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‘The fatigued athlete’ and RED-S: Lessons from the field and the BASEM spring conference

16 Apr, 14 | by Karim Khan

Sport and Exercise Medicine: The UK trainee perspective, a monthly blog series

athlete fatigue

By Dr Khine Swe Win

I recently attended the British Association of Sport and Exercise Medicine (BASEM) spring conference, “The fatigued athlete” in Manchester. It was a great opportunity to see many old and new friends and colleagues, and discover the latest evidence in diagnosis, prevention and management of underperformance syndromes.

Unsurprisingly, the new IOC consensus statement on Relative Energy Deficiency in Sport (RED-S) was a discussion topic of interest at the conference. The RED-S replaces the previous term “female athletes triad” (a medical condition often observed in physically active girls and women, that involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density, (Mary Jane De Souza et al 2013)). The new term recognizes the complexity of the condition’s pathophysiology and multisystem involvement, affecting both men and women. The background theory of RED-S is the imbalance in the energy availability and the energy expenditure, or misbalance between training load and recovery. Low energy availability can have serious implications for many body systems such as nutrient deficiencies, low immunity, risk of infections and illnesses, and chronic fatigue, resulting in short-term and long-term compromise of optimal health and performance.

Multiple monitoring tools have been used to detect early signs of fatigue and health decline in athletes. A good monitoring tool should be reliable, reproducible, standardized and sport specific and has the ability to provide immediate feedback. Of the many monitoring models, here are some examples that I have come across:

  • Daily monitoring of rated perception of exertion (RPE), sleep hygiene, muscle soreness, fatigue level, readiness to train, attractiveness of training day, general health, mental wellbeing (POMS).
  • Physical tests and examination such as range of movement, adductor squeeze test, FABER test, Functional movement assessment (SFMA), counter movement jump (CMJ).
  • GPS data on duration, covered distance, speed, acceleration, total work, metabolic power.
  • Physiological markers such as heart rate, heart rate recovery, heart rate variability.
  • Monitoring by blood tests and biochemical markers.

The key is to effectively analyze data and utilize it to boost performance. There are multiple factors that enhance team performance. The sum of many little improvements or marginal gains can provide a big leap in performance.

Further points to highlight from the conference discussion include:

  • Load can influence performance and hence, appropriate load management is crucial. Athletes should be exposed to different stimuli on a day-to-day basic and should avoid monotony of training.
  • Establishment of recovery strategies within the team is important.
  • It is essential that athletes have a balanced nutritious intake with a mixture of macro and micronutrients.
  • Nutritional interventions can be considered for low immune athletes, such as Vitamin D
level, high carbohydrate, whey protein, open window theory (post exercise recovery shakes),
probiotics (illness prone athletes)
and Colostrum (influencing the gut barrier).
  • Sleep efficiency is slowly gaining its popularity in maximizing performance. The issue of sleep and its impact on performance was discussed recently by Dr Andy Franklyn-Miller in his research review blog (HERE)
  • Athletes’ personal, environmental and emotional issues should be addressed efficiently.
  • Dr John Roger discussed that the athletes should be “Happy, Healthy (heart rates normal), Hungry (appetite excellent)
and Horny (libido in good working order) (4Hs)
  • There are also other multiple factors that can influence performance, such as time zone transition, jetlag and altitude exposure.

Finally, I would like to conclude by sharing Tom Lancashire’s thoughts, from an athlete’s perspective, that as core staff we should “know the athletes, understand the sport, and communicate and co-ordinate effectively within the team.”

Read more in BJSM:


Dr Khine Swe Win is a final year sport and exercise medicine registrar, undertaking her training in West Midlands deanery. 

Dr James Thing co-ordinates “Sport and Exercise Medicine: The UK trainee perspective” monthly blog series.

Preventing sudden cardiac death (SCD) in athletes: the IOC World Conference Prevention of Injury and Illness in Sport session highlights

14 Apr, 14 | by Karim Khan

By Jessica Orchard, Sydney Medical School, University of Sydney


Cutting edge research was presented at many IOC World Conference Prevention of Injury and Illness in Sport 2014 Monaco sessions. Among these, was a focus on cardiology, and specifically, preventing sudden cardiac death (SCD). Speakers discussed the importance of screening, interpretation of athletes’ electrocardiographs (ECGs), the roles of ethnicity, gender and age, and how to prepare for a sudden cardiac arrest (SCA).

Dr Matthew Wilson explained that SCD is rare, with an incidence of about 1 in 50,000. The mean age of death is 23 years; it is more common in males (9:1), with 90% of events occurring during or immediately after exercise (Bille et al, 2006). The most common cause is hypertrophic cardiomyopathy (HCM), accounting for about 36% of SCD (Maron et al, 2003). HCM is frequently genetic, and the prevalence is about 1 in 500, although it can be as high at 1 in 100 for black athletes.

IOC pic

Peak organisations including the American Heart Association, the European Society of Cardiology and the International Olympic Committee recommend pre-participation screening including a 12-lead ECG. However, there remains some debate about screening, regarding which elements to include (history, physical, ECG) and the sensitivity, specificity and cost-effectiveness of a program. The value of screening may be proportional to the background risk of SCD in the population (according to Bayes theorem). For example, on the basis of risk stratification, black male basketball players are a good population to screen because their background risk of SCD is higher.

While the ‘history’ element of screening is frequently used, it has generally poor sensitivity and specificity, and the particular questions asked have not been well-studied. For the physical exam, Professor Mats Börjesson emphasised the importance of looking for Marfan’s syndrome, any heart murmur, the femoral pulses and brachial artery blood pressure. However, the physical exam alone has very low sensitivity. Adding a 12-lead ECG dramatically improves sensitivity and specificity, particularly when interpreted according to the new Seattle criteria.

In terms of the specificity of interpreting athletes’ ECGs, Dr Wilson emphasised that the most difficult thing for physicians is to recognise what is normal. To help sports physicians understand features of athletes’ ECGs, there is a free online unit available through BMJ Learning.

Dr Wilson and Professor Jonathan Drezner explained the key point that a normal athlete’s heart is different from the heart of a sedentary individual due to the athlete’s electrical adaptation for greater cardiac output. The way the heart adapts depends on age, ethnicity and gender. Therefore, interpretation of an athlete’s ECG requires an understanding of these changes and is quite specialised. In this context, an athlete is defined as someone aged 14-35 who has done more than 6 hours per week of organised, intensive physical activity in the year prior to the ECG.

The important role of an athlete’s ethnicity in interpreting their ECG was emphasised by the presenters. While it may be a contentious issue, evidence suggests that there are very big differences between Caucasian and black (African) athletes’ ECGs. What is normal for a black (asymptomatic) athlete may be very concerning in a Caucasian athlete (e.g. anterior T-wave inversions in leads V1-V4, preceded by a convex ST-segment elevation) (Papadakis et al, 2012). Therefore, it is ideal for the person interpreting the ECG to have information about an athlete’s ancestry (including grandparents).

In terms of the anxiety associated with screening, Dr Irfan Asif’s study found that the reason for the false positive (history, physical or EGC) was irrelevant to the level of anxiety. Rather, the level of distress was related to the time taken for the follow-up test.  Once a diagnosis of an underlying pathology is made, it is important to ensure the athlete has mental support at an early stage, as well as having their physical condition treated.

Professor Drezner also gave a very useful presentation highlighting the importance of preparing for the possibility of an SCA. The single greatest factor affecting survival is the time from cardiac arrest to defibrillation. Sporting clubs should have a written emergency access plan, including the location of defibrillators (must be accessible within 3 minutes, batteries working) and who to call, and must practise using it.

In the event of an SCA event, the key steps are:

  1. Recognition. A seizure or loss of consciousness should be assumed to be SCA until proven otherwise.
  2. Chest compressions
  3. Automated external defibrillator (AED).

For more detail, see Toresdahl et al, 2012.

Science of Cycling, Injury Prevention: 20 to 22 June 2014 Australian Institute of Sport, European Training Centre. Varese, North Italy.

11 Apr, 14 | by Karim Khan

science of cycling jpeg

A three day conference involving a Friday evening Masterclass, Saturday Symposium and Sunday Practical workshops. The content is focused towards Cycling Related Injury Management, with a detailed analysis of the theory and practice of Bike Set-Up and Body Assessment of the cyclist. Muscle Activation in Cycling and the Biomechanics of Cycling will be discussed, within a clinical reasoning framework, especially in relation to injury presentation and fatigue/high workload states.

Other topics include (but are not limited to) the aetiology and management of major cycling injuries, as well as their epidemiology. The conference will take place at the Australian Institute of Sport (AIS) European Training Centre (ETC) in Varese, Northern Italy, with accommodation available on-site.

Take your Cycling Injury Prevention and Management knowledge to a new level, visit the AIS ETC and enjoy the wonders of Northern Italy!

For more information:


Sports-Related Concussion in Youth- Improving the Science, Changing the Culture: Book review by Dr. Michael Turner

9 Apr, 14 | by Karim Khan

Book review by Dr. Michael Turner

Sports-Related Concussion in Youth- Improving the Science, Changing the Culture (336 pages)

sports related concussion cover.phpThis is essentially the 2012 Zurich Concussion Consensus process applied to research in youth sport – a great summary of the topic but not an easy read.

For anyone versed in concussion the themes will be familiar:

  • A very high profile topic
  • Very few good quality articles published in the recent literature relating to concussion in youth sport
  • Epidemiology data non-existent for grass roots sport
  • The culture in youth sport is to play down concussion and avoid letting the team down
  • A single definition of concussion is not universally applied so data gathering is a mess
  • Little research has taken place on the molecular changes that occur in the young brain when a concussion occurs
  • Mixed findings on the long term effects of repetitive concussions and sub-concussive episodes
  • Risk factors for post-concussion syndrome and CTE have not been identified
  • No studies on the pre-high school group have tracked the post-concussion changes found in the following activities – physical, cognitive, emotional or sleep
  • There is no data to establish a threshold for concussion in young athletes
  • The is no equipment that can mitigate or prevent concussion, despite the manufacturers claims to the contrary
  • There is currently inadequate information to establish what combination of tests is best to identify and monitor concussion in youth sport (using hospital based or non-hospital based assessment tools)
  • Despite the consensus agreement that concussion should be treated with physical and cognitive, there is little empirical evidence to establish what is the optimal degree and duration of physical rest and if cognitive rest is necessary

The authors explore these problem areas and offer a detailed review of the published literature:

  • Neuroscience, biomechanics and risks of concussion in the developing brain
  • Concussion recognition, diagnosis and acute management
  • Treatment and management of prolonged symptoms and post-concussion syndrome
  • Consequences of repetitive head impacts and multiple concussions
  • Protection and prevention strategies
  • Conclusions and recommendations

 The authors make 6 recommendations:

  1. Surveillance – establish a national surveillance program for children aged 5-21
  2. Evidence based guidelines for concussion diagnosis and management – should be established and research supported
  3. Short and long term consequences of concussion and repetitive head impact – should be evaluated using a controlled, longitudinal, large scale study
  4. Age appropriate rules and playing standards – should be rigorously evaluated by sports associations, schools and national governing bodies of sport
  5. Biomechanics, protective equipment and safety standards – should be evaluated by research funded by the National Institutes of Health and the Department of Defence
  6. Culture change – the NCAA and other organisations should develop, implement and evaluate the effectiveness of the large scale efforts to increase knowledge about concussion and change the culture surrounding concussion (among elementary school through college-age youth, their parents, coaches, sports officials, educators, athletic trainers and health care professionals)

The book costs just US$64-00; the recommended research will cost a great deal more

Sports-Related Concussion in Youth – Improving the Science, Changing the Culture (336 pages)

Institute of Medicine and National Research Council of the National Academies

ISBN – 13: 978-0-309-28800-2

ISBN – 10: 0-309-28800-2


Dr. Michael Turner, MB BS, FFSEM is the Chief Medical Adviser for the Lawn Tennis Association, London

Listen HERE to the BJSM podcast interview about his time as chief medical adviser of the Lawn Tennis Association, including the medical scandals that have cropped up and the advances he’s seen in the game’s sports medicine.


Dutch Minister welcomes recognition of Sports Medicine as a specialty

8 Apr, 14 | by Karim Khan


“Sport and exercise are becoming more and more important to Dutch healthcare”

Sports medicine is as of today, April 8th, 2014, a recognized specialty in the Netherlands. The Minister of Health, Welfare and Sport has accepted the decision to this effect by the College of Medical Specialties (CGS) of the doctors Federation KNMG. The title Sports physician is now a legally recognized speciality in the Netherlands.
After a thorough preliminary phase, the CGS decided that sports medicine is now a specialty. This decision is now supported by the Minister. The CGS sees an independent field of healthcare for this domain, where the sports physician is particularly complementary to and in synergy  with the existing disciplines. “Sport and exercise  medicine/health care are becoming more and more important. Due to the increase in the number of elderly and chronically ill, it is necessary to increase the specific expertise of the sports physician” said Dr. Ted van Essen, President of the CGS.

Van der Gaag, President of the KNMG calls it a historic moment. “It’s been a very  long time since another field has been recognized as a specialty.”
Independent field

The Netherlands Association of Sports Medicine presented the application for recognition as a specialty. For the last ten years the field has experienced a great development in quality, training, scientific research and positioning. Sports medicine has developed into an independent discipline with its own scientific domain and scientific research. The recognition as a specialty contributes to a high quality of medical care.

In addition, healthcare costs could decrease due to good sport health guidance, interventions and injury prevention.
For more information Anja Bruinsma, Netherlands Association of Sports Medicine +31 302252290+31 302252290

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Easy to use mobile app for ankle sprains prevention and rehabilitation

7 Apr, 14 | by BJSM

 By Evert Verhagen 

In recent years, knowledge about the prevention and rehabilitation of sport related injuries has grown exponentially. We are able to significantly reduce the burden of injuries in sports for most participants across many activities with current scientific evidence. However, we still struggle to implement effective measures on a wider scale, and fully unleash the potential of our preventive and rehabilitative knowledge.

one leg balance ankleThere is a recent push towards e-health in general and mobile media in particular to tackle this implementation gap. There are about one billion smartphones in use across the globe, signifying that access to mobile platforms is nowadays not a limiting factor. Also, with contemporary technology, mobile platforms can provide tailored information with ease of self- monitoring, portability and all-round availability.

Increasing uptake of evidence based prevention and rehabilitation of ankle sprains

We have a broad scientific sense of effective measures for ankle sprain injuries, but fail to actually transfer this knowledge to practice. Ankle sprains are amongst the most prevalent injuries across a wide variety of sports, carry high societal costs, and may result in long-term complaints. Active implementation approaches have led to wide-scale uptake of neuromuscular training for the prevention and rehabilitation of ankle sprains. However, the individual athlete’s compliance to such programs remains suboptimal.

ankle exercisesThis, in part, led researchers from the Department of Public and Occupational of the VU University Medical Center in the Netherlands to develop an interactive and evidence-based ‘Ankle’ application, which contains a neuromuscular training program [3-5]. The App guides the athlete through an eight-week training program using animations, feedback, and so-called push messaging.

The British Journal of Sports Medicine supports this app and the knowledge to practice gap it seeks to bridge. Listen to more about this app, on the BJSM podcast Evert Verhagen makes social media and apps intelligible.

The App is now available in  iTunes (HERE) and Google play store (HERE)

ankle app week chart












Evert Verhagen (@EvertVerhagen) is a human movement scientist and epidemiologist.

NICE QUALITY STANDARD STAKEHOLDER ENGAGEMENT EXERCISE – Physical activity: encouraging activity in all people in contact with the NHS

3 Apr, 14 | by BJSM

Dear colleagues,

You may be aware that a NICE quality standard on Physical activity: encouraging activity in all people in contact with the NHS is currently being developed. A NICE quality standard is a concise set of prioritised statements designed to drive measurable, quality improvements within a particular area of health or care.

Photo credit: Getty Images

Photo credit: Getty Images

Today we have published the topic overview and core element description for this quality standard, on the NICE website. We are inviting submissions from registered stakeholders identifying which areas for quality improvement may have the greatest potential to improve the quality of care for this area.

In support of suggestions for quality improvement, stakeholders are asked to provide any supporting evidence or information that care in the suggested key areas for quality improvement is poor or variable and requires improvement. This information will be considered by the Quality Standards Advisory Committee (QSAC) who will agree which areas should be developed for the quality standard. Please note, this is not a consultation on the draft quality standard; there will be a consultation on the draft quality standard on 31st July 2014.

Please visit the following page to view the topic overview for Physical activity: encouraging activity in all people in contact with the NHS and download a comments pro-forma:

Physical activity: topic engagement exercise

This engagement exercise will run from 1st April until 15th April 2014 at 5pm.

Kind regards,
NICE Quality Standards Team

Introduction to Sports Injuries Management, Royal College of Surgeons: A Course Review

2 Apr, 14 | by BJSM

By Thomas Harte

RCS logoAn “Introduction to Sports Injuries Management” is a one-day course run by the Royal College of Surgeons (England). It was held on the 5th of December 2013 and cost £150.

The Royal College of Surgeons state the aim of the course is to provide “an introductory overview of the diagnosis, predisposing factors, mechanisms and treatment options, including surgical techniques, of commonly encountered injuries sustained playing sport.”

The course Director is Mr Mike Carmont, Consultant Trauma and Orthopaedic surgeon and President of the British Orthopaedic Sports Trauma and Arthroscopy Association.

Who is the course’s target audience?

Primarily: junior doctors, including sports exercise medicine, emergency medicine, rheumatology, orthopaedic and general surgical trainees.

Why did you attend it?

As a core surgical trainee with an interest in Trauma & Orthopaedics I was very keen to improve my clinical knowledge of examining and treating sports injuries.

Working in a central London hospital surrounded by a large student population, I often find myself in A&E struggling with soft tissue injuries, a topic which is often over looked at medical school.

As well as an aspiring “Orthopod”, I am also keen to pursue a career in pitch side medicine and gain further experience within this field.

What was your experience of the course?

Overall it was a fantastic day and extremely useful.

I was pleasantly surprised by the course program, as from the RCS website my initial expectation was that the course would be “Orthopaedic heavy”. However, while there was excellent Orthopaedic teaching the program was extremely diverse and well balanced; instructors covered a broad spectrum of sports injuries from maxillofacial to exercise related collapse.

Highlights included a talk on Head Injuries by Dr Simon Kemp, Head of Sports Medicine at the Rugby Football Union.

The Faculty created an extremely relaxed and open environment, providing plenty of opportunity for open discussion and questions.

Would you recommend the course to others?

Definitely. This course offers a fantastic introduction to the management of sports injuries and is relevant for any doctor interested in pitch side medicine or a future in A&E, General Practice, Orthopaedics or Surgery.

I felt that the course offered great value for money and, being hosted by the RCS, there was also a great lunch.

Further Information:

Competing Interests: None Declared


Thomas Harte is a Core Surgical Trainee in Trauma and Orthopaedics University College Hospital, London, UK

SASMA Wins (3rd year in a row) – Best BJSM Cover

31 Mar, 14 | by BJSM

Congratulations to the South African Sports Medicine Association (SASMA) for winning best BJSM cover of 2013. This is SASMA’s third consecutive victory. Find previous issues of BJSM in this archive.

Dr Jon Patricios, SASMA President, stated: “We are delighted to receive the most votes for the best BJSM cover. At SASMA we are committed to building a network of SEM professionals which thrives on evidence informed practice. BJSM is a great resource for education and also for sharing our own best practices. I think our success in the cover competition stems from this ongoing cross-pollination.”

may 2013 cover 2.5

Thanks to everyone who voted. Stay tuned for us to announce the winners of  Brukner and Khan’s Clinical Sports Medicine, 4th Edition or  The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr. 

USEMS 2014 National Conference – Tickets going fast, register now!

26 Mar, 14 | by BJSM

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

By Steffan Griffin (@lifestylemedic)

USEMS are proud to announce the second annual student Sports & Exercise Medicine (SEM) conference, hosted in 2014 by the Birmingham University Sports & Exercise Medicine Society (BUSEMS).

SEM career aspirations?…then don’t miss this event

This conference features engaging and informative talks by: BJSM Editor Prof. Karim Khan, Dr. Peter Brukner, Dr. Aseem Malhotra and Prof. Lennard Funk, and many more. It promises to be a great educational experience AND a chance to network with some of the biggest names in the SEM world. You will be able to create opportunities to get that SEM dream job.

For less than you’d spend at the local curry-house (and with lunch & refreshments provided) you can attend one of the biggest SEM events in the UK this year!

Sign-up here

Tickets are going fast and the deadline is on the 25th of April. Get your tickets today so you don’t miss out!

The conference is aimed primarily at juniors. Both undergraduate and postgraduate students qualify for the £15 ticket. If you are not a student but still interested in coming, please contact the organiser at


Steffan Griffin is a third year medical student at the University of Birmingham. 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 combines a passion for all things SEM related with an avid interest in sport, and tries to live as active a life as possible.

Liam West BSc (Hons) is a final year medical undergraduate student at Cardiff University, Wales. He coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series for BJSM.

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