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Current Soft tissue techniques for Physiotherapists in Sport and Exercise: developing skills and justifying treatment choices

19 Oct, 17 | by BJSM

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


By Vikki Mills  @vikki_mills80 and Faith Fisher-Atack BSc @physiofaith

The ACPSEM recently hosted the 2 part soft tissue techniques course, “Current Soft Tissue techniques for Physiotherapists in Sport and Exercise”. This course is an integral part of the ACPSEM pathway which develops clinicians and enables them to progress to Bronze, Silver and Gold levels. It was aimed at practicing clinicians in sports medicine to equip them with the hands on skills necessary for soft tissue management.

There are many schools of thought emerging in sports and exercise medicine which question the use of “hands on” physiotherapy, specifically massage or soft tissue mobilisation. As physiotherapists working in elite sports settings, the thought of completing a day without utilising “hands on” techniques in some capacity is difficult for us – as Physiotherapists- to imagine. Patients often expect massage as a part of treatment too. In spite of massage being an integral part of our day to day routines, many attendees could not recall having formal massage training. It is also important for clinicians to be able to justify soft tissue work as a valid treatment choice, and feel confident that an evidence base underpins decision making. Thus, the course provided details on current research and how massage fits into a wider treatment plan addressing all components of musculo-skeletal and biomechanical dysfunction.

Here are some examples of how course attendance has influenced our clinical reasoning and changed our clinical practice.

Evidence base

During the course we explored the evidence base behind sports massage, and discussed the justifications articulated to clients. It became quickly apparent that course attendees were not fully aware of several fundamental reasons for using massage, with most attendees noting blood flow improvement as the main justification. We were exposed to many other reasons, including the positive impact of wellbeing, biomechanical, physiological, neurological and psychological effects (Moraska 2007).

Practical skills

The content of this course was highly practical, allowing us to develop our techniques and gain feedback from both tutors and peers. Evidence has suggested that differences in practitioners’ proficiency affect the effectiveness of massage (Donozama et al 2010). Therefore, handling and optimising patient position was fundamental to the effectiveness of not only the treatment but the wellbeing and comfort of the therapist.

Technical skills gained included a detailed breakdown of individual massage technique during the first course session, with further study and practice of more advanced skills involving tool assisted soft tissue release techniques, cupping and myofascial release in the second course session. Development of massage techniques and application over the entire 4 days addressed specific soft tissue dysfunction, which included muscular imbalances, trigger point development and altered motor patterns.


To host a course for 4 days (the course was held over 2 weekends, 6 weeks apart) to teach fundamental skills to clinicians already practicing in the sporting environment is no easy feat, yet Colin Paterson and Ros Cooke managed to pull this off. Their knowledge, skills and experience in addition to their enthusiasm made for an engaging and enjoyable learning experience.

For any clinician embarking on the ACPSEM CPD pathway it is compulsory that they undertake and evidence post graduate training in massage. This course provides an opportunity for any practicing clinician to challenge their current knowledge and practice. The theory and content challenged thoughts, beliefs and existing skills. We now feel better equipped to justify, articulate and carry out soft tissue techniques as a treatment modality.

Further information on this and other courses which underpin the ACPSEM CPD pathway can be found at


Vikki has been a charted physiotherapist for 15 years working in both the private and elite sport setting. Vikki divides her clinical practice between Leeds United Academy and community MSK services. Her clinical interests include paediatric lower limb biomechanics and growth related pathology.



Faith is a chartered Human and Veterinary Physiotherapist and clinical director of Equine Physio Services, a physiotherapy practice specialising in equine and rider biomechanics and performance. Former Head of Sports Science and Medicine at Leeds United Academy.



Donozama N, Shibasaki M (2010) Differences in practitioners’ proficiency affect the effectiveness of massage therapy on physical and psychological states.
Journal of bodywork and movement therapists. Volume 14 issue 3 July 2010 pages 238-245

Moraska A (2007) Therapist education impacts the massage effect on post-race muscle recovery. Medicine and science in sport and exercise

Internal Biological Clocks and Sport Performance

17 Oct, 17 | by BJSM


Dr Nicky Keay

A Nobel Prize was awarded two weeks ago to researchers who uncovered the molecular mechanisms controlling circadian rhythm: our internal biological clock.


Circadian Hormone Release

These mechanisms rely on negative feedback loops found in many biological systems where periodicity of gene expression is key, such as the Endocrine system. Internal biological clocks allow for anticipation of the requirements from body systems at different times of the day and the ability to adapt to changes in external lifestyle factors. What is the clinical significance of biochronometers?

The importance of integration of lifestyle factors, such as timing of eating, activity and sleep with our internal biological clocks is revealed in situations of circadian misalignment that lead to suboptimal health and disease states in the longer term.

Consideration of our biochronometers is especially important for athletes in order to synchronise periodised training, nutrition and recovery and thus optimise health and sports performance.

Athletic Performance 

Performance in a cycle time trial was found to be better in the evening, rather than the morning, proposed to be due to a more favourable endogenous hormonal and metabolic internal milieu. Certainly there were some disgruntled swimmers at an international event, when the usual pattern of morning heats and evenings finals was switched, to accommodate television viewing spectators.

Female athletes: menstrual cycle/training season

 Women have an extra layer of endogenous biological periodicity in the form of the menstrual cycle controlled by temporal changes of hormone release in the hypothamalmus-pituitary-ovarian Endocrine axis. Changes in external factors of training load, nutrition and recovery are detected by the neuroendocrine gatekeeper, the hypothalamus, which produces an appropriate change in frequency and amplitude of GnRH (gonadotrophin releasing hormone), which in turn impacts the pulsatility of LH (lutenising hormone) release from the pituitary and hence the phases of the menstrual cycle, in particular ovulation. Even short term reduction of energy availability in eumenorrhoeic female athletes can inhibit LH pulsatility frequency and release of other hormones such as IGF1. Disrupted release of sex steroids and IGF1 has a negative effect on bone turnover: increased resorption and decreased formation. Active females have been found more susceptible to reduction in energy availability impacting bone metabolism than their male counterparts.

Another consequence of the phasic nature of the menstrual cycle relating to external factors such as exercise, is that injury risk could be linked to changes in the expression of receptors for for sex steroids oestrogen and progesterone in skeletal muscle. Certainly during pregnancy and the post partum period, relaxin hormone increases the laxity of soft tissues, such as ligaments, and hence maintenance stretching, rather than seeking to increase flexibility, is recommended to prevent injury.

In order to produce desired temporal adaptive changes in response to exercise training, signalling pathways mediated by reactive oxidative species and inflammatory markers are stimulated in the short term, with supportive Endocrine interactions in the longer term. However, an over-response can impair adaptive changes and impact other biological systems such as the immune system. This maladaptive response could occur as a result of non-integrated periodisation of training, nutrition and recovery in athletes and, in the case of female athletes, oral contraceptive pill use has been implicated, as this effectively imposes a medical menopause, preventing the phasic release of endogenous hormones.

Considering a longer time scale, such as a training season, female athletes were found to have a more significant fall ferritin during than male athletes. Low normal iron does not necessarily correlate to iron deficiency anaemia, but low levels in athletes can impact bone health. Supplementation with vitamin C to improve absorption may help, although iron overload can have deleterious effects. As training intensity increases as the season progresses, six monthly haematological reviews for female athletes were recommended in this study.

Changes in set point feedback 

Feedback control of the Endocrine system, for example the hypothalamic-pituitary-thyroid axis is dynamic: both anticipatory and adaptive, depending on internal and external inputs. However, presentation of a prolonged stimulus can result in maladaptation in the longer term. For example, disruption of signalling pathways leading to hyperinsulinaemia results in insulin resistance, which represents the underlying pathophysiological mechanism of obesity and the metabolic syndrome. In other words a situation of tachyphylaxis, where prolonged, repeated stimulus over time results in insensitivity to the original stimulus. This also applies to the nature of exercise training over a training season and diets that exclude a major food type: temporal variety is key.

Lifespan (prematurity, ageing) 

Changes during the lifespan represent an important biochronometer. Premature and small-for-dates babies are at risk of long term metabolic and Endocrine dysfunction, potentially due to intrauterine reprogramming of the hypothalamic-pituitary axis. At the other end of the biological time scale, with advancing age, DNA methylation and changes in epigenetic expression occur. It has been suggested that this age related methylation drift could be delayed with calorie restriction. Melatonin, a key player in intrinsic biological time keeping has been proposed to attenuate bone resorption by reducing relative oxidative stress. This would potentially explain why shift workers with disrupted sleep patterns are reported to be at risk not only of metabolic dysfunction, but also impaired bone health. Disrupted sleep patterns are a concern for athletes, especially those whose training and competition schedule involve frequent international travel across time zones.

In summary, respecting your internal biological clocks and integrating your lifestyle and your training, nutrition and recovery with these intrinsic pacemakers in mind will optimise health and performance.

For further discussion BASEM annual conference 22/3/18: Health, Hormones and Human Performance


The Nobel Prize in Physiology or Medicine 2017

Circadian clock control of endocrine factors Nat. Rev. Endocrinol

Temporal considerations in Endocrine/Metabolic interactions Part 1 Dr N. Keay, British Journal of Sports Medicine 2017

Temporal considerations in Endocrine/Metabolic interactions Part 2 Dr N. Keay, British Journal of Sports Medicine 2017

Athletic Fatigue: Part 2 Dr N. Keay 2017

Effect of Time of Day on Performance, Hormonal and Metabolic Response during a 1000-M Cycling Time Trial Plos One 2017

Big Game, Little Needles: Acupuncture in Professional Football

11 Oct, 17 | by BJSM

Note from the Karim Khan, Editor BJSM: 

I expect this blog to generate a lot of discussion. On the one hand will be the folks who argue that if there are no RCTs for a treatment then it shouldn’t be discussed on the BJSM blog. If we extend that argument then Jenny McConnell’s taping for knee pain should have been banned from its birth in 1989 until the RCT that proved its value 20 years later. Similarly we wouldn’t have knee arthroscopy for meniscal tears or arthroscopic ACL reconstruction. No RCT, no treatment. 

On the other hand, there are clinicians who treat patients and who swear by a technique that provides patient-reported benefits. In many cases the clinician has no incentive to conjure up a treatment effect and the patient is entering the clinical contract in good faith. You’ll see example of that abounding in the piece below. 

BJSM revels in criticism so if you have an opinion about this fire away – via letters, your favourite social media channels; feel free to submit a’discussion’ or an ‘editorial’ submitted to the BJSM.  Instructions for authors here

Press Release emailed to BJSM (among others) by The Acupuncture Association of Chartered Physiotherapists

Football is the most internationally recognised sport of our era with the FIFA World Cup one of the most watched events worldwide, reaching a global in-home television audience of 3.2 billion in 2014. Due to the strenuous, repetitive movements and physical contact they endure on a regular basis, professional footballers are rarely short on injuries needing treatment. Given the detrimental effect on training and results, clubs need to focus on prevention and treatment for such injuries to ensure success. Football teams increasingly employ acupuncture to treat musculoskeletal injuries and long term conditions. Acupuncture is used both on its own and in conjunction with other therapies such as physiotherapy.

One team that has utilised acupuncture to support its players is Notts County FC who recently let the Acupuncture Association of Chartered Physiotherapists (AACP) film inside their treatment room. Watch full video here:

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Head of Sports Medicine Johnny Wilson advocates for players’ autonomy of care and as such always gives his players the option of acupuncture, many of whom have seen benefits to their fitness and performance. Wilson sees acupuncture’s value as one part of a multi-model approach to footballer’s physiotherapy. He often uses it as an additional method to more standard treatment regimes. Wilson states:

“We have three aspects to our philosophy; reduce their risk of injury, improve their athletic performance and help them tolerate the demands of the game . . . we look at how we can enable the players to run economically and efficiently”.

Notts County Player-Manager Kevin Nolan highlights acupuncture’s role within professional football:

“Acupuncture has become a part of everyday modern football. You see it used often, there wouldn’t be a day go by that I wouldn’t see the needles come out. It’s something, if we’re going to be moving forward as a medical department, that we need to study and know about and make sure we don’t get left behind and we can give our athletes the best possible rehab.”

Notts County Midfielder Curtis Thomson, who receives acupuncture within the video, comments that as a midfielder he amounts a lot of running time during matches and training which causes his back and legs to cease up “I find that the acupuncture helps release [the tension] and gives me more mobility on the pitch”. Within the video we see Wilson acupuncture three points to treat Curtis’s acute hamstring pain alongside the exercise and stretches that make up the holistic approach championed at the club.

There are many proposed theories of how acupuncture works. One western medical theory discussed by Wilson within the video puts forward that acupuncture modulates spinal signal transmission and the brains perception of pain. Wilson summarises how Acupuncture does this in a three-fold effect:

  • Local tissue – the inserted needle provides the initial stimulus which creates a local trauma around the needle. This causes a release of calcitonin gene peptides (thought to play a role in the transmission of pain) and histamines which causes a local flammatory response around the needle.
  • Spinal segmental approach – following the initial response from the insertion of the needle delta fibres are excited, they in turn excite beta endorphins and encephalons. These neurotransmitters work to decrease the input of pain by asking the brain to attend to the needle rather than the pain that the patient was originally experiencing.
  • Supraspinal – cells within the spinal cord communicate with specific areas of the brain, in response, further neurotransmitters are released which help block the sensation and perception of pain.

Wilson concludes “you’re almost taking your own painkillers.”

Ex-England Striker Alan Smith also credits acupuncture for a quick recovery before a Champion’s League quarter finale against Deportivo de La Coruña. “The Saturday before the Tuesday evening game I had a bad effusion on my right calf . . . I got to Tuesday mid-afternoon and I was still struggling to make any progress. The physio said to me do you want to try acupuncture. That was my first experience and with great results . . . it just dispersed of all the hematoma that I had around that area, the initial reaction was great, I managed to play a full game. I was probably a major doubt for the game beforehand.”

The Acupuncture Association of Chartered Physiotherapists (AACP) is a professional network representing physiotherapists who are interested in integrating Western Evidence Based Acupuncture into mainstream Physiotherapy for the management of pain and systemic conditions. The AACP represents over 6,000 members making it the largest professional body for acupuncture in the UK. AACP members are all qualified and chartered physiotherapists who have successfully completed acupuncture training at a postgraduate level. Acupuncture combined with physiotherapy is widely accepted within both the National Health Service (NHS) and private practice. Your local AACP acupuncture-physiotherapist can be found by visiting

Full references on file at the AACP.
Organization contact:

Paraceta-MORE: The increasing over-reliance on painkillers in sport

7 Oct, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog series

By Adil Iqbal 

Rugby World magazine ran an article back in April which really got me thinking. The article focused on painkiller use in rugby featuring a prominent ex-professional player’s first-hand account of frequent painkiller use and all the issues he was now suffering from(1). I came to realise how often I had seen team-mates and opposition players rely on painkillers to get them through a game and the week that followed. Not long after this article the wider media coverage of the issue began, on a drive home I ended up catching a BBC Radio 4 documentary focusing on whether painkillers were a career necessity or a serious long term health risk(2).

This all got me thinking, it’s one of those things that isn’t really apparent until you look deeper into it, in fact 60% of us amateur ‘athletes’ take them once a week(3), but have you ever stopped to ask yourself the consequences of something so seemingly trivial?

A fear of failure seems the main instigator in professional sport when it comes to painkillers. Often their use seems to be linked to being replaced(1), that is after all the way the modern professional sporting world works. You are only an ‘asset’ for as long as you are performing well and with a vast number of teammates and competitors vying for your position it’s easy to see why individuals choose to compete through the pain, but at what cost?

In Amateur Sport

Unlike professional sport where most painkiller use seems to stem from the fear of losing your place in the team(1) or withdrawing from a competition, from my own experience, in amateur sport it arises from the fact there is often a lack of replacements. This leads to individuals choosing to ‘pop’ pills to either make up the numbers or when the numbers fall keep playing on despite injury. Playing student rugby myself, I’ve often been on the wrong side of not being able to put out a full team and starting the game with 14 men on the pitch. As injuries start to strike we have been left with 13 or even 12 players on the pitch. There have been times where I have unwisely stayed on the pitch knowing I would have left if there had been someone to replace me, and I’m sure I’m not the only one.

Instigating change

In my mind it seems that the way to combat this increasing overuse and, in some cases, dependency on painkillers in all areas of sports is widespread education. Only through effective education can we hope to prevent long-term overuse of analgesia.

With various testimonies from players citing how readily available stronger painkillers were to them(1), on a professional level there must be an onus on healthcare professionals to see the individual they are treating as a patient primarily and the fact they are a sportsperson should in theory have little influence. However in reality this is often difficult, saying no to any patient can be difficult especially when there is an actual medical issue, and in the realm of elite sport it can be even harder with there often being increased pressure and scrutiny from a manager and often the player themselves. This is of course if the player reveals themselves to be injured. Studies on concussion which mainly focus on high school and college level athletes in America found there to be a ‘culture of resistance’ (4) and often less than 40% of concussion events are actually reported often in the days and weeks after the actual event (5)(6)

On a more day to day level it is everyone’s responsibility to take care of their own health, there is by no means anything wrong about having to take painkillers but having to rely on them in the long-term and at increasing doses is a completely different matter. It should be the case that minimising dosage and duration are a priority when painkillers are used(7).

Athletes, especially at an elite level inherently understand and accept the risks that come with playing sport(8). Psychological studies point towards an assumption by athletes that playing through pain and injury is a step towards success(9) and it has been found that this assumption causes a shift in attitude to using painkillers leading to a culture of their overuse to facilitate this step(10).

Perhaps there would be a rethink to people’s approach if they knew some of the side effects of longer term painkiller use, not with the intention of being a scare tactic but to make them think of the effects they will be having during the prolonged period over which they are taken. Things such as renal impairment, stomach ulcers, haemorrhages and even an increased risk of MI and strokes(11)(12).


From a young age children everywhere are taught pain is just weakness and to fight through it. Sportspeople need to understand the limits of their own bodies rather than be under this illusion of pain being weakness, more often than not pain is the later stages of your body telling you you’ve had enough.

Showing weakness is nothing to be ashamed of, individuals who stay on after having suffered substantial injuries tend to get praise whilst those who are replaced after taking a little knock often get jeered. Surely there should be a comfortable middle ground where if injured an individual isn’t praised for staying on and torn into for deciding they can’t carry on. After all only you know the limits of your own body. How many of us will be regretting the fact we didn’t give ourselves enough time to recover, or playing on through the pain later on in our lives.

Everyone is always looking for a quick fix an easy way to get or feel better and in the context of sport this more often than not falls to the use of painkillers. However next time you reach for the painkillers in the lead up to competing whatever the level may be, think to yourself ‘do I really need those’ and no matter what the answer consider sitting on the sidelines and cheering your team on instead.


  1. Playing through the pain: an investigation into painkiller use in rugby. Rugby World Magazine
  2. Gain Without the Pain: Legal Drugs in Sport. File on 4. BBC Radio 4.
  3. Gain Without the Pain: Legal Drugs in Sport. BBC Sport.
  4. Culture of resistance: self-reporting concussions in youth sports
  5. Knowledge, Attitude, and Concussion-Reporting Behaviors
  6. Reports of head injury and symptom knowledge among college athletes
  7. Guidelines for sensible NSAID use. BJSM
  8. Sage dictionary of sports studies: Risk. Page 218
  9. Sage dictionary of sports studies: Risk-Pain-Injury Paradox
  10. Painkilling drugs in collegiate athletics: knowledge, attitudes, and use of student athletes
  11. Non Steroidal Anti-Inflammatory Drugs. British National Formulary 2017. [online].
  12. Painkiller Side Effects. Cancer Research UK

Adil Iqbal  is a 3rd medical student at Leeds University, where he is President of the Medical School Representative Council. He has an interest in all things related to sports and exercise and orthopaedics.

Jonathan Shurlock is an academic foundation year 2 doctor based in Sheffield. He coordinates the BJSM Undergraduate Perspective blog series. If you would like to contribute to the blog series please email

Temporal considerations in Endocrine/Metabolic interactions Part 2

3 Oct, 17 | by BJSM

By Dr Nicky Keay

As discussed in the first part of this blog series, the Endocrine system displays temporal variation in release of hormones. Amplitude and frequency of hormonal secretion display a variety of time-related patterns. Integrating external lifestyle factors with this internal, intrinsic temporal dimension is crucial for supporting metabolic and Endocrine health and sport performance.

Circadian misalignment and sedentary lifestyle has been implicated in the increased incidence of metabolic syndrome driven by insulin resistance and associated metabolic inflexibility and decrease in fat oxidation. However, a recent study of overweight individuals, found that increases in fat oxidation from lifestyle intervention, corresponded to different clinical outcomes. Both those who maintained weight loss and those who regained weight displayed increased fat oxidation compared to baseline. How could this be? Increased fat oxidation is only part of the equation in overall fat balance. What adaptations in the metabolic and Endocrine networks were occurring during rest periods? In the case of those that maintained weight loss, increased fat oxidation was reflected in biochemical and physiological adaptations to enable this process. Whereas for those that regained weight in the long term, increased fat oxidation was enabled by increased availability of lipids, indicating increased fat synthesis over degradation.

Clearly there is individual variation in long-term Endocrine and metabolic responses to external factors. Focusing on optimising a single aspect of metabolism in the short term, will not necessarily produce the expected, or desired clinical outcome over a sustained period of time. As previously discussed the single most effective lifestyle change that induces synchronised, beneficial sustained Endocrine and metabolic adaptations is exercise.

It will come as no surprise that focusing on maximising use of a single substrate in metabolism, without integration into a seasonal training plan and consideration of impacts on internal control networks, has not produced the desired outcome of improved performance amongst athletes. Theoretically, increasing fat oxidation will benefit endurance athletes by sparing glycogen use for high intensity efforts. Nutritional ketosis can be endogenous (carbohydrate restricted intake) or exogenous (ingestion of ketone esters and carbohydrate). Low carbohydrate/high fat diets have been shown in numerous studies to increase fat oxidation, however, this was at the expense of effective glucose metabolism required during high intensity efforts. Potentially there could be adverse effects of low carbohydrate intake on gut microbiota and immunity.

This effect was observed even in a study on a short timescale using a blinded, placebo-controlled exogenous ketogenic intervention during a bicycle test, where glycogen was available as a substrate. The proposed mechanism is that although ketogenic diets promote fat oxidation, this down-regulates glucose use, as a respiratory substrate. In addition, fat oxidation carries a higher oxygen demand for a lower yield of ATP, compared to glucose as a substrate in oxidative phosphorylation.

Metabolic flexibility the ability to use a range of substrates according to requirement, is key for health and sport performance. For example, during high intensity phases of an endurance race, carbohydrate will need to be taken on board, so rehearsing what types/timing of such nutrition works best for an individual athlete in some training sessions is important. Equally, some low intensity training sessions with low carbohydrate intake could encourage metabolic flexibility. However, in a recent study “training low” or periodised carbohydrate intake failed to confer a performance advantage. I would suggest that the four week study time frame, which was not integrated into the overall training season plan, is not conclusive as to whether favourable long term Endocrine and metabolic adaptations would occur. A review highlighted seasonal variations in male and female athletes in terms of energy requirements for different training loads and body composition required for phases of training blocks and cycles over a full training season.

Essentially an integrated periodisation of training, nutrition and recovery over a full training season will optimise the desired Endocrine and metabolic adaptations for improved sport-specific performance. The emphasis will vary over the lifespan of the individual. The intricately synchronised sequential Endocrine control of the female menstrual cycle is particularly sensitive to external perturbations of nutrition, exercise and recovery. Unfortunately the majority of research studies focus on male subjects.

In all scenarios, the same fundamental temporal mechanisms are in play. The body seeks to maintain homeostasis: status quo of the internal milieu is the rule. Any external lifestyle factors provoke short term internal responses, which are regulated by longer term Endocrine network responses to result in metabolic and physiological adaptations.

For further discussion on Health, Hormones and Human Performance, come to the BASEM annual conference



Temporal considerations in Endocrine/Metabolic interactions Part 1 Dr N. Keay

Sports Endocrinology – what does it have to do with performance? Dr N.Keay, British Journal of Sports Medicine 2017

Sedentary behaviour is a key determinant of metabolic inflexibility Journal of Physiology 2017

Influence of maximal fat oxidation on long-term weight loss maintenance in humans Journal of Applied Physiology 2017

One road to Rome: Metabolic Syndrome, Athletes, Exercise Dr N.Keay 2017

Metabolic and Endocrine System NetworksDr N. Keay 2017

Nutritional ketone salts increase fat oxidation but impair high-intensity exercise performance in healthy adult males Applied Physiology, Nutrition, and Metabolism 2017

Endocrine system: balance and interplay in response to exercise training Dr N. Keay 2017

No Superior Adaptations to Carbohydrate Periodization in Elite Endurance Athletes Medicine & Science in Sports & Exercise 2017

Total Energy Expenditure, Energy Intake, and Body Composition in Endurance Athletes Across the Training Season: A Systematic Review Sports Medicine – Open 2017

Successful Ageing Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N. Keay, British Association of Sport and Exercise Medicine 2017



Keywords:  athletesBiochronometrydietEndocrine,exercisefitnesshealthhormonesketogenic dietlifespanlifestylemetabolic flexibility,metabolic syndromemetabolismnutrition,performancephysiologyREDssleepsport,trainingtraining season

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Temporal considerations in Endocrine/Metabolic interactions Part 1

29 Sep, 17 | by BJSM

By Dr Nicky Keay

The Endocrine system displays temporal variation in release of hormones. Integrating external lifestyle factors with this internal, intrinsic temporal dimension is crucial for supporting metabolic and Endocrine health.

Amplitude and frequency of hormonal secretion display a variety of temporal patterns:

  • Diurnal variation, synchronised with external light/dark. Orchestrated by a specific area of the hypothalamus, the neuroendocrine gatekeeper.
  • Circadian rhythm, roughly 24-25 hours which can vary with season according to duration of release of melatonin from the pineal gland.
  • Infradian rhythms longer than a day, for example lunar month seen in patterns of hypothalamic-pituitary-ovarian axis hormone release during the menstrual cycle.
  • Further changes in these temporal release and feedback patterns occur over a longer timescale during the lifespan.

Hormones influence gene expression and hence protein synthesis over varying timescales outlined above. The control system for hormone release is based on interactive feedback loops. The hypothalamus is the neuroendocrine gatekeeper, which integrates external inputs and internal feedback.  The net result is to maintain intrinsic biological clocks, whilst orchestrating adaptations to internal perturbations stimulated by external factors such as sleep pattern, nutrition and exercise.

Circadian alignment refers to consistent temporal patterns of sleep, nutrition and physical activity. Circadian misalignment affects sleep-architecture and subsequently disturbs the interaction of metabolic and Endocrine health. This includes gut-peptides, glucose-insulin interaction, substrate oxidation, leptin & ghrelin concentrations and hypothalamic-pituitary-adrenal/gonadal-axes. The main stimuli for growth hormone release are sleep and exercise. Growth hormone is essential for supporting favourable body composition. These integrated patterns of environmental factors may have a more pronounced effect on those with a genetic predisposition or during crucial stages of lifespan. For example curtailed sleep during puberty can impact epigenetic factors such as telomere length and thus may predispose to metabolic disruption in later life. Regarding activity levels, there are strong relationships between time spent looking at screens and markers, such as insulin resistance, for risk of developing type 2 diabetes mellitus in children aged 9 to 10 years.

In addition to adverse metabolic effects set in motion by circadian misalignment, bone turnover has also shown to be impacted. Circadian disruption in young men resulted in uncoupling of bone turnover, with decreased formation and unchanged bone resorption as shown by monitoring bone markers. In other words a net negative effect on bone health, which was most pronounced in younger adult males compared with their older counterparts. These examples underline the importance of taking into account changes in endogenous temporal patterns during the lifespan and hence differing responses to external lifestyle changes.

For male and female athletes, integrated periodised training, nutrition and recovery has to be carefully planned over training seasons to support optimal adaptations in Endocrine and metabolic networks to improve performance. Training plans that do not balance these all these elements can result in underperformance, potentially relative energy deficiency in sport and consequences for health in both short and long term.

Part 2 will consider the longer term consequences and interactions of these temporal patterns of lifestyle factors, including seasonal training patterns in male and female athletes, on the intrinsic biochronometry controlling the Endocrine and metabolic networks during lifespan.

For further discussion on Health, Hormones and Human Performance, come to the BASEM annual conference


Sports Endocrinology – what does it have to do with performance? Dr N.Keay, British Journal of Sports Medicine 2017

One road to Rome: Metabolic Syndrome, Athletes, Exercise Dr N. Keay

Metabolic and Endocrine System Networks Dr N. Keay

Endocrine system: balance and interplay in response to exercise training Dr N.Keay

Sleep for health and sports performance Dr N.Keay, British Journal of Sports Medicine 2017

Factors Impacting Bone Development Dr N. Keay

Sleep, circadian rhythm and body weight: parallel developments Proc Nutr Soc

Sleep Duration and Telomere Length in Children Journal of Paediatrics 2017

Screen time is associated with adiposity and insulin resistance in children Archives of Disease in Childhood

Circadian disruption may lead to bone loss in healthy men Endocrine today 2017

Successful Ageing Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Clusters of Athletes – A follow on from RED-S blog series to put forward impact of RED-S on athlete underperformance Dr N. Keay, British Association of Sport and Exercise Medicine 2017

Optimal Health: For All Athletes! Part 4 – Mechanisms Dr N. Keay, British Association of Sport and Exercise Medicine 2017

World University Games 2017: an ideal learning environment for SEM registrars

26 Sep, 17 | by BJSM

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

By Philippa Turner and Chris Speers

The 2017 Summer Universiade aka World University Games, organized by The International University Sports Federation (FISU), was recently held in Chinese Taipei from the 19th – 30th August.

This biennial event is widely recognised as the second largest multisport Games in the world after the Olympics. It is World Class in scale and standard, with over 10,000 participants from 160+ countries.

We worked as trainee doctors at this event with high level athletes and coaches. It was a rare opportunity to gain a wide range of “hands-on” practice, at a international, multi-sport event, under the supervision of appropriately qualified SEM professionals. Below we share highlights from our experience.

Team GBR medical team

Structure of medical services

Similar to the set-up at an Olympics, the organising committee provide a 24 hour Polyclinic within the Athletes’ Village with Accident & Emergency facilities, pharmacy, laboratories, Outpatient clinics (including General Medicine, General Surgery, Gyaenecology, Orthopaedics, Rehabilitation, Ophthalmology, ENT and Dental) and imaging (Ultrasound and Xray). There was also an overnight acute medical unit for patient observation. For this edition of the Games, Western Medicine and Chinese Medicine was practiced (personal preference based, of course)!

There were medical services at all venues for immediate care and local hospitals were available for use if required. Each venue had a fully equipped athlete medical station, staffed by a local doctor, two nurses and two emergency medical technicians.

The GBR medical team

The GBR Medical team was made up of four doctors, led by a SEM Consultant, and ten physiotherapists from a wide sporting background, including a mix of new team members and those with previous World University, Commonwealth or Olympic Games experience.

To aid continuity of care, each sport had a nominated physiotherapist and doctor who they could go to for any illness or injury inquiries, although 24 hour on-call was available. Team GBR set up their own Medical and Physiotherapy Clinic, housed within the GBR HQ building in the residential area of the Athletes Village. This included a 5-bed open-plan treatment area, confidential consultation room, rehab & ice-bath space and staff office. The environment within HQ at the World University Games is perfect for learning from experienced practitioners. It also provides opportunities to work with a range of individual and team sports, some of which are difficult to gain experience in back in the UK.

During the initial phases of the medical HQ set up and lead up to the competition we saw first hand the logistics behind setting up such an environment. Important issues addressed included: venue and hospital visits, athlete 1:1’s, drug and equipment inventory and allocation of medical support for each competition through a risk assessment process.

We also saw a wide spectrum of sports medicine presentations during the Games, ranging from gastroenteritis, fractures, dislocations, cardiac screening issues and heat-related illness. Further, we were involved in a case requiring an emergency retroactive TUE application, as well as Anti-Doping processes. These experiences facilitated our practice and development of a wide range of skills during the Games. Excellent communication and team working skills were particularly critical. It was also vital to be adaptable and resourceful, and develop strong management, leadership and conflict resolution skills.   

A major highlight was working closely with a great group of hugely experienced health professionals and HQ staff as part of a ‘Team within a Team.’ We put Sports Medicine theory into practice within a unique and positive learning environment.

We highly recommend that other SEM trainees to apply for this, or similar opportunities in the future.

More about the athletes of team GB

Fifty-six members of Team GB at London 2012 competed for Great Britain at a World University Games, including medalists Beth Tweddle, Gemma Gibbons, Michael Jamieson and Lutalo Muhammed, followed up by 38 members at Rio 2016 including Danny Willet and Jessica Ennis-Hill.

The Summer Universiade consists of 13 compulsory disciplines and up to 3 optional sports chosen by the host country. Team GBR took 111 athletes and a total delegation of 163 to Taipei, with representation across Men’s & Women’s Waterpolo, Women’s Football, Tennis, Table Tennis, Archery, Rhythmic Gymnastics, Athletics, Swimming, Taekwondo, Weightlifting and Golf.


Philippa Turner is an ST6 in Sport & Exercise Medicine in the East Midlands Deanery. She has been the SAC Trainee Representative for the last year. Philippa currently works with the England Disability Cricket Squads and England Women’s Cricket Senior Academy. Previously Philippa has worked at numerous BUCS event.

Chris Speers is an ST6 in Sport & Exercise Medicine in the West Midlands Deanery. He currently works with Aston Villa Men’s Academy and has previously worked at Bristol Rugby Club as well as numerous BUCS events.

Farrah Jawad is an ST6 in Sport and Exercise Medicine in the London Deanery and coordinates the BJSM Trainee Perspective blog.

Take action for injury prevention – Call for abstracts 13th Australasian Injury Prevention and Safety Promotion Conference (closes Oct 10th)

22 Sep, 17 | by BJSM

In his closing remarks to the 2016 World Safety conference, Professor Adnan Hyder encouraged delegates to “take action.” These words also weave through the Tampere Declaration which encourages a global commitment for stronger injury and violence prevention by integrating injury and violence prevention into other health and safety advocacy platforms.

The Australian Injury Prevention Network (AIPN), Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP) and Federation University Australia, are pleased to be hosting the 13th Australasian Injury Prevention and Safety Promotion Conference, to be held at The Mercure Hotel and Convention Centre, Ballarat, Victoria, 13 – 15 November 2017.

Take Action is the theme of the 2017 Australasian Injury Prevention and Safety Promotion Conference.

The conference will celebrate five ways in which we can Take Action:

  • Systems for safer cities and stronger communities
  • Injury prevention through the arts
  • Advancing approaches to injury and violence prevention
  • Applying data in policy, planning and research
  • Understanding outcomes and experiences

You can read more about our keynote speakers here. Readers of BJSM will recognise Dr Kathrin Steffen and Professor Steve Marshall, from the sports injury prevention field.

Presentations from all fields of injury and safety promotion are, and will be, included in the program (sports injury prevention, child and family safety, road and transport safety, falls and ageing, water safety and drowning, burns prevention, workplace safety, injury amongst Aboriginal and Torres Strait Islander communities, intentional injury, trauma outcomes and registries, plus many more…). The preliminary program is now online.

The conference program also includes a pre-conference short course on taking systematic reviews to the next level through meta-analysis with Associate Professor Jake Olivier, and a special student program.

For now, we encourage everyone to Take Action on their abstracts – late breaking submissions close 10 October 2017.


It is time to stop wasting time and money debating graft types and surgical approaches for ACL injuries: The secret probably lies in optimising rehabilitation

20 Sep, 17 | by BJSM

By Adam Culvenor, PT, PhD, @agculvenor; and Christian Barton, PT, PhD, @DrChrisBarton

Last month, Professor Lars Engebretsen expressed concern on this blog regarding the potential return to popularity of synthetic grafts for cruciate ligament deficient knees in an attempt to optimise outcomes. There has been a great deal of research attempting to identify the optimal surgical technique and ligament substitute since the first report of surgical repair for a ruptured cruciate ligament in 1895. Today, the two mainstay choices are hamstring-tendon and bone-patellar tendon-bone autografts, with preferences differing around the globe (1).

Systematic reviews of randomised controlled trials have identified few differences in outcomes more than 2-years postoperatively between these two popular graft choices (2, 3). Similarly, variations of surgical technique, such as double-bundle reconstruction or different drilling techniques, while potentially providing greater passive stability, offer no more superior clinical or functional outcomes (4, 5).

Professor Engebretsen cites the quest for the Holy Grail – a quick return to sport without re-injury or increased osteoarthritis risk – has led to an alarming resurgence of synthetic ligaments. But do we really need to pursue unconventional surgical interventions that have failed to stand the test of time?

Perhaps the secret lies not in chasing the next sexy surgical trend but in completing an outstanding rehabilitation program. Dare we say it; many individuals suffering an ACL rupture may not need surgery. Optimal non-operative management may even fast track a return to competitive sport. A recent BMJ Case Report detailed an elite English Premier League player’s return to full-competition within 8-weeks of a complete ACL rupture with a problem-free follow-up at 18-months (6). And importantly, you cannot re-rupture a graft that doesn’t exist.

Evidence for considering a progressive non-operative approach to ACL injury management is not isolated to case studies of patients with access to elite medical teams. The prominent KANON trial – the only high-quality randomised controlled trial comparing early reconstruction to rehabilitation alone (with the option of delayed reconstruction if indicated) for acute ACL injury – clearly demonstrated that functional, symptomatic, radiographic and activity level outcomes do not differ up to 5-years post-injury in non-elite athletes (7). If surgery is to continue in practice, perhaps research endeavours to identify those who might benefit should be the focus, rather than what seems to be futile efforts to identify better graft and surgical approaches.

If surgery didn’t make a difference in outcomes, what did?

The difference in achieving outstanding functional outcomes, irrespective of surgical or non-surgical management was physical performance (8). Preventing a delayed ACL reconstruction in those starting with rehabilitation alone, was also related to higher physical performance (8). An even more important finding of this study is possible long-term detrimental effects of early surgical management, with conservative management shifting prognostic factors for 5-year outcomes in a positive direction (9).

With evidence clearly showing the benefits of (at least) trialling a non-operative approach for ACL injury management in most scenarios, and in cases of ACL reconstruction, completing a well-designed progressive postoperative rehabilitation program, do we need to make rehabilitation and exercise-therapy more sexy? Is it any wonder that patients often wish to avoid the arduous, dull and boring sounding ‘conservative management’ when they can get a ‘quick fix’ from the surgeon? But with re-rupture rates so high and no apparent benefit based on current high quality research, this surgical ‘fix’ is not necessarily a fix.

Targeting patient buy-in through quality patient education, goal-setting and repeated functional testing to provide feedback and enhance motivation to complete adequate exercise and ‘sport-specific rehabilitation’ based on accepted resistance training principles should be a priority for all clinicians. The world leaders in this field use these approaches successfully to achieve outstanding outcomes (10).

Additionally, it is time we translated evidence-based rehabilitation programs into clinical practice. Our current pilot research indicates few patients continue rehabilitation guided by physiotherapists beyond 3-months, with minimal shared decision-making in the return-to-sport transition occurring (11). This means achievement of physical resilience before return-to-sport is unlikely, and may be a key contributor to failed return-to-sport with or without surgery.

Based on current research, we propose the first line treatment for people following ACL injury should be ensuring adequate exercise rehabilitation involving addressing range of movement deficits, lower-limb strength (with a focus on quadriceps) and a progressive return to pain-free function and sport. Surgery may remain relevant in some, but may not be the key determinant of return-to-sport or prevention of osteoarthritis. In light of these points, it is time to shift focus and funding from ‘sexy’ new synthetic graft research to understanding who needs any form of surgery and ensuring all patients receive adequate (and wherever possible, intense and progressive) exercise rehabilitation.


Adam Culvenor PT, PhD, is a physiotherapist and National Health and Medical Research Council (NHMRC) of Australia Early Career Fellow at La Trobe University’s Sport and Exercise Medicine Research Centre, and a BJSM Associate Editor.

Christian Barton PT, PhD, is a physiotherapist and post-doctoral researcher at La Trobe University’s Sport and Exercise Medicine Research Centre, and a BJSM Associate Editor.


  1. Chechik O, Amar E, Khashan M, Lador R, Eyal G, Gold A. An international survery on anterior cruciate ligament reconstruction practices. Int Orthop. 2013;37:201-6.
  2. Li S, Chen Y, Lin Z, Cui W, Zhao J, Su W. A systematic review of randomized controlled clinical trials comparing hamstring autografts versus bone-patellar tendon-bone autografts for reconstruction of the anterior cruciate ligament. Arch Orthop Trauma Surg. 2012;132:1287-97.
  3. Li S, Su W, Zhao J, Xu Y, Bo Z, Ding X, et al. A meta-analysis of hamstring autografts versus bone-patellar tendon-bone autografts for reconstruction of the anterior cruciate ligament. Knee. 2011;18:287-93.
  4. Li YL, Ning GZ, Wu Q, Wu QL, Li Y, Hao Y, et al. Single-bundle or double bundle for anterior cruciate ligament reconstruction: a meta-analysis. Knee. 2014;21:28-37.
  5. Riboh JC, Hasselblad V, Godin JA, Mather RC. Transtibial versus independent drilling techniques for anterior cruciate ligament reconstruction. Am J Sports Med. 2013;41:2693-702.
  6. Weiler R, Monte-Colombo M, Mitchell A, Haddad F. Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less han 8 weeks: applying common sense in the absence of evidence. BMJ Case Reports. 2015:bcr2014208012.
  7. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ. 2013;346:f232.
  8. Ericcson YB, Roos EM, Frobell RB. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years. Br J Sports Med. 2013;47:980-5.
  9. Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. Br J Sports Med. 2017;Epub ahead of print.
  10. Grindem H, Risberg MA, Eitzen I. Two factors that may underpin outstanding outcomes after ACL rehabilitation. Br J Sports Med. 2015;49:1425.
  11. Patterson BE, Culvenor AG, Barton CJ, Crossley KM. Shared decision making rarely occurs during return to sport following ACL reconstruction. The Future of Football Medicine Conference, Camp Nou Barcelona. 2017;Presented abstract.

Inspiring the next generation in sports medicine: Utilising the USEMS e-publication to bridge the knowledge gap between student and clinician

18 Sep, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine – a BJSM blog series

By Liam Newton @newton_liam  and Sean Carmody @seancarmody1 

Today’s sports medicine clinicians have a wealth of quality educational resources on tap. The British Journal of Sports Medicine blog series, podcasts and original articles are easy examples to cite. They are also complimented nicely by many others including the Aspetar Sports Medicine Journal, Yann Le Meur infographics and Physio Edge Podcasts. However, back in 2016 we recognised that the extent of resources tailored specifically to undergraduates didn’t reflect the burgeoning interest among that population. Thus, the Undergraduate Sport and Exercise Medicine Society (USEMS) eMagazine was created to serve students who are passionate about SEM.

The aim of the publication is to inspire the next generation of sports medicine professionals by providing expert analysis, insight and comment from prominent figures within the field in a modern, easy-to-read format. Similarly, it allows a platform for undergraduate students to write and contribute their unique perspective on key issues within the specialty. We want to produce content which generates debate, raises contentious issues and is as equally appealing to established clinicians as to students.

Perhaps the most valuable aspect of producing the eMag has been the opportunity to engage with and build relationships with influential clinicians and researchers in sports medicine. Their willingness to volunteer their time to create quality content to advance student knowledge of sports medicine is a huge testament to the spirit of collaboration and sharing within the specialty. In addition to their efforts, this simply wouldn’t have been possible without the design genius of Dr Fadi Hassan (and my architect sister Rachel Carmody for the 2nd edition!).

To wet the appetite, below we have list 10 important quotes taken from the editions published to date:

  1. “I think it is vital to build a rapport with all the players and develop an open and trusting relationship. When I took over as the Lead Doctor my first objective was to build my relationship with the players. I ensured I made time to speak to them on medical and not medical matters to help build that bond. I have learnt from working in sport over the years that unless the players trust you there is no point in being there.” – Dr Ritan Mehta, England Women’s Performance Doctor, shares his experiences of looking after an international team in our first edition here.
  2. “There has been much debate and controversy regarding the effects of the menstrual cycle on athletic performance. Paula Radcliffe is quoted as saying that “Sport has not learned how to deal with elite athletes’ periods” and that this was attributable to a “lack of learning” and understanding often from male doctors.” – Dr Kirsty Elliot-Sale delves into the effects of menstruation on sports performance in our edition on The Female Athlete published here.
  3. “Feedback from all 20 teams and team doctors has confirmed that the medical logistics and support provided during RWC 2015 was the best ever. All medical scenarios had been analysed, dissected and planned for efficient management at all stadia. Back up medical services for teams away from competition were also excellent with designated area medical officers and priority access to key medical support services being available.” – Chief Medical Officer of World Rugby Dr Martin Raftery reflects on the successful medical provision at the Rugby World Cup in our second edition.
  4. “Tournament competition is always high-pressured. Regardless of whether you are a player or member of the management team, personal and public expectation always weighs heavily on every team. Everyone is looking to compete at the highest level and to give the best account of themselves and their country they represent.” – In our second edition, Prav Mathema, National Medical Manager of the Welsh Rugby Union, records the challenges faced by his medical team during a week at the Rugby World Cup.
  5. “Managers, Chief Executives and fans alike demand the opportunity to see the best players in the team pitted against the opposition. Prevention is much more ethical, sustainable and cost-effective than treatment and cure. The issue is how do we better prevent injuries, or more so, how to we avoid many of the injuries, especially the non-contact, that often blight the game ?” – Mike Davison, of the Isokinetic Medical Group, sets out his vision of the future of football medicine in our third edition.
  6. “For those of you looking to work in SEM, I can strongly recommend spending some time working in disability sport. Although it may be perceived to be less glamorous or “sexy” than other forms of elite sport medicine, the athletes you are working with will provide you with clinical reasoning challenges that will be far more complex (and in my opinion more interesting!) than working with mainstream athletes.” – In the third edition, Osman Ahmed lays out the unique challenges faced in looking after the Great Britain Cerebral Palsy Football Squad.
  7. “We do, however, have to acknowledge that injuries and illness occur, and contingency planning has occupied much of our thoughts – what if our main medal hopes get injured? How do we ensure they receive speedy access to the best medical care when they train on the other side of the country to our base in Lilleshall? Each potential Olympic Team member has a contingency plan in place so that all eventualities are covered.” – In our fourth edition themed Lessons from Rio: Reflecting on the Olympic Games , Chief Medical Officer for British Gymnastics, Dr Chris Tomlinson spoke about the challenges of preparing for a major event. Team GB gymnasts subsequently finished the Rio Olympic Games with seven medals across all three gymnastics disciplines, making it their most successful Olympic performance in history.
  8. “As the competition draws to a close on Sunday, most players make their way straight from the locker room to the airport as they head on to the next event. The tour schedule, in particular the European Tour, can be relentless and this high volume of flights, temporary time zones and often new/foreign cuisines all increase the risk of illness for the players and caddies” – Top sports nutritionist David Dunne dissects the nutritional requirements of elite golfers in our most recent edition here.
  9. “Any sport worth its salt has a joint or body part to claim as its own. Football has claimed the knee, rugby has claimed the brain, and the wrist belongs to golf. In the past, there was a poor understanding of the wrist among sports physicians, and we were referring cases that weren’t particularly complicated to specialist wrist surgeons, when in truth, they didn’t really require a surgical input. As a consequence, I have tried to foster better knowledge among trainees and doctors that work on the Tour in the clinical assessment of the wrist.” – Chief Medical Officer of the European Tour Dr Roger Hawkes shares key lessons for young clinicians hoping to work in professional golf here.
  10. “Sports medicine professionals are imperative to upholding integrity in sport. Clinicians need to be conscious of the wider personnel influencing the decisions of golfers – it is equally important that the anti-doping messages reach them too. It is a difficult environment to work in, because golfers are on the road so often, and getting messages to them is not always easy.” – Michele Verroken, Anti-Doping advisor to the PGA European Tour, demands change in how we tackle anti-doping issues here.

All editions are available through this link:

If you would like a .pdf copy of any edition, please email

Liam Newton works as a musculoskeletal physiotherapist in the NHS as well as AFC Bournemouth Academy. You can find him on Twitter @newton_liam.

Sean Carmody is a junior doctor working in London. He tweets regularly on topics related to sports medicine, health and high performance @seancarmody1.

Jonathan Shurlock is an academic foundation year 2 doctor based in Sheffield. He coordinates the BJSM Undergraduate Perspective blog series. If you would like to contribute to the blog series please email





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