPT Competencies.

Part of my trip to Japan was to provide support and advice on their preliminary discussions about developing their own specialty pathway. The build up to the 2020 Olympic Games are motivation and an opportunity to negotiate change. The IFSPT sees mentoring and support, on an individual or wider scale as an important element of developing the specialty worldwide. The IFSPT competencies underscore the skills and knowledge required to be a sports physical therapist. They also promote what the profession can offer (by and for individuals, educators, and employers) and guide development. The journey from being a novice to expert requires more than years of experience. Research highlights the need for the development of critical reflection skills, deliberate action/practice, organised and varied knowledge, and having a patient centred focus (Paterson and Chapman 2013. Higgs et al 2008. Jensen et al 2006. Edwards and Jones 2007). When did you last look at the competency document and reflect on your skills and development?!

Standing on the shoulders of giants

Personally I would like to thank all those sports physiotherapists who have impacted me, mentored me and provided me with opportunities to develop and learn. I am not sure I have thanked them enough. Have you thanked your mentors? UK sports physiotherapists must thank the work of the current ACPSEM committee and also all those members of previous executive and regional committees who have put in the hours to develop and provide the opportunities that currently exist for sports physiotherapists. The status we have as a profession and Physiotherapy specialty is taken for granted by some, but it has been earned.

Still, there is always more to be done and developed.

Reflecting back and aspiring forward

I will finish by asking you to take a moment to reflect on your career to date; how have you got to where you are? What/who are your influencers? Are you providing opportunities for others? Can you call yourself a registered international sports physical therapist?

We all have a role to play in maintaining the strong reputation and skill level of sports physiotherapists in the UK and globally. This involves promoting what we can offer and looking to make developments where appropriate. What capacity do you have to contribute? I will leave you with one last question to reflect on: do you take the sports physiotherapy specialism for granted?


Bulley, C., Donaghy, M., Coppoolse, R., et al (2004) Sports Physiotherapy Competencies and Standards. Sports Physiotherapy for All Project.(online) available at (accessed 07.07.16)

Edwards, I and Jones MA 2007 Clinical reasoning and expert practice. In: Jensen GM, Gwyer J, Hack LM, Shepard KF 2007 Expertise in PhysicalTherapy Practice,2nd edition.

Higgs, J., Jones, M.A., Loftus, S and Christensen, N 2008. Clinical Reasoning in the Health Professions. 3rd Edition. London. Butterworth Heinemann

IFSPT 2016 (accessed 27.7.16)

Jensen, G.M., Gwyer, J., and Hack, J 2006. Expertise in Physical Therapy Practice. 2nd Ed. Elsevier, St Louis

Paterson, C and Chapman, J 2013. Enhancing skills of critical reflection to evidence learning in professional practice. Physical Therapy in Sport. 14(3); 133-138


By Colin Paterson MSc PGCert(Ed) MCSP SFHEA RISPT, Senior Lecturer (Physiotherapy) Brighton University. UK, Member of the IFSPT Registration Board. Chair of the ACPSEM UK


Job posting: Professor or Associate Professor, Sport Injury Prevention and Sport Medicine Centre, Faculty of Kinesiology

13 Sep, 16 | by BJSM

Job ID: 10996

Location: Main Campus


Position Description

The Faculty of Kinesiology at the University of Calgary invites applications for a full-time tenured Associate Professor or Full Professor position and potential scientific leadership role in the Sport Injury Prevention Research Centre and/or Sport Medicine Centre. The appointment commencement date for the successful candidate is anticipated to be January or July 2017.

The successful candidate at the Associate Professor level will have earned a PhD in Sport Injury Prevention, Sport Medicine, or Rehabilitation research field and be at a mid-phase of their academic career.  The successful candidate will have a demonstrated track record in peer-reviewed research publications, external research funding, knowledge translation, and building capacity in government, industry, and/or community partnerships leading to impact in practice and/or policy in the field. The successful candidate will also have evidence of a commitment to teaching excellence with successful graduate and post-doctoral fellow supervision. The successful applicant will have an established research program with a focus on the prevention of injuries in sport and recreation, and/or sport medicine, and/or rehabilitation and will be recognized as a leader in their research field. The candidate will have a plan for significant contribution to the Faculty of Kinesiology in high-quality undergraduate and graduate teaching, graduate student and post-doctoral scholar supervision and mentorship, and service.

