A recent editorial by Babette Pluim entitled, “A doping sinner is not always a cheat” [excerpt below], has created some fiery discussion amongst BJSM editors and readers this month.

The doping rules these days are really tough. The basic principle is: first offense gets a 2 year ban, second offence a lifetime ban. Everyone seems to agree that doping is cheating, and those who cheat should be sanctioned, so if an athlete provides a positive sample in any sporting situation, the inference must be that they are cheating. Unfortunately, both for the athlete and the anti-doping system, that is not always the case.

Here is a selection of BJSM editors’ & readers’ reactions:

“Drug cheats – or are they?”
By Dr Tim Wood, Chief medical officer for the Australian Open Tennis Championship and a member of Tennis Australia’s Anti-Doping Review Board

With the formation of the World Anti-Doping Agency (WADA) and the universal harmonization in the fight against the drug cheats in the late 90s everyone applauded. What we didn’t realize at the time was how many ’innocent’ victims would be caught up in the new rules and regulations. I therefore applaud Dr Babette Pluim’s BJSM editorial which reviews the positive doping cases recorded by the International Tennis Federation from 2001-07. She found that the majority of so-called ‘positive’ tests are no more than innocent mistakes by players and officials alike. Nevertheless, the trauma suffered and the tainting of these players is irreversible.

Having been involved in professional tennis for the last 7 years, I also experience frustration at the paperwork required to allow player with genuine medical conditions to take legitimate, scientifically proven drugs that certainly do not enhance performance. The most recent ‘crazy redtape’ is the requirement for a full Therapeutic Use Exemption (TUE) to allow an athlete to have intravenous fluid during elective surgery (Babette has some stories about that!).

Fortunately, it would appear that sanity may be about to prevail on at least three fronts. First, abbreviated TUEs (ATUES for those in the know, even though it sounds like a sneeze) that are currently required for intra-articular cortisone injections will be changed to notification via ADAMS (WADA’s web-based anti-doping management system). Second, ATUEs for beta-2 agonists will be valid for four years instead of needing to be renewed annually but this will come with more stringent proof of the player’s asthmatic status. And finally, many of us hope that the intravenous rule will revert to the 2007 ruling ‘… except for genuine medical situations’.

Everyone involved in professional sport strongly supports WADA and their efforts to catch the cheats but the rules shouldn’t catch innocent athletes, particularly those with genuine medical conditions.

“WADA is on the verge of losing the plot”
By John Orchard, Sports Physician

The idea to create the World Anti-Doping Agency (WADA) was a good one, particularly for international sports. It meant that rogue states like the USA, which had a track record of going soft on their own athletes who tested positive, could be forced to implement universal sanctions.

The big problem with WADA is that it is a monopoly. And it is being run increasingly like one, currently under the Presidency of our own ex-politician John Fahey. WADA’s aim should be to stamp out cheating in sport. This is quite difficult to do, as the cheats are usually very clever. WADA instead is trying to maximise scalps of athletes who “test positive for drugs”, without apparent concern for whether they are actually cheating. Instead of concentrating only on the genuinely performance-enhancing (and usually difficult-to-detect) drugs, the WADA banned list is ever-expanding. It now includes commonly used medications which are much easier to detect and “might conceivably” be used for performance-enhancing in rare circumstances. Whether these rare circumstances exist when an athlete tests positive don’t seem faze WADA, as there is a presumption of guilt rather than innocence.

Banned medications now include asthma puffers and cortisone injections, which are generally considered by doctors and scientists to not be performing-enhancing. Intravenous fluids, including those given for an anaesthetic as part of surgery, are now also banned as of 2008. The status quo is now the farcical situation that the vast majority of athletes are breaking the WADA code whenever they go in for elective surgery. In theory, the only thing stopping these athletes from being suspended is that drug testers aren’t (yet) following them into hospitals.

An editorial just published in the British Journal of Sports Medicine found that in the last 5 years of drug testing in tennis, it was accepted that 68% of the players who were banned for positive drug tests were not actually cheating. They were banned presumably because WADA wanted to increase their tally of convictions. They include cases such as known asthmatics taking puffers such as Ventolin for asthma attacks, but whose ‘permits’ to treat their asthma with appropriate medication had either recently expired or been faxed to the wrong number. In 2009, WADA has plans that asthmatics should apply to a panel to ‘prove’ they have asthma, or else they will be banned from sport for using their puffers. The Howard government basically held the funding gun to the head of all Australian sports in 2005 and forced them to sign up to WADA, despite many sports fearing the situation we are now in. This being that the universal drug code has become draconian and the sports have signed away all rights to do anything about it.

