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

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

17 Sep, 14 | by BJSM

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

Aside from the interactive seminars, keynote speakers will include:

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

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

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

Tickets available:

Plantar fasciitis – important new research by Michael Rathleff

15 Sep, 14 | by BJSM

Blog by @MichaelRathleff 

Introduction by Tom Goom @TomGoom

Originally posted on the Running Physio blog

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

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

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

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

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

Table 1: Advice given to the patients

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

Figure 1: Plantar-specific stretching

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

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

Figure 2: High-load strength training

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

13 Sep, 14 | by BJSM

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

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

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

Current Climate for Premier League Club Doctors

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

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

The benefit of research and relationships

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

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

Medical Professionals’ Qualifications and FA Standards

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

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

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

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

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

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

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

In Closing

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


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

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

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

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

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

10 Sep, 14 | by BJSM

By Paul Dijkstra @DrPaulDijkstra & Jill Cook @ProfJillCook

Micrograph of tendon insertion 'tide line'.

Micrograph of tendon insertion ‘tide line’.







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

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

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

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

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

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

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

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

It’s NEVER simple!

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

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

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


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

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

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

#Tendons2014 – Day 1 BJSM exclusive. Guest blog @DrPaulDijkstra. 5 highlights…

6 Sep, 14 | by Karim Khan

CelloThe 3rd International Scientific Tendinopathy Symposium: on donuts and female tenocytes… bridging science & practice.

The Jacqueline du Pré Music Building at St. Hilda’s College in Oxford is a very fitting venue for the 3rd International Scientific Tendinopathy Symposium. It’s a stone’s throw away from the Iffley Road track where Sir Roger Bannister broke the four-minute  60 years ago. For 800 years Oxford has led innovation and scientific rigor. In 1214, Roger Bacon taught at Oxford and “was instrumental in setting science on the path towards modernity, as an inductive study of nature, based on and tested by experiment”. (1) He developed the principles of experimental science in his Opus Majus, an encyclopaedia of current knowledge of the natural world completed in 1266.

This 3rd International Tendinopathy Symposium (#Tendons2014) links scientists and clinicians. This is not a new idea. Thomas Sydenham (1624 – 1689),  an Oxford-based physician and one of the fathers of the science of epidemiology, influenced medical teaching in Britain for centuries. He was a “champion of bedside experience” and believed “that medical progress could best be achieved by discarding the trappings of preconceived hypotheses…”(1)

Thus, bridging theory and practice is a tradition on the banks of the River Thames in Oxford; yesterday’s first day of #Tendons2014 provided a healthy dose of translational and basic science as well as clinical practice pearls.

Top 5 flavours of the day:

1. Tendon loading, tendon structure and tendon pain… with terms like ‘overuse’, ‘normal loading’ and ‘abnormal loading’ featured in numerous talks and discussions. What causes the pain? Is there abnormal neural ingrowth into the tendon proper and if so what is the clinical relevance? Abnormal loading / overuse cause hypoxia, heat shock and apoptosis resulting in tendinopathy though complex and highly individual cell mediated reactions.

Appropriate loading results in healthy tendon adaptation via mechanotransduction/mechantherapy. What constitutes normal and abnormal load remains very complex and highly individual. What is quite clear is that appropriate loading stimulates healthy cell reaction, (including Tendon Stem Cell (TSC) differentiation into tenocytes) and tendon adaptation. Good evidence exists to suggest that the normal part of the tendon reacts to loading and grows to support the abnormal / tendinopathic part – ‘It’s about the donut, not the hole’ – Craig Purdam

2. I was surprise by the number of speakers still using the word ‘inflammation’ without clearly defining what they mean by it or necessarily understanding its role in clinical practice. There is no conclusive evidence that inflammation play a key role in tendinopathy and I haven’t heard anything today to convince me otherwise. (For more on this see Rees, Stride & Scott here)

3. Ultrasound Tissue Characterisation (UTC) was the topic of a number of oral and poster presentations. UTC is a novel imaging modality reporting 4 different echotypes representing different qualities of tendon structure. It is an interesting tool but with limited clinical application at the moment with certainly no link between pain and UTC structure.

4. Genetic researchers conclude that genetic testing has little or no role in identifying talent. With respect to injury, it should be used cautiously as part of the many factors influencing (i) (tendon) injury risk and (ii) an individual’s response to training. Finally, genetic testing should never be direct to the consumer (DTC) but always through appropriately qualified clinicians or geneticists. (@MCollinsSA but not active on twitter yet!).  (Editor – a top link on genes in sport broadly is @DavidEpstein podcast here)

5. The lid has been lifted from the ‘Plantaris tendon pot’… but still a lot of steam fogging the glasses… Note that of some of the ‘champions of bedside (trackside!) experience’ like Noel Pollock (@DrNoelPollock), Toby Smith, Lorenzo Masci and Hakan Alfredson are firm believers. Abberant (?) plantaris insertion complicating Achilles tendinopathy is certainly a real entity in elite Track and Field. Also, isolated plantaris tendinopathy might trigger a medial mid-portion Achilles Tendinopathy (perhaps irrespective of its distal insertion anatomy). Scraping of the ventral surface of the Achilles tendon and excision of the plantaris tendon remains one of the most prevalent surgical procedures in the British elite Track and Field cohort. Clearly the treatment approach remains speculative (no RCTs) but a clinical pearl is to put plantaris tendinopathy in your differential diagnosis when ‘straightforward midportion Achilles tendinopathy’ is not responding to appropriate Rx.

PS: The ‘donut’ refers to the apparent ‘hole’ within the donut which represents tendinopathy on an ultrasound scan. Of course there is no ‘hole’ in reality. The  ‘donut’ itself represents the tendon tissue surrounding the ‘hole’. Tomorrow’s blog will reveal the significance of female tenocytes…

Some reflections…

It is often “the simple, telling experiment” that provides the catalyst for substantial change in thinking and practice. On the 25th May 1940 Norman Heatley gave eight mice a lethal dose of streptococci bacteria – four of the eight were then given penicillin and they survived. In 1990 Heatley, a biochemist, became the first non-medic in the 800-year history of the University of Oxford to be awarded an honorary doctorate of medicine. (1)

There has been a lot of development in tendon science and the clinical practice application. We still lack ‘the simple, telling, tendon experiment’ though… I’m already looking forward to the 4th Symposium! Who knows…

@DrPaulDijkstra is an Associate Editor of BJSM, a regular guest blogger and sports physician at Aspetar, Qatar Orthopaedic and Sports Medicine Clinic. He served TeamGB at the 2008 and 2012 Olympic Games and TeamEngland at the Commonwealth Games in Glasgow in July-August.

BJSM is a sponsor of the 3rd International Scientific Tendinopathy Symposium (ISTS); The summary statement from the 2nd International Symposium (Vancouver, 2012) is here

Reference:  C. Keating, Great Medical Discoveries An Oxford Story Bodleian Library, Oxford, 2013

Hertford Bridge, also known as the Bridge of Sighs, links two parts of Hertford College at Oxford University and crosses New College Lane

Hertford Bridge, also known as the Bridge of Sighs, links two parts of Hertford College at Oxford University and crosses New College Lane

4 ‘must attend’ BASEM/FSEM conference sessions on physical activity and young people

6 Sep, 14 | by BJSM

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

action schools logoThis year’s joint BASEM and FSEM Conference, Walk 500 Miles, will include four, not to be missed, sessions covering paediatric medicine. The session starts at 2pm in Edinburgh’s historic Assembly Rooms, on Thursday 2nd October, with Heather McKay, Professor of the Faculty of Medicine University of British Columbia, opening with A School-Based Physical Activity Success Story – Action Schools! a trial based in British Columbia.

The Action Schools! programme uses a comprehensive health model (socio-ecological approach) to provide children with healthier opportunities for physical activity and healthy eating at school. Professor McKay’s presentation will cover 10 years of practical lessons from school based trials and evidence from efficacy, effectiveness and implementation trials from the inception of Action Schools! in 2004 covering 10 schools, to its scale-up covering 1500 schools.

The second session brings us closer to home with Dr Nicola Crabtree, Principal Clinical Scientist and Research Physicist at Birmingham Children’s Hospital, presenting Physical Activity during Childhood. Dr Crabtree will discuss bone as a living tissue, which responds to local and environmental stimuli and howphysical activity and mechanical loading plays an important role in the development of an optimal skeleton resistant to fracture, both during childhood and later adult life.

Neil Armstrong, Professor of Paediatric Physiology and the Provost of the University of Exeter, will follow this by asking: Young People are Fit and Active – Fact or Fiction? This presentation will provide critical analysis of what we know about young people’s physical activity and aerobic fitness in relation to health and well-being. The dose-response evidence underpinning the health-related benefits of physical activity and aerobic fitness during childhood and adolescence is not as compelling as that during adulthood. How many young people are fit and active enough?

The Paediatric session closes with Dr Karl Johnson, Consultant Paediatric Radiologist at Birmingham Children’s Hospital, talking about Imaging Acute and Chronic Injuries in Children and Adolescents. This talk will highlight the imaging differences between children and adults and illustrate the various imaging modalities available. In many instances, the injuries are specific to the paediatric age group as a consequence of the inherent weakness of the growing skeleton and the different dynamics of the paediatric musculoskeletal system.

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

Competing interest: This page was posted directly by @FSEM_UK via the BJSM Blog Editor – it was NOT commissioned by the Editor in Chief of BJSM Karim Khan, nor was it edited in any way by him. (arm’s length)

ACL reconstruction to pain science: Top 5 most played BJSM Podcasts

4 Sep, 14 | by BJSM

By Olivia Halfacre

  1. Chris Littlewood – Tendons: Where does pain fit in the continuum model?

Based on the connection between pain and pathology in the tendons, this podcast is presented to the listener in the form of a debate – a new different format to those previous. Jill Cook welcomes three expert perspectives on the nature of tendons and their relation to pain. Chris Littlewood, a clinician and rotator cuff researcher, poses questions to Craig Purdam and Ebonie Rio. Throughout the debate, each person takes different viewpoints on the relationship between pain and pathology. This format exposes listeners to a diversity of issues that may address their questions and/or spark even more questions to uncover through further research.

  1. Andy Franklyn-Miller – Tuning up rehabilitation after ACL reconstruction

Andy Franklyn-Miller is a well-known name in the sports medicine world and has a vast twitter following. He talks about the rehabilitation required after ACL reconstruction. Anterior cruciate ligament reconstruction is a surgicaltissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after anterior cruciate ligament injury. Whether a BJSM podcast listener with experience in this topic and knowledge on rehabilitation, or someone with less expertise, Dr Franklyn-Miller will give you lots of think about.

  1. “Mythbuster” on NSAIDs in sports medicine, challenging nutrition dogma, and evidence-based practice

Professor James McCormack, a Professor in Pharmaceutical Sciences, evaluates trials from drug companies and extensively studies results from major studies. This podcast is most useful and interesting for the general practice audience as the main focal point of this podcast is on non-steroidal anti-inflammatory drugs (NSAIDS). General practitioners can prescribe these drugs to patients as NSAIDS are used to relieve pain, reduce inflammation and, bring down a high temperature. However, at one stage in the interview, Professor McCormack states that there is no evidence that NSAIDS improve the outcome of acute sports injuries, furthermore he states that he has seen no evidence indicating that NSAIDS reduce swelling.lorm screen shot

  1. Professor Lorimer Moseley on the brain and mind in chronic pain

Professor Lormier Moseley answers questions that Ebonie Rio presents to him. The conversation revolves around the idea of the importance between pain and nociception which isthe encoding and processing of harmful stimuli in the nervous system, which essentially is the ability of a body to sense pain. Also Professor Moseley shares his views and opinions on the role of pain science in providing information to Sports Medicine Clinicians.

  1. Adam Meakins’ practical physio tips – explaining neural pain, shoulder rehab and managing knee load

Through this highly controversial podcast, Adam Meakins touches on questions such as ‘Is diagnostic palpation accurate?’, ‘Can the sacroiliac joint really be ‘unstable?’ and ‘How does touch in physiotherapy have its therapeutic effect?’ as well as many more. For any listeners going through shoulder rehabilitation, Adam discusses his blogs on ‘5 Least Favourite Shoulder Rehab Exercises’ as well as ‘Top 5 Shoulder Rehab Exercises’, both of which may prove useful. Check out his twitter @thesportsphysio for more interesting articles and blogs based around rehabilitation.

BJSM has a steady stream of new and exciting podcasts, check them out on SoundCloud:


Olivia Halfacre is a Work Experience Student at BMJ who is currently studying biology, psychology, physical education and German. She loves to travel and learn new things.


Tennis: Field-based fitness tests – the 7 domains every coach needs to test

2 Sep, 14 | by BJSM

By Dr. Babette Pluim (@DocPluim)

tennis ball and racketAt the start of the indoor tennis season, many fitness trainers and coaches use a set of ‘fitness tests’ to evaluate their junior player. What they really want to know is whether they have a new Federer amongst their pupils (talent identification), what strengths and weaknesses the player has (injury prevention), and their basic fitness level (periodisation).

Which tests do I recommend? There is no simple answer. Test choice depends on availability of facilities, time, finances, and the ultimate purpose of testing.

Do you want to know if your player has a good basic fitness level? Do you want to see how fast and strong they are in comparison to other players? Or is your primary goal just injury prevention?

This video gives an impression of a testing day of the junior players at the Dutch Tennis Federation (KNLTB):

In a BJSM open-access overview article, Jaime Fernandez-Fernandez and colleagues describe all the existing physical tests for tennis and discuss their advantages and disadvantages. They also include a summary table of recommended tests. The full article and table are available HERE.

Tennis involves short bursts of intense effort (rallies last 2-10 seconds), followed by breaks of 10-25 s (between rallies) and longer breaks of 60-90s during the change of ends. A typical 3 set match lasts about 1.5 hours, but this varies depending on playing style, level of competition and court surface. A player must cover a mean distance of 3 meters to reach the ball, runs 8-15 m with 3 to 4 directional changes per point, hits the ball 4 to 5 times per rally and covers 2.5-3.5 km per hour of play. During singles matches, the mean heart rate is 70-80% of maximum with peaks of 100% and the mean oxygen uptake 50-60% of VO2 max, peaking at 80%.

Thus, for optimal tennis performance and a rapid recovery, a player needs speed, strength, agility, power and, a good level of basic fitness. Below I discuss the commonly used field tests for a high level, tennis performance program. These are generally cheaper than those used for indoor or laboratory-based testing and are more suitable for large groups of players. If you are interested in laboratory based testing, please refer to the original article.

1. Aerobic endurance

Most tennis federations choose the shuttle run, the Yo-Yo Intermittent Recovery Test or the 30-15 Intermittent Fitness Test. Unfortunately, relatively little normative data is available for young tennis players and the tests are not quite equivalent to the loads in tennis.

Several researchers have tried to develop tests, which mimic the game itself by using the dimensions of a tennis court, and involve tennis strokes in addition to running ability. Weber has developed a test using a ball serving machine in which the ball is hit alternately to the left and right corner of the court and the player must run faster and faster to hit the ball back. However, the quality of the stroke is rapidly lost, you can test only one player at the time, it is not very realistic in tennis terms – and you need a ball machine to perform the test!

There are two other field tests that involve simulated tennis strokes – the Girard test (2006) and the hit-and-run test but I would opt for one of the simple tests (Shuttle run or Yo-Yo IR test). These have the additional advantage that if you measure heart rate, you can monitor progress without having to perform a maximal exercise test.

2. Anaerobic endurance

Anaerobic endurance can be measured relatively easily in the laboratory using a 30 second Wingate test and, in the field, you can use a repeated sprint test. Since there is a high correlation between the speed of a single sprint test (20 meters) and repeated sprint tests (e.g. 10 x 20 m.), a single sprint test is usually sufficient.

3. Strength

Using gym-based equipment, dynamic strength can be measured with a 1 Repetition Maximum (1RM, the maximum weight that can be lifted with one repeat) but this is associated with a high rate of injury so I would recommend using multiple repetitions at the start of the season (e.g. 3RM, 5RM or 10RM).

4. Power

In the field, jumping height measures lower extremity power, and throw distance of the medicine ball measures upper body power. These tests are widely used by tennis nations, so there is plenty of normative data available for these tests.

Radar speed gun measures speed of service and ground-strokes and this has a reasonably good correlation with the tennis ranking.

5. Speed ​​

Electronic interval timing equipment measures speed in the field – a stopwatch is simply not accurate enough. The 20m sprint (with split timing at 5m and 10m) has a high reliability and, because most tennis nations use it, has adequate normative data for the various age groups.

6. Agility

Agility is the ability to change speed or direction quickly and research shows that this is clearly different from pure sprint speed. Agility is usually tested using a noise (acoustic) or light signal as seen in the hexagon test, the spider test, and the Illinois agility test .

7. Musculoskeletal system

A general assessment of the musculoskeletal system is normally included in any screening protocol and a physiotherapist often conducts this. The United States Tennis Association (USTA) have developed a dynamic examination protocol specifically for tennis (High Performance Profile), but unfortunately they do not provide normative data (read more HERE ).

7. The Functional Movement Screen (FMS) is probably the most popular tool internationally and is used by physiotherapists to detect weaknesses and asymmetries of the musculoskeletal system with a view to implementing injury prevention strategies.

If you choose one or two simple tests from every domain, you and your player(s) will have more than enough to work with during the upcoming tennis season.

Useful link:
The test protocol guide of the German Tennis Federation can be found HERE


Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer, KNLTB,Netherlands). She is Deputy Editor of BJSM. Follow her on twitter @DocPluim

Brilliant, engaging, relevant! 2013/14 BJSM Systematic Review Award Winners

24 Aug, 14 | by BJSM

Systematic reviews provide critical high-level evidence to influence practice. BJSM prioritises publication of quality SRs.

systematic review awardThe winning papers are enjoyable to read and their messages easily incorporated into clinical practice. The selected papers adhered carefully to PRISMA guidelines. The results were skilfully analysed and synthesised into a clinically relevant discussion which links well to the study objectives. A reviewer independent of BJSM editors chose the winners after an iterative evaluation of BJSM systematic reviews published between July 2013-June 2014.

1st equal (£500) prize winners:

  • Christian Barton, Vivek Balachandar, Simon Lack, Dylan Morrissey

Patellar taping for patellofemoral pain: a systematic review and meta-analysis to evaluate clinical outcomes and biomechanical mechanisms Br J Sports Med 2014;48:6 417-424 

  •   Jeppe Bo Lauersen, Ditte Marie Bertelsen, Lars Bo Andersen

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials Br J Sports Med 2014;48:871-877

3rd prize:    

  • Lot Verburgh, Marsh Königs, Erik J A Scherder, Jaap Oosterlaan

Physical exercise and executive functions in preadolescent children, adolescents and young adults: a meta-analysis Br J Sports Med 2014;48:12 973-979

Congratulations to all the BJSM Systematic Review Award recipients.

Congratulations to all authors who had systematic reviews published in BJSM (which has an acceptance rate of 23%).

For last year’s award winners, and the judging criteria – CLICK HERE.

To MSc or not to MSc; a doctor’s perspective

22 Aug, 14 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine - a BJSM blog series

Part 1 of a 2 part series on making your post-graduate plans. Read part 1 HERE

By Liam West (@Liam_West)

weight liftign in chairRather than waiting for my specialist training in Sport & Exercise Medicine (SEM), I  undertook the SEM Masters (MSc) as a Foundation Year One Doc (UK version of a resident). Below are some of the questions that junior doctors should consider when thinking about whether to attempt the same challenge…

Is it worth it for a Doctor?

After graduating from medical school, junior doctors rotate through various jobs for a few years before specialization and even more years of training and exams. In line with the advice given by Prof. Khan in his “Career Development – #DreamJob”blog, I believe students should ‘differentiate’ themselves from their peers and ‘add value’ by undertaking post-graduate studies in Sport & Exercise Medicine (SEM) during these rotations years. Whilst the SEM specialist training pathway covers content taught within a SEM MSc, embarking upon an MSc also gives you the chance to ‘network’ with like-minded individuals whilst also improving research and literature based skills – this experience could reveal a hidden passion for research…

When in your training?

If you are serious about an SEM career, I must ask – why wait? I made the decision to study whilst in my first year as a junior doctor as I would have less commitments (i.e. family or elite sport) and I wanted the knowledge before entering the clinical aspect of SEM.

Part-time or Full-time Student?

So let’s say that you want to do the SEM Masters, over what duration should you complete it? Students need to be realistic – the commitments of a junior doctor with long days, on-call, weekend and night shifts are not ideal when you have strict coursework deadlines. I believe that to achieve high marks (you have chosen to do this degree so you no longer want to ‘just pass!’) you must either consider taking a year out to do the course or do it part time. I went for the part time route as this gives me five years to complete the degree and therefore if for one year the degree does not fit my schedule, I can postpone exams till the following year. I will also get to meet and network with more people and it will give me time to think what I’d like to complete a dissertation upon as currently I have no idea!

These are just a few questions you should ask yourself when considering whether to undertake postgraduate studies in SEM. I would suggest you plan well ahead, research the different courses and speak to former students.

Dr. Liam West, BSc (Hons) MBBCh ECOSEP(ac) PG-Cert SEM, is a junior doctor at the John Radcliffe Hospital, Oxford. He is a founder and current President of USEMS and is also the founder of Cardiff Sports & Exercise Medicine Society (CSEMS). In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series. He has a passion for developing the SEM movement amongst undergraduates and sits on the Council of Sports Medicine for the Royal Society of Medicine as Editorial Representative and on the Educational Advisory Board for the British Association of Sport and Exercise Medicine (BASEM). He has also now been elected as the President of the Junior Doctor’s Committee for the European College of Sport & Exercise Physicians (ECOSEP). His Twitter handle (as above) is @Liam_West.

BJSM blog homepage


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

Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine