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Guest Posts

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

6 Sep, 14 | by Karim Khan

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

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

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

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

Top 5 flavours of the day:

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

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

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

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

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

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

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

Some reflections…

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

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

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

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

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

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

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

A SACRUM TOO FAR – Tiger withdraws from Ryder Cup. What advice would we offer one of the world’s greatest ever golfers? Guest Blog @NicolvanDyk

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, with TW aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

“If there’s a fork in the road, take it.” Yogi Berra

Tiger Woods has officially withdrawn from the Ryder Cup – a move that makes a lot more sense than his starting the PGA last week. It seems like he is now following sound medical advice. A proper break aimed at full recovery. He is aiming to return in December for the World Challenge tournament, which seems reasonable. But what will happen beyond that. What does his future hold?

That was the question some colleagues asked me at the Aspetar Orthopaedic and Sports Medicine Hospital on Wednesday (prompted by a recent blog from Prof Karim Khan (@BJSM_BMJ). How would I advise perhaps the greatest golfer ever? Can we base it on evidence?

I am sure we can. Sports Medicine Physicians and Physiotherapists make such assessments every day, from elite level athletes to all the rest of us. Here’s a short proposal that may resonate with many Sports Medicine clinicians’ reasoning in this scenario. (And to Mr. Woods, I would hope to think your team is doing the same.)  (And of course I’m keen to learn from those more expert than I).

  1. Correct Diagnosis (correction, hypothesis)

Let’s open the box and look inside. No, unfortunately no rabbit. It is rare for a single diagnosis to capture the full spectrum of what has transpired for an injury to happen. And no doubt, without any knowledge of the specific medical condition or advice Tiger Woods has received to this point, what we need to do first (or at least redo again) is work through some hypotheses, to  make a proper clinical diagnosis.

Unfortunately another MRI scan would most likely not help us (see reference here). Imaging is useful, and there are a couple of things we want to exclude, but what we see must make sense in light of the whole clinical picture. As a suggestion, let’s call it a holistic assessment. We need to look at all the aspects influencing current pain experience, playing performance, and then do a full musculoskeletal examination looking at movement patterns and muscle recruitment, to understand the current condition. It needs to include history, both past and present, classification based cognitive functional therapy (CB-CFT), pain science education, nutrition and conditioning.

Our diagnosis will perhaps not be catchy, or sexy like “sacrum out” or “disc popped”, but it will be as accurate and inclusive as possible, (maybe something like “intervertebral joint dysfunction with movement restriction into flexion”) which will guide us in our treatment and rehabilitation. This sort of thinking allows different information to be taken into account, it creates the opportunity to evolve if needed (conditions change over time) and allow us to adapt whatever treatment we choose to utilize. This is necessary for achieving our goal. And yes, then do need to identify the goal, but hang on, we’ll get to that. We need to have something to test ourselves again, and some objective signs we can measure – other than eyeballing the sacrum.

  1. Correct Treatment and Rehabilitation

Unlike our colleagues in the 70s, 80s and 90s, we do not have to rely on expert opinion anymore. Not that expert opinion is not important, or valuable, but in the context of modern sports medicine, we have a growing body of evidence to support what we do, and why we do it.

And in this scenario, here is the key message – exercise works.

It is a proven therapy that has been found in most cases to trump the quick manipulation, magic tape or the odd bit of dry needling (or a hug). The scientific search here would lead you to mechanotherapy, or mechanotransduction, but let’s not be distracted by the details right now.

Research (see here a great editorial by Prof Peter O’Sullivan (@PeteOSullivanPT) on how we manage back pain) tells us to strengthen and rehabilitate the correct movement patterns (for the individual, no recipe’s needed, thanks) rather than spend hours rubbing lotion on your back, or cracking things into place. Firstly, perhaps most importantly, we need to ensure that you understand and comprehend the condition, the pain and what it means to you as a person. And then, perhaps as important, we need you to move, and move as well as you can. (Note to TW, the writer is a qualified manual therapist). Next, a gradual return-to-play programme where you build up the necessary strength, endurance and loading of the structures in your back so that when you get back, you really are “good to go.”

  1. Finding the TEAM that works towards injury free* peak performance
    (*injury free = minimal risk of injury with maximum benefit from performance parameters)

Sports Medicine requires a team approach. And a good team will help you to integrate the evidence into a quality clinical decision. Of course I am not attempting to take away the complexities of these decisions in any way. But we have certainly come a long way from “the doctor said I shouldn’t play.”

Instead, we need to develop better algorithms to help make these decisions. Dr. Paul Dijkstra (@drpauldijkstra) has captured these difficulties in his open access BJSM article “Managing the health of the elite athlete: a new integrated performance health management and coaching model” highlights the difference when practicing integrated care medicine, and this article develops a health and performance grading system (see Table 3). This kind of system assists not only the Sports Medicine team, but it creates better understanding for the athlete of what all the information means.

Because related to rehabilitation that is (and should be) the main focus now, is performance. And having gone through 4 swing changes with 3 coaches in his career, Mr. Woods is hardly the same player as when he started. So has it backfired? And having the advantage of retrospection, was it worth it? Could these changes have influenced or played a part in the multiple knee injuries (and surgery) and ultimately the back injury leading to surgery this year?

Of course, the other question with any child prodigy who turns professional (and has a long, successful career) is load management. Prof Roald Bahr (@roaldbahr) from Norway suggests in a recent editorial for BJSM that “We now have the evidence to show that extra caution is needed when managing the gifted athlete.” Did we also fail Tiger Woods in this regard? Seeking to make the near perfect player even more perfect, asking too much of his gifted body?
Perhaps, although I am weary of the hindsight trap. We have to assess where we are now, and if we change anything again, it must be an integrated decision that allows ultimate performance with minimizing injury risk. Which brings us to perhaps the most pertinent question:

  1. The Risk-Reward Ratio – Will life after golf still allow playing some golf?

In 2008, aged 32, Tiger Woods had won 14 majors. It seemed likely (in an incredible fantastic way) that he would surpass Jack Nicklaus’ record of 18 majors. In December, when Tiger Wood plans to return, he turns 39. Is there still time? Jack Nicklaus was 46 when he won number 18, and a few other greats (Phil Mickelson, Ernie Els, Gary Player, Ben Hogan) have won majors in their 40s. But will he win another 5, with the rise of the young guns and the trail of injuries behind him? Mr. Woods wants to win majors, of that I am sure. But what will it take to win another four? What would be left? So here we have to ask, is the REWARD worth the RISK?

To really answer that question, we need to know from the athlete what the perceived reward is, versus the perceived risk. REWARD would be to hold the record number of major wins, to be the unchallenged greatest golfer that ever lived (if we classify greatest by number of major wins, although many might view Tiger Woods as the greatest already). REWARD would be to continue competing, and continue being the guy that everyone wants to beat (not sure if that’s true, but Jack Nicklaus still thinks so). REWARD could simply be to keep doing the thing you love to do, at the highest level. Yes, the rewards will be great. If this is indeed how TW sees the REWARD as well. So what then of the RISK?
There is a continuous effort among sports medicine researchers to identify risk factors for athletes, (e.g. IOC Injury Prevention Conference 2014). So when Sports Medicine Clinicians explain risk to an athlete, we try (or at least should attempt) to present all the information, and make the decision with all the components weighted. In this case, we have to consider the RISK of re-injury, of developing persistent pain, and dare I say, the RISK of not being able to continue playing golf at all? Have we even considered presenting out athlete with these scenarios? And more importantly, how we present this information, in a non-threatening and easy digestible way, might be crucial to the outcome

It’s a complex decision. But this needs thought, and all the possibilities considered. And I am not suggesting the answer is simple. Playing golf with the kids on a Saturday afternoon 20 years from now versus surpassing Jack’s record? (Oversimplification, I confess). It needs a sports medical team that is honest and clear, without seeking yes/no scenarios. (I would suggest this podcast by Prof Peter O’Sullivan here. He deals with the temptation to overdiagnose and overtreat brilliantly) And it would likely not be an “either/or” , but a “yes, and” answer that will allow the best outcome for the athlete.

As a sports physiotherapist, I wish Tiger Woods all the best with his rehabilitation and return to play. And I hope that he (and every elite professional athlete) will have the opportunity to make these decisions with the support of a good team and the value of current research and best practice guidelines driving the process.

Nicol van Dyk is a sports physiotherapist with special training in manual therapy. He is writing this in his personal capacity as a physiotherapist.



The 7 most common injuries and illnesses seen at major multisport games

3 Aug, 14 | by Karim Khan


By Team England Sports Physicians: Paul Dijkstra & Noel Pollock (@DrPaulDijkstra / @DrNoelPollock)

**Podcast with Dr Paul Dykstra sharing the UKAthletics Model for providing integrated (clinicians & coaches/S&C) – click here)

Tonight is the closing ceremony of what has been an amazing 20th Commonwealth Games here in Glasgow; the most successful ever for Team England who topped the medal table with just under 60 gold medals!

The Team England Medical facility was a constant hive of activity with doctors and therapists working side-by-side for very long hours to assist athletes to give their very best. The polyclinic was no exception. On our occasional visits there it was obvious that the excellent facility (sports medicine, pharmacy, 24 hour emergency care, dental, ophthalmology, radiology – including mobile MRI and CT imaging facilities) was being well utilised by all the teams; some more than others…

What were the 7 most common injuries and illnesses seen and how did we manage them?

  1. Upper respiratory symptoms (commonly allergy driven). Asthma and allergy are very common amongst elite athletes. More than 50% of elite athletes have hay fever and a significant percentage will have asthma (up to 25% of elite athletic teams!). Asthma and EIB are more prevalent in swimmers. Hay fever (and especially itchy and watery eyes) has been a problem here brought on by the few very hot and windy days we’ve had in the lead up to the Games. (It was close to 30 degrees on the first day of competitions here on the 24th July.)

Management Tip: Otrivine and a corticosteroid nasal spray are an excellent combination for quick control of nasal congestion and mouth breathing sleep

  1. Viral illness – both respiratory and gastrointestinal. Prevention and early precautionary isolation is key. Travel well-prepared with personal hand gels. Wash hands; everybody was encouraged to use the hand gel provided at the entrance to the dining hall. Paracetamol, and decongestive nasal spray. Martin Schwellnus published an excellent study in the BJSM on the effect of time zone travel on athlete risk of illness. Travelling more than 6 time zones more than doubles the risk of illness while in the foreign environment in professional rugby players.

Gastrointestinal illness is a constant threat when travelling with teams. There was some media attention to an early outbreak of Norovirus among workers here in the village before the start of the games. Due to the excellent work by the Scottish Public Health authorities and others here, the disease has not spread further. It warns us to be ready to manage this kind of problem when travelling with teams to any destination.

Management Tip: Always travel with probiotic capsules. There is some evidence that regular use will shorten the number of days of diarrhoea and also boost the immune system, particularly in endurance athletes.

  1. Emotional stress and sleep problems are common especially in younger athletes competing at a major event for the first time and living in a very big and busy athlete’s village environment. Athletes here are all share rooms and a few have Tweeted their frustration with the noise level!

Management Tip: Encourage athletes to minimise impact to their normal routines and to bring ear plugs and eye masks

  1. Chronic overuse injuries especially affecting lower limb, obviously depending on the type of sport and discipline. The most common of these are Achilles and Patella tendinopathies, plantar fasciosis and stress injuries of tibia and foot / ankle.

Management Tip: One athlete recorded a doubling of daily steps taken while in the village – encourage athletes to limit unnecessary walking and to use appropriate footwear (not flip-flops!)

  1. Acute muscle injuries – especially hamstring and calf muscles. These are common running injuries in sports like track and field, rugby and football.

Management tip: Most sprinting athletes will present with some hamstring symptoms through the rounds of a championships – particularly if they compete in multiple sprints/relays. Team clinicians should be experienced in the management and differentiation of hamstring presentations to assist the coaches and athletes in decision making and performance. As always know your sport!