“Accidental cheating?”
By Giuseppe Lippi, Associate Professor of Clinical Biochemistry, Università di Verona

In an overview of the 40 most recent cases of doping in tennis, Babette Pluim highlighted that in only 13 of the cases (32%) was a prohibited substance taken to enhance performance, whereas most frequently banned substances were taken with no intent to enhance performance or without (significant) fault or negligence.1

I definitely agree that products that are on the list of prohibited substances should be critically reviewed, but I also emphasize that the current anti-doping policy is essentially a costly, repressive, zero tolerance approach, which seems only partly successful.2 It is also to mention, however, that there may be additional explanations to justify adverse findings on antidoping testing, which have little to do with cheating.

The use of dietary supplements is commonplace in sports, most elite athletes using some form of licit supplementation to burst athletic performance and improve recovery after training or competition. Nevertheless, there is widespread evidence that some of these legitimate products, especially those sold on the “black market”, contain banned substances that are not claimed as a result of poor manufacturing practice or adulteration.

Contaminants mostly include anabolic androgenic steroids, hormones, ephedrine and caffeine.3,4 Indeed, in some cases the adverse findings might be the consequence of deliberate cheating. However, we should still consider the possibility that some positive tests might arise from unintentional consumption of prohibited substances, contaminating dietary supplements. In this respect, not only antidoping agencies should focus on products that are truly harmful and performance-enhancing, but they should also issue a clear regulation on the use of nutritional supplements and establish appropriate bans for inadvertent use of banned molecules. Doping is always to blame, especially when the athletes use illicit methodsor substances that might produce a serious risk for their health. However, as different sanctions are imposed when crimes are intentional or preterintentional, bans should also be clearly differentiated from deliberate and unintentional positivity to banned substances.

References

1. Pluim B. A doping sinner is not always a cheat. Br J Sports Med 2008;42:549-50.

2. Kayser B, Smith AC. Globalisation of anti-doping: the reverse side of the medal. BMJ 2008 Jul 4;337:a584. doi: 10.1136/bmj.a584.

3. Maughan RJ. Contamination of dietary supplements and positive drug tests in sport. J Sports Sci 2005;23:883-9.

4. Linksvan der Merwe PJ, Grobbelaar E. Unintentional doping through the use of contaminated nutritional supplements. S Afr Med J 2005;95:510- 1.

Another response by Fergus J. Dignan to Noakes’ paper <em>How did A V Hill understand the VO2max and the “plateau phenomenon”? Still no clarity?

Click to view more reader responses to this article.

Dear Editor,

I very much enjoyed reading the Review article (1) by Professor Noakes and the letter (2) in the same edition of the BJSM July 2008.

As he rightly states measurement of VO2max has several limitations in determining an athlete’s potential. He also pointed out in the letter that research has shown that ‘the rating of perceived exertion (RPE) rises as a linear function of the duration of exercise that remains’, and extrapolation from this ‘that humans have an exquisite capacity to predict accurately the duration of exercise they will be able to sustain at any exercise intensity’.

Would it therefore not be possible to determine an athlete’s optimal running distance by getting them to run on a treadmill for 10 minutes and asking them to run as fast as possible for imagined
distances of 5k, 10k, 40k, etc?

1. NOAKES TD. Testing for maximum oxygen consumption has produced a brainless model of human exercise performance. Br J Sports Med 2008; 42:551-555

2. NOAKES TD. Rating of perceived exertion as a predictor of the duration of exercise that remains until exhaustion. Br J Sports Med 2008; 42:623-624

Physically active women are 25 per cent less likely to get breast cancer, but certain groups are more likely to see these benefits than others — please see link.

The type of activity undertaken, at what time in life and the woman’s body mass index (BMI) will determine how protective the activity is against the disease.

Lean women who play sport or undertake other physically active things in their spare time, especially if they have been through the menopause, have the lowest risk of breast cancer.

The researchers reviewed the literature and analysed 62 studies looking at the impact of physical activity on breast cancer risk. They then examined how breast cancer risk was affected by type of activity, intensity of activity, when in life the activity was performed and other factors.

The most physically active women were least likely to get breast cancer. All types of activity reduced breast cancer risk but recreational activity reduced the risk more than physical activity undertaken as part of a job or looking after the house. Moderate and vigorous activity had equal benefits.

Women who had undertaken a lot of physical activity throughout their life had the lowest risk of breast cancer, and activity performed after the menopause had a greater effect than that performed earlier in life.

Physical activity reduced breast cancer risk in all women except the obese and had the greatest impact in lean women (BMI of less that 22kg/m2).

Women who were mothers, had no family history of breast cancer, were not white also had a reduced risk of breast cancer.

The authors said the way in which physical activity protected against breast cancer was likely to be complex and may involve effects on sex hormones, insulin-related factors, the immune system and other hormone and cellular pathways.

Contact:
Dr Christine M Friedenreich
Division of Population Health and Information,
Alberta Cancer Board.

Two posts of note about Australian footballer, Nick Malceski and ACL reconstruction from The Australian:

Malceski returns at a bionic pace

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans - who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks - and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal - though Geelong and Hawthorn might have something to say about that.”

Miracle op to melt down surgeons’ phones
- James Fardoulys, May 10, 2008

IF Nick Malceski survives his first game back from injury next weekend, the phone lines of every knee surgeon in the country will run hot on Monday morning with patients asking for “the Malceski operation”.

Why?

Because Malceski injured his knee on February 17. That makes it a mere 12 weeks since his surgery on February 22, a lightning-fast recovery period compared to the traditional 12-month lay-off.

Malceski underwent a new type of anterior cruciate ligament repair, known as the Ligament Augmentation and Reconstruction System (LARS). Like most “new” technology, the history of this type of surgery goes back a couple of decades.

ACL surgery has been around since the 1950s, but became common from the 1980s.

In the past, attempts to directly repair the ligament have failed because it is difficult to suture and the knee difficult to adequately immobilise, which risks loosening the repair.

Surgeons then started using tendons from other sites as substitutes, or grafts, to make a new ACL. These were structurally stronger than the shredded ACL.

The downside was that new blood vessels and nerves had to grow into the graft, and structural changes occurred within the fibres of the graft, before it resembled the original ACL.

This “remodelling” process takes about a year, which is why traditional ACL graft patients are off sport for that length of time.

In the mid-1980s surgeons tried shortening this time off by removing the damaged ACL and replacing it with grafts made of artificial materials such as Dacron or Gortex. The new graft was at maximum strength from day one. There were additional benefits in avoiding problems such as pain, weakness, scarring or infection at the donor graft site, known as “donor site morbidity”.

Unfortunately the initial good results produced by artificial grafts were short-lived.

A knee moves backwards and forwards through about two million cycles per year. No artificial material lasts forever, and within a year most of these grafts have disintegrated.

Worse still, the ground-up debris often causes severe reactions within the knee joint. Typically these players, such as Footscray’s Rod MacPherson and Zeno Tzatsakis, returned for a handful of games, but didn’t play again after the artificial graft failed. The notable exception was Doug Hawkins, who took a year off, then played on for another decade.

In Canada a group tried a slightly different approach. They used an artificial graft stitched inside a hamstring (biological) graft. This was known as the Kennedy Ligament Augmentation Device (LAD).

“Augmentation” means to support a ligament rather than replace it. The idea was for the synthetic device to give short-term support to the hamstring graft until it became strong enough to carry the stresses and strains.

The key difference in this process is that the synthetic graft isn’t being relied upon to carry the long-term load.

The process worked for the Canadians surgeons. It didn’t seem to have the problems of the artificial ligaments used alone, but the biologic graft still took a year to remodel. With no great advantage, most surgeons simply ignored it and stuck to the standard biologic graft techniques.

Enter the LARS. With this technique the surgeon preserves and repairs the original ACL (which is removed with most of the other operations) and augments it with an artificial polyester graft.

It is closer in concept to the Kennedy LAD than the Gortex and Dacron devices. The LARS ligament is buried within the repaired ACL, supporting it while it heals. Because the preserved ACL already has its blood and nerve supply it heals more quickly than a graft — in about three to four months instead of 12.

French surgeon JP Laboureau, who developed the LARS, also looked at some of the other issues in the construction of artificial ligaments to make them friendlier to human biology.

Several thousand LARS devices have been inserted in Europe, so why is this new to us in Australia?

The answer is geography. The LARS was developed in Europe and most of the published data is in non-English journals.

The Europeans have traditionally been prepared to think outside the box and try new ideas, more so than the litigation-conscious English-speaking countries.

Some of their concepts are now widely used. The French decided to put the ball and socket of shoulder replacements the wrong way around in severe rotator cuff deficiencies — it works brilliantly.

The Germans and Swiss invented ways of fixing fractures which are now standard textbook stuff.

On the other hand, Europe is also home to so much voodoo, quackery, and snake-oil remedies, that English-speaking doctors are always cautious about seemingly wondrous claims, and like to test the merits of new techniques for themselves.

On the surface of it Laboureau seems to have done his homework. He has done extensive basic science work on his ligament design and manufacture, and on his operation technique.

In normal medical practice the patient will discuss with their surgeon the pros and cons of all their options. In the case of the LARS ACL reconstruction, do they want a tried and tested biological graft, for which they need one year off sport? Or do they want a LARS ligament repair, where they may be part of the surgeon’s learning curve, but the recovery is significantly shorter?

What about donor site morbidity versus foreign material? The last 20, or 50, or 200 cases the surgeon performed will influence the discussion. This is how medical decisions are normally made.

In practice this is what will happen:

Nick Malceski will run onto the paddock.

If he goes down in the first five minutes clutching his knee, the LARS ligament people might as well pack up and go on holidays for the next six months, because things are going to go very quiet for them.

If he gets through the game, and especially if he kicks a goal, they can cancel all their plans for the immediate future because they will be busier than the proverbial one-legged fireman stamping out bushfires.

That’s how sports people make decisions. Such is the fickle world of sports medicine.

James Fardoulys is a Brisbane orthopedic surgeon specialising in sports injuries

SYDNEY’s bionic man, Nick Malceski, is expected to line up with the Swans’ reserves next weekend, exactly three months after he tore the anterior cruciate ligament in his right knee.

It will be a timely boost for the Swans - who have missed Malceski’s sublime ball skills and hard-running from defence during the past few weeks - and an extraordinary ray of hope for athletes who suffer serious knee injuries.

Yesterday, exactly 11 weeks since he had a revolutionary knee operation that repaired his damaged ligament with a super-strong synthetic fibre, Malceski took part in a training session that went for nearly two hours.

If he had opted for a traditional knee reconstruction, using tendon taken from another part of his body to repair the ligament, he would not have started running yet and he would not be playing until next year.

But there he was at the Lakeside Oval next to the SCG, sprinting, chasing, kicking the ball long and moving freely alongside his team-mates.

“He is fully fit, but he has also got mental confidence,” said Sydney physiotherapist, Matt Cameron.

“If he looked tentative, we might hold him back, but he isn’t at all.”

Cameron and fitness head Rob Spurrs designed Malceski’s unique program, which condenses the usual 12 months rehabilitation into three months.

“Nick did a 1km time trial last Monday and did the same time (just over 3min10sec) he did in late January. He is back to the fitness levels he was at just before he got injured,” Cameron said.

Malceski only stood aside yesterday during a full contact tackling drill. While he has done some body-on-body training since re-joining team practice a week ago, he will be put to the sword with rigorous full contact training on Monday.

He ruptured his ACL in a pre-season NAB Cup game on February 17, and had the surgery, known as LARS (Ligament Augmentation and Reconstruction System), five days later.

Malceski walked out of the hospital unaided and club doctor Nathan Gibbs says he has been “great from day one”.

“Everything about Nick’s operation has gone as well as you could expect and we just hope it continues.

“You would not normally run for three to four months and he was running at one month, sprinting at two months and should be playing next week at three months,” Gibbs said.

Coach Paul Roos said it looked as if Malceski had not missed a beat.

“He still has to get through a couple of training sessions next week, but at this stage Nick is on track to play with the reserves next Sunday,” Roos said of Malceski, who was second in the Swans’ best and fairest award last year.

“We will get more of a gauge over the next week or so as to how close towards senior selection he is.”

Despite the optimism, there will be a good deal of finger-crossing and touching wood at the Swans during the next week and beyond as Malceski returns to the seniors.

The club came in for criticism from the medical profession when it was first revealed Malceski had opted for the radical procedure which is not commonly performed in Australia.

Gibbs and Cameron became familiar with it during visits over to European sporting clubs such as soccer giant AC Milan, and decided there was enough positive evidence to try it.

Gibbs knows the club will be under the spotlight as the sports’ medical profession watches to see if Malceski’s operation is successful.

“His accelerated rehab has gone very well … the risk is that he re-ruptures it,” Gibbs said.

“But people who have done the operation overseas say the risk is no different to a traditional ACL operation, which is that one in four or five rupture again.

“It is a calculated risk that we took for good reasons.”

But Gibbs won’t judge it successful just yet.

“I am ecstatic that the rehab has gone so well and ecstatic that he is on schedule to play at 12 weeks, but we are still very mindful that he is not out of the woods,” Gibbs said.

“There is a long way to go before we say it has worked.”

And when would that be? “When Nick finishes the year playing at a high level, does not re-injure it and wins the Norm Smith medal - though Geelong and Hawthorn might have something to say about that.”

Editorial Board member Bruce Forster shared an interesting issue for debate. As head of imaging for the 2010 Winter Olympic Games, he is responsible for deciding whether the service should include injecting tendons/joints at the Games or not. In Torino 2006, the imaging services were diagnostic only.

We invite BJSM blog readers to engage in the debate as to whether the sports medicine service should offer full therapeutic capacity or not. Where does one draw the line? Would the imaging physicians be legally liable if the athlete had a complication on return to play?

A comment from Editorial Board Member Chris Milne, New Zealand Olympic Sports Physician:

I’ll kick off. In my view, the imaging services at the games should offer as close as possible to a world class service, since they are dealing with world class athletes. The clinician looking after the athlete should have the ultimate responsibility as to what care is offered to that athlete.

In Sydney 2000, there was a superb imaging service that included CT guided nerve root sleeve injections, and the NZ team made use of this for 3 of our athletes. Issues of return to play are best dealt with by the clinican[s] who are managing that athlete, with consultation/liaison with the coaching staff once a treatment plan has been formulated.

Another comment from Dr Lynley Anderson, Senior Lecturer, Bioethics Centre, Medical and Surgical Science, Dunedin School of Medicine.

I would agree with Chris, if there are sound clinical reasons for something then it probably needs to be supplied.

Am I right to imagine that the underlying question you are getting to is would the image guiding system be used appropriately or inappropriately? That is, is such a service being used to return people to competition when such competition is dangerous to their health?

Here I think we would want to explore issues about the level of consent the patient has given, is the patient being coerced or manipulated by the coach or others, and has such a decision been freely made? Are they fully aware of the consequences of such action? Although high levels of risk taking is not uncommon among athletes, it could be argued that patient awareness and free choice might mitigate this to some extent.

Also I might want to explore the level of independence of the doctor, is he/she acting in the best interests of the patient? Or, is he or she acting outside acceptable medical practice in sport for whatever reason. We might also want to explore whether provision of the service gives the coach or team management another outlet for further pressure on doctors and/or athletes.

So back to Chris’ comments if a service is required for good clinical reasons, I don’t think we should let the fact that it could be abused put us off supplying that service. But it could be an issue if it encourages greater risk taking behaviour and raises expectations and pressure on the doctor.

I think this is an interesting area of debate and discussion.

Dr Paul McCory, BJSM editor at large, adds this comment:

That needs to be balanced by team docs who may not be as knowledgeable or discerning. In Sydney 2000 games (soccer) we had certain team docs who insisted on doing plain xrays on all athletes in their teams at the conclusion of each match. Under the Olympic ‘agreement’ we (as polyclinic volunteer docs) were obliged to facilitate their request in spite of the fact that we felt it unethical and potentially dangerous. We were firmly told by the Olympic organisation to but out when we raised this issue. I have serious concerns with imaging being anything other than diagnostic unless their is some level of certification of
team physician skills (which is of course unrealistic).

Comment from Dave Gerrard, BJSM editorial board member.

I’m in Manchester at present attending a FINA Medical Congress. I am of a mind to say that if injecting in the manner suggested is in accordance with accepted therapeutic practice it should first be done in accordance with WADA TUE (Therapeutic Usage Exemption) requirements.

If it is to simply accelerate a return to sport then the WADA requirements are not met and WADA rules would indicate that TUE should be declined. I believe that imaging services ought to be available to confirm diagnostic suspicions rather than to facilitate return to play.

Dr Paul McCory, BJSM editor at large, adds another comment:

I agree with your sentiment but the host city actually signs an agreement that allows team doctors unrestricted medical rights to treating their teams and that the host city doctors are obliged under that agreement to support those team doctors desires !!

Chris Milne, BJSM editor and New Zealand Olympic Sports Physician replies:

Perhaps with the upcoming European initiative of trying to establish a world curriculum in SEM, we can then follow up with some form of credentialling that would enable Fellows [or their equivalent] to order interventional procedures. Certainly the scenario you describe in Sydney is scary, and there must be a place for the venue/IOC Med Commission people to step in and say that x investigation or procedure is so out of touch with world best/evidence based practice, that it cannot be permitted at a major games…. I realise this is a potential hornet’s nest, but I personally would not shrink from such a proposal, as the ultimate beneficiaries will be the athletes, who will be getting a consistent high standard of care. I’d be interested in the views of others, although I have only 6 months to run in my Presidency, and a fairly short list of what I believe to be achievable goals in that timeframe. This is an item for the long term.

I didn’t realise it was so presciptive, and here’s me being compliant for all these years. Actually, we’ve had great support everywhere from venue docs. However, it’s good to know that background in the event of things getting sticky up in Beijing later this year.