The successful candidate at the Full Professor level will have earned a PhD in Sport Injury Prevention, Sport Medicine, or Rehabilitation research field, be well established in their academic career, have demonstrated a significant track record in peer-reviewed research publication, evidence of an established and externally funded research program, expertise in knowledge translation, successful partnerships in government, industry, and/or community leading to impact in practice and/or policy in the field. The successful applicant will have evidence of an outstanding teaching and graduate supervision record. The successful applicant will have a fully established research program with a significant focus on the prevention of injuries in sport and recreation and/or sport medicine and/or rehabilitation. The successful candidate will be well established as a leader in their research field with a plan for significant contribution to the Faculty of Kinesiology in high-quality undergraduate and graduate teaching, graduate student and post-doctoral scholar supervision and mentorship, and service.

Interested individuals are asked to submit their application package electronically. Please provide a cover letter (including a teaching philosophy and summary of your research program), curriculum vitae, three (3) examples of relevant publications, three (3) letters of reference, and any other supporting materials.  Please indicate for which rank you are submitting your application.

Application packages, including letters of reference, should be sent to the Dean, Dr. Penny Werthner via the following contact:

Cheryl Gathercole,
Executive Assistant,
Faculty of Kinesiology
University of Calgary
2500 University Dr. NW
Calgary, AB, T2T 4N1

The closing date for applications is September 30, 2016

Additional Information

The Sport Injury Prevention Research Centre (SIPRC) in the Faculty of Kinesiology at the University of Calgary is one of nine International Olympic Committee (IOC) Centers of Excellence in Injury Prevention in Sport, and the only IOC Centre in North or South America. The focus of the interdisciplinary research team is injury prevention in sport and recreation with a significant focus in youth populations. The Sport Medicine Centre (SMC) is a world-class leader in Sport and Exercise Medicine and clinical service.  Since the Sport Medicine Centre opened its’ doors following the 1988 Winter Olympic Games, clinicians have been serving Canada’s Olympians, the University of Calgary Dinos varsity athletes, professional and elite athletes, and the broader community. The SIPRC research program and SMC mission aligns with the vision of the Faculty of Kinesiology which is to be an international leader in the study and advancement of human movement, sport, health, and wellness. The four research themes of focus within the Faculty of Kinesiology include Musculoskeletal Health, Injury Prevention, Sport Medicine and Rehabilitation, Exercise and Nutrition in Health and Sport, and Psychosocial Aspects of Health and Sport.

The University of Calgary believes that a respectful workplace, equal opportunity and building a diverse workforce contribute to the richness of the environment for teaching, learning and research, and provide faculty, staff, students and the public with a university that reflects the society it serves. All qualified candidates are encouraged to apply; however Canadians and permanent residents will be given priority. In this connection, at the time of your application, please answer the following question: Are you a Canadian citizen or a permanent resident of Canada? (Yes/No)

Additional Information

To learn more about academic opportunities at the University of Calgary and all we have to offer, view our Academic Careers website. For more information about the Faculty of Kinesiology visit Careers in the Faculty of Kinesiology.

About the University of Calgary

The University of Calgary is Canada’s leading next-generation university – a living, growing and youthful institution that embraces change and opportunity with a can-do attitude. Located in the nation’s most enterprising city, the university is making tremendous progress on its Eyes High journey to become one of Canada’s top five research universities, grounded in innovative learning and teaching and fully integrated with the community it both serves and leads. Ranked as the top young university in Canada and North America, the University of Calgary inspires and supports discovery, creativity and innovation across all disciplines. For more information, visit

About Calgary, Alberta

Ranked the 5th most livable city in the world, Calgary is one of the world’s cleanest cities and one of the best cities in Canada to raise a family. Calgary is a city of leaders – in business, community, philanthropy and volunteerism. Calgarians benefit from a growing number of world-class dining and cultural events and enjoy more days of sunshine per year than any other major Canadian city. Calgary is less than an hour’s drive from the majestic Rocky Mountains and boasts the most extensive urban pathway and bikeway network in North America.

