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Life saved in semi final of SAFF Championship 2013 by FIFA-supplied AED (FMEB – FIFA Medical Emergency Bag)

11 Sep, 13 | by Karim Khan

Preventing sudden cardiac death was a critical forum topic at the 2012 FIFA Medical Conference in Budapest.  Advocates argued that pitch-side automated external defibrillators (AED) be required at FIFA competitions all over the world. In the last 5 years, only 24 of 84 football players who suffered cardiac arrest survived. Tragically, there was no AED available at the stadium in 80% of cases. 

So what happened next – what ACTION was taken?

We are delighted to share this good news story, this GREAT news story forwarded via email to us by Jiří Dvořák (FIFA Chief Medical Officer, Chairman F-MARC, BJSM co-author of: Consensus statement: The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care)     

Dear Dr. Jiri,

Wanted to inform you that in Kathmandu, Nepal during a semi final match of SAFF Championship 2013 between Nepal and Afghanistan on 8th September 2013 one player of the Afghanistan team, had a minor cardiac arrest. His life was saved due to timely intervention of competition doctor Dr. Binmra Bista. He used the FIFA-supplied AED to successfully revive the player and then quickly shifted to hospital within the span of 3-4 minutes. In hospital all tests were carried out and the tests reports were normal.

I spoke to Dr. Bista after the end of the match, he used the AED for the first time and he also thanked FIFA for supplying AEDs. It was a great experience for this doctor and he was very quick sense the real problem and thus he ended up using  the AED.

I think tomorrow you might be able to read some news stories on this.

Thanks and best regards,


Shaji Prabhakaran, Regional Development Officer at FIFA

Remember that BJSM has published theme issues on Sports Cardiology including screening and prevention of sudden cardiac death (November 2012 and February 2013). The AMSSM and FIFA collaborated on an ECG interpretation module hosted by BMJ Learning

AMSSM Module


Zlatan Ibrahimovic – The passionate football star on physical health and team doctors

8 Apr, 13 | by Karim Khan

This interview was published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Qatar Orthopaedic and Sports Medicine Hospital. For information about the Aspetar Journal or for a complimentary hard copy email


With Zlatan Ibrahimovic


Not every athlete has had their name entered into the dictionary. Zlatan Ibrahimovic has. As of 2012, to ‘zlatan’ means ‘to dominate’, which he has consistently done on the football field for clubs like Barcelona and Paris Saint-Germain. Known for his exciting and unpredictable technical skills, he is an athlete who plays with passion.

Throughout his career he has received medical care from all over Europe, but there is one consistent experience that he takes wherever he plays: his relationship with his doctor is one of closeness and confidence – like a best friend. Here, the Swedish striker tells Dr Nebojsa Popovic about his relationship with his doctor and his growing awareness for his own physical health.

What is football to you?

Football is everything. It is made up of many small parts to make it whole. It is being healthy, being happy and something I love. For me, it is passion.

How tough is it to be a top athlete?

I think it is very tough. You have to work very very hard. You train every day to get better but in doing that, you take risks every day too. Injuries happen – you hope that they don’t but sometimes they do. Essentially, you sacrifice your body.

People think that it’s easy, but they don’t understand that football is our whole lives and it is hard. We have to stay at our best constantly, when in reality it’s easier to fluctuate, to go up and down. It’s difficult to stay on top – you have to perform well every single day to demonstrate every day that you are working hard and are at your best.

How much is talent and how much is work when it comes to making a professional athlete?

I think talent is about 30% and then the rest is hard work. Talent doesn’t mean you will win. Talent is something you are born with. You see the opportunity of somebody with talent, but if you don’t work hard, this talent is a waste of time.

What is your personal relationship with the team doctor? What kind of doctor would you like to work with?

For me, the doctor is my best friend. He is the one I give the most confidence to because he doesn’t see me as a football player. It’s different to a relationship with the coach; when the coach sees me, he only thinks about football and how he can use me to play. But when the doctor looks at me, he sees a person rather than a player. He thinks about my health and how I feel and that I have to be 100% healthy, not 99%.

If you are injured, the coach will still push you on the field, but the doctor will not. I remember when I was in Inter I got a kick to the head and a scan showed I had a lesion in my head. The coach felt I could still play but the doctor said no, I couldn’t, I had to rest. So you have two different ways of thinking: the doctor thinks about your health and the coach thinks about how you can be used to win games. It is important for me to have a doctor with a strong personality because I have to be healthy – that is the most important thing.

Every time that we players have a problem, we go to the doctor. It is important that he knows his profession and he has confidence in his knowledge but he must have a good relationship with every player because whenever there is a problem, we don’t go to anybody else. The first person we look for is the doctor, because he is the one who has to make you feel good and who can make you better and he becomes like a best friend to you.

You have played for many teams all over the world and at each new club you had a new medical staff. Tell us about the differences between them.

To start with, in Sweden we actually didn’t have a doctor with the team all the time. Instead we had a doctor at the hospital, so if we had a problem we went there. I really didn’t notice how important the doctor is for the team while I was playing in Sweden, but when I moved to Ajax it was different. There we had a full-time doctor with us.

But I was young then. When you are young you can afford injuries without the consequences of an older player. When I moved to Italy and played for Juventus I was a little bit older. Of course they had some problems with doping before my time, but the doctor I worked with there was very good and always helpful.

