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Vote now: Round two 2014 BJSM Cover Competition

20 Dec, 14 | by BJSM

Will SASMA win for the third year in a row? Will someone’s vote break the current tie in round one, and help either the Running Injuries and Return to Sport (with Guest Editor Philip Glasgow, ACPSEM) issue, or the issue that contains the 3rd international patellofemoral pain research retreat consensus (with Guest Editors Kay M Crossley, Mario Bizzini, and Erik Witvrouw) move on to the next round? Will you be the winner of this years prize-draw (that includes two new prizes to be revealed next round) and have your work, research interests, and/or studies featured on the BJSM blog? Your and your SEM allies have a chance to influence the answers to these questions. It starts now, with voting in Round 2 of the 2014 BJSM cover competition:


Cover 7: April 2014 (i)

Cover 7: April 2014 (i)

Cover 8: April 2014 (ii)

Cover 8: April 2014 (ii)

Supl issue: April 2014 (iii)

Supl issue: April 2014 (iii)

May 2014, Volume 48, Issue 9

Cover 9: May 2014 (i)

Cover 9: May 2014 (ii)

Cover 10: May 2014 (ii)

Cover 11: June 2014 (i)

Cover 11: June 2014 (i)

Cover 12: June 2014 (ii)

Cover 12: June 2014 (ii)

Supl issue: June 2014 (iii)

Supl issue: June 2014 (iii)




























Yes, mobile apps (for ankle sprains and more) provide valuable preventive tips & clinical guidance

17 Dec, 14 | by BJSM

 By Evert Verhagen @EvertVerhagen

 Last week I stumbled upon the following blogpost on, — “Mobile Apps for Ankle Sprains? Not Yet… or Ever” [1]. My interest was sparked as the title of the blog suggested there are no apps for ankle sprains available, or at least no proper apps. According to the blog, apps to treat and prevent ankle sprains are the most searched for apps. Yet, the blog (and who can trust blogs!) said that ‘legitimate’ apps that can benefit patients were lacking. As you may know, we developed the ‘Ankle App’ (with support from BJSM), by which we digitized a set of exercises that prevent ankle sprain recurrences [2,3]. So then why did this blog state that therew were no decent Apps? Reading on,  I found two answers to this question.

State of play – what apps are out there?

First, there was no mention of the Ankle App in the blog. Likely, this is our own fault — we may not promote the app sufficiently (although we did tell you where to get it on this previous BJSM blog). Naturally we think our app as being of good quality and one of the few that provides the user with evidence based content. Yet, providing a high quality product is not enough to translate an effective program to the public. An app has more value than the application for the end user; i.e. users don’t care much about any technology that sits in the back end, they just want something that is easy to view, press and swipe. That is why – when you truly look with a professional perspective at what is available – the quality of available apps is very low.

I agree with the mhealthwatch blog’s statement that “practical apps that could do any legitimate good for ankle sprain patients are almost entirely lacking altogether”. We performed a review on this topic [4], and recently another review came out in the BJSM on concussion Apps [5]. Both reviews concluded that “the surge in availability of apps in an unregulated market raises concerns as to the appropriateness of their content for different groups of end users” [5]. In short – between the lines -most apps are just built for the sake of building apps. That is not the way to go forward, especially not when it concerns topics around athletes’ health. We need to start developing more user friendly apps around our evidence to provide users with high quality and appealing solutions.

There’s an App for that?

Secondly, and again I agree with the blog’s message, there is a general misconception that there’s an app for everything. I have always been skeptical about the current trends for the application of technology in healthcare in which a professional positions technology as a replacement for hands-on care. Technology should support healthcare! That’s why we developed the Ankle App — to support the professional to provide the best available care. However, in regards to ankle sprains the blog says it is not worth the effort to download an app offering basic ‘preventive’ advice. I disagree with this. The blog the author points towards contains  preventive advice given on the Wasatch Foot and Ankle clinic website [6]: “To prevent ankle sprains, try to maintain strength, balance, and flexibility in the foot and ankle through exercising, stretching, and wearing well-fitted shoes.” Ironically, this advice is not fully evidence based in itself as there is no conclusive evidence that shoes or stretching are effective factors in the prevention of ankle sprains [7]. Research has proven the need for neuromuscular exercises after an ankle sprain [7,8], but has also indicated that patients’ compliance with exercises is low [9]. Thus, the outcomes of an effective treatment are diluted. The Ankle App has been specifically designed for the professional to provide patients an interactive and evidence based exercise scheme, boosting compliance and improving clinical outcomes.

Mobile Apps for Ankle Sprains? Yes, they exist and provide benefits! And I would even argue this goes further than ankle sprains alone. Apps provide a valuable platform to support the dissemination of preventive research knowledge to the field.

Listen to more about this app, on the BJSM podcast where Evert Verhagen makes social media and apps intelligible.


[1] Essany M. Mobile Apps for Ankle Sprains? Not Yet… or Ever. Accessed 11/11/14

[2] Accessed 11/11/14

[3] Accessed 11/11/14

[4] van Mechelen DM, van Mechelen W, Verhagen E. Sports injury prevention in your pocket?! Prevention apps assessed against the available scientific evidence: a review. Br J Sports Med. 2014 Jun;48(11):878–82.

[5] Lee H, Sullivan SJ, Schneiders AG, et al. Smartphone and tablet apps for concussion road warriors (team clinicians): a systematic review for practical users. Br J Sports Med. 2014:bjsports–2013–092930.

[6] Accessed 11/11/14

[7] Verhagen E, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010 Dec;44(15):1082–8.

[8] Hupperets MDW, Verhagen E, van Mechelen W. Effect of sensorimotor training on morphological, neurophysiological and functional characteristics of the ankle: a critical review. 2009;39(7):591–605.

[9] Verhagen E, Hupperets MDW, Finch CF, et al. The impact of adherence on sports injury prevention effect estimates in randomised controlled trials: looking beyond the CONSORT statement. J Sci Med Sport. 2011 Jul;14(4):287–92.

[10] Fortington LV, Donaldson A, Lathlean T, et al. When “just doing it” is not enough: Assessing the fidelity of player performance of an injury prevention exercise program. J Sci Med Sport. 2014 May 16.

ECOSEP, A tale of European SEM Success – The future’s bright, the future’s SEM!

14 Dec, 14 | by BJSM

By Amit Chauhan (@AmitC_SEM) & Liam West (@Liam_West)

ECOSEP DEC 2014What was the aim of The European College of Sports & Exercise Physicians (ECOSEP) 2014 Sports & Exercise Medicine (SEM) Trainee Conference (November 22-23rd) that recently took place? We wanted to organise a highly interactive event for delegates from a broad spectrum of specialities and arm them with the essential skills to kick-start their career in SEM. The 150 delegate tickets sold out within 2 weeks of the event going live so if you missed out, fear not, below is a brief summary on the event!

Even though we are babies in the SEM game, between the both of us we have attended over 40 conferences around the UK and abroad – we know what juniors want from an SEM conference! Professionals take note J #Lesson1: namely, affordable admission prices, big names, practical experience and networking opportunities.

Keynote Speakers

The conference included 8 fantastic keynote talks:

  • Dr Shabaaz Mughal, Team Doctor to Tottenham Hotspurs FC and Dr Amir Pakravan, Team Doctor to Crystal Palace FC, kicked off the conference explaining the difference between Sports Medicine and Exercise Medicine.
  • Dr Ian Beasley and Steve Kemp, Team Doctor & Physio to the Senior England Men’s Team respectively talked about working within Elite Sport at home and abroad and tips to get to the top.

On the Saturday afternoon, we had 4 further keynote talks aimed at gaining the perspective of those working alongside SEM practitioners. Mike Davison journalist for the Telegraph and Managing Director of Isokinetic, gave us a great insight into how to get recruited into SEM and what the media wants from SEM. He was followed by Jon Goodman, Performance Director at the Nike Academy and Founder of Think Fitness who entertained the delegates with stories of both good and bad SEM experiences he has encountered; #Lesson2 – first be a good person before second being a good practitioner.

To close Charlie Taylor, GB Rower on the Road to Rio, and Alejandro Faurlin, Argentinean professional premiership footballer for Queens Park Rangers gave an athlete’s perspective on SEM. #Lesson3 – Know your sport, know your athlete and know when to be quiet! The first day was closed by Nikos Malliaropoulos, founder of ECOSEP and co-organiser of this event, who repeated the importance of becoming active within the SEM community as early as possible.

ECOSEP DEc 132014Embedded Workshops
In total, we organised 16 workshops over the two days; #Lesson4 – (from the feedback) practicals make delegates happy! The first set of 4 parallel workshops on Saturday addressed knee, foot & ankle, hip & groin and shoulder joints, taking delegates through the anatomy, acute and chronic pathologies, rehabilitation and then physical examination of the musculoskeletal area allowing delegates to get hands-on!

The afternoon consisted of four absolutely fantastic parallel workshops, all of which had three talks from highly qualified professionals; “Sports Cardiology” (Sponsored by Doctors Academy), “Environmental Extremes”, “Technology, Performance and Sports Science” (Sponsored by Catapult) and “Nutrition for Performance and Health” (Sponsored by Bio-Synergy). This vast array of topics not only showed the diverse careers in SEM that could await many of the delegates but also offered some interesting #KnowledgeBombs. #Lesson5 – Students take note, SEM is much more than looking after a Premier League footballer’s knee!

The aim of second day of the conference was to arm delegates with key diagnostic and management skills to succeed in SEM. How did we (hopefully) achieve this? We ran 8 workshops in total where delegates spent 30 minutes at each workshop and rotated through four workshops in the morning and four more in the afternoon. The first 4 workshops comprised of diagnostic master-classes in 1) MRI imaging, 2) Radiography and CT imaging, 3) & 4) Ultrasound of the upper and lower limbs respectively (Sponsored by Sonosite and Centre for Ultrasound Studies). #Lesson6 – The ultrasound needs to become an extension of your arm to succeed in SEM! After this, we finished off with 4 workshops on common treatment modalities used in SEM; 1) Shockwave therapy (Sponsored by Venn Healthcare) 2) Injection therapy 3) Exercise prescription and 4) Manual therapy & taping (sponsored by FirstAid4Sport). The delegates had a lot of fun using the US and shockwave machines and came up with #Lesson7 – To know abnormal, you first need to know what is normal!

Venue & Support

Lunch and refreshments were provided throughout both days in the fantastic, historic, specimen-filled St Bartholomew’s Pathology Museum. The conference was proudly endorsed and supported by numerous national and international organisations. We appreciated all the help and support we received from the 25 sponsors involved with the conference. Special thanks must go to the invaluable help from family (parents, brother and sister-in-law J) and friends who spent their entire weekend helping to ensure the event ran smoothly!

If you are an SEM enthusiast or someone new to this incredible field, make sure you attend any of the many events being organised and promoted right now, all over Twitter and Facebook. The SEM following is growing, at both an undergraduate and trainee level; there are SEM societies all around the UK, hosting high quality events with eminent speakers, and the opportunity to learn about a whole host of SEM-related topics. Going to these events is a really good way to meet like-minded individuals and possibly even organise research projects or shadowing opportunities in the SEM world.

You could (if you are brave enough) set-up your own SEM society at your university or even organise your own conference! This is a huge commitment, not to be taken lightly – you will have to invest a significant amount of time and effort, but it’s extremely satisfying and definitely worth it when you see delegates enjoying and gaining a lot from the events that you have organised. If you like the sound of this, please get in touch with USEMS. Each year, they help set up SEM societies all over the UK and also allow an SEM society to organise and run the annual undergraduate SEM conference.

For more information, or if you would like to get involved with LSEMS or the ECOSEP Student Committee, please contact me at

Amit Chauhan BSc (Hons) ECOSEP(ac) is a final year medical student at Barts and The London who achieved a first class honours in his intercalated BSc in Sports & Exercise Medicine and was awarded the Principal’s Prize at graduation. Amit is also the President and Co-Founder of The London Sports & Exercise Medicine Society (LSEMS), a regional society promoting the field of SEM to all undergraduate and postgraduate medical and physiotherapy students across London, with representatives at 8 major London universities. He was also recently elected as the President of the Medical Student Committee for the European College of Sports & Exercise Physicians (ECOSEP). His Twitter handle (as above) is @AmitC_SEM.

Dr. Liam West, BSc (Hons) MBBCh ECOSEP(ac) PG-Cert SEM, is a junior doctor in the Oxfordshire Deanery. In addition to his role as a Senior Associate Editor for BJSM, he coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series. He is passionate about developing the SEM undergraduate movement and sits on the Council of Sports Medicine for the Royal Society of Medicine as Editorial Representative, founder, and is the founder & current President of USEMS. He is also the elected President of the Junior Doctor’s Committee for the European College of Sport & Exercise Physicians (ECOSEP). His Twitter handle is @Liam_West

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Common ground and continued debate: further response to “Strong evidence against PRP injections for chronic lateral epicondylar tendinopathy: a systematic review”

10 Dec, 14 | by BJSM

The rich academic discussion continues! Here is a Letter to the Editor from Renee Keijsers, Denise Eygendaal, Michel P. J. van den Bekerom that they wrote in response to a blog from RJ de Vos and colleagues (read it here), who wrote an initial Letter to the Editor (read it here) in response to: Robert-Jan de Vos, Johann Windt, Adam Weir. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956.  Have something to add? Send us your thoughts or comment below!


We thank RJ de Vos and colleagues for the response on our comments. We do agree that there is a lot of common ground between the two groups. This is probably the main reason for this lively discussion. The enthusiasm of the authors is reflected in both the original article as in the fast response to our comment.

The diagnostic terminology ‘tendinopathy’ is indeed substantively better than ‘epicondylitis’. The terms ‘lateral epicondylitis (LE)’, ‘lateral epicondylar tendinopathy’, ‘lateral epicondylalgia’ or ‘tennis elbow’ are often used interchangeably, where the same condition is meant. The Cochrane Library overcomes this by using the term lateral elbow pain; which is not an actual diagnosis, but only a description of the localization of the pain. The majority of cases are believed to be caused by a tendinous lesion of the common extensor tendon origin at the lateral epicondyle as a result of repetitive microtrauma. There are several hypotheses regarding the cause of the tendinosis in LE based on histopathological, biochemical and clinical findings. Cell apoptosis, angiofibroblastic features, or abnormal biochemical adaptations, largely suggesting that a failed healing response underlies the condition. (1,2)

We would also like to refine our criticism: we do agree that the design of the systematic review was performed correctly and with respect to the PRISMA guidelines. Nevertheless we think that the interpretations of these results are oversimplified. Due to the different techniques and the use of different concentrations of PRPs (with different platelet count, leukocyte concentration and activation of PRP) it is too hasty to definitively abort the use of PRPs. We do agree that a beneficial effect of PRPs (especially in relation to infiltration of whole autologous blood) in the treatment of LE has not been proven; therefore we need more placebo-controlled RCTs. Or to be more specific: we need more placebo controlled trials in which the technique is uniformly performed and controlled. We think that many of the infiltrations are not in the area of the ECRB tendon. When injection therapies are not performed in a standardized way by ultrasound guidance and with a well defined injection technique it is not possible to compare injection therapies with one another.

The authors state in their comment that ‘Comparison with autologous blood injections would only make sense if this would was “usual care” for tendinopathies’. A more recent review, than the one cited by the authors on the effect of different injectables in the treatment of LE, found a paucity of evidence from unbiased trials on which to base treatment recommendations for LE. However, this meta-analysis by Krogh et al. (2013) showed that injection therapy with autologous blood, PRP, hyaluronic acid and prolotherapy (injection with dextrose) were all more efficacious than placebo.(3) Therefore, we think there is still a place for injection therapy with autologous blood or (more expensive) PRP in the standard treatment of chronic tendinopathies of the elbow.

A hypothesis is that perforations of the affected tendon alone (without application of an injectable) could also have a therapeutic effect; the needle is used to either break up scars or poke holes in the injured tendon so that bleeding occurs. The blood cells carry precursors, which eventually develop into collagen to replace the damaged tendon. Therefore it is quite possible that all currently used injectables are not effective at all. As long as there is no consensus on the best treatment of LE, there will be many items to discuss about.

To our opinion the bottom-line should be that it is very important to remain critical about promising new developments in health care, and that results should be viewed in the right perspective.


1. Pitzer ME, Seidenberg PH, Bader DA. Elbow tendinopathy. Med Clin North Am. 2014 Jul;98(4):833-49.

2. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010;30:167-184.

3. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2013 Jun;41(6):1435-46

Tragic injury in sport: the shock, grief, and honouring of cricket player Phillip Hughes

8 Dec, 14 | by BJSM

Photo: Reuters

Photo of Phillip Hughes: Reuters

Tragically Phillip Hughes died on November 27th 2014 in Sydney after being hit in the neck by a cricket ball two days previously in a cricket match. He never regained consciousness after collapsing shortly after being hit by a bouncer bowled by Sean Abbott. He was aged 25.

David Burdon died playing football on September 24th 1988 after sustaining a blow to the abdomen during a heavy tackle. He fell in to haemorrhagic shock and died on the way to hospital. He was aged 19.  He was my brother.

What connects these two men in the prime of their lives is the freak nature and incredible rarity of these injuries and the amount of shear shock and grief that this causes.  Dr Peter Brukner as Australian cricket team doctor, explained shortly after Phillip died that the cause of death was vertebral artery dissection – a very rare condition that had only been previously described once before in cricket.

Death from traumatic injury in football is also very rare. A quick literature search on this reveals almost complete absence of any described cases. There are a few cases of splenic injury but liver haemorrhage from fractured ribs in a healthy 19 year old I cannot find described.  After attending several trauma courses as a sports medicine consultant including the excellent FA AREA course, I am met with almost disbelief when I describe what happened to my brother.

Of course tragic cases of sudden cardiac death are well known but traumatic death appears to be much rarer.

The sheer grief of these events are clear and it is very hard of course to comprehend the nature of the tragedy. A healthy sportsman competing in a sport that he loves and then not returning home.

Different sports, different countries and different times but the similarity is very clear.

Sean Abbott as the bowler who delivered that bouncer will be raw with grief and emotions of guilt.  The player that tackled my brother felt the same. He came to see my family the next day in tears after Dave died. All my mum could do was to hug him and tell him it was not his fault. The family of Phillip Hughes have been doing the same for Sean Abbott. I read the comments of Australian captain Michael Clarke who today said to Sean Abbott…

” Sean. When you feel like getting back on your horse mate, I promise you that I will be the first to strap on the pads and go stand up the end of the net to hit them back at you. It’s what Hugh Dog would want us both to do”.

Inspiring words from a great captain.

When the Australians play their first game since Philip died, they will go through what my other brother Paul and I also had to do- to continue playing sport knowing that this is what our loved one would have wanted.

The first hard tackle will be equivalent to the first bouncer faced.  At 17 years of age could I walk away and avoid football for ever in light of my brother’s death ?  We decided that as brothers we should carry on -of course at the time this was extremely painful and hard to do.

This will be the same for the Australian players, Sean Abbott and family of Phillip Hughes – you have my thoughts, deepest sympathy and understanding of what you are going through.

Sport is fundamental to many cultures and essential in promoting health, competition, fun and much more.  For those of us that love sport it would be impossible to imagine life without sport. These types of traumatic deaths are incredibly rare and whilst of course any safety implications if they exist should be implemented, we cannot fully prevent such tragedies from ever happening.

Sport and life goes on. Compete and be healthy. But please always remember those that have tragically not come home in our thoughts and in our prayers.


Dr Mike Burdon , Consultant in Sports and Exercise Medicine, Peninsula Sports Medicine,

Twitter: @peninsulasport





Return to Sport After Total Knee Replacements?

5 Dec, 14 | by BJSM

By Alexander Wood

knee run

The number of total knee replacements (TKR) performed annually has doubled over the last decade1. TKR is common in the young population2 and an increasing number of elderly patients are playing sport and sustaining sports related injuries3. Considering the above factors combined with improvements in life expectancy and in overall general health4, more patients will likely require or demand a knee replacement, and question the likelihood of returning to sport.

Return to sport post TKR

Whilst a total knee replacement does not preclude a return to sport, research suggests that patients can return to light sporting activities like walking, swimming, golf, yoga and cycling5. Despite this, research also suggests that far less people who regularly participate in sports prior to surgery, participate in sports after surgery4,6,7, and that only around one in twenty patients will return to sports after surgery6. Five years after a TKR, one in twenty patients reported participating in more than 2 hours of sport, compared to almost one in ten prior to surgery4. Notably, this effect may be associated with other age related impairments8.Whilst it may be possible to return to sport after a TKR, it should not be a primary reason for individuals to undergo a TKR; the evidence suggests that sports participation decreases rather than increases.

Will I be able to run or ski post TKR?

Running or skiing post TKR is not advised8 although this is currently debatable.  However, only 1-2% of patients participate in these activities post TKR4.  The advice from the American Academy of Orthopaedic Surgeons10 is to avoid activities like jogging, racquetball and skiing and the NHS strongly advises against running and jumping11.

Should I participate in any sport after a TKR?

Whilst any sport may increase the wear on implants, the benefits of aerobic activity outweigh these possibilities and therefore health practitioners should encourage patients to participate in aerobic activity post TKR12.


Elderly patients are increasingly participating in sport and consequently the number of  knee replacements are on the rise.  Whilst the polyethylene used in total knee replacements and their survivorship has improved, current advice for patients is that activity level is not likely to increase after a TKR. Lastly, encourage patients to perform aerobic exercise post TKR surgery, but avoid high impact sports.


  1. Weinstein AM, Rome BN, Reichmann WM, Collins JE, Burbine SA, Thornhill TS, Wright J, Katz JN Losina E. Estimating the burden of total knee Replacement in the United States. JBJS AM 2013 6;95(5):385-92
  2. Wood AM, Keenan A, Arthur C, Aitken S, Walmsley P, Brenkel I, “The Functional Outcome of Total Knee Replacement in Young Patients: A 10-Year Matched Case Control Study,” Open Journal of Orthopedics, Vol. 3 No. 2, 2013, pp. 128-132. doi: 4236/ojo.2013.32024.
  3. Court-Brown CM, Wood AM, Aitken SA. The epidemiology of acute sports-related fractures in adults. Injury 2008; 39(12):1365-72
  4. Huch K, Muller KAC, Sturmer T, Brenner H, Puhl W, Gunther KP. Sports activities 5 years after total knee or hip arthroplasty: the ulm osteoarthritis study. Ann Rhem Dis 2005;64:1715-1720
  5. Accessed 14 August 2014)
  6. Bradbury N, Borton D, Spoo G, Cross MJ. Participation in Sports After Total Knee Replacement. AJSM 1998:26(4);530-535
  7. Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16(10):973-979
  8. Zahiri CA, Schmalzried TP, Szudzczewicz ES, Amstutz HC. Assessing activity in joint replacement patients. J Arthroplasty 1998;13:890-5
  9. Kuster MS, Spalinger E, Blanksby BA, Gachter A. Endurance sports after total knee replacement; a biochemical investigation. Med Sci Sports Exerc 2000;32:721-4
  10. (Last Accessed 14 August 2014)
  11. (Last Accessed 14 August 2014)
  12. McGrory BJ, Stuart MJ, Sim FH. Participation in Sports after Hip and Knee Arthroplasty: Review of Literature and Survey of Surgeon Preferences. Mayo Clin Proc 1995;70:342-348


Alexander Wood BSc MB ChB, MSc (SEM) FRCSEd (T&O)

ST8 Trauma and Orthopaedics, Royal Victoria Hospital Newcastle UK


Musculoskeletal ultrasound (MSKUS) in physiotherapy: practice based insights

2 Dec, 14 | by BJSM

By @Peter_Gettings


As a Physiotherapist splitting time between Rheumatology and MSK, I was kindly asked to share my experience – with the BJSM blog community – of learning and using musculoskeletal ultrasound in my clinic. I have held roles in private clinics, private hospitals, an EPL football academy and a professional cricket team, although I now exclusively work within the NHS.

My first experience of using diagnostic ultrasound (MSKUS) was via two colleagues that purchased two scanners that pretty much became expensive doorstops. The scanners were massively under used and often brought out to review patients that hadn’t progressed as expected prior to onward referral or change of treatment plan. I had no idea what I was looking at but was fascinated by these grainy, grey-scale images and wanted to learn more.

I attended the an introductory course on diagnostic ultrasound but still wanted more. I then undertook further training for MSK sonographer qualification, and that is where I am as I write, just about to hand in my portfolio for final marking.

In the UK, the profession of Sonographer is not recognised by Health and Care Professions Council (HCPC). There are no legal requirements to use ultrasound in practice. It is actually quite easy (some might argue too easy) to get started. There are plenty of short courses that will teach you the basics of scanning, giving you the minimum you need to pick up and use a scanner. A good option is a weekend course that provides enough teaching and scanning time to allow you to get going. An important point to consider is that some courses are more clinically focussed than others. Before parting with your hard earned cash, research the tutors’ credentials and if the course comes with recognised CPD accreditation (eg from the Royal College of Radiologists/European Society of Musculoskeletal Radiology).

Progressing from the basics

There is a steep learning curve to MSKUS. It takes a significant investment of time to improve once you have learned the basic skills of probe handling and image interpretation. It is a huge bonus if you can work with someone as a mentor that continues to teach and challenge you once you get started. The hardest thing for me was gaining confidence in my own scanning ability and reporting on the clinical relevance of what I see. It is so easy to see something abnormal on a scan and assume that it is the cause of the symptoms. As a physiotherapist I find MSKUS incredibly useful as an integrated part of my every day practice. This does not mean that I scan every patient I see. I am a big believer that if the scan is unlikely to have a direct impact on the management of the patient then it is not worth doing. That being said, having the ability in clinic to carry out a diagnostic scan that will offer important information to assist clinical decision making is a huge bonus.

Practice based lessons

One of the biggest lessons that I have learned from scanning is that there is often little correlation between the degree of abnormality seen on a scan and the severity of patients’ symptoms. It is really useful to show patients ‘abnormal pathology’ on their pain and symptom free side to get them on board with rehab. I have been scanning for three years in total and am still learning!

I feel strongly that physiotherapists are ideally placed to make good use of MSKUS. Generally speaking we are experts in musculoskeletal examination, so we are able to take a thorough history from patients, carry out a physical examination and then use this information to formulate a diagnosis and treatment plan. It is this combination of skills that give us an edge when it comes to the use of MSKUS; the scan should never be viewed in isolation but always in relation to the patient and their history. A big advantage of MSKUS is that you can view structures dynamically rather than statically, like images from XR or MRI and you can even scan while you are carrying out physical tests. It is often the correlation between the history, imaging and talking to the patient while scanning that will give the most useful information. There are also lots of incidences where MSKUS has picked up findings, such as fractures or the presence of foreign bodies, that have been missed on other imaging and the use of MSKUS has had a direct impact on the further management of the patient.

If you are interested in starting to use MSK ultrasound, I have written a short piece here on points to consider when purchasing a scanner and I would highly recommend checking out for a wealth of further information.

I also post the occasional tweet (@Peter_Gettings)

RFU’s Rugby Medicine Meeting – The Highlights!

28 Nov, 14 | by BJSM

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

By Steffan Griffin (@lifestylemedic)

rugby logoThe RFU’s Rugby Medicine Meeting, suitably held at the location of next year’s Rugby World Cup final, a chance for all those working within the game to catch-up and listen to expert opinion on a variety of topics and their relevance to current practice – from tendinopathy to occlusion training.

In case you missed it, here a few information highlights:

Session 1: Tendinopathy

Dr Jonathan Rees: Current models of tendinopathy

  • Take tendinopathy research with pinch of salt if there are small sample sizes and recruitment bias (which is common due to the relapsing-remitting nature of the condition (= most will improve naturally after a relapse anyway!))
  • There are many theories surrounding the cause of tendinopathy:
    • Professor Jill Cook’s model with load as the centre of the model
    • Sai-Chuen Fu’s theory that clinical presentation is preceded by a failed healing/repair response
    • Dr Rees’ model that there is an element of inflammation present showing an active process at work in the process
  • Treatment protocols using eccentric exercises have effect via force fluctuation within the tendon and not simply the magnitude of force
  • Denervation techniques such as high-volume injections treat the pain but not the tendon
  • PRP/stem cell treatments lack a strong evidence base despite their popularity

Professor Hakan Alfredson: Surgical decision making in respect to rehabilitation

  • Ultrasound and Doppler are considered gold-standard diagnostic tools, they are dynamic and can assess neovascularity
  • If a tendon is thickened with more hypo-echoism than usual, consider a partial tendon rupture as a differential diagnosis
  • Best current surgical management of tendinopathy in elite athletes focuses on structures around the tendons such as fat pads, where neovascular structures seem to originate. This means minimal disturbance to the tendon, allowing early and aggressive rehabilitation and good results in this cohort

Dr Dylan Morrisey: Rehabilitation of Achilles and Patellar Tendinopathy

  • Is there an inflammatory element to the healing process? Research needed in this area
  • Mobile phone technology to help educate and show patients how to correctly perform their prescribed exercises is a new and novel tool
  • Despite many new advances, loading is still the core management principle. However, the degree is dependent on multiple intrinsic and extrinsic factors from age to demand
  • Current evidence shows a role for shockwave therapy as an adjunct with a positive effect on pain scores and function

Session 2: Rugby World Cup 2015 & Concussion Update

  • RWC 2015 is a unique challenge for medical staff as they have to prepare the squad for a (hopeful!) 7-game tournament with short turnaround between matches
  • Need to prepare players for 100-minute matches as a huge emphasis on scoring points in the last quarter – see the All Blacks!
  • Preparation for the tournament includes identifying surgical cases for next January and implementing a clear recovery protocol
  • The medical board ensures training of all incoming medical teams in immediate care, thus creating an international legacy benefiting the sport whilst also distributing the equipment to clubs after the tournament for a more local legacy
  • The RFU are currently designing an e-resource to all Premiership/Championship coaches and players, which will be mandatory and will educate them about concussion
  • There will also be a video repeat of any suspected concussion incident available to the medical teams, which will be mandatory viewing before being able to return the player to the field (This will be trialled in the Premiership next year)
  • PSCA now renamed ‘head injury assessment’ and updated to include element of the SAC test and tandem-gait test
  • Practice review of the last 2 years show that more players are being removed, although this is still less than the number returning to play

Session 3: Masterclasses

Masterclass 1: Current concepts in surgical decision making when treating the professional rugby player. Mr Andrew Wallace

  • The tackle is the most common injury event
  • There are some general rules regarding mechanism of injury and pathology
    • Try-scoring associated with labral injury
    • Tackling associated with labral/rotator cuff pathology
    • Direct impact associated with labral/AC-joint and clavicular fractures
  • In elite rugby players, over 30% of operations reveal multiple pathologies
  • Bony defects are a good prognostic marker for recurrence of injury
  • Distal biceps and pectoralis major injuries are on the rise

Masterclass 2: Current concepts in athletic groin pain. Dr Andy-Franklin Miller

  • Groin pain is the third main cause of time-out and is strongly associated with impaired performance
  • There is a general difficulty in diagnosing pathology due to different terminologies and understanding of pathology
  • Knowing anatomy is important: the pelvis should be seen as a ‘polo-mint’, it’s integrity unable to be compromised at one-point alone
  • The pubic symphysis can take linear load but not rotational forces, and so there is a role to discover the biomechanics of movements affecting the pelvis so that we are able to target cause of pain and dysfunction
  • In sport, the pelvis has to absorb a significant force, and so poor pelvic control and poor turning techniques increases susceptibility to injury
  • Rehabilitation should not be seen as a means to treat pain, but as an opportunity to develop and improve controlled sport-specific movement and thus potentially enhance performance

It was a fantastic day spent listening to some leading figures in the field as they discussed some of topical issues in the sport, and to hear about the enormously exciting medical and logistical challenge that the Rugby World Cup presents. Many thanks to Dr Simon Kemp for allowing me to attend the meeting and write a blog of it’s fantastic content.

Steffan Griffin is a third year medical student at the University of Birmingham currently intercalating at Cardiff Metropolitan University in Sports Science. As an ambassador for Move.Eat.Treat and the president of the Birmingham University Sport and Exercise Medicine Society (BUSEMS), he is passionate about the role of exercise as a proactive healthcare tool. He is involved with the Undergraduate Sports & Exercise Medicine Society (USEMS) committee as the Conference Officer. He combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

Dr. Liam West BSc (Hons) MBBCh PGCert SEM (@Liam_West) is a graduate of Cardiff Medical School and now works as a junior doctor at the John Radcliffe Hospital, Oxford. In addition to his role as an associate editor for BJSM he also coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.


Zero to 25,000 steps a day: My personal story (and numbers) of lifestyle, and physical transformation

25 Nov, 14 | by BJSM

By Stephen Morrison @howmanymiles_

“People remember dead babies,” not the most heart-warming of statements, but one that Professor Karim Khan used to illustrate a point in a recent presentation; point being that you will remember an emotional story or event more than a set of statistics. The audience at the FSEM and BASEM Walk 500 miles Conference will indeed remember his story.

People remember stories and not necessarily facts and data because people need to feel engaged and connected to what they are being told. If we are to effectively combat inactivity, we must remember to use stories and not just numbers.

However, sometimes numbers and stories can work together. For example, I am a story of numbers.

Stephen BeforeThe first number was 354. That was the number of pounds I weighed on Jan 9th 2011. Fifty-two was the percentage of fat in my body and 58 were the inches in my waist. Zero was the amount of hours of daily activity I undertook while 5,600 were the calories I consumed daily. 1,000 was the number of times that friends, family and health professionals told me to lose weight. 12 were the times I had tried and failed.

One picture changed all this.

People say that a picture is worth a 1,000 words. This one picture left me speechless. It horrified me and I felt ashamed. How had I let myself become so unhealthy? How could I continue to ignore my increasing weight and how could I now succeed in losing weight when I had failed previously?

The answer lay in numbers. I am a Lean Practitioner. I look at processes and identify ways to continuously improve them. I measure all the metrics involved in delivering a service, identify waste and then opportunities to improve.

I decided to literally Lean My Life. I looked at my past mistakes to identify the root causes. I looked at what barriers lay in front of me and I learned and adapted my behaviours.

I would not make the same mistakes again and I would not fail again.

I identified that my efforts lacked consistency and that I followed plans that worked for others, but not necessarily for me. Using Lean, I used tools that helped me devise a way that worked specifically for me.

weightlosscentreI designed a spreadsheet that I used to measure and evaluate my weight, my body fat, my daily steps, and my nutritional intake. It charted my progress and helped me identify what changes were working and which ones were not.

I adopted a ‘try everything’ approach, making one small change at a time, agreeing a review period, and measuring its effectiveness. Over time, the small steps and changes that I deemed successful became part of my daily life.

The biggest step was also the simplest of steps. It was to take more steps. I had measured that I was averaging below 3,000 steps each day against the recommended 10,000. I wouldn’t try and change that overnight and instead signed up to a Step Count Challenge. Over the course of 12 weeks I went from my lowly 3,000 steps to hitting 25,000 on most days. I walked 7 miles to work, I walked up and down the 22 steps in my house and I walked my 2 dogs several times a day.

I became a Step Count Champion, recruited my friends and colleagues and in 10 months I managed to lose 150 lbs. I regained my self-confidence, my health and my happiness.

I now lead 100s in annual Step Count Challenges, coordinate weekly Great Run Local 2 mile running events and try 1 new activity almost every week, becoming a try athlete, FSEM Lay Adviser, Fitin14 Ambassador and blogger in the process.

PaddleI also ran my first 26.2 miles earlier in the year. However the most important number in my life is 2. This is for the 2 little boys that have become part of my life and who now follow in my footsteps and are inspired by my stories of cycling up mountains and paddling in Lochs.


Stephen Morrison, 41, is a Lay Adviser to the Faculty of Sport and Exercise Medicine (FSEM). Since transforming his life in 2011, he has become a passionate advocate and ambassador for physical activity and active travel. He has become a “Try Athlete” and highly regarded blogger and commentator on physical inactivity and obesity issues, with various roles for several organisations, including Great Run, Fit in 14, Spogo and Man V Fat. He also charts his own experiences in his inspiring blog and can be followed on Twitter at @howmanymiles_

MD to PhD: Returning to school to explore physical activity in respiratory disease

22 Nov, 14 | by BJSM

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

By Dr. Ruth Pearson

OLYMPUS DIGITAL CAMERADiversity and flexibility of both training and career possibilities was part of the appeal for my perusal of Sport and Exercise Medicine Training. Now, compelled by a fervent obsession with health improvement through physical activity, I am returning to student life and embarking on a clinical PhD. Through an exciting collaboration between Loughborough University’s School of Sport, Exercise and Health Sciences and the Leicester Respiratory Biomedical Research Unit, my PhD will explore Physical Activity in Respiratory Disease. Against the backdrop of the new multi-million pound National Centre of Sport and Exercise Medicine and amidst the surrounding buzz of athletic ability and achievement there is no excuse for a lack of inspiration.

Physical activity improves health. This statement is well established. We also know that its lack is a risk factor for mortality. Exercise and physical activity as part therapeutic interventions are becoming more and more employed across a wide range of diseases including respiratory diseases such as COPD. Pulmonary rehabilitation provides a good example. Although some of the outcomes of muscle and cardiovascular training may seem logical, the we need to learn more about the influence of physical activity on the actual disease processes.

Further, translating knowledge into behaviour change at individual and population levels are one of our biggest challenges. As the development of technology and labour-saving devices escalates, the need for novel approaches to encourage physical activity grows.

An interdisciplinary lens to tackle complexity in health 

The 2012 Olympics in London are fading into the past, but on the Loughborough University Campus, the legacy lives on in the form of the National Centre of Sport and Exercise Medicine. As the building’s construction reaches its final stages, anticipation about its occupation increases. The new facility will house researchers, clinicians, applied practitioners, and translational scientists who will work together to address five key areas: Physical Activity in Disease Prevention, Exercise in Chronic Disease, Sports Injuries and Musculoskeletal Health, Mental Health and Wellbeing, and Performance Health.

Why respiratory disease? 

Well, although I find the relationship between physical activity and a wide range of diseases interesting, respiratory disease and respiratory physiology has always been particularly fascinating. I recall a particular encounter as a medical student: I was introduced to an elderly gentleman who had had a partial pneumonectomy for TB when he was younger. Despite having part of his lung removed, his level of function was not significantly reduced. COPD is a heterogeneous condition and there is frequent disparity between symptoms and function with some of the implicated causes being physical deconditioning, dynamic hyperinflation and skeletal muscle dysfunction. This tells us that there are many questions surrounding respiratory disease and physical activity, and I look forward to further investigation.

Meanwhile, as the war against physical inactivity rages on, I am battling a potentially less active lifestyle as I now spend more time in library and labs than on clinical rounds.  Lucky for me, I am armed with my new pedometer and standing desk!


Ruth Pearson trained at St George’s Hospital and following training through the Acute Care Common Stem pathway, began training in Sport and Exercise Medicine.  She has spent three years as a registrar in the East Midlands before recently stepping out of programme to commence a PhD.  She has always enjoyed playing and being involved in sport.

Farrah Jawad is currently a ST4 doctor in Sport and Exercise Medicine in London and co-ordinates the trainee perspective blog series. 

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