Technology in Sport and Rehab Autumn Study Day: Register now!

12 Sep, 16 | by BJSM


Working in gymnastics – it’s a balancing act

7 Sep, 16 | by BJSM

By Emily Ross (@EmilyRossPhysio)

Whoa…working in gymnastics, where do we start?

Gymnastics is a mesmerising sport which requires a level of power, flexibility, and not to mention a dedication and focus I have never previously witnessed in a childhood and adolescent age group. We are going to do a roundoff full twist through my top 5 tips from working in the world of gymnastics.

acro gymWe will cover:

  1. What is needed in Acrobatic Gymnastics?
  2. .. Gymnastics and Rugby Union are basically the same?
  3. How a physio’s role in gymnastics can include risk assessment on acrobatic moves
  4. Why we must remember that gymnasts and rugby players are similar characters
  5. The role of a physiotherapist in a childhood and adolescent sport

Professionally I have had the opportunity to work with two very different sports; on one hand, Men’s Rugby Union, an open-skilled, dominated by male adults, contact sport with an 80 minute weekly peak in performance and on the other hand Acrobatic Gymnastics, a closed-skilled, female dominant population, aged pre and post maturation, who perform 2-3 minute routines just a handful of times across the competitive season. Now first things first, I have to admit I am not an ex-gymnast, although I am flattered when people ask; so the world of gymnastics was a brand new experience when I joined an Acrobatics Gymnastics Club 4 years ago.

I highly recommend working in gymnastics. This sport presents exciting challenges as a medical professional, and the opportunity to work closely with gymnasts from their initial development stages, up to, career highlights of international competition. We have all recently enjoyed the Artistic and Rhythmic gymnastics disciplines at Rio 2016. If you’re wondering what Acrobatic Gymnastics is, then I would liken Acrobatic gymnastics to the floor element in Artistic gymnastics.

Here are my top five tips for working with gymnasts…

acro gym 2No.1: Spend time watching training, understanding the movement and strength requirements for gymnastics.

In acrobatics gymnastics, for the majority, gymnasts work in Pairs (Base and Top) or Trios (2 Bases and a Top), although you can also see a Men’s 4. If we take a Trio as an example; a Base will need to support the body weight of up to 2 gymnasts in both static and dynamic positions. The variety of partnerships and multidirectional nature means gymnastics is difficult to explain succinctly. You could describe Acrobatic Gymnastics as a sport of flexibility, strength and power throughout a multiple planes of movement [1].

The interesting medical challenge of gymnastics presents itself in the population of athletes you are working with. You are working with young female (predominantly in our club) athletes in a sport which combines non-modifiable intrinsic risk factors for injury; age, anatomical, hormonal, as well as the post-menarche neuromuscular control deficits, although the latter can be addressed [1-7]. Consider that these young athletes are required to hold load and complete movements in such outer ranges, which most fully developed adults would struggle to complete without issue, injury or long term effects. When I started at the club, it was eye-opening to find out that regular medical provision was relatively rare in club gymnastics.

No.2: Spend time with the coaches to appreciate the way movement is judged in competition.

The sports medicine discipline is a common skill-set needed to work in sport. However my experience in rugby, regarding power and movement efficiency in conditioning, needed to be built upon when I also started working in gymnastics. In rugby, as like many other sports, conditioning focuses on the action, be it sprinting efficiency to make that break away try, the power behind a tackle, a time efficient tumble turn in the pool, or serving an ace in tennis, the list goes on. There are many ways you could complete all of these, however usually coaches and the medical team would support an athlete to complete it in the most physically efficient and powerful manner, to produce the result successfully and safely without injury. Whereas in gymnastics, it is not just about the efficiency of an action, but the aesthetics of how gymnasts complete it, which was a new clinical consideration for me.

