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The rise of Brazilian Sports Physiotherapy: one of the legacies of the RIO 2016 Olympics

20 Oct, 16 | by BJSM

By Mario Bizzini (@SportfisioSwiss)

On August 12th, I visited the Polyclinic at the Olympic Village, to meet my Brazilian Sports PT friends Felipe Tadiello and Luciana de Michelis (the current president of Sport Physical Therapy Group in Brasil – SONAFE> The purpose of my visit was, on behalf of the  International Federation of Sports Physical Therapy (IFSPT;, to officially welcome SONAFE as IFSPT Member Organization, whose application was accepted few weeks prior to the start of the Olympic Games in Rio de Janeiro.

Strong leadership

Felipe Tadiello led the organization of the sports physiotherapy at the Polyclinic of Rio 2016. He tactfully managed more than 800 physiotherapists (the majority were from Brasil, Argentina, Chile; 15% were international). This 800 included those sports PTs working at the training and competition (stadiums, training facilities) and those available in case of emergencies or extra support (medical responders).

Dedicated team


SONAFE lead group at Polyclinic Rio 2016. Left to right: Felipe Ferreira Tadiello, lead manager, Christiane Guerino Macedo, Mario Bizzini (IFSPT), Leonardo Trocoli de Medeiros, and Luciana de Michelis Mendonca, SONAFE president.

All PTs were volunteers, and underwent a rigorous selection process: in total there were almost 3000 interested Brazilians sports PTs who participated at several “pre-olympic” educational courses (organized by SONAFE) across Brazil. SONAFE, the largest sports PT association in South America, thank to the work and dedication of its leaders, has really raised the bar in providing quality education to its members. This process followed the recommendations by Phillips et al, a milestone publication on the preparations for the London 2012 Games (1). According to Luciana (the other important driving force within SONAFE) and Felipe, these 2 years of intensive preparation work toward the Olympics (the story was also featured on the WCPT website and the RIO 2016 experience represent an important legacy for the future of Brazilian sports PT!

Polyclinic services

At the Polyclinic different treatment options were offered to the athletes (from all nations, not only for those nations arriving without their own medical team): sports physiotherapy, electrotherapy, sports massage, cold water immersion, acupuncture, chiropractic, osteopathy, and a department for insoles and braces.

Here’s an example of a working day (August 11) at the Polyclinic: 72 athletes were treated by sports PTs, 62 received sports massage, 22 were seen by osteopaths, 15 by chiropractors and 108 (!) did cold water immersions. Those are some impressive figures underlying the role of sports physiotherapy at the Olympic Games (2), considering that many national teams were present in Rio with their own medical and physio staff.

All illnesses and physical problems, injuries (and subsequently treatments) were systematically recorded in a special online system, which was monitored by Felipe Tadiello and Mary Elaine Grant (Dublin, IOC Physiotherapy responsible). This was part of the comprehensive IOC injury documentation system (Injury Surveillance System) at the Olympic Games, coordinated by a research group with Lars Engebretsen and Roald Bahr (IOC Research and Oslo Sports Trauma & Research Center).

A model of national advancement

Higher quality sports PT means also better protection of health of the athletes, which is also one of the major objectives of the IOC (Engebretsen, Steffen 2015). The leadership of SONAFE before and at RIO 2016 sets an example for those countries hosting future Olympic Games (i.e. Japan in 2020), in terms of preparation and education following international guidelines and through international cooperation. Knowing the mentality and peculiarity of South American physiotherapy (often “isolated” within Portuguese- and Spanish-speaking world), one can only applaud the significant development of SONAFE towards a truly international organization, which will certainly benefit all the sports PTs in Latin America. IFSPT and BJSM have already and will continue to further support and promote sports physiotherapy worldwide, with the ultimate goal to continuously improve athlete’s health globally.


  1. Using criteria-based interview models for assessing clinical expertise to select physiotherapists at major multisport games. Phillips N, Grant ME, Booth L, Glasgow P. Br J Sports Med. 2015 Mar;49(5):312-7. doi: 10.1136/bjsports-2014-094176. Epub 2015 Jan 6.
  1. The role of sports physiotherapy at the London 2012 Olympic Games. Grant ME, Steffen K, Glasgow P, Phillips N, Booth L, Galligan M. Br J Sports Med. 2014 Jan;48(1):63-70. doi: 10.1136/bjsports-2013-093169.
  1. Protection of the elite athlete is the responsibility of all of us in sports medicine. Engebretsen L, Steffen K. Br J Sports Med. 2015 Sep;49(17):1089-90. doi: 10.1136/bjsports-2015-095221.


Mario Bizzini, PhD, MSc, PT is as a research associate at the Schulthess Clinic in Zürich, Switzerland. He works there for the FIFA Medical Research and Assessment Center (F-MARC), the Swiss Concussion Center and the Human Performance Lab. His research interests focus on prevention and rehabilitation of sports injuries.

Mario is BJSM Deputy Editor, a reviewer for various scientific journals, and also a specialist in sports physiotherapy (committee member of the Swiss and of the International Federation of Sports Physical Therapy).

Can blood flow restriction training improve outcomes in clinical populations?

18 Oct, 16 | by BJSM

By Paul Head @PHphysio

Blood flow restriction training (BFRT) has been shown to increase muscular strength and hypertrophy using loads less than half of what’s recommended by the ACSM (>60% of 1RM) (1). The proposed mechanisms for BFRT include metabolic accumulation (2-5); fast-twitch muscle fibre recruitment (6,7); increased protein synthesis through the mammalian target of rapamycin pathway (8); and cell swelling (9).

Increasing muscular strength and size would be advantageous for most, if not all clinical population groups in my opinion. Especially since heavy lifting (>60% of 1RM) is contraindicated for most painful conditions or until the end stage of rehabilitation. The evidence supporting BFRT in healthy subjects is substantial, and growing. Current research, suggests the training guidelines below.


BFRT evidence in clinical populations

BFRT has also been shown to be as safe as traditional resistance exercise (10,11), however little evidence exists regarding BFRT on clinical populations (12-17). Therefore the ‘jury is still out’ on its effectiveness and safety in clinical and post-operative populations, where it may be most beneficial.

I will briefly discuss the evidence of BFRT on clinical populations. In a case report, a body builder suffered an osteochondral fracture and was able to continue training and compete using elastic wraps to perform BFRT (12). Radiographs indicated that the bone had healed suggesting that this type of training may also benefit bone healing. However the subject was not tested pre and post this intervention for changes in muscular strength or hypertrophy, and the osteochondral fracture may have healed regardless of therapy. A case study was also conducted using BFRT with pneumatic cuffs post ACL reconstruction (13). The authors showed BFRT attenuated muscle loss that is associated with this procedure. They also found significant improvement in functional outcomes and thigh girth measurement 3 months post surgery following 12 weeks of BFRT during immobilization and also 10-30% of 1RM. A BFRT randomized controlled trial (RCT) after ACL reconstruction was also conducted (14). 44 subjects were randomized into a BFRT group and a control without restriction. Both groups followed the same training schedule. Knee extensor and flexor torques 16 weeks post surgery showed a significant increase in muscular strength in the BFRT but not the control. Also quadriceps cross sectional area showed a statistically significant enlargement in the BFRT group, as compared to control.

A case series of the effect of BFRT on seven patients who suffered from chronic traumatic injuries ranging from ankle instability to explosive wounds who had previously failed conventional rehabilitation, also was assessed (15). They found peak torque, average power and total work all improved significantly after 6 weeks of BFRT shown in the graph below.


A RCT performed on female knee OA patients, randomized to a high intensity training (70% of 1RM) (HIT) or BFRT group (30% of 1RM) for 6 weeks (16). They found both the BFRT and HIT groups had significant improvements in function (Lequesne and TUG test), pain and strength, but there was no differences between groups. However the BFRT group experienced significantly less anterior knee pain during the exercise sessions. BFRT (30% of 1RM) for 12 weeks, has also been assessed in polymyositis and dermatomyositis patients (17). They found the BFRT was effective in significantly increasing the maximal dynamic strength, timed-stands, TUG and quadriceps hypertrophy. Importantly, no clinical evidence or any other self-reported adverse events were found.

These results are very promising, however, no control group was used so it is unknown if a low intensity strength program would have been effective without a BFR stimulus.


Substantial evidence supports BFRT’s use in increasing muscular strength and size in healthy adults when combined with low intensity resistance training (10-30% of 1RM). The evidence supporting its use in clinical populations is limited but shows promising results.

If increasing muscular strength is your aim of treatment and your patients are unable or contraindicated to lift >60% of 1RM, then BFRT is a viable option. However more research in different clinical populations especially RCT’s is needed to assess if low intensity resistance exercise to fatigue without BFR causes similar results. Future research on BFRT should clarify if this method of training is valid, reliable and safe for clinical populations and during home exercise plans.


  1. Ratamess N, Alvar B, Evetoch TK, Housh TJ, Kibler WB, Kraemer WJ, Triplett NT. Progression models in resistance training for healthy adults. Medicine and Science in Sports and Exercise. 2009; 41: 687-708.
  2. Kawada S, Ishii N. Changes in skeletal muscle size, fiber-type composition and capillary supply after chronic venous occlusion in rats. Acta Physiol Scand. 2007; 192: 541-549.
  3. Kawada S, Ishii N. Skeletal muscle hypertrophy after chronic restriction of venous blood flow in rats. Med Sci Sports Exerc. 2005; 37: 1144-1150.
  4. Reeves GV, Kraemer RR, Hollander DB, Clavier J, Thomas C, Francois M, Castracane VD. Comparison of hormone responses following light resistance exercise with partial vascular occlusion and moderately difficult resistance exercise without occlusion. J Appl Physiol. 2006; 101: 1616-1622.
  5. Takarada Y, Nakamura Y, Aruga S, Onda T, Miyazaki S, Ishii N. Rapid increase in plasma growth hormone after low-intensity resistance exercise with vascular occlusion. J Appl Physiol. 2000; 88: 61-65.
  6. Takarada Y, Takazawa H, Sato Y, Takebayashi S, Tanaka Y, Ishii N. Effects of resistance exercise combined with moderate vascular occlusion on muscular function in humans. J Appl Physiol. 2000; 88: 2097-2106.
  7. Takarada Y, Takazawa H, Ishii N. Application of vascular occlusion diminsh disuse atrophy of knee extensor muscles. Med Sci Sports Exerc. 2000; 32: 2035-2039.
  8. Takano H, Morita T, Iida H, Asada K, Kato M, Uno K, Hirose K, Matsumoto A, Takenaka K, Hirata Y, Eto F, Nagai R, Sato Y, Nakajima T. Hemodynamic and hormonal responses to a short-term low-intensity resistance exercise with the reduction of muscle blood flow. Eur J Appl Physiol. 2005; 95: 65-73.
  9. Loenneke JP, Fahs CA, Rossow LM, Abe T, Bemben MG. The anabolic benefits of venous blood flow restriction training may be induced by muscle cell swelling. Medical Hypotheses. 2012. 78: 151–154.
  10. Loenneke JP, Wilson JM, Wilson GJ, Pujol TJ, Bemben MG. Potential safety issues with blood flow restriction training. Scand J Med Sci Sports. 2011; 21: 510-518.
  11. Loenneke JP, Thiebaud RS, Abe T. Does blood flow restriction result in skeletal muscle damage? A critical review of available evidence. Scand J Med Sci Sports, 2014; 25(4): 521-534.
  12. Loenneke JP, Young KC, Wilson JM, Andersen JC. Rehabilitation of an osteochondral fracture using blood flow restricted exercise: a case review. J Body Mov Ther, 2013;17(1):42-5.
  13. Lejkowski PM, Pajaczkowski, JA. Utilization of Vascular Restriction Training in post-surgical knee rehabilitation: a case report and introduction to an under-reported training technique.The Journal of the Canadian Chiropractic Association, 2011; 55(4), 280–287.
  14. Ohta H, Kurosawa, Ikeda H, Iwase Y, Satou N, Nakamura S. Low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. Acta Orthop Scand, 2003;74(1):62-8.
  15. Hylden C, Burns T, Stinner D, Owens J. Blood flow restriction rehabilitation for extremity weakness: a case series. J Spec Oper Med; 2015; 15 (1):50-6.
  16. Fernandes-Bryk F, Dos-Reis AC, Fingerhut D, Araujo T, Schutzer M, Cury RPL, DuarteJr A, Fukuda TY. Exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial, Knee Surgery, Sports Traumatology, Arthroscopy, 2016; 1-7.
  17. Mattar MA, Gualano B, Perandini LA, Shinjo SK, Lima FR, Sá-Pinto AL, Roschel H. Safety and possible effects of low-intensity resistance training associated with partial blood flow restriction in polymyositis and dermatomyositis. Arthritis Res Ther, 2014; 16(5):473.


Paul Head is a Musculoskeletal physiotherapist and PhD candidate at St Mary’s University, Twickenham, in practical blood flow restriction training in clinical populations.


Assessing the Mental Health of the NFL: Bullying, hazing and workplace harassment at the Miami Dolphins

14 Oct, 16 | by BJSM

By Ian R Tofler

BJSM readers, curious scientists and sports enthusiasts all, must be interested in the inner workings of the American National Football League (NFL) and its politically astute iron fisted chief executive Roger Goodell.

INDIANAPOLIS - JANUARY 21: A referee holds a football during the AFC Championship Game between the Indianapolis Colts and the New England Patriots on January 21, 2007 at the RCA Dome in Indianapolis, Indiana. (Photo by Andy Lyons/Getty Images)

Photo by Andy Lyons/Getty Images

The NFL, despite setbacks regarding the taboo concussion/CTE scandal; large financial payouts, and players ending up in jail, has maintained its equanimity, spin and balance like a running back cutting in between defensive players.

Supporting the NFL’s defense of the sheen on its sometimes tarnished corporate image has been a host of lawyers led ably, it seems, by the Ted Wells firm of New York.

The first Wells Report of 2014, addressed in more detail in the International Review of Psychiatry article of August 19th, 2016, confronts another taboo, that of mental health in the professional sporting context.

Jonathan Martin, an offensive line player, now retired, resigned from and sued the Miami Dolphins in October 2013 for Workplace Harassment. This set in train a fairly rapid “damage control” proactive intervention by the NFL which became the first Wells Report. The second was the “Deflategate” Report addressing the Patriots scandal related to football inflation which has Tom Brady sitting out the first 4 games of this 2016-2017 season.

What were the repercussions of Wells One? A player resigned from the team, two players were hospitalized psychiatrically with suicidal thinking, and a manager /coach was fired. The player who was blamed for much of the hazing, harassment, Richie Incognito, subsequently successfully transitioned to another team – leadership ability intact, and the sport “moved on,” reputation untarnished.

Bullying and workplace harrassment

Bullying, could be seen as the verbal, physical and now the more pervasive social media “cyber” aggression towards a child or adolescent and sometimes adult individual or group, perceived as weak or different. A conduct disordered or gang membered “in group,” in high school “the jocks” such as the highly valued football team, with control, power and popularity at stake in an environment such as a high school.Depression, social isolation, ostracism and even self- harming and suicidal behavior can be the result. Preventive measures such as school policies and child protective service involvement have made in-roads into limiting the trauma and abuse associated with bullying.

Hazing, is a component of the “toughening up” process, and arguably an integral part of the rookie experience in any professional sporting team.

It has been defined by Allen and Madden, updating Nuwer in 2008 as “Any activity expected of someone joining or participating in a group that humiliates, degrades, abuses or endangers them regardless of a person’s willingness to participate.” In the US this isargely a college based initiation to highly valued, high status groups such as fraternities, sororities, school marching band and sporting teams.

Workplace harassment delineates a form of abuse seen in professional settings. Which can of course include professional sporting teams. All of the features of bullying and hazing can also be present and a part of the sporting team’s tradition and ethos. Harassment across professions, the subtle and not so subtle messages against reporting; arcane reporting procedures may actually intensify harassment are all part and parcel of this systemic challenge.

An important “pearl” regarding bullying, hazing and harassment is the temporal factor. How long did it last?

Hazing should be a time limited, somewhat stylized process, one would believe limited to the “rookie” phase usually the first year of involvement in a new program. After that one usually becomes an accepted and trusted member of the organization or group. Bullying and harassment may be time limited by the time a child or adult is a part of that institution, but could be time unlimited and ongoing.

The Miami Dolphins case has been carefully documented through “text messaging”.

Richie Incognito’s immortal message to Martin “ F.. you, you’re still a rookie. You’re still my O-Line bitch” (Wells Report, page 100). Into his second year in the team, this may have been the precipitant to Martin’s decline in performance, helplessness, hopelessness, increased social isolation and ability to function within this challenging, aggressive, physically demanding, “rough and tumble” and substance infused workplace environment.

The International Society for Sport Psychiatry ( is an organization focused, since early 1990s on the mental health of athletes. We believe in the importance of understanding the role of sports in the development of children, adolescents and adults. While we also see the critical role of performance enhancement from a psychological standpoint, we are also concerned about the management of psychopathology and organizational, systemic challenges and the safety of the individual within the sporting context.


Ian R Tofler, MBBS, Los Angeles, CA; Kaiser Permanente West Los Angeles; UCLA clinical faculty; Vice President of the International Society for Sport Psychiatry.


Tofler, I; Bullying, hazing and workplace harassment: The nexus in professional sports as exemplified by the First NFL Wells report;  International Review of Psychiatry; Taylor, Francis, August, 19; 1-6; 2016, E Publish, ahead of print.PMID:27541590.


IOC Consensus Statement concludes little evidence of negative outcomes associated with strenuous exercise in pregnancy

13 Oct, 16 | by BJSM

By Professor Gregory Davies, MD

But the overall quality of the available evidence on the impact of intense exercise is not strong, with few studies carried out in elite athletes, the statement warns.


Alysia Montano, 34 weeks pregnant (photo: Getty Images)

The statement is the second in a series of five issued by the IOC on exercise and pregnancy, focusing on elite athletes. It draws on a systematic review of the available published evidence, presented by an international panel of experts at a three day meeting in Lausanne, Switzerland, last September.

Traditionally, there has been concern that strenuous exercise during pregnancy may divert critical oxygen flow to skeletal muscles rather than to the uterus and developing fetus. The systematic review evaluated an extensive list of pregnancy outcomes and reached the following conclusions:

  • Elite athletes planning pregnancy may consider reducing high impact training routines in the week after ovulation and refraining from repetitive heavy lifting regimens during the first trimester as some evidence suggests increased miscarriage risk.
  • There is little risk of abnormal fetal heart rate response when elite athletes exercise at <90% of their maximal heart rates in the second and third trimesters.
  • Baby birthweights of exercising women are less likely to be excessively large (>4000g) and not at increased risk of being excessively small (<2500g).
  • Exercise does not increase the risk of preterm birth.
  • Exercise during pregnancy does not increase the risk of induction of labour, epidural anesthesia, episiotomy or perineal tears, forceps or vacuum deliveries.
  • There is some encouraging evidence that the first stage of labour (before full dilatation) is shorter in exercising women.
  • There is also some encouraging evidence that exercise throughout pregnancy may reduce the need for caesarean section.

The IOC Committee identified the need for more research around these issues, specifically in elite athletes.

You can find the first of the five IOC statements on Exercise in Pregnancy here:

All 5 IOC statements will be Open Access.




Gregory Davies, MD, Professor and Chair, Maternal-Fetal Medicine
Queen’s University, ON


AMSSM/OHSU Basic and Intermediate Sports Ultrasound Course – a few spots still available

11 Oct, 16 | by BJSM

Looking to jump into Sports Ultrasound?

Need to expand your skill set? 

Want to learn and practice some new injection techniques?

american-logo ohsu-logoJoin the American Medical Society for Sports Medicine (AMSSM) and Oregon Health and Science University (OHSU) Sports Ultrasound courses November 11-13, 2016 in Portland, Oregon.

We offer both Basic (one day) and intermediate (two day) courses. The intermediate course has already sold out, however, both basic and intermediate courses combine didactic sessions and hands on ultrasound practice with supervision by a diverse and experienced staff. The intermediate course includes a full day of injection practice in the OHSU VirtuOHSU cadaver lab. Please contact us (info below) if you are interested in future intermediate course offerings.

AMSSM is the national leader in Sports Ultrasound education. VirtuOHSU is a state of the art facility that provides cutting edge simulation and technical skills training. Portland Oregon is a vibrant city with a wealth of dining, food carts, culture and outdoor recreation.

For more information, click here! or email course director Kevin DeWeber MD ( or OHSU contact Ryan Petering MD (


Counseling athletes with hypertrophic cardiomyopathy; a difficult task for the sports physician.

7 Oct, 16 | by BJSM

By Dr. Tijmen van Assen, Wouter van Everdingen, and Prabath Lodewijks

Recently the combined American Heart Association / American College of Cardiology (AHA/ACC) taskforces defined eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities [1]. In this blog we discuss the recommendations of the task force concerning hypertrophic cardiomyopathy (HCM). HCM is the most common non-traumatic cause of sudden death in young competitive athletes [2]. HCM is also a common genetic heart disease, occurring in at least 1 in 500 people in the general population [3]. The diagnosis HCM is usually based on a typical and homogenic clinical phenotype; left ventricular (LV) hypertrophy without chamber dilatation in the absence of another cardiac or systemic disease capable of producing the magnitude of hypertrophy [4, 5]. The biggest challenge in counseling these patients may be the genetic heterogeneity of the disease. Over 1500 mutations from at least eleven major genes are described in HCM [6]. Potentially all unique genetic mutations behave different, leading to a rather complicated risk stratification strategy and counseling of athletes.

Sudden death risk

Recent risk stratification algorithms have effectively identified people at high risk for ventricular tachyarrhythmias (≥1 of the following risk factors; non-sustained VT on ambulatory (Holter) ECG, family history of HCM-related sudden death, unexplained syncope, massive LV hypertrophy ≥30mm on echocardiography or MRI [7]). Primary prevention of sudden cardiac death in these patients is effectuated by implantation of an ICD. ICD implantations have reduced HCM related sudden death to 0.5% per year [8]. In these HCM patients 4% receive appropriate ICD interventions per year. Nevertheless a subgroup of HCM patients without conventional risk factors, and thus without ICD, still die (0.6% per year in non ICD-populations) [8].

An additional risk factor for sudden cardiac death in HCM patients is high intensity competitive sports. High intensity activities cause physiological stress and have an unpredictable interaction with the underlying electrophysiological substrate. The interaction is possibly influenced by alternations in hydration, blood volume, electrolytes, as well as cathecholamine surge [1].

A new patient population is emerging, due to an increasing number of HCM family members which are diagnosed with documented disease causing mutations but without the clinical HCM phenotype [6]. Conversion to LV hypertrophy occurs most often in adolescence, but has also been observed in midlife and beyond [9, 10]. The difficulty is that the onset of hypertrophic growth is unpredictable and usually not accompanied by cardiac symptoms. But when LV hypertrophy is present, the patient may theoretically be subject to an unstable HCM electrophysiological substrate [1].

The abovementioned remarks and influencing factors indicate the difficulty to apply conventional risk-stratification strategies and to advise competitive athletes accordingly. Therefore, the AHA/ACC task force states that conservative and prudent recommendations regarding sports eligibility apply across the broad HCM disease spectrum and they come forward with four recommendations (table 1).




The recommendations stated in the table are rather black and white, while counseling of athletes is often more of a grey zone. According to recommendation 1, an asymptomatic, genotype-positive HCM patient without evidence of LV hypertrophy may be allowed to participate in competitive sports. An important addition however, is that the physician must agree with the athlete on the follow up frequency and modalities, as the physician should not miss an asymptomatic conversion to LV hypertrophy, because this could be subject to an unstable HCM electrophysiological substrate.

In these AHA/ACC statements the allowed sports intensity is limited to class 1A sports, corresponding with sports such as bowling, curling and golf. One may think that a slightly more liberal policy with appropriate follow up should be possible. Sports with a high static component cause high cardiac pressure load. This can result in cardiac hypertrophy and in that case may accelerate the HCM process in this patient group. Although it is not a dichotomous concept, sports with a predominant dynamic component cause pressure load in a lesser extent and therefore may be allowed in some HCM patients [11].

Statement 4 regarding the use of prophylactic ICD’s is quite clear. These devices should not be implanted for the primary purpose of permitting participation in high intensity competition. However, no statement is made for HCM patients who did receive an ICD because of a high risk profile. Again a more liberal policy on sports with a more dynamic component may be considered.


Key point in the counseling of athletes with HCM is to give advice tailored to the individual and to perform proper follow up in order to assess the myocardial consequences of the level of activity. In this way the patients’ policy can be adjusted in accordance to the progression of disease. A fully informed athlete who is at low risk on forehand should be enabled to play a role in shared decision making. However, final decision should always be in concert with all engaged parties, including the physician.


  1. Maron, B.J., et al., Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation, 2015. 132(22): p. e273-80.
  2. Maron, B.J., et al., Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation, 2009. 119(8): p. 1085-92.
  3. Maron, B.J., et al., Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation, 1995. 92(4): p. 785-9.
  4. Maron, B.J. and M.S. Maron, Hypertrophic cardiomyopathy. Lancet, 2013. 381(9862): p. 242-55.
  5. Maron, M.S., et al., Hypertrophic cardiomyopathy phenotype revisited after 50 years with cardiovascular magnetic resonance. J Am Coll Cardiol, 2009. 54(3): p. 220-8.
  6. Maron, B.J., M.S. Maron, and C. Semsarian, Genetics of hypertrophic cardiomyopathy after 20 years: clinical perspectives. J Am Coll Cardiol, 2012. 60(8): p. 705-15.
  7. Maron, B.J., et al., Implantable cardioverter-defibrillators and prevention of sudden cardiac death in hypertrophic cardiomyopathy. JAMA, 2007. 298(4): p. 405-12.
  8. Maron, B.J., et al., Hypertrophic Cardiomyopathy in Adulthood Associated With Low Cardiovascular Mortality With Contemporary Management Strategies. J Am Coll Cardiol, 2015. 65(18): p. 1915-28.
  9. Maron, B.J., et al., Onset of apical hypertrophic cardiomyopathy in adulthood. Am J Cardiol, 2011. 108(12): p. 1783-7.
  10. Maron, B.J., et al., Development of left ventricular hypertrophy in adults in hypertrophic cardiomyopathy caused by cardiac myosin-binding protein C gene mutations. J Am Coll Cardiol, 2001. 38(2): p. 315-21.
  11. Pluim, B.M., et al., The athlete’s heart. A meta-analysis of cardiac structure and function. Circulation, 2000. 101(3): p. 336-44.

Tijmen van Assen, MD PhD is a resident in sports medicine at the University Medical Center (UMC) in Utrecht. Before the start of his residency, he conducted his PhD studies on the Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), a frequently overlooked abdominal wall pain syndrome due to an entrapment of anterior cutaneous branche of the intercostal nerve (see for pdf:

Wouter van Everdingen, MD is a PhD-student at the Cardiology Department of the University Medical Center (UMC) in Utrecht. He also works as a physician in the Sports Department of the UMC Utrecht.

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

The tradition continues..2016 BJSM cover competition: vote now!

4 Oct, 16 | by BJSM


We are doing some inventory here at the BJSM. Although still 3 months until the New Year, we have lots to celebrate. New Impact factor: 6.7 and #1 in the field. Member societies number 23 with over 12,000 members. Still ranked #1 for ‘Immediacy’ – papers cited within a year of publication –i.e hot topics. Broke the 1 million for podcasts with 24 presenters, 250 quality interviews.  Mobile App rocking on at #1 in our field.

Over 60,000 enjoying Facebook & Twitter combined. That’s a thank you to everyone who puts a clinical face on those numbers. Creating them or using them.Gracie, Danke, Obrigado.
Same ol’ cover competition-where you vote for your favourite issue in the preliminary rounds. Prelude to the final ‘sudden victory’ round, where voters are entered into a prize draw and featured on the blog with massive prizes (see last year’s winners HERE). This year’s prizes are a secret but will be massive. Think Barcelona in May but it’s a secret…

Let’s get to voting. The poll is open for one week.


January-50-1: Preventive Measures in Alpine Ski Racing

January-50-2: Sports Cardiology: Lowering the risk in athletes

February-50-3: mental health in athletes

February-50-4: Back pain and sport

March-50-5: Rowing injury guidelines

March-50-6: Physical activity: What should you do?








Pain, Performance, Rehabilitation and Life: BASRaT Symposium 2016 – 18 Nov 2016, London 

1 Oct, 16 | by BJSM

Top 5 reasons why you need to attend the BASRaT Symposium (in no particular order)

  1.  An invaluable day full of renowned experts in the field of pain and workshops to help attendees put theory into practice. Focussing exclusively on pain and all its forms and manifestations it will be vital for practitioners to manage and manipulate pain and help people from all walks of life.
  2. Key note speech by Richmond Stace: Richmond has created the Pain Coach Programme – pain neuroscience-based coaching and treatment to overcome pain.
  3. Closing speech by Professor Jones :“Pain, the brain and a little bit of Magic” Professor Jones leads the Human Pain Research Group.
  4. Gold from Rio! We welcome BASRaT’s own Sport Rehabilitator, Hannah Crowley who helped Ed Clancy’s recovery and path to gold at Rio.
  5. Gain your CPD points and help put theory, expert advice and knowledge into practice.


Focussing exclusively on pain and all its forms and manifestations, the 2016 BASRaT Symposium is a vital opportunity for practitioners to help others, from all walks of life,  better manage and manipulate pain.

Our unmissable range of speakers includes Richmond Stace who is leading advances in understanding and treating pain and has created the pain coach programme – pain neuro-science based coaching and treatment to overcome pain, he has clinics in Harley Street, Chelsea and Surrey. Richmond will look into the importance of the first point of contact, how we can gain information from the first few words.

We have a range of workshops including ‘Gold from Rio’- BASRaT Sport Rehabilitator, Hannah Crowley helped Ed Clancy on his road to recovery from a back injury and to his gold medal win at Rio.

Our closing keynote “Pain, the Brain and a little bit of Magic” will be presented by Professor Anthony Jones. Professor Jones is an MSK pain specialist and leads the Human Pain Research Group. His talk will include identifying potential mechanisms for increased resilience to chronic pain and explain how existing therapies may modify these mechanisms. He will also outline how this understanding may be used to develop new brain-focussed therapies for acute intermittent and chronic persistent pain.

This one day event on Friday 18th November will be packed full of essential speeches, presentations and seminars, enriching your knowledge and aiding your work.

Follow @BASRaTSymposium on Twitter


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.


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