I think every culture has a very different way of having contact and giving medicine to the players. In Italy, doctors are very close to their players. In Holland, they keep their distance a bit more. It was similar in Spain. Of course, if I ever got sick I’d have a doctor beside me every time. I think it just comes down to culture. I have been lucky in my career and I have not had a big injury. I have met fantastic doctors wherever I have played and that is why they are there, so I haven’t had any problems. If I had to choose, I would prefer to have the doctor as my best friend and give him my full confidence but basically it’s different in every country depending on the culture.


Surviving thirty years on the road as a team physician

19 Mar, 13 | by Karim Khan

By Dr. Peter Brukner (@PeterBrukner)

Atlanta openingI realised the other day that it was thirty years since I did my first overseas tour as a team doctor (World University Games, Edmonton, Canada 1983). Since then I have lost count of the number of trips that I have done with a succession of Australian national sporting teams (swimming, athletics, field hockey, soccer and cricket). It has taken me to Olympic, Commonwealth and World University games, World Championships and World Cups. I have seen parts of the world I would never have otherwise been to (often for good reason) from Cuba to Uzbekistan, from Vietnam to Norway.

It has always seemed pretty straight forward, you travel with the team, you just do your job as conscientiously and enthusiastically as you can, you contribute to the team in as many ways as possible, and you get a lot of satisfaction and enjoyment. You get to work with some amazing athletes and at times make a small contribution to their success.

And yet what seems a fairly simple task does not go well for many sports medicine professionals. I have heard many stories of doctors who have”failed” on tour and their passports stamped “never to tour again”.

Ways to fail as a doctor on tour

There have been the party animals, the ones who are in the bar every night. There are the ones who try and be best mates with the athletes and join them out socialising. There have been the ones who are branded as “tourists”, always out shopping or sightseeing and never there when needed.

There have been doctors who spent the whole tour taking literally thousands of photos (and have been mistakenly identified as the team photographer). Then there was the one who arrived at his first training session took his shirt off and proceeded to work on his suntan for the duration of the tour. Or the doctor who sat in the front seat of the tour bus in the seat usually occupied by the coach and refused to budge. Then there was the doctor who drank too much and tried to move in on a player’s romantic interest. There are those who are always running late, keep the team bus waiting, late for team meals, wear the wrong uniform and basically think there is a rule for them and one for the rest of the team. They don’t last long.

I suspect the reason that some doctors struggle is that they are used to being the centre of their working universe. Hospitals and clinics revolve around doctors; staff such as receptionists, nurses and paramedical staff are there to make the doctor’s working life easier. On tour however, the doctor is a small cog in a very large wheel where the players and the coach are the key people. The doctor is there to provide service. If you can’t handle that concept then probably you shouldn’t tour.

Habits of Highly Effective Team Doctors

Socceroos bench

So, what is the secret of survival? More importantly, what does it take to do a good job and enjoying the experience? The first rule is: be available. Unfortunately as a doctor you can never predict when you will be needed and there is nothing worse than an athlete looking for the team doctor and being told that he can’t be contacted, or that he is off shopping or sightseeing. So I rarely go shopping or sightseeing unless the whole team is doing something similar. I don’t drink much alcohol on tour again because you never know when you may be called.

You need to be especially available on the last night of a tour when athletes who rarely drink might overindulge with sometimes adverse results. I have been required to suture tipsy athletes who have tried unsuccessfully to scale fences. There are rumours that semi-conscious drunk athletes have vomited violently all over a doctor’s bathroom. The last night on tour is definitely not one for the doctor to disappear.

Socceroos Training SessionFitting in with the team rules and customs is essential. You don’t want to draw attention to yourself by being different. Wear the correct uniform, turn up on time (I always aim for 10 minutes early) for meals and the team bus, find out where you should sit on the bus and sit there (there is often a pecking order of seating on team buses). Don’t hide in your room; be seen in the treatment room.

As a doctor you spend a lot of time at team training. Don’t sit down and read a book. Get involved, help out, pick up stray balls, fill drink bottles, put out cones for the fitness staff or coaches, record times and other data, generally assist the team as much as you can. When travelling or packing up after a game, help carry equipment and bags to the bus and help unload at airports and hotels.

Sometimes there is not much to do within what would be a narrow scope of ‘doctor’ tasks. Thus, having additional skills such as spinal mobilisation, dry needling, massage or taping can come in very useful. You help the physiotherapist and it gets you more involved in patient care. But it’s important to work this out in advance with the physiotherapist and be explicit that the two of you are working in a team. Communication between physiotherapist and doctors is critical and must be founded on mutual trust and respect. There are many examples of great physio/doctor combinations serving high-performing teams.

You can also contribute to team events and culture. I have organised quiz nights, tipping competitions, arranged guest speakers and even done a “This is your life” show.

Maintain your professionalism at all times. There is a fine line between being friendly with the players in a professional sense and trying to become too friendly. I always politely refuse invitations to join players in a night out, although I will accept an invitation for a quiet dinner with one or two players. I don’t address players by their nicknames and always treat them with respect even when fellow players are “taking the mickey”.

You need the support of your work colleagues who may get annoyed at your prolonged absences from the clinic. They need to understand the benefits for you personally and indirectly for the practice by you working with an elite team. Our clinic has always had the policy of encouraging our staff to be involved with elite teams although this has cost us in terms of lengthy periods of absence of key staff. However we believe the advantages outweigh the disadvantages.

Remember the most important people in your life. One of the most difficult things about being away is missing loved ones. You certainly need a supportive family if you are going to be away on a consistent basis. Nowadays with Skype and text messages it is a lot easier. Make sure you buy good presents to bring home and ensure that you have quality time when you get home. Don’t arrange to go back to work the next day. I always tried to organise extra special family holidays when I have been away for prolonged periods in a year. It is when kids or elderly parents are sick that you feel worst. I have certainly felt very guilty on occasions after phoning home to be told about various “disasters” that were happening on the home front.

With kids, there are benefits and losses associated with being away. My kids have benefited from access to Olympic Games and World Cups, but they and I have found the prolonged absences difficult at times. I actually gave away touring for seven years when my kids were teenagers as I felt it important to be around. At the end of that time I was offered a job that would hopefully lead to an involvement in World Cup finals and we discussed it as a family. They were keen for me to do it as long as they could come along at the end to the World Cup. That is exactly what happened.

If you have been counting, you’ll know that the 7th habit relates to the most important person of all — your partner. Be sure to choose a supportive partner if you plan to make touring part of your sports medicine career! Fortunately I was very lucky in that regard, although there were times!!!

Experiences you can only get by working with a team on the road

I have been fortunate to be involved with some wonderful practitioners on tour especially physiotherapists. You all know who you are so I won’t name you all, but the exchanges of ideas and friendships have been very stimulating. I have gained enormously from the opportunity on tour to observe closely physiotherapists at work and to discuss cases and treatment with them.  I have always said that I have learnt most of my sports medicine from physiotherapists and touring has been a great environment for that.

You do have plenty of spare time while on tour and I have always tried to use that time productively. I save much of my journal reading for trips away and try and do some writing – I am writing this in the Australian Cricket Team’s dressing room at Chennai, India during the First Test.

In summary …

I would encourage anyone to take the opportunity to travel locally (for experience) and internationally with a team if they get the chance. It doesn’t suit everyone’s personality or their desired work environment, but the benefits are many.

You really should enjoy the touring experience. Here is a chance to travel with some of your country’s best athletes, get to know them personally, and help them on their path to success. You see some amazing places and get to meet some remarkable individuals, often including your own sporting heroes. You also make lasting friendships with other staff members, both fellow health professionals and others.


Dr Peter Brukner (@PeterBrukner)MBBS, FACSP, Sports Physician, Melbourne, Australia, is an experienced team physician and writing in his capacity at BJSM Senior Associate Editor and regular blogger.

‘FIFA 11 for Health’ – a School-based Intervention in Mexico for the Prevention of Obesity and Non-communicable Diseases

17 Mar, 13 | by Karim Khan

By: Barriguete Melendez J A1, Dvorak J 2, Córdova Villalobos J A3, Juan Lopez M4, Davila Torres Javier5, Compeán Palacios J6, Junge A2 Fuller C W2, Valdés-Olmedo JC7. (See below for affiliations)

Currently, in all regions of the world apart from Africa, more deaths are linked to non-communicable diseases (NCDs) than communicable diseases [WHO, 2010]. Being overweight is a major contributory risk factor for non-communicable diseases such as high blood pressure, coronary heart disease and Type II diabetes. Of the six World Health Organization (WHO) designated regions, the Region of the Americas has the highest prevalence (>60%) of overweight adults (aged 20+ years). Mexico is no exception – the proportion of Mexican adults who are overweight or obese has increased from 61.8% in 2000 to 69.7% in 2006 to 71.2% in 2012.1

The prevalence of overweight and obese adolescents is of even greater concern; for example, the prevalence of overweight and obesity among girls (12 to 19 years old) has grown rapidly in less then 30 years; in this period, the prevalence has more than tripled, rising from 11.1% in 1988 to 28.3% in 1999 to 33.4% in 2006 and now standing at 35.8% in 2012.2 There are 22 million adolescents many of whom are overweight or obese and this imposes a large financial burden on the universal public health system. This situation sent strong alarm bells to the Government and Ministry of Health in Mexico as the prevalence of NCDs represents an important economic impact for families and countries. In 2008, medical expenditure on overweight and obesity in Mexico cost US$4.5 billion (~0.5% of GDP).3

Solutions – a partnership between government and FIFA

Following a detailed evaluation of successful ‘Community-based Interventions’ for adolescents involving sport, the Mexican Ministry of Health found that in 2006 Fédération Internationale de Football Association (FIFA) recognised the unique role that football could play in the promotion of exercise and health behaviours to reduce the burden of NCDs through an initiative entitled `Football for Health´. 4 The role that sport could play in combating NCDs was later reinforced by the International Olympic Committee.5,6 In 2009, FIFA began implementing the ‘FIFA 11 for Health’ programme in Africa.4, 6,7

 Implementing the ‘FIFA 11 for Health’ programme as a community-based intervention to tackle obesity and NCDs in Mexico offered many potential benefits. The program provides a positive collaboration with the Mexican Football Federation which provides access to a huge number of active football players and fans all around the country. Football is enormous popularity in Mexico — national teams won the 2011 FIFA U-17 World Cup and the 2012 Olympic Football Tournament. A collaborative group consisting of the Mexico Ministries of Health and Education, Mexico Football Federation and FIFA, decided to implement the ‘FIFA 11 for Health’, Mexico, first as a pilot study, in three cities – Toluca, Puebla and Mexico City. These efforts were supported by three professional football teams and coaches – Toluca, Puebla and Cruz Azul – to evaluate the logistics and resources within the country. This was then followed by a staged nationwide implementation.

A global program with a Mexican focus

The ‘FIFA 11 for Health’ programme was specifically adapted for implementation to boys and girls within Mexican schools over an 11-week period. The programme consisted of 11 ‘Play football’ sessions: Passing, Heading, Dribbling, Shielding, Defending, Trapping, Building fitness, Shooting, Goalkeeping and Teamwork, with 11 complimentary ‘health messages’: Play football, Respect girls and women, Protect yourself from HIV and sexually transmitted diseases, Avoid drugs, alcohol and tobacco, Control your weight, Wash your hands, Drink clean water, Eat a balanced diet, Get vaccinated, Take your prescribed medication and Fair play.

Each ‘health message’ is supported by an international football star: Chicharito (Mexico), Diego Forlan (Uruguay), Neymar (Brazil), Cristiano Ronaldo (Portugal), Samuel Eto’o (Cameroon), Carles Puyol (Spain), Marta (Brazil), Lionel Messi (Argentina), Didier Drogba (Ivory Coast), Gianluigi Buffon (Italy), Vicente del Bosque (Spain). The implementation methodology for the ‘FIFA 11 for Health’ programme was taught to 21 physical activity school teachers and 9 football team coaches during a 5-day training course. These teachers and football coaches subsequently presented the programme to 842 high school 1st grade children. The programme not only increased the children’s knowledge on health issues and football skills, but was also popular among children who recommended the programme to other children because it was fun and easy to participate in.

National role out – scale up

After the successful pilot study in 2012, it was decided at Ministerial level to go ‘nationwide’ with the project, in four phases involving public, and social institutions: Foundations (Fundación Mexicana para la Salud [FUNSALUD], Fundacion Rio Arronte, Fomento Banamex), Football Federation. The aim is to expand the implementation, from the 21 schools involved in the 2012 pilot study to a nationwide implementation of 32,135 public schools in 2015; from 21 physical activity teachers in 2012 to 22,141 teachers in 2015; from 840 children in 2012 to 2’173, 406 children in 2015. The ‘FIFA 11 for Health’, Mexico project is an ambitious project that aims to reach the whole country, to share successful preventive interventions, to promote health and to tackle the problem of obesity and NCDs in Mexico.

This success story in Mexico provides an important model for other nations considering how to address the major problem of NCDs. Mexico is among the 19 countries that have adopted FIFA’s  ’11 for Health’ – a program that fits very well within the World Health Organizations ‘7 Investments’9 for NCD prevention. The BJSM welcomes success stories from all nations and diverse community settings (e.g., sport, schools) as part of its commitment to implementation.



Acknowledgement. Salomón Chertorivski, Decio de María, Javier Salinas, Miguel Limón, Gloria Cervantes and Cecilia López. Edomex Gabriel O`Shea y Raymundo Martínez. Puebla Jorge Aguilar y Luis Maldonado. Mexico City. Armando Ahued y Luis Eduardo Sánchez.


1. Encuesta Nacional de Salud y Nutrición (ENSANUT 2012). Instituto Nacional de Salud Pública. Secretaría de Salud. Mexico. P 28.

2. Encuesta Nacional de Salud y Nutrición (ENSANUT 2012). Instituto Nacional de Salud Pública. Secretaría de Salud. Mexico. P 30.

3. Economic Department 2011 MoH Mexico.

4. Fuller CW, Junge A, DeCelles J, et al. ‘Football for Health’–a football-basedhealth-promotion programme for children in South Africa: a parallel cohort study. Br J Sports Med 2010; 44:546–54.

5. The Olympic Movement in Society. Proceedings from the XIII Olympic Congress. Recommendations of Theme ‘Olympism and Youth’. Olympic Congress 2009. Copenhagen, Demark, 2009.

6. Mountjoy M, Andersen L B, Armstrong N, et al. International Olympic Committee consensus statement on the health and fitness of young people through physical activity and sport. Br J Sports Med 2011; 45:839–848.

7. Fuller CW, Junge A, Dorasami R, et al. ‘11 for Health’, a football-based health education programme for children: a two-cohort study in Mauritius and Zimbabwe. Br J Sport Med 2011; 45: 612-618.

8. Dvorak J, Fuller CW, Junge A. Planning and implementing a nationwide football-based health-education programme. Br J Sports Med 2012; 46: 6-10.

9. Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD Prevention: Investments that Work for Physical Activity. Br J Sports Med 2012;46:709–712. Br J Sports Med 2012;46(10):709-12.

Authors’ affiliations: 1Instituto Nacional de Ciencias Médicas y Nutrición. Mexico; 2 FIFA Medical Assessment and Research Centre, Zurich, Switzerland; 3 Medicine National Academy, Mexico; 4 Ministery of Health, Mexico. 5 IMSS, Mexico; 6 Mexican Football Federation. Mexico; 7 Mexican Health Foundation (FUNSALUD).


FIFA and education representatives join forces to combat childhood obesity and improve health

29 Oct, 12 | by Karim Khan

Congratulations to Mexican public schools representatives and FIFA, for leading the Latin American development of a joint initiative to combat childhood obesity and implement programs in schools to improve health.

FIFA’s 11 for Health was launched in Mexico in summer of 2011:

The “11 for Health” programme complements the Mexican government’s “5 Pasos por tu Salud”  (“Five Steps for Your Health”) and “Mídete, cuida tu peso” (“Measure Yourself, Watch Your Weight”) campaigns to harness the full potential of using football to promote health. Studies show that playing football, competitively or just for fun, reduces the risk factors for many diseases indicated by the World Health Organization (WHO). Based on these findings, F-MARC decided to combine the direct health effects of the game with its unique power in education and prevention to create this comprehensive health programme, using top players such as Mexico’s Carlos Vela and Javier “Chicharito” Hernández, Argentina’s Lionel Messi and Portugal’s Cristiano Ronaldo, to name just a few, to deliver health education messages to young people.

                                    -FIFA’s press release July 7, 2011

In Mexico City last week, Ministers and Vice-Ministers of education from 31 countries, along with representatives from international organization met to discuss the program’s further implementation into educational curricula.

The specific aims for Mexico (the first country outside of Africa to implement the program), includes a phased plan with targeted objectives to both ‘train-the-trainers,’ and ‘train-the students.’ A preliminary goal is to reach 22,100 of Mexico’s public secondary schools by 2014-2015.

Mexico’s Health Minister, Dr José Ángel Córdova Villalobos underscores the importance of action to improve the health of Mexican youth. He states that the average age when youth start smoking and consuming alcohol is 13.7 years — younger than in previous years.  Youths’ unhealthy consumption habits, combined with sedentary behaviour pose a great public health risk for Mexico which has a relatively young demographic.

The hope is that through football – “the world’s most popular language” – FIFA and their allies will communicate positive health messages that result in long-lasting behaviour change.

For more on the 11 for health program go here

Hamstring injury mini-symposium (BJSM papers that will help you manage hamstring injuries).

16 Oct, 12 | by Karim Khan

Bruce Hamilton’s article (Hamstring muscle strain injuries: what can we learn from history? 2012;46: 900-903) is receiving a lot of attention. Current in this month’s BJSM print edition, >6,000 people have already downloaded and digested it (free full text!). This October issue has been shaped by the Australasian College of Sports Physicians, one of BJSM’s 8 member societies (and more to be announced shortly!).

Clinicians’ interest in hamstring injury prevention, diagnosis, and management is no surprise. Elite athletes from American Football (i.e Jets’ tight end Dustin Keller who has missed four weeks – to date – with a hamstring injury), to European Football (i.e Manchester City’s Jack Rodwell who may be warming the bench for England in Tuesday’s Euro 2013 decider) suffer from hamstring injury. Rodwell has the classic ‘recurrence’ issue – six such injuries this season.

As a ‘mini-symposium’ we share 4 recent papers below. Their take-home messages include that: (i) focussed eccentric loading – in the appropriate functional range of motion is critical, (ii) that there are different types of hamstring strains with different prognosis (Type 1 ‘sprinters’; Type 2 ‘dancers’), (iii) there remains an element of art in treatment – but don’t give up the science as the first option. And don’t forget Carl Askling’s podcast – one of BJSM’s most popular of all time.

BJSM senior associate editor Roald Bahr (@RoaldBahr) vouches strongly for the ‘nordic hamstring’ exercises to prevent recurrence. He suggest that EPL teams should be ensuring the high-risk players (those with previous injury) perform the program. You can see the video of this program at the Oslo Sports Trauma Research linked web-page. (Skadefri which means ‘Injury Free’). The words are in Norwegian but the images speak for themselves. And while you are on that site check out the IOC Manual of Sports Injuries – great value and completely up to date.

In short – no-one has all the answers but progressive and functional training – with a particular focus on players who have already had a hamstring strain – is a way to go. Please do share your solutions confidentially or in public.

Related publications

Mendiguchia J, Alentorn-Geli E,Brughelli M. Hamstring strain injuries: are we heading in the right direction? Br J Sports Med 2012;46:81–5.

Askling CM, Malliaropoulos N, Karlsson J. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis Br J Sports Med 2012;46:2 86-87 Published Online First: 14 December 2011

Orchard JW, Best TM, Mueller-Wohlfahrt HW, et al The early management of muscle strains in the elite athlete: best practice in a world with a limited evidence basis. Br J Sports Med 2008;42:158–9. (Free full text)

Askling CM, Tengvar M, Saartok T, et al. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Am J Sports Med 2007;35:197–206.

 Askling C, Saartok T, Thorstensson A. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Br J Sports Med 2006; 40: 40-4. 


Concussion management in England’s FA – better than it appears in new BJSM paper….

10 Oct, 12 | by Karim Khan

E-letter and update by Dr Ian Beasley (FFSEM)

In response to:

Jo Price, Peter Malliaras, Zoe Hudson. 2012. Current practices in determining return to play following head injury in professional football in the UK. Br J Sports Med 2012; 0: 201109068 (Original article). [this paper is Online First and is included in the upcoming November Print Issue of BJSM [BASEM Theme Issue].

There is no doubt that since the first consensus statement on concussion, conceived in Vienna in 2001 (read BJSM summary article here), every sport has raised its game on head injury and concussion management and reviews by the various sports over the years have resulted in updated and improved practice.

Football in this country has been similarly active.  At the behest of the FA medical committee, and as a result of collaboration between an eminent Premier League medical officer, and a Neurosurgeon working in sport, the current FA head injury guidelines were devised.  They were circulated to clubs in November 2009, and have been in use since then.

Since its inception the SCAT 2 form has been included in these guidelines, and is published as part of the head injury guidelines in the FA handbook (1), and on our website (here).

In their study Price et al (2) mention that many club medical officers ‘are not required to demonstrate any expertise in concussion management’.

Medical indemnity providers have insisted for some time that medical practitioners attending sporting events must ensure they are adequately trained to provide appropriate care for their athletes (3).  We would encourage any medical practitioner involved in sport to heed this message.

The initial questionnaires in this study (2) were sent to clubs before the availability of current guidelines. By the time the second batch of questionnaires were sent out, all clubs were in receipt of the current guidelines from the FA.  Hence, by the time conclusions were drawn in this study, they were not contemporary. They do not reflect current practice within professional football.  Nor do they represent the stance of the FA in dealing with this important issue.

In my experience, governing bodies and their medical officers will always be of help when trying to obtain up to date information regarding practice and policy within their respective sports if asked.

1. The FA Handbook, Rules and Regulations of The Association, season 2012-13.
2.  Current practices in determining return to play following head injury in professional football in the UK. Price, J., Malliaras, P., Hudson, Z.  Br J Sports Med 2012;0:1-5
3. MPS issues advice to doctors assisting at sporting events :  07 Jul, 2006. 

Editor’s note – link to the most current consensus document here – the Zurich (3rd) concussion guidelines (>47,00o page views as of October 8th, 2012).

Dr Ian Beasley MBBS, MRCGP, MSc, DIP.Sports Med, FFSEM (UK) is Head of Medical Services Club England Division The FA Group Wembley Stadium, Wembley, London, HA9 0WS

Injuries will decide the English Premier League Title (once again!)

27 Aug, 12 | by Karim Khan

Guest Blog by Peter Brukner (@PeterBrukner)


What will determine who will win the 2012-13 Premier league title?

Money, manager, quality of squad – all these factors are obviously important, but in the end when you look at the teams that have top quality squads – and I would probably include Man City, Man United, Chelsea, Arsenal and Tottenham in that list – then the biggest single factor will be the injury record of these clubs.

One only has to look back at last season to see how important injuries were in deciding the eventual winner. Here are the stats on the top eight teams in last year’s Premier League (courtesy of the excellent website


If we compare the two Manchester clubs, Manchester City had a fraction of the games missed compared to United. Remember United had a number of long term injuries to key players Nemanja Vidic, Darren Fletcher and Anderson.

There is no doubt that had there been parity, or anywhere near parity, between the two with injuries, then the title would have gone to United once again.

Are injuries just a matter of bad luck or can they be prevented?

There are a lot of factors that can influence injury rates. These include the number of games played, the type of training and the age of the players. If players have to regularly play twice a week (e.g. Premier League and Champions League matches), then they are more likely to be injured. Those clubs with greater depth in their squads who can afford to rotate players and reduce the game load should be in a better position to reduce injuries.

The last but by no means least factor is luck. The majority of injuries are probably not preventable and are the inevitable result of the physical demands placed upon players in the Premier League.

However there is a particular group of injuries that may be “preventable”.

Clubs generally divide their injuries into muscle and tendon injures such as hamstring, groin, calf and achilles problems, and other direct contact injuries. Most clubs now pay particular attention to reducing the number of those muscle and tendon problems. There is considerable evidence now that a comprehensive injury prevention program can significantly reduce muscle and tendon injuries.

Getting managers and players to embrace the concept of injury prevention has been a challenge for club medical and fitness staff. Managers will always tell you how keen they are on injury prevention (a “no-brainer”), but actually getting them to allocate part of the precious time spent at the club to prevention is another matter. It amazes me that players earning £100,000 per week are not expected to commit additional time other than the 1-2 hours on the training ground to matters such as injury prevention.

When I arrived at Liverpool two years ago I was told by numerous people that we would never get the players to embrace a culture of injury prevention and spend the time on the necessary exercises to achieve that. However the opposite has been the case and once the players realised the benefit of what we were proposing, they fully embraced the change of culture. By the end of last season, most were in the gym doing their personalised injury prevention programs every day.

There is unfortunately a culture among Premier League clubs of not asking the players to do anything they don’t want to do. The challenge for club fitness and medical staff is to convince players and management that a little time and effort spent on prevention will be more than worthwhile by the end of the season.

Should clubs be making their medical and fitness departments a higher priority?

It makes sense from a business point of view that when you have extremely valuable assets (the players), one should look after those assets as well as possible. It is an interesting point to note that Chelsea, Liverpool and Man City, three clubs which had significantly lower injury rates than the other top clubs last season, have all invested heavily in their medical and fitness staff in the past few seasons, allocating more resources and recruiting high quality personnel.

One thing for certain is that once again this season injuries will play a major role in determining the Premier League title and clubs will be paying more and more attention into ensuring that their players get the best medical, physiotherapy and fitness advice to reduce the number of games missed by key players through injury.

Related Articles

J W Orchard. (2009) On the value of team medical staff: can the “Moneyball” approach be applied to injuries in professional football? Br J Sports Med 2009;43:13 963-965  (viewed over 3000 times) 

Arnason A, et al. 2004. Physical fitness, injuries, and team performance in soccer. Med Sci Sports Exerc. Feb;36(2):278-85.

Eirale, C et al. Low injury rate strongly correlates with team success in Qatari professional football Br J Sports Med bjsports-2012-091040Published Online First: 17 August 2012  (not free – Online first for subscribers and BJSM member societies)



Dr Peter Brukner (@PeterBrukner) is an Associate Editor of BJSM and an Australian sports medicine physician, author and media commentator living in Liverpool, UK. Currently working with Sky Sports News and one of the sports physicians working with the Australian cricket team.

Reposted with permission from Peter Brukner’s website  – a site for provocative and insightful sport and exercise medicine columns. Follow @PeterBrukner on Twitter.

BJSM invites your comments on Twitter using the #EPL hashtag or @PeterBrukner to help us follow the conversation.

Dr John Orchard on the “metal staples – no local anaesthesia” – discussion. Guest Blog.

18 Aug, 12 | by Karim Khan



 Interchange laws, bleeding and apparently dying players


I am very interested to have read the Blog by Drs Fowell and Earl ( about the use of staples to close lacerations on the side of the pitch in football matches.

I used metal staples like this quite a few times myself in the early 2000s in rugby league and wrote up one of the cases in the BJSM (Orchard JW. Video illustration of staple gun to rapidly repair on-field head laceration.  Br J Sports Med 2004;38(4):e7). Now I still use staples as one of the options for closing wounds in rugby league players, although no longer do I do it on the sidelines. Shortly after the 2003 case (which was subsequently written up) a further case which was far more notorious occurred when I closed an eyebrow laceration on Michael De Vere in a rugby league State of Origin game

This was done on the pitch itself whilst a video refereeing decision was being made, meaning that the player didn’t leave the field – he didn’t miss any playing time at all. The video of the procedure, however, was captured on TV and shown to millions of viewers. The reaction to the vision was that the NRL (National Rugby League) banned the use of the staple gun outside the dressing room, meaning that players have to now leave the field to have a laceration closed.

The issue of management of lacerations is one which not only is of concern to team doctors – who must weigh up both (1) optimal medical treatment of an injury and (2) minimising loss of game time for players – but it now also needs to be a major concern for sporting administrators.

I cover some of the related issues in an Editorial in the August 2012 BJSM (Click here for: Orchard J. More research is needed into the effects on injury of substitute and interchange rules in team sports Br J Sports Med 2012;46:10 694-695). All sporting bodies should engage Medical Directors and medical/injury management concerns must to be prominent when considering existing and proposed new rules. Whether use of staple guns pitchside should be recommended in a sport depends on quite a few factors, including (but not finishing with) whether it will lead to unpleasant images on TV.

Blood management will be influenced by substitution rules

The sports rules for handling blood and the interchange/substitute laws clearly have a major impact on medical management. If the rules allow for “free” interchanges/substitutes for bleeding wounds (as per rugby union), then the player can be treated in the dressing room with minimal time pressure. However, this privilege (‘free’ substitution to respect the bloody player) can also lead to the distortion that it is advantageous for a team to have a player suffer a laceration (as they get an extra interchange in these circumstances). This, of course, is the scenario under which the “Bloodgate” affair arose. If it is disadvantageous for a team to have a player missing from action, then extremely rapid wound closure becomes a valuable priority. The challenge for all sports lies in balancing all of these concerns.

Practical implications of Fowell and Earl’s new data (blog, above)

I suspect that some football team doctors will look at the large case series of Fowell and Earl and decide that under the current FIFA rules (3 substitutes but no interchanges or “blood bins”) it makes sense to use staples on the side of the pitch, without local anaesthetic, for the uncommon scenario (in football) of a head laceration. History is in danger of repeating itself; this practice may be tolerated until children are exposed to it in their living rooms (e.g. by seeing a replay of it being done in an FA Cup final, for example).

More substitutes in football? (soccer)

A benefit of any debate on whether or not to ‘ban’ pitchside stapling in football will be that it should include a consideration about introducing an interchange player to the game itself. If soccer was to allowed 3 substitute players but also 1 roving interchange – the converse of the current ‘bench’ in the AFL (Australian Football League) – then a player could be interchanged off for 5 minutes for stapling/suturing to be done in the dressing room, without penalty to the team. It would also allow the player to be more thoroughly assessed for any co-existing concussion from the same blow to the head. This would fix an uncommon but consistent problem in the sport — how to deal fairly with the bleeding player.

It may also help fix a consistent but far more common problem – the exaggeration of minor injuries. If a player who was tapped on the shins and needed 2-3 minutes to recover was able to be interchanged off the field and temporarily replaced until this recovery, there wouldn’t be as much benefit in “playing dead” to stop the game if the temporary replacement could be made without hurting the team. A hybrid bench of substitute and interchange players (or one with a limited number of interchages rather than substitutes) probably leads to optimal injury management and perhaps even fewer injuries overall.

To close, I contend that the debate about what is best for a sport shouldn’t start with an argument of “this is how it’s always been done” but it should finish with “this is how we will make sure our sport gets the balance right between entertainment, fair play and optimal injury management”.

This Guest Blog relates to the BJSM Blog posted on August 16th – please scroll down.

John Orchard is an Australian sports physician who has worked with numerous professional team sports. His sometimes controversial views are personal and not necessarily representative of organisations he is affiliated with. You can read more at and/or follow @DrJohnOrchard on Twitter


Closing soft tissue wounds rapidly at pitchside – A role for metal skin staples without anaesthesia?

17 Aug, 12 | by Karim Khan

Guest Blog by Drs Christopher Fowell and Phillip Earl

*Please also see the commentary from @DrJohnOrchard on this blog here

* You  can vote on whether you think metal staples are a good idea via the BJSM ‘Current Issue’ page here:


You are working pitchside and your player receives a facial laceration. What are your options for fast wound closure? Are metal staples an option?


Head and facial soft tissue injuries occur frequently during contact sports, especially those in which headgear is not routinely used.  Professional sport is continuous in its nature; hence a prompt return to competitive action is usually desired when rules require a bleeding player to leave the field.

Different methods of wound closure have been described and reviewed extensively in both the surgical and traumatic settings1,2.  Although skin staples are superior to sutures in the surgical head and neck setting1, their use has gained little popularity in the sports medicine setting of traumatic wounds to the head and neck.

In this BJSM Blog, we describe a case series of professional and semi-professional footballers sustaining lacerations to the face and scalp. Since 2004, all players returning to action were managed rapidly at the pitchside using metal skin staples, without complication.

Subjects and Methods

Using a physician’s clinical database, we undertook a retrospective cohort study of patients treated for soft tissue lacerations sustained during competitive play between 1987 and 2012.  All injuries were treated by the same clinician.


Sixty-four patients had sustained 64 separate lacerations.  Fifty-seven (89.0%) of lacerations were sustained to the head and face (Table); most commonly to the scalp and supra-orbital tissues.

Table.  Site of lacerations.


Number (%)

Head and Face

57 (89.0)

   – Head / scalp

20 (31.3)

   – Periorbital

18 (28.1)

   – Other face

7 (10.9)

   – Intra-oral

4 (6.3)

   – Lip

4 (6.3)

   – Ear

3 (4.7)

   – Tongue

1 (1.6)

Other (all lower limb)

7 (10.9)


Prior to 2004, all patients were treated under local anaesthetic, using a combination of resorbable, synthetic, braided (Vicryl®, Ethicon Inc.) sutures and a non-resorbable, synthetic, monofilament (Ethilon®, Ethicon Inc.) sutures for wound closure.  Since 2004, 11 patients who were planning to return immediately to play had lacerations to the scalp, forehead and supra-orbital rim closed using metal skin staples (Weck Visistat® 35W disposable skin stapler, Teleflex Medical).   No local anaesthetic was infiltrated prior to skin closure for these patients.  Patients withdrawn from the match were managed using sutures as previously.


Soft tissue injuries occur frequently during athletic activities3, ranging from lacerations to superficial abrasions. Following any orofacial injury, initial structured assessment using the ABCDE approach of Advanced Trauma Life Support is required.  Once significant injury has been excluded or treated appropriately, prompt, thorough debridement and surgical repair of lacerations is required to restore function and anatomical form.  Players who sustain injuries that cause bleeding are required to leave the field of play immediately in most sports.  Players may return following definitive closure, when the risk of transmission of blood-borne infections decreases.

Surgical staples have been a common method of wound closure in the surgical setting since the 1990s, and are gaining popularity in the traumatic setting.  Do they have a role for pitchside closure of lacerations sustained during sport? Dr John Orchard (@DrJohnOrchard) reported a case of a patient sustaining an eyebrow laceration during an Australian rugby league game in 20044.  He closed the wound directly on the touchline using metal skin staples, a technique he reported having used previously. The case courted controversy due to the televised nature of the game.

An overwhelming advantage of skin staples is very speedy wound closure. That stapling is faster than suturing has been reported in 5  randomised controlled trials1.  Prompt return to competitive play in these circumstances is beneficial to both the individual and the team’s performances.  In the one previous reported case of skin staples used in closing wounds on the touchline, the player returned to play within 80 seconds of injury, and touching the ball within 40 seconds of having the final staple placed.  The reported case and the author’s direct observation of patients tolerating wound closure using staples in the absence of local anaesthetic further decreases the time away from competitive play.

RCT evidence indicates that skin staples have a lower wound infection rate than sutures1.  With regard to cosmetic outcome, studies have shown staples to be comparable to, and in some studies better than sutures at long term follow up.  Previous reports have described the removal of staples at the end of a game, followed by definitive wound closure under local anaesthetic with sutures.  We believe this is unnecessary, assuming the wound was cleaned appropriately and adequate wound edge approximation was achieved at initial closure.

Metal staples are more prominent from a wound than sutures and present a theoretical risk of causing damage to other players.  Wound coverage with a simple soft bandage eliminates this risk.   No players in the study have suffered further injury, or inflicted injury on another competitor, through having staples in situ and returning to competitive action.

Staples are not appropriate for lacerations on all sites of the head and neck.  They are contra-indicated on mucosal areas, and hence should not be used on intra-oral wounds.  Other sites which staples should not be used include the eye-lids, lips, ears and nose.

What about tissue glues?

Tissue adhesives are a effective and rapid method of closing traumatic wounds to the head and face2.  They are comparable with other methods of closure with regards to cosmesis, pain and procedure time, their disadvantage is a their greater rate of wound dehiscence.  Following repair of lacerations on the touchline with sutures or tissue adhesive, further collisions have caused wounds to re-open.  It is felt the extra strength of staples helps to prevent this4.

In summary, metal skin staples are a safe, effective and rapid method of achieving closure of traumatic wounds in the touchline environment.  This allows very prompt return to competitive play following blood injury.


  1. Iavazzo C, Gkegekes I, Vouloumanou EF et al. Sutures versus staples for the management of surgical wounds: a meta-analysis of randomised controlled trials. Am Surg 2011;77(9):1206-1221
  2. Farion KJ, Russell KF, Osmond MH et al. Tissue adhesives for traumatic lacerations in children and adults.  Cochrane database of systematic reviews  2002; Issue 3. DOI:10.1002/14651858.CD003326
  3. Ranalli D, Demas P. Orofacial injuries from sport, preventative measures for sports medicine.  Sports Med 2002;32(7):409-418
  4. Orchard JW. Video illustration of staple gun to rapidly repair on-field head laceration.  Br J Sports Med 2004;38(4):e7

Dr Fowell is at the University Hospitals Coventry & Warwickshire NHS Trust – Oral & Maxillofacial Surgery
University Hospital Clifford Bridge Road Walsgrave, Coventry CV2 2DX, United Kingdom

Dr Earl is at the Worcestershire Acute Hospitals NHS Trust – Oral & Maxillofacial Surgery, Worcester, United Kingdom

No conflicts declared and specifically there was no support for the authors’ research or publication from the makers of Weck Visistat® 35W disposable skin stapler, Teleflex Medical.

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