Gymnastics has a unique focus on specific limb alignments in scoring and deductions, where a limb may not be scored as ‘straight’ unless there is a degree of hyperextension at the knee or sufficient plantarflexion at the ankle. In rugby, I would aim to target excessive knee hyperextension on grounds of minimising joint translation, stress on the passive system and improving neuromuscular control of end range extension in basic tasks and progressing this into sport-specific loading drills. In gymnastics hyperextension is sought after; entering the world of gymnastics challenged my previous experience and understanding on sport-specific targets. For these reasons I believe No.2 is a relevant point for those transitioning from other sports as well as any new graduates joining the sports world.

No.3 : Consult with the coaches on safety screening acrobatic moves they selected in a routine.

I am proud to work in a club where the coaches’ main focus is long term health beyond gymnastics. Acrobatic gymnastics is not directly focused on efficiency of movement; it challenges the parameters of balance, joint range and motor control in each routine. I questioned what I could add to the club, as I have had no previous experience in gymnastics. Learning idiosyncrasies of the sport was accelerated from listening to coaches’ feedback on training; this can highlight where to aim any screening and prevention ideas. My role in gymnastics became clear when coaches asked about making gymnasts more flexible, more ‘fast-twitch’, or more powerful to throw higher. This is where my in experience rugby and sports medicine was truly complementary. I found building an inter-professional relationship with the coaches adds so much to a team and buy in is tenfold when they know you’re working towards joint goals, points mean prizes…literally.

acro gym 3The safety screening term developed from the coaches asking for my clinical opinion on gymnasts’ biomechanical risk/suitability for a move of higher acrobatic tariff (difficulty) or new routines when partnerships change. The coaches say this is one of the most valuable roles; particularly when they are pushing the boundaries of a gymnast’s capability with new elements. If you are venturing into gymnastics, clinically this is reassuring to be able to avoid putting a gymnast’s musculoskeletal system at more risk by adapting elements of a gymnast’s routine. Adaptations will occur either because anatomically they do not have the range or strength deficit in a certain range for an acrobatic element.

Now this assessment is not fool proof, and I do not have hard-and-fast criteria. I understand the current discussion on movement analysis and other screening efficacy [8-11], maybe screening is the wrong term, but I would advocate the value of our clinical opinion to assist coaches in risk assessment. This allows the gymnasts to develop routines which they will be able to safely maintain, and I will implement a supplementary programme for that gymnast to aim at a higher tariff moves through the season. In fact this is where I came across my research idea to examine the neuromuscular control in young female gymnasts for my MSc, which I’m preparing for submission, but that is for another blog.

No.4: Pay attention to the potential to underreport symptoms.

I have identified many differences in rugby and gymnastics; after time, if you squint and tilt your head to the side, you realise as athletes, they’re hugely similar, yep, I did say similar! Both of these multidirectional-team sports demand incredibly strong athletes, who can regularly withstand an extraordinary load!

One of the fundamental reasons I work in rugby and gymnastics is that both athletes have this overt resilience, drive and committed mind-set. It is these characteristics, which will lead them to national and international levels but can also mask injuries. By comparison, weekly competitions in rugby, the drive for the players to make the next match is clear – I’ve found gymnastics is no different, and even harder at times in run up to competitions, as a gymnast cannot be as substituted out of a Trio, as easily as a rugby player in a 45-man rugby union side. Be careful that their enthusiasm to compete doesn’t overshadow the gymnasts’ communicating symptoms to you.

gym 4No.5: Build a rapport and communication with gymnasts’ of all ages is vital.

Working in a childhood and adolescent sport, you will meet gymnasts who may act with the professionalism of an adult, but they will only be 8 years old. Often gymnasts will never have been taught how to do basic S&C movement patterns, much as we don’t understand the Acrobatic specific terminology. We need to remember they are used to a different sporting-language, they may have not experienced an injury before, or know what an appropriate stretching sensation should be, or the difference between DOMs and a muscle tear. Certainly you will get some puzzled faces with Visual Analogue Scoring.

With symptom reporting in mind, I focused my first season at the club on communication rapport and educating the squad on what we called ‘good and bad pains’. This included teaching the gymnasts what physio can do to help them, why that will help in competitions, and what they can tell me regarding what they are feeling or concerned about.

I enjoy gymnastics because you are working with athletes who are developing in socially, physically, and mentally. Never underestimate gymnasts’ ability for information retention, but you must also not forget their ages. I feel we have a responsibility in their development, and I’m talking more than just physical performance. On reflection, so many times in the rugby world, I have run through players’ past medical history and hear stories of previous injuries as juniors that weren’t flagged, or investigated as you might have hoped, which leads to a frustrating unknown in baseline and query over initial prognosis of an injury.

Working in gymnastics we have an exciting opportunity to be the first medical professional to teach efficient loading strategies and movement patterns, to athletes new to non-sport specific conditioning. We have the responsibility to make sure they complete conditioning safely and efficiently for their developmental stage and anatomy, and the opportunity to further diminish the old school negativity around extreme gymnastic conditioning. We can help to start their athletic career with a professionalism (sports medicine hat on); from explaining strength and conditioning, the importance of communication, to highlighting the benefit of continuing other sports at school. I have found, this results in gymnast buy in, support from their parents and satisfied coaches’ by excelling in performance and long term resilience, which is pretty damn satisfying in the SEM WORLD.

Summary of advice!

  • Spend time watching training, understanding the movement and strength requirements for gymnastics Rugby and gymnastics are more similar than you think…. Understand the resilience 
  • Spend time with the coaches to appreciate the way movement is judged in competition
  • Consult on safety screening with the coaches on acrobatic moves selected in a routine and assess the risk/suitability
  • Be careful that gymnasts’ enthusiasm to compete doesn’t overshadow their symptoms reporting.
  • Building a rapport and communication with gymnasts’ of all ages, educating them to address sport with a sports medicine hat on.
  • Never let rugby players in sparkly gymnastic leotards, there isn’t therapy for that.

Emily Ross is a Specialist MSK and Sports Physiotherapist with a special interest in Rugby Union and Acrobatic Gymnastics. She has been the Head of Medical Services at the Oxford School of Acrobatic Gymnastics for 4 years, she has worked at Harlequins RFC Academy and at Championship level rugby. She also works at the Centre of Health and Human Performance. You can follow her on Twitter (@EmilyRossPhysio)


[1] Deley, G, Cometti, C, Fatnassi, A, et al. Effects of combined electromyostimulation and gymnastics training in prepubertal girls. J Strength Cond Res 2011;25:520–526

[2] Hewett, T, Myer, G, Ford, K. et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the  Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. American Journal of Sports Medicine 2005;33:492-501. DOI: 10.1177/0363546504269591

[3] Lim, B-O, Lee, Y, Kim, J, et al. Effects of Sports Injury Prevention Training on the Biomechanical Risk Factors of Anterior Cruciate Ligament Injury in High School Female Basketball Players. American Journal of Sports Medicine 2009;37:1728-34. DOI: 10.1177/0363546509334220

[4] Myer, G, Ford, K, Palumbo, J, et al. Neuromuscular training improves performance and lower-extremity biomechanics in female athletes. Journal of Strength and Conditioning Research 2005;19:51-60.

[5] Myer, G, Ford, K, Brent, J, et al. Differential neuromuscular training effects on ACL injury risk factors in “high-risk” versus “low-risk” athletes. BMC Musculoskeletal Disorders 2007;8:39 DOI:10.1186/1471-2474-8-39

[6] Myer, G, Brent, J., Ford, K, et al. A pilot study to determine the effect of trunk and hip focused neuromuscular training on hip and knee isokinetic strength. British Journal of Sports Medicine 2008; 42:614-619. DOI: 10.116/bjsm.2007.046086

[7] Myer, G, Sugimoto, D, Thomas, S, et al. The influence of age on the effectiveness of neuromuscular traiing to reduce anterior cruciate ligament injury in female athletes: a meta-analysis. American Journal of Sports Medicine 2013;41:203 – 215.

