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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.

Valerie Adams – Greatest shot putter ever talks about her physio & sports medicine team / And you can get the Aspetar Journal (96 pages) hard copy for free!

22 Oct, 13 | by Karim Khan

This interview was published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Qatar Orthopaedic and Sports Medicine Hospital.

Just email with the address you want the excellent Aspetar Sports Medicine Journal sent to and you’ll join 1000+ on the subscriber list. No junk mail, no selling your details – just this excellent high-quality content journal that has emerged from Qatar (now in Volume 2).


Her career speaks for itself: two Olympic Games gold medals, two Commonwealth Games gold medals, two World Indoor Championship gold medals and four World Championship gold medals. In 7 years, there has been only one time when New Zealand shot putter Valerie Adams didn’t take home gold, and even then it was a silver. In the world of track and field, she was the first woman to win four back-to-back individual world championships. When it comes to shot put, she is the most successful shot putter (man or woman) of all time.

How did she get there? A combination of discipline, pain and very little downtime. Here the 29-year-old tells Nick Cowan about her love of competition and great support team.

Tell us about some of your career highlights.

Highlights for me have been the 2008 Beijing Olympic Games where I won a gold medal, the 2001 World Youth Championships which was my first big win, 2011 World Championships in Daegu where I equalled the championship record with a personal best throw of 21.24 m and the London Olympics last year – eventually!

What is your current training programme?

My training programme consists of two sessions a day. I do a lot of weight lifting, throwing, plyometrics, medicine ball work, a lot of specific training for throwing the shot and recovery and rehab on top of that.

My coach, Jean-Pierre, designed an eccentric-concentric machine that we use for base training in Switzerland. There are no machines like this in New Zealand and so we travel to Switzerland to start new phases. This type of training enables me to get maximal strength and get a real base under me, in contrast to normal training in the gym.

With the athletic schedule the way it is, do you ever get any downtime?

I get about 4 weeks off in October when the season’s done, that’s it.

My holiday period is basically just the month of October and, thankfully, it’s a good month for me. I get to party because it’s my birthday and I try and be a ‘normal’ citizen for that month.

You spend most of the year living outside of New Zealand. What’s it like to live away from your home?

It’s just part of life and it’s something that I’ve chosen to do. My career as an athlete won’t last for the rest of my life so I’m giving it my best shot while I can. It’s good to be away from New Zealand because there are no distractions, meaning there’s more time to train and recover.

And Europe this is where the competitions are, so it makes more sense to be based here instead of New Zealand.

What would you say is the toughest part about the sport of shot put throwing?

Every aspect of it is challenging.

Have you ever had an injury that threatened your career?

In 2006 I had shoulder surgery. I had two cm cut from my clavicle because of overuse. It didn’t stop my career as such, fortunately, because it happened in the off season and I was able to get without it interfering in any competitions.

I’ve been quite lucky in that I haven’t had to skip a season through injury so far. That’s down to having a great physio and also the support team who have been able to manage me.

Then again, I’m not the kind of athlete to stop for anything. My pain threshold is very high, I’m an animal like that and I love to compete very much. I’ll do anything to compete, pain or no pain. But pain is just part of an athlete’s life.

How do you treat an acute injury?

Basically I call my physio, Louise Johnson. She’s been working with me since day one; we’ve worked together for 14 years. She assesses the situation from near or far and we try and get the help we need immediately. It can be hard if I’m overseas but she runs the show and gets help to me as soon as possible.

I am pretty good at self-managing but she calls the shots on doctors and scans and I just have to listen to her.

Who makes up your medical support team?

I work on a day-to-day basis with my physio, Lou. She’s my right-hand man, the person who is on my phone’s speed dial. It’s very important to have a good relationship with someone like that.

I don’t travel with a doctor. Because my physio knows me so well, she knows what I need and what to do when things come up. But I do have a doctor, chiropractor and massage therapist and as far as ay medical conditions are concerned, those are the people that look after me.

Who makes the decisions around your health?

It’s a team approach but I basically have the last choice. The doctor’s opinion will usually have the biggest impact but then again I have both a sports doctor and a general practitioner who I see.

What is your relationship like with your coach?

My coach is awesome! He’s saved my career and made me a better athlete than ever. With his training and planning I’ve been able to save my back from injury. It’s very important that he is kept in the loop on everything. If you’re a team, there’s nobody kept in the dark.

He’s a very hands-on coach. He likes to know what’s going on and will adapt things accordingly – which is very important – as opposed to shutting down on you. I’ve been lucky to work with my coach, Jean-Pierre.

Do you follow any injury prevention programmes?

No, not at the moment.

Do you follow a nutritional strategy?

I don’t follow any nutritional programme but do have supplements to take. I work with High Performance Sport New Zealand who help me figure out what to take pre- and post-competition. As far as eating is concerned I look after myself.

Do you find much difference in the medical treatment you receive when you travel, compared to back home in New Zealand?

This is only my personal experience, but I have found that European physios are not as hands on. In Europe they tend to give you a lot of stretching and exercise and ask you to come back in a few days. I prefer to feel like I’m getting more benefit from hands on work.

What do you think the athletic world can learn from New Zealand?

I think it goes both ways. In New Zealand, we have to fight all our own battles because we’re stuck at the bottom of the world – we have to research what the rest of the world is doing. We do well for a small country but I think we have our own strategies which work for us. Of course, there are things in Europe that we could benefit from. For example, their technology tends to be slightly better.


Australian Football League considers Concussion Consensus Statement

12 Mar, 13 | by Karim Khan

Interesting take on the Consensus statement from the Zurich 2012 Conference on Concussion In Sport. This paper is Open Access on BJSM and BJSM is the exclusive publisher of the 12 systematic reviews that underpin the Consensus statement. This special issue of BJSM is an Injury Prevention and Health Protection (IPHP) issue of BJSM – supported by the International Olympic Committee.

Click here for the full AFL blog:



Celebration of life and sport: World Transplant Games – Durban, 2013

9 Jan, 13 | by Karim Khan

 By Dr. Efraim Kramer

WTGF_Durban_2013The XIX World Transplant Games (Games), under the auspices of the World Transplant Games Federation, is heading for Durban, South Africa in July 2013. These Games are open to all organ transplant recipients internationally and it is expected that 1500 athletes from 52 countries will participate in the 5 day sporting event. This major sporting event, a celebration of life by those who have been afforded a second chance, consists of exclusively  non-contact events such as track and events, cycling, mini marathon, ten pin bowling, volleyball, pétanque, lawn bowls, badminton, tennis, squash, table tennis, golf and a wide spectrum of swimming events. All sporting events are further risk categorised into physiological low (golf), medium (table tennis) and high (athletics) stress level sporting events.

Swimmer from WTG 2011, Göteborg, Sweden (Photo courtesy of

Swimmer from WTG 2011, Göteborg, Sweden (Photo courtesy of

Several things makes this sporting event unique. Beyond the special medical entry requirements of each athlete, there is:

  1. The array of approved anti-rejection and related medications administered by each athlete.
  2. The requirement for a transplant physician medical certificate confirming the athlete’s health and fitness to participate in the sporting events selected. And;
  3. The participation of both children and adults in the Games, albeit in different events.

No athletes are permitted to participate if they are undergoing any form of organ rejection or renal failure, anaemia, immunosuppression instability, hypertension, cardiac arrhythmia or infection.

Most participating teams are accompanied by medical personnel who take overall responsibility for each team member’s medical requirements and occasional problems, but this may not necessarily be so for smaller teams. Therefore the medical services plan for these Games cover an anticipated spectrum of medical incidents, including those related to organ transplantation matters. As such, the local organising committee (LOC) includes organ transplant medical and professional personnel  and organ transplant delegated medical institutions, so that any non-sport related, organ transplant specific medical event, including acute organ rejection, acute infections or organ dysfunction, to mention a few, may be immediately referred for organ transplant medical specialist opinion and management, if required. It is also mandatory that the medical LOC has access to the medical file of every participant. This is necessary not only to confirm participation on health grounds, but to have advanced knowledge of the athlete’s medications, their local availability, organ transplant approved infectious disease prophylaxis and immunization status. Immunizations may include tetanus, malaria and rabies if the Games athletes engage in local safari, a major tourist attraction in this part of the world.

Needless to say, an international sporting event of this nature is a valuable educational opporunity for athletes and medical LOCs.  We will update the BJSM Blog with highlights during the Games.


Efraim Kramer, Chief Medical Officer: World Transplant Games, South Africa 2013

Professor + Chair: Division of Emergency Medicine

Honorary Professor: Exercise Science + Sports Medicine

University of the Witwatersrand, Johannesburg.

Insights from the 2012 Paralympic Games

28 Sep, 12 | by Karim Khan

By Dr Dinesh Sirisena

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

Billed by the official television broadcaster as the main event following the Olympic Games ‘warm-up’, the Paralympics have surpassed all expectations and will undoubtedly change perceptions of disability sport in Great Britain. For most, it has been an awakening as to what these athletes can achieve.

Working at the games

Having worked at both the Olympic and Paralympic Games this summer, I gained insights into the international sporting events.  While both were enjoyable, the Paralympics have been somewhat humbling. Especially when witnessing some of the adversities that the athletes have overcome in their bid to become champions.

Based at the Olympic stadium during the Paralympic Games, I was exposed to challenges different to those at other multi-sport athletics events.  With the variety of track and field competitions occurring simultaneously, one is always conscious of giving all events equal attention.  This is challenging at best, but with additional functional impairments and variations within each category, these athletes were at greater risk of injury compared to able-bodied athletes.  Where this was particularly evident was during the F11/12 (visually impaired) triple jump event; unable to visualize where they were aiming, athletes would veer across the track and land dangerously close to the edge of the sandpit.  Additionally, athletes in the T31-38 events (cerebral palsy) could have quite variable degrees of disability.  For some, simply completing the race was an achievement.

From the field of play perspective, it meant planning and rehearsing moulages to ensure our skills were kept sharp and that we worked seamlessly within the team.  Inventing worst-case scenarios, such as wheelchair crashes and extracting seated athletes, kept the training challenging and meant we were confident to deal with any situation.

In addition to the sport, I was privileged to be present at the opening and closing ceremonies.  Uninitiated in Paralympic ceremonies, it was particularly unnerving when fire and water hazards were mixed in with Paralympians and dancers somersaulting through the air.  Although it meant little respite for the medical team, it was a true spectacle and was memorable for all.

The Legacy

With the catchphrase “inspire a generation”, for some, the 2012 Games will do exactly that.  Built on the pledge that sport can inspire, change and improve lives, an NHS document in 2009 stated that the Games would change health beliefs and practices by targeting unhealthy behavior and reducing levels of physical inactivity in London and indeed nationwide.

An additional objective was to inspire the next generation of athletes.  By introducing families to sports, the Games brought to the limelight those events that are infrequently televised and made them centre-stage, seeding ideas for our future athletes.

Personal thoughts

Whether these ambitions will materialize depends on numerous factors beyond our control as doctors.  Nevertheless, many of my patients have witnessed the Paralympics and I will endeavor to build on this interest and enthusiasm towards sport, encouraging people to be more active in their daily routines.  Whether it will involve taking up a new sport or simply considering cycling to the station instead of taking the bus, I am optimistic that the Paralympics were a step in the right direction.

Irrespective of the legacy ambitions, the Paralympics showed us what can be achieved despite adversity.  With personal sacrifice and self-belief, these athletes have brought their individuality and sport to the forefront of our consciousness, leaving little doubt that they are indeed elite sports people and not simply individuals with a disability.



Dr Dinesh Sirisena is a Sport and Exercise Medicine Registrar in London.  He is an Honorary Clinical Lecturer at Bart’s and the London Medical School and is Team Doctor at AFC Wimbledon.

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

London 2012, the highs, the lows and……the Legacy: A UK trainee perspective

31 Aug, 12 | by Karim Khan

By Dr Ritan Mehta

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)


We have just witnessed the ‘Greatest Show on Earth’.  Over 10,000 athletes from 204 National Olympic Committees competed in 26 sports in a total of 39 disciplines at the London 2012 Olympic Games.  Whether you are a sport enthusiast or not, there was an attraction to the Olympics that one could simply not resist. If it wasn’t the exhilarating sport on offer, there was also the torch relay and the fascinating opening and closing ceremonies.

The Highs

On a personal note the Olympics were an incredible high in my life. When I first thought about working in Sport and Exercise Medicine (SEM) I would never have dreamt of working at an Olympic Games, never mind at one staged in my home city. It was an amazing experience, witnessing great sporting achievements at first hand.

My role involved being a Field of Play Retrieval Team Member at the Olympic Stadium. I was fortunate to be sitting trackside, looking out for and assisting in the safe and timely retrieval of injured athletes.  Each shift involved working with different individuals from a variety of clinical backgrounds. The ability of teams to bond and work effectively and quickly together was outstanding.  There was also room for some continuing professional development (CPD) consisting of specialist lectures by well renowned experts on topics ranging from hamstring injuries and exercise associated collapse  to concussion and knee assessment .

From a sporting point of view, the Games had countless highs but for me there were a few defining highlights.

  1. The three gold medals for Team GB in 46 minutes on the first Saturday night will go down in history as one of the best ever nights of sport in Great Britain.
  2. The fastest man in the world, Usain Bolt winning the 100m, 200m and the 4x100m finals.
  3. The young, inspirational 15 year old swimmers Ruta Meilutyte and Katie Ledecky winning gold medals, showing their generation what can be achieved through dedication and hard work.
  4. The cycling legends, Sir Chris Hoy winning his sixth Gold Medal and Bradley Wiggins becoming the most decorated British Olympian. They, together with the GB cycling team, have inspired the nation to get back on the bike.

The Lows

The Games did not pass without its problems. Sport is about fair play and competing on a level playing field. The Chinese, Indonesian and Korean players expelled from the Olympics for match-fixing surely showed the ugly side of sport.  One hopes that this will not be allowed to happen again. Performance enhancing drugs and sport are never far apart but with only three positive tests during this Olympics, it was one of the cleanest Games. This however does not tell the whole story. The World Anti-doping Agency reported that over 100 athletes were prevented from competing prior to the games because of doping offences. One must also question whether the limited number of positive tests indicates a reduction in athletes using performance enhancing drugs or whether they are simply getting better at hiding it. This is discussed at length in Dr Peter Brukner’s guest blog: Drugs and the London Olympics.

Comparisons have frequently been made between Olympians and Footballers with the criticism for the latter group. I would question why the racism accusations against Luis Suarez and John Terry have made front page news when there were also three Olympic athletes who were censured for racism, including Petras Lescinskas who was fined £2500 for making Nazi Salutes and Monkey noises when the Lithuanian basketball team played Nigeria, which has barely made the news at all. The International Olympic Committee is commended for making an example of these cases and helping the worldwide fight against racism in sport.

The legacy

Legacy has been a key part of the London 2012 Olympics ever since the Games were awarded in 2005. Every individual has their own thoughts as to what the Olympic legacy really means.  I wanted it to inspire people to take up physical activity in an attempt to reduce the growing obesity epidemic. I was also hoping that it would be a catalyst for the development and sustainability of Sport and Exercise Medicine as a medical speciality.

Strategies have been put into place to encourage individuals to take up physical activity, which I believe will help, at least in the short term.  Time will tell whether this will continue in the long term.

What will happen to Sport and Exercise Medicine?

As a trainee in SEM I am worried about the lack of NHS consultant posts being developed and even more troubled by the lack of new trainees coming onto the training scheme. This topic is raised by Liam West in his BJSM podcast [link to come] .There is a lot of work being done behind the scenes and a £30 million capital grant to develop a National Centre for Sport and Exercise Medicine (NCSEM) is a step in the right direction. I am however left wondering whether the funding and drive for SEM will continue once the Olympics and Paralympics have passed.

The Olympics has been a truly memorable experience for all involved. I am fortunately not yet suffering from Post Olympic Depression Syndrome as I eagerly await working at the biggest Paralympic Games the world has seen starting on 29th August 2012.

For those who can’t make the Paralympics but need a sports medicine fix – remember that the BASEM conference is on November 22 and 23, 2012. Just 100 days to go!


Peter Brukner on Drugs and the London Olympics.


Dr Ritan Mehta is a General Practitioner, Specialist Registrar in Sport and Exercise Medicine and Club Doctor for Watford Football Club.

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

“How does a clinician know what’s in the athlete’s best interest?” An Olympic experience

24 Aug, 12 | by Karim Khan

By Dr Amir Pakravan

Sport and Exercise Medicine: The UK trainee perspective (A twice-monthly Guest Blog)

The practice of medicine, by its very nature, is prone to ethical problems and dilemmas. This is even more evident when providing pitch-side or field of play medical care to professional athletes. Whether it is Fencing’s 10 minute or Taekwondo’s 1 minute rule, the medical practitioner is almost invariably pressed for time to assess an athlete in a less than ideal consultation area and make on-the-spot decisions which could potentially end either the athlete’s hopes and dreams of glory or their professional career.

The London Olympic games saw more than 10,000 elite athletes from 204 countries competing across 26 different sports. Considering the current number of UN member states at 193, one can only anticipate an exceptionally diverse population of highly motivated individuals from different cultural backgrounds, all of whom are determined to perform to the best of their ability and beyond.

Cultural differences and their impact on individuals’ perception of and attitude towards injury, pain, suffering, and chivalry can immensely influence athlete’s reactions and expectations. To further complicate matters there is media attention, coaching and support team expectations, potential financial gains, and more often than not, governments’ invested interest in Olympic teams for publicity and propaganda purposes.

Be it repeated injections of local anaesthetic into an injured limb or complacency in providing adequate care, we have all heard of medical team members who for one reason or another, and either by informed choice or through sheer pressure of on the spot snap decision making, have treaded into the grey zone between what is considered ethical and unethical practice.

Such decision making dilemmas became vividly evident to me when, in my role on the Field of Play during the Games, I got involved in assessing and providing medical care to an Olympic gold medal hopeful whose injury meant he would have to leave the competitions without a medal. In addition to an intensely emotional reaction from the athlete and his initial resolve to