  1. Acute ankle ligament injuries – especially in contact sports like rugby sevens, netball and hockey. The lateral ankle joint ligament sprains were the most commonly ligament injuries seen here.

Management Tip: Determine the severity of the injury and treat aggressively with immobilisation, cold compression, elevation, rest and strapping / taping for competition. It is important to include the athlete and coach when the relative risk of further competition is being discussed.

  1. Acute (and chronic) hand injuries are more common encounters by medical teams covering the boxing, judo and weightlifting events.

Management Tip: We’ve seen some excellent management of hand injuries by therapists and doctors with a combination of ice-compression, therapy, strapping, injections and anti-inflammatory medication being used.

Conclusion: The overall message is teamwork. Its an easy word to use but there are huge challenges to effective teamwork in a high performance environment (a topic for another blog!). Athletes and coaches usually benefit most when supported by doctors, therapists and management working in synergy towards a common performance goal.

Thanks to all our colleagues in Team England and to the coaches & athletes; as ever, its a privilege to work with such talented people. ————–



@DrPaulDijkstra’s paper on the Integrated Performance Health Management & Coaching model here (please see podcast note at top of blog too).



Live from Glasgow’s Sports Medicine Tent – 5 tips from #Games Doctor

29 Jul, 14 | by Karim Khan

By Doctor Rebecca Robinson @RjpRobinson

In July 2014, I was fortunate enough to be offered the opportunity of a registrar’s lifetime. Working with Team England in medical headquarters for the Glasgow Commonwealth Games. Here are my Top 5 Tips:

Glasgow1. Preparation, preparation, organisation

Games time comes and goes fast, so do your homework. Arriving a week before the Opening Ceremony in Glasgow provided a great opportunity to set up an efficient medical room. Check out competition schedules, venues and transport systems now to deliver care smoothly.

Medically screening the majority of the 600 Team England competitors as they arrived was invaluable to avoid last-minute concerns, with additional benefits in establishing athlete-doctor relations.

Familiarise yourself with the arena and its rules: can you see the athlete in the mixed zone? Where is the defibrillator and can you switch it on? Who can treat a blood injury in a boxing ring? With a grasp of the basics, immersing yourself in the squash court, judo hall, velodrome and track adds immeasurably to theoretical knowledge.

2. Work with the best to become better

A multisport games is a unique melting pot. The world’s best athletes supported by expertise in sports medicine, physiology and management garnished by multinational cultures.

Working alongside a wealth of experience in Team England Headquarters revealed a group of individuals every bit as dedicated as the podium athletes with their indefatiguable work-ethic.

Simply existing in this environment is a unique learning experience. Be observant.

Key to Team England was a cohesive, supportive team environment across medics, physios and HQ staff, in which all members views were valued.

There will be times to take initiative, but recognise the expertise around you. With hard work, you’ll be back for future games, but your athlete may not. If in doubt or if you think you know the answer: ask. Remember there’s no such thing as a stupid question. Do not work in isolation or outside your competency.

3. Pace Yourself

It’s a marathon. And a sprint, rugby sevens, a triathlon and track cycling: and that’s just day 1!

With a 3-week stay in the Village bubble, it was imperative to sustain energy to respond safely to medical emergencies, meet last-minute needs of anxious athletes calmly and keep a ready smile for every single volunteer, physio, cleaner and policeman (yes, they really do smile at you at Games time!)

Everyone making the games happen faces challenges and will be both exhilarated and exhausted at times. Remembering to eat, sleep, communicate with loved ones outside are essentials. Turn around to make sure your colleagues do this too. A smile, a coffee run or a supportive shoulder can make a world of difference.

4. Primum non nocere

The first rule of medicine generates ethical debate in the elite sporting arena, where medals define careers.

What is your role: to help win the medals or protect the athlete’s health? Injuries in competition demand precise evaluation: how will they impact performance now and what are the longer-term health outcomes your focused athlete cannot visualise?

The depth of senior medical experience contributing to Team England meant athletes were able to make informed decisions with their team.

Sometimes dreams are shattered in the field of play. A sensitive approach to the injured athlete, with a clear team-based management plan will not lessen the pain but can help ensure healing starts in the Village.

Management in Glasgow was facilitated by good venue medical facilities and safe field-of-play retrieval, followed by accessible Polyclinic resources including 24-hour on-site clinics and onsite radiology.

5. ‘Be Kind’ (Dr Mike Loosemore, CMO Team England)

The Commonwealth ‘Friendly Games’ is a microcosm in which tiny countries can produce sporting greatness alongside larger, expectant nations. Like all major Games, it is also a hotbed of ambition, where 7000 dreams shimmer on the cusp of reality.

An 11-day Games represents the pinnacle of careers, dreams and sheer sweat, blood and determination. Be mindful that this will alter over the course of a games as winners and losers emerge. Be on hand in triumph or disaster but don’t intrude. Resist the urge to take that selfie or add pressure to the expectations of an athlete. On the flip side, you can be well-placed to advise the hurt, anxious or unwell athlete who approaches you. Be sensitive. Be kind.

With special thanks to:

Dr Mike Loosemore, Dr Pippa Bennett, Dr Paul Dijkstra, Dr Graeme Wilkes, Dr Mike Rossiter, Dr Abosede ‘GB’ Ajayi, Dr Stephen Chew, Dr Greg Whyte, Chef de Mission Jan Patterson and Team for all their support.

Editor’s question: Is Chessboxing in the Commonwealth Games?

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7 key attributes of Sports Doctors and Physiotherapists at The Commonwealth Games

24 Jul, 14 | by Karim Khan

PhotobombHow can young doctors and physiotherapists get involved?

Paul Dijkstra (@DrPaulDijkstra)

I’m passionate about high performance medical teams and how they work. I used the lead-up to yesterday’s opening ceremony of the 20th Commonwealth Games in Glasgow, Scotland, to chat with participants from different countries here with me in the Village. The excellent sports clinicians are very busy, running around and working long hours to plan and deliver world class medical services to thousands of elite athletes and officials (6500 from 71 nations competing in 17 sports over 11 days!).

I asked “What are the key attributes of Sports Doctors and Physiotherapists working at a major event?”. I asked clinicians and also asked the coaches and management what they expect from good medical teams. Here are top attributes:

  1. Be comfortable to work in an open and collaborative clinical environment (a flat hierarchy) amongst a group of medical, science and coaching professionals where good people do what they’re good at’: Dr Mike Loosemore, Chief Medical Officer of Team England. (@DoctorLoosemore)
  1. Make sure you’re well qualified and experienced for the job’. Easier said than done… It takes 10-12 years of hard work and study to become a specialist Sport and Exercise Medicine Physician and good jobs don’t fall into your lap! Medical students and young doctors in training should not hesitate to get out there and volunteer. ‘Chase knowledge’ said one coach. ‘Build relations with colleagues, physiotherapists, teams, coaches, athletes and sporting officials’. Angela George, Team England physiotherapist agrees: ‘Be prepared to volunteer for every opportunity, get your name known and gain experience in lots of different sports. We all started out in community sport and now have the opportunity to work at the pinnacle of elite sport.’ Really good advice – offer to shadow and assist senior clinicians in the policlinics or next to the fields in smaller local clubs or school events. Be willing to work hard for little or no pay. (@PhysioAnge)

Kudos to Mike Loosemore and Team England management who’ve allowed British marathon runner and Specialty Registrar in Sport and Exercise Medicine (ST5 SEM), Rebecca Robinson to work as part of the Team England medical staff. Market yourself: ‘Blog, write and tweet…’ watch this space: Rebecca will share her experience in a BJSM blog soon! (rjpRobinson)


  1. Connect with the athlete’ says Paul Treu, Head Coach to the Kenyan Rugby Sevens team. ‘It is so important for the Team Physician to be able to really understand and appreciate the expectations of each individual athlete’.Dr Stephen Chew, Team England doctor agrees: ‘Attention to detail is important – know the athlete, know the venue and know the sport’. (@paultreu)


  1. Be able to adapt to the different environments without compromising on your standards of clinical care’ says Dr Karen Schwabe, here with the South African Team. She added: ‘Be ready to give energy – know how to pace yourself, do some exercise and get down time’. Karen has vast experience in rugby and endurance sport having just published three landmark papers in the BJSM – the SAFER studies.


  1. Know your place – the athletes are here to perform. When you’ve seen an injured athlete, don’t keep focusing on that injury or illness by constantly asking the athlete how he / she is doing. They will tell you!’ A valuable lesson I think; our instinct as doctors is to be caring, empathetic and protective. These are all good attributes but should be applied in a sensitive way in a performance focused environment.


  1. Laura Hanna is a very experienced physiotherapist and leading Team England’s physiotherapy team: ‘Experience, sound clinical knowledge, flexibility and ability to deal with whatever comes through the door gives physiotherapists working in a multi-sport an advantage. Long hours and putting your hand to anything will help and importantly having a great sense of humor and fun makes anything seem possible.’li>


  1. You have to be able to enjoy working in a complex and challenging environment and be passionate about working in sport’, wise words to end this short blog from Dr Bruce Hamilton, leading the New Zealand medical team here.


Enjoy the Commonwealth Games!

PS: BJSM Editor’s comment – Follow @DrPaulDijkstra and when he get clearances he’ll keep us informed. Health professionals are part of the TEAM at the Commonwealth Games so they need media clearance of course. He’ll be contributing to the @weRengland twitter feed (Who comes up with those nAmes?)

Paul was too humble to put this in his Blog but his BJSM paper “Managing the Health of the Elite Athlete” has taken off – it’s gone viral as far as journal articles go.  You can read it free tonight here once you turn the TV off.

Exercises to prevent sports injuries – lots of talk, but do they work?

20 Jul, 14 | by BJSM

Letter to the Editor

By Dr. Babette Pluim (@DocPluim)

In response to: Jeppe Bo LauersenDitte Marie Bertelsen, Lars Bo Andersen.

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trialsBJSM. 201448:11 871877 .

Strength training was the big winner in a recent BJSM systematic review and meta-analysis of Lauersen et al.1 The authors carefully quantified the preventive effect of several different forms of physical activity programs. They differentiated between the effect on acute and overuse injuries. Previous studies on musculoskeletal injuries, have focused on one particular intervention, one injury type or location, one specific sport, or were narrative reviews. This is a quantum step forward.

The field is relatively mature with 25 RCTs to study, including 26 610 participants with 3464 injuries. The studies were grouped into strength exercises, stretching exercises, proprioception exercises and multiple exposure studies.

Strength training was the most effective intervention and reduced sports injuries to less than one third (RR 0.315 (0.207-0.480). Proprioception exercises were also effective and reduced the number to almost half (RR 0.550 (0.347-0.869). Contrary to my expectations multiple exposure interventions were less effective (RR 0.655 (0.520-0.286) and stretching had no beneficial effect at all (RR 0.963 (0.846-1.095). Outcome analysis showed that both acute (RR 0.647 (0.502-0.836) and overuse injuries (RR 0.527 (0.373-0.746) could be reduced by preventative exercise programs.

exposure plot

Clinical implications

1. There is great potential in strength training — we should utilize this more. The results from the strength training studies were consistent, despite different programmes being used and despite different outcomes of interest, which points towards a strong generalisability of results. This means that many types of strength exercise have the potential to prevent many types of injuries.

2. Was it a nail in the coffin for stretching exercises? Stretching did not prevent injuries, whether done before or after training. However, this analysis included only two studies on army recruits and one internet-based study on the general population, so more data are badly wanted.2-4 Stretching may serve other purposes, and it may still be relevant for the upper extremity, but NOT for injury prevention of lower extremity exercises. It may be helpful in specific cases if there has been a previous injury. But today, there is no evidence supporting stretching for injury prevention.

It makes intuitive sense to combine several interventions to prevent all injuries, and I was therefore surprised that see that multiple intervention studies had smaller effect size that strength training or proprioception alone. However, the authors point out that each component may be reduced quantitatively or qualitatively by designing a program with an array of exposures (the proportion of effective interventions may be smaller, compliance may suffer etc). They therefore suggest these type of programs should be built from well-proven single exposures and they stress the importance of further research into single exposures.

The take home message for me as a sports physician is that I will take strengthening exercises to prevent injuries even more seriously than I already did:

– hip abduction, lunges, squats, step ups and step downs to prevent ACL injuries and anterior knee pain
– leg curls and Nordic hamstring exercise to prevent hamstring injuries
– proprioception exercises for the ankle (the ankle app!)5 to prevent ankle injuries

The recent data of Clarsen et al. on the shoulder are promising,6 and as a tennis doctor, I would love to see an RCT on the effect of external rotator cuff strengthening as a follow up to their cohort study :-).


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


1. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2014:48:871-7.

2. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sports Med 2010;44:1002–9. LaBella CR, Huxford

3. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 1998;44:65–72.

4. Pope RP, Herbert RD, Kirwan JD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000;32:271–7.

5. Verhagen E. Easy to use mobile app for ankle sprains prevention and rehabilitation.

6. Clarsen B, Bahr R, Andersson SH, et al. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med 2014. Published Online First 19 June 2014.



Australian Open – Hot Tennis. To play or not to play? That is the question!

18 Jan, 14 | by Karim Khan

By tennis physician, Dr Babette Pluim (@DocPluim)

RodLaverThe scorching Australian Open has stirred up debate as to how safe it is to play tennis under extreme conditions. Some claim that it is part of the game, just like wind, rain, and playing late at night and that you just have to deal with it. Prepare, and try to beat the heat!

Others find the conditions to be unacceptable and too dangerous for health, and argue that play should be stopped when drinking bottles start melting on the court surface. Their main concern is that the extreme heat may lead to severe heat illness and possibly even the death of an athlete.

Emotions run high in these heated conditions, so let us try to separate fact and fiction by using available science.


A number of studies have investigated the thermoregulatory response of tennis players to heat stress.[1-3] These show that core temperature can be maintained at a safe level across a wide range of environmental conditions and is determined mainly by the intensity of the exercise and the resulting metabolic rate. The cooling mechanisms of the body (sweating and cutaneous vasodilatation) work in optima forma under normal environmental conditions and thermal equilibrium is reached and maintained after approximately 40 minutes of tennis match play.

However, in hot ambient conditions, core body temperature (CBT) is determined not only by the metabolic rate, but also by the environmental heat load.[3] The body’s cooling system has to work hard to reduce excessive heat when both the metabolic rate and environment heat load are high, causing extra strain on the heart. Work by Périard et al, who studied male tennis players during tennis match play in cool (~19°C WBGT, 22ºC) and hot weather (~34°C WBGT, 37ºC), showed  mean CBTs of ~38.7ºC under cool and ~39.4ºC under hot conditions, respectively.[3]  In addition, adverse environmental conditions (e.g. high air temperature, high humidity, solar radiation and no wind) will result in a high skin temperature and increased thermal discomfort (irrespective of the actual CBT).

As thermal discomfort increases, players decrease the pace of the match, which results in a drop in metabolic rate: an excellent example of autoregulation.[1,3] Players will generally take additional measures to cool their bodies and may use fans, ventilators, parasols, ice vests, ice towels, and cold water. BJSM’s ‘Online First’ includes a systematic review on the effect of cooling by Professor Christopher Tyler (UK). Currently the heat rules in tennis allow juniors, women and seniors to have a ten-minute break – and 15 minutes for wheelchair tennis players – between the second and third set to allow some extra time for cooling the body when the WBGT hits 30.1°C. This can reduce the CBT by 0.25°C.[4]

When must play stop?

But is there an air temperature or a WBGT when CBT will continue to rise over 40°C up to 42°C, because the environmental heat load is so high and the metabolic heat production so great that equilibrium cannot be reached? When are tennis players at risk of developing hyperthermia and possibly heat stroke and multi-organ failure? When do we need to stop play?

Cooling is easier in tennis than in some sports. American Football is requires players to wear protective clothing and running requires high intensity continuous work. In those sports, heat illness is more common than in tennis.

However, even the tennis player may be at risk if he/she is ill (cytokines raise the temperature set point), is severely dehydrated (less circulating blood to the skin and less cooling), has an underlying heart condition (increased strain on the heart) or has autonomic dysfunction (high spinal cord injury, less sweating). In these situations, great care must be taken to protect the players from potentially life threatening heat illness or heart problems.

This year’s Australian Open has illustrated that there should be an upper limit above which play should be suspended, even for healthy athletes. This upper limit seems to be around an air temperature of 42°C-43°C or a WBGT of 32°C; if not for the players, at least for the long-suffering spectators!


1. Morante SM, Brotherhood JR. Air temperature and physiological responses during competitive singles tennis. Br J Sports Med 2007;41:773-8.

2. Hornery D, Farrow D, Mujika L, et al, An integrated physiological and performance profile of professional tennis. Br J Sports Med 2007; 41:531-536

3. Thermal, physiological and perceptual strain mediate alterations in match-play tennis under heat stress. Périard J, Racinais S, Knez W, Herrera C, Christian R, Girard O. Br J Sports Med 2014  (accepted)

4. Tippet M, Stofan J, Lacambra M, et al, Core temperature and sweat responses in professional women’s tennis players during tournament play in the heat.  J Athletic Training 2011, 46:55-60


Babette Pluim  is a Sports Physician KNLTB and Deputy Editor BJSM. Tennis, healthy lifestyle, injury prevention, sports medicine education. Follow her on twitter:  @DocPluim





Guest Blog: What if Nelson Mandela was a Sports Medicine Physician? by @DrPaulDijkstra

7 Dec, 13 | by Karim Khan



Nelson Mandela died on the 5th December 2013.

How will we remember this man of immense stature? This man who truly loved his people, his country – and sport! How did he change my life and career and how will his legacy continue to do so for me and many others?

I grew up and completed my medical studies in the privileged, white South Africa of the 1970s and 1980s, while political prisoner number 46664, Nelson Rolihlahla Mandela was in solitary confinement on Robben Island, just off the west coast of Cape Town. He was found guilty of high treason and jailed for life in 1962, before I was born. This was after he launched Umkhonto we Sizwe, the military wing of the African National Congress (ANC) in response to the banning of this organization by the South African white minority government at the time. I remember his name mentioned on television, mainly in the context of terrorism, protests, anti-apartheid activists and a growing chorus of international leaders calling for his release. But I never saw a photo of him – it was illegal to print or possess any image of ‘Mandela’ at the time. There were separate hospitals, clinics, churches, libraries and public building entrances for whites and ‘non-whites’ at the time – a morally corrupt and divided society with a massive white sheet covering the mountains of hatred, nepotism, racism, self-enrichment, pride, vanity, deception and self-righteousness. (Sadly still the case in many parts of the world…)

I remember the day when South African President FW De Klerk announced the end of Apartheid and the imminent release from prison of Nelson Mandela. It was early 1990 and I was in 5th year medical school.

Then the big day, 11th February 1990 when, after serving 27 years, Nelson Mandela was released from the Victor Verster prison in Paarl near Cape Town, a short drive from my first primary school.

The 1992 Barcelona Olympics was South Africa’s first Games since 1960. On Friday evening 7th August 1992 Ethiopian, Derartu Tulu became the first black African woman to win Olympic Gold, finishing ahead of white South African Elana Meyer in the 10,000m event.  The images of these two sporting heroes completing a lap of honor hand in hand, symbolising the true nature of sport and new hope for Africa, captured the imagination of the world. I remember huge crowds gathering and celebrating on the streets of South Africa. There was hope…

Many innocent people, however, continued to lose their lives. One of them was Chris Hani, the South African Communist Party leader who was assassinated on the 10th April 1993 outside his home in Dawn Park, Johannesburg. The country was on the brink of civil war. Mandela, not yet president went on national television delivering an incredible message to the nation and I remember listening in awe: “Tonight I’m reaching out to every single South African, black and white, from the very depths of my being,” he began. “The cold-blooded murder of Chris Hani has sent shock waves throughout the country and the world. Our grief and anger is tearing us apart.” He urged against violence and retaliation. “Our decisions and actions will determine whether we use our pain, our grief, and our outrage to move forward to what is the only lasting solution for our country – an elected government of the people, by the people, and for the people.”

Nelson Mandela and FW De Klerk were jointly awarded the Nobel Peace Prize later that year and the Nobel Committee hailed them for “looking ahead to South African reconciliation instead of back at the deep wounds of the past.”  De Klerk, a deeply religious man and a remarkable statesman in own right, sacrificed his career; Nelson Mandela sacrificed his life and he had forgiven his jailers.

I have very clear memories of the 27th April 1994: following years of liberation struggle and 3 years of intense negotiations, millions of South Africans voted in the first democratic elections. I lived and voted in Potchefstroom, a small University town that many international Olympic athletes, including double Olympic champion in Athens, Kelly Holmes, would later use as warm weather training base. In 2010 Spain used Potchefstroom as the base for their successful FIFA World Cup campaign.

I was at the Union Buildings in Pretoria on the 10th May 1994 to witness one of the most important events in the history of South Africa: the inauguration of Nelson Mandela as President.  I was a young doctor and part of a small team of military medical officers responsible for the medical care of the attending local and world leaders. I stood no more than 30 meters from the podium listening to Nelson Mandela’s inauguration speech – not far from where Benazir Bhutto was sitting. After delivering his speech and following the inauguration ceremony, Mandela and De Klerk both turned to the huge crowd, Mandela raising the hand of the former president saying: “We have to do this together.”

I will never forget the 24th June 1995, the final of the South African Rugby World Cup. Just before kick-off, in probably one of the greatest political gambles of his career, Nelson Mandela appeared before the mostly white crowd of more than 60000 wearing a green and gold Springbok jersey to shake the players’ hands. The crowd erupted and of course we won! Nelson Mandela and Francois Pienaar together on the podium in green and gold holding the Webb Ellis Trophy marked the emergence of the ‘Rainbow Nation’.

“Sport has the power to change the world. It has the power to inspire, it has the power to unite people in a way that little else does.”

I remember 2010 – Nelson Mandela’s public triumph of an amazing Football World Cup in Africa. I also remember his personal tragedy when he lost his granddaughter in a motor vehicle accident in Gauteng at the same time.

What is the legacy of this remarkable man?  Can we learn anything from him, his life, his words, his choices? What if Nelson Mandela was a Sports Physician?

‘In judging our progress as individuals we tend to concentrate on the external factors such as one’s social position, influence and popularity, wealth and standard of education. These are, of course, important in measuring one’s success in material matters and it is perfectly understandable if many people exert themselves mainly to achieve all these. But internal factors may be even more crucial in assessing one’s development as a human being. Honesty, sincerity, simplicity, humility, pure generosity, absence of vanity, readiness to serve others – qualities which are within easy reach of every soul –  are the foundation of one’s spiritual life. Development in matters of this nature is inconceivable without serious introspection, without knowing yourself, your weakness and mistakes.’[1]

If Nelson Mandela was a Sports Physician he would probably not have been famous. He would have been profoundly human, showing emotion, compassion and real humility. He would have acknowledged his imperfections and asked for forgiveness where he perhaps failed to diagnose a stress fracture early enough or recommended a treatment without taking into account the feelings and circumstances of the athlete: “I have made missteps…” He would have forgiven missteps against him: “resentment is like drinking poison and then hoping it will kill your enemies.”

He would have sat down with an athlete who just missed out on an Olympic medal or who failed to make the team; perhaps with comforting words or possibly just a quiet firm hand on a shoulder. He might have cried alone in his room later because he would have felt the pain of that athlete in his own heart. And in the morning they would have had breakfast or tea together and he might have said: “Difficulties break some men but make others. No axe is sharp enough to cut the soul of a sinner who keeps on trying, one armed with the hope that he will rise even in the end.”

To the young athlete and coach preparing for his first major event he might have commented: “I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.”

He would have known when to stand still and quietly observe or when to walk away and reflect. He would have known when it is not a doctors’ business; when the athlete and coach needed to be alone. He would however have known when to sprint to assist on a football pitch.

He would have known when and how to protect the vulnerable.

He would have truly acknowledged the unsung heroes: the clinic cleaners, the hospital security guards, the volunteers, the midnight nurses and paramedics, the lonely receptionist whose mother is critically ill in hospital. He would have stopped and asked about their lives, their worries, their triumphs, their ambitions… “Man’s goodness is a flame that can be hidden but never extinguished.”

He would have wept about the ongoing injustices to fellow human beings around the world; injustices based on race, religion, sex, education, wealth or class. “… to be free is not merely to cast off one’s chains, but to live in a way that respects and enhances the freedom of others.”

As a hospital executive or medical team leader he would have remembered that “a good head and a good heart are always a formidable combination”. He would therefore have “lead from behind and put others in front, especially when celebrating when nice things occur.” He would have “taken the front line when there was danger.” He would have loved “independent minds because they tend to make you see problems from all angles”.

He was indeed a remarkable man, touching and forever changing the lives of millions.

My privileged life was touched by his life. It is his humanity, his forgiveness that gave me wings.

I salute this man, this fellow African. I celebrate the life of a humble giant who lived the true meaning of forgiveness, generosity, sincerity and compassion.

Hamba kahle Madiba.



1              Mandela N. Conversations with myself. New York: : Picador 2011.


You can follow Dr Paul Dijkstra on Twitter @DrPaulDijkstra




7 Nov, 13 | by Karim Khan

(A full version of the Daily Mail publication, page 75, November 7). The Daily Mail @DailyMailUK is doing a tremendous service to improve concussion awareness and player management. Kudos Daily Mail.

Now that the dust (if not Hugo Lloris’ scrambled brain) has settled on the Spurs keeper’s knock to the head on Sunday, let’s review the situation and ask what we can learn. Let’s remember that the focus must be on what is best for this player, and sportsmen and women the world over


  • Lloris was clearly concussed. He was knocked out, was wobbly on his feet and in his manager’s own words after the game “Hugo still doesn’t recall everything about the incident”
  • The Spurs doctor (who is highly regarded and was commended for his work on resuscitating Fabrice Muamba) wanted the player removed from the pitch. I have looked at the TV coverage numerous times and he clearly signals that the player should go off. In fact Villas-Boas admitted as much after the match when he said “the medical department was giving me signs that the player couldn’t carry on because he couldn’t remember where he was” and that “he went against medical guidelines to keep the goalkeeper on the pitch”.
  • The decision to keep the player on the pitch was solely the Managers. He admitted that after the game “’It was my call to delay the substitution, you have to make a decision in situations like this”
  • Loris had a CT scan performed after the game and the club’s website said “The Club can confirm that Hugo Lloris underwent a precautionary CT scan and was given the all-clear and travelled back to London last night”
  • A CT scan is performed to rule out more serious head injury. It cannot exclude concussion which probably explains why the Spurs statement said given “the all-clear” which in reality was from serious head injury but the media interpreted as from concussion
  • Despite the clear cut evidence of concussion and the Manager’s admission that he was responsible for the decision, Spurs changed their tune the following day presumably on advice from the club’s PR department (otherwise known as the “Protect the manager at all cost department”)
  • Their Head of Sports Medicine, physiotherapist Wayne Diesel was quoted as saying “Once the relevant tests and assessments were carried out we were totally satisfied that he was fit to continue playing.”
  • Spurs have a Europa League game on Thursday, 5 days after the Everton game
  • The most recent World Concussion meeting was co-sponsored by FIFA and held at the FIFA headquarters in Zurich last November. The Consensus Statement from that conference published in March this year is quite clear on management guidelines for concussion
  • Regarding return to play (RTP) on the same day, it states it was unanimously agreed that no RTP on the day of concussive injury should occur”.
  • Regarding a graduated RTP following concussion “RTP protocol following a concussion follows a stepwise process as outlined in table 1. With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally, each step should take 24 h so that an athlete would take approximately 1 week to proceed through the full rehabilitation protocol once they are asymptomatic at rest and with provocative exercise. If any post-concussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24 h period of rest has passed”.





  • Following the recommended protocol, the minimum time before returning to play is 6 days assuming that the player is totally asymptomatic (no headaches, nausea, “foggy” feeling etc) the day after the incident and right through the rehabilitation
  • Most Premier League clubs would also perform a computerised neuropychological test at the end of the rehabilitation process to confirm full recovery
  • The Spurs Manager explained his decision to over-rule the club doctor on this basis “I made the call to keep him on the pitch because of the signs he was giving. When you see this kind of assertiveness from the player it means that he is able to carry on. He was determined to continue and looked concentrated, driven and focused enough for me not to make the call to replace him. The saves he made after the incident proved that right”.
  • The Manager was overly influenced by the player, rather than the expert medical opinion. The fact that Lloris made some good saves after continuing is not relevant, as it is the long term effects of playing concussed that are a concern. There are plenty of historical precedents for players playing quite effectively immediately after a concussion. It does not justify the decision.
  • To be fair to the Manager, the medical profession’s stand on the management of concussion has changed over the past few years and the Manager may not be aware of this
  • Previously concussion was thought to be a self-limiting relatively benign condition. In the past few years there is increasing evidence of long term brain problems in retired footballers. Most of the research has come from the NFL who recently settled a lawsuit form a large group of retired players for $750 million (without admitting any guilt).
  • Clearly we as a profession have not succeeded in educating football club managers as to the change of attitude and the new protocols
  • Football in the UK would be wise to follow the lead of the English Rugby Union who have summoned all their coaches to Twickenham this Thursday to hear the latest on the management of concussion.
  • When a player is suspected of being concussed, he should be immediately removed from the field of play and assessed to determine whether he indeed has concussion. This assessment, which should ideally be done in the medical room, takes approximately 5 minutes. See SCAT3 (Free). As a result the other football codes have introduced a temporary substitution which can be made while the player is being assessed. In rugby this is a 5 minute period, in Aussie Rules football it is 20 minutes. Soccer needs to consider something similar.

What now?

The short term dilemma for Spurs is whether Lloris plays tonight (Thursday night). They have put themselves in a difficult position. If he plays, then in addition to their breach of concussion protocol on Sunday, they will be breaching the RTP protocol which requires a minimum of 6 days graduated rehabilitation

  • If they rule him out, then they are admitting that he was concussed and that they were wrong to allow him to continue playing
  • If that PR department had been doing its job they would have said that they had always planned to play their No 2 goalkeeper on Thursday and got out of it that way!!
  • The team doctor has the expert knowledge and is the one person who has the player’s health as his/her primary responsibility and therefore should be the sole arbiter of whether a player is concussed.

[BJSM Editor’s note: Credit to Tottenham for clearly following the Zurich Concussion Guidelines here: The Manager is quoted as resting Lloris as a result of Sunday’s concussion. For non-expert readers, when Lloris returns to play should depend on his symptoms (and potentially neuropsychological tests, not a specific ‘time’ . One week is a minimum to progress through the stages (above) but it can take longer if symptoms (headache, unusual tiredness, dizziness) persist. ] Posted on Thursday Nov 7th after the Europa Cup game.

How should this have been handled?

  • It would have been nice yesterday instead of Spurs trying to shift the blame to their (absolutely innocent) medical staff, to hear the Manager publicly state that he had made a mistake, that he was not up-to-date regarding the changes in guidelines for the management of concussion, state his total support for the club’s medical team, and state clearly that he will not interfere in the future.
  • That would have made a positive out of a negative.
  • Instead Villas-Boas has come out and abused those of us who have expressed concern calling us “incompetent”.
  • Sadly he had missed a wonderful opportunity to get the message out there that concussion must be taken seriously.



Everest – The First Ascent: A great read on the importance of an exercise physiologist

4 Sep, 13 | by Karim Khan

Book review by Chris Milne, Sports Physician Hamilton, New Zealand 

*Please note, neither BJSM nor Chris are sponsored to endorse this book


Photo by Edmund Hillary, Source:

Ever wanted to know how important exercise physiologists can be?  Then read Everest – The First Ascent.  Written by the daughter of Griffith Pugh, the physiologist who accompanied the successful 1953 expedition, it provides a unique perspective that should be of particular interest to the exercise physiologists and clinicians who read BJSM.

Lest you think it is purely a laudatory account by an admiring daughter, I can assure you that it is not.  The book opens with Harriet, the relatively estranged daughter, being present at a lecture given 10 years ago by Michael Ward, the Everest expedition doctor in 1953.  By this stage Pugh was old and wheelchair bound. Harriet listened, transfixed, as she heard her father’s contribution to the Everest expedition described in glowing terms.  You will be too as you get into this book, he was truly the unsung hero of Everest.

Prior to the 1953 expedition there had been numerous attempts on Everest but all had been failures due to a variety of reasons. The Swiss got close in 1952 with extensive use of supplementary oxygen and it Pugh’s recognition of the importance of oxygen was possibly the most critical contribution to the success of Sir John Hunt’s expedition in 1953.  Hillary and Tenzing used oxygen at a rate of 3L/min (they were originally budgeted 4L/min but supplies ran short) and this undoubtedly helped them climb at a faster rate than would have been possible without oxygen.

Pugh’s contributions were not limited to oxygen alone, however.  He also designed some particularly well-insulated climbing boots and double-layer air mattresses plus specially constructed tents to withstand the winds that prevail at high altitudes.  He also perfected cookers that would function well up high mountains.

However, Everest was not the end of it – rather, an important stepping stone in Pugh’s career.  Buoyed by the success of innovations in 1953 he went on to make a substantial contribution to high altitude medicine, with research carried out at the Silver Hut perched at high altitude on Everest; it has subsequently been relocated to Darjeeling, where it stands to this day. He realised the importance of keeping the scientists well fed and watered, and readers of the book will be impressed to see the range of food and drink that he had set up.

Pugh was also much in demand once the 1968 Olympics were allocated to Mexico City.  The events were held at an altitude of 8000 feet and his predictions regarding athlete performances were pretty much spot on.  As he thought, the sprinters and jumpers would do well and there would be a progressive fall off in performance as running distances got longer and the athletes became more dependent on oxidative metabolism.  He also made important contributions in research into hypothermia using cross-Channel swimmers as his subjects.

On a personal basis, his daughter comments that her father could be “remote and irascible” and he frequently clashed with his superiors at the Medical Research Council. However, he had a few well-placed supporters who recognised his particular genius and enabled him to continue his work relatively unfettered by administrative demands.

As a Kiwi reading the book I was intrigued by his relationship with Sir Edmund Hillary, a national icon in my country. The two men obviously saw things differently: Hillary was a climber in the stoic/heroic tradition; Pugh was a practical scientist who also happened to be a pretty competent climber, having served as an instructor for the School of Mountain Warfare in the Lebanon. He also skied at the Olympics and, therefore, saw the mountaineers as fellow athletes rather than as lab rats.  Even though there were tensions, the mutual respect between the two men shines through.

So who should read this book? Anyone with an interest in the practical application of sports science, i.e. every reader of BJSM.  Also those who wish to see how a man could be rather neglected in his lifetime and yet gain true recognition for his work many years later.  Serendipity is a wonderful thing and it is only due to the survival of Pugh’s personal papers and his daughter’s labour of love that we have got to read of Pugh’s immense contribution.  Truly an inspiring book.  Read it.

Title:               Everest – The First Ascent

Author:          Harriet Tuckey

Publisher:     Random House, 400 pages

Price:              £20

ISBN:               9781846043499


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