[8] Clarsen, B, Berge, H. Screening is Dead! Long live Screening. Br J Sports Med 2016;50:769. DOI:10.1136/bjsports-2016-096475

[9] Hewett, TE. Response to ‘Why screening tests to predict injury do not work- and probably never will…a critical review’ Br J Sports Med Published online first: [07/07/16] 2016. DOI:10.1136/bjsports-2016-096388

[10] Moran, R, Schneiders, A, Major, K, et al.  How reliable are functional movement screening scores? A systematic review of rater reliability. Br J Sports Med 2015. DOI:10.1136/bjsports-2015-094913

[11] Wright, A, Stern, B, Hegedus, E, et al. Potential limitations of the Functional movement screen: a clinical commentary. Br J Sports Med 2016 50:13 770-771 DOI:10.1136/bjsports-2015-095796

Thoughts and impressions midway through the FIFA Sports Medicine Diploma

4 Sep, 16 | by BJSM

By Nash Anderson

I first heard about the FIFA Sports Medicine Diploma in 2015 and was impressed to hear that a free course existed from the sporting organisation body FIFA.1 I started the course in June 2016 for two reasons. Firstly, I had more free time this year and I was curious to see this new course created by world leading clinicians. Secondly, I have worked on the sideline for various sporting codes over the years however never football specifically. I hoped this course would help me to develop my knowledge and confidence in football medicine for not only any potential sideline work in football but also for dealing more proficiently with my football playing patients. Below I share some pertinent information and my personal experience thus far.

ref standing footballWhat is the FIFA Sports Medicine Diploma?

The Diploma is a free course by FIFA covering major medical and musculoskeletal issues in football. It also covers ‘special topics’ including: event planning, team travel, female athletes, anti-doping and more. More modules are added regularly. The aim is to provide a total of 42 modules, one from each of the FIFA Medical Centres of Excellence. 1

The course shares clinical experience and evidence from lead researchers as well as the theoretical knowledge amassed by F-MARC over the last 22 years.

Who is F-MARC?

The FIFA Medical Assessment and Research Centre (F-MARC), established in 1994, is a prestigious independent research body of FIFA uniting an international group of experts in football medicine.2 They are world leaders in football medicine and have produced hundreds of publications in peer-reviewed journals. 3

Besides research and educational courses,3 they have been involved in many initiatives including: improved screening for sudden cardiac arrest; the FIFA Sudden Death Registry;4 5 the FIFA 11+, an effective programme to prevent football injuries in various player groups worldwide; 6 as well the FIFA 11 for Health program. 7 The FIFA 11 for Health program illustrates the health benefits of football for population groups. One such recent example is that small-sided football in schools and leisure-time sport clubs improves physical fitness, health profile, well-being and learning in children. 8

Why is the FIFA Sports Medicine Diploma essential to clinicians interested in football medicine?

“Education is the key to prevention and therefore FIFA supports the “Diploma in Football Medicine” for doctors, physiotherapists and paramedical staff”

– Prof Jiří Dvořák. FIFA Chief Medical Officer & F-MARC Chairman.1

After completing these modules, participants will be better able to identify and treat injuries and illnesses as well as be more aware of injury and illness-prevention programmes. Due to the great breadth of topics there is something to learn even for the most experienced football medicine clinicians.

The FIFA Sports Medicine Diploma is essential to create an education platform for multidisciplinary cooperation. In turn, football will become a more safe 6 and rewarding pursuit for patients, athletes, clinicians and football associations.

I have currently completed a number of modules. Here are some of thoughts thus far:


  • Free. A free resource from a leading sports medicine organisation.
  • Comprehensive resource. This course covers a variety of topics. This is not just a course but also a brief online sports encyclopaedia.
  • All-star line up. In addition to up to date topics, modules are written by international experts with a wealth of practical and academic experience. The curriculum also includes insights from high-profile players.
  • Multidisciplinary depth of topics. MSK topics are generally broken down into initial presentations, radiological investigations, physical therapies, reasons for referral and surgical options. This helps to establish clear roles for football organisations and clinicians.
  • Excellent testing and feedback. Knowledge is tested using multiple-choice questions; however, if you do not select the correct answer, it prompts constructive feedback.
  • Web based course. Being entirely web based, participants can engage in content through multiple platforms, such as PCs and smartphones. There is also synchronisation between devices.
  • There are no deadlines! The course can be completed online at your own pace.

Constructive feedback

  • Technical. I have thoroughly enjoyed the depth of the content. Although one website comment suggested that the course was for “anyone with an interest in sports medicine”. I believe that may be a stretch. The original target audience was sports physicians and, although somewhat simplified, it is still very technical for “anyone with an interest”.
  • Where to go for practical skill growth? Although this course is very accessible and the practical assessment videos hugely helpful, I am interested to see what steps or courses FIFA recommends for clinicians for further practical skill development beyond the FIFA Sport Medicine Diploma, the FIFA Sports First Aid and their FIFA Nutrition Course.
  • Football Medicine Manual, web version please! 9
  • The key resource for this course is currently only in PDF form. On smaller devices it is difficult to read. A web enabled version would enable enhanced readability on all mediums such as PC and smartphone. This is, however, only a criticism to user friendliness of the manual and not its content.

Thank you to the F-MARC Team for producing an excellent and free resource. Kudos in particular to Dr Mark Fulcher, the New Zealand team doctor and editor-in-chief of the project. I look forward to viewing more modules in the future including as of yet unreleased modules.

I would also like to thank Dr. Reidar Lystad @RLystad for his assistance with this blog and the support of the BJSM @bjsm_bmj dream team for letting me share my thoughts.


For further information and to sign up for the course please visit:

You can download the Football Medicine Manual from here:

Also here you can also read the BJSM Course review on The FIFA Sports Medicine Diploma from Adam Culvenor. 10



Nash Anderson is a Chiropractor in private practice in Farnham. He has a special interest in sideline care, sports medicine and created, an open access health and sports medicine resource for clinicians and the public. He enjoys working pitch side and has recently finished up with the Farnham Knights American Football team but still works to provide care at cycling events with @roadsideteam. You can follow him on Twitter (@sportmednews).



  1. F-MARC. Football Medicine Diploma | FIFA Diploma in Football Medicine 2016 [Available from:
  2. Excellence FMCo. FIFA Medical Centre of Excellence – FIFA & F-MARC: FIFA Medical Centre of Excellence; 2016 [Available from:
  3. F-MARC. FOOTBALL MEDICINE the complex medico-social milieu 2016 [Football Medicine Courses provided]. Available from:
  4. Kramer EB, Dvorak J, Schmied C, et al. F-MARC: promoting the prevention and management of sudden cardiac arrest in football. Br J Sports Med 2015;49(9):597-8.
  5. Scharhag J, Bohm P, Dvorak J, et al. F-MARC: the FIFA Sudden Death Registry (FIFA-SDR). Br J Sports Med 2015;49(9):563-5.
  6. Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med 2015;49(9):577-9.
  7. F-MARC. FIFA 11 for Health 2016 [Available from:
  8. Krustrup P, Dvorak J, Bangsbo J. Small-sided football in schools and leisure-time sport clubs improves physical fitness, health profile, well-being and learning in children. Br J Sports Med 2016.
  9. (FIFA) FIFA. Football Medicine Handbook. In: FIFA Medical Assessment and Research Centre (F-MARC) FMOc, Production F, eds.
  10. Culvenor AG. FIFA Diploma in Football Medicine: free knowledge from expert clinicians to improve sports medicine care for all football players (continuing professional development series). Br J Sports Med 2016.


BJSM blog homepage


A peer review journal for health professionals and researchers in sport and exercise medicine. Visit site

Creative Comms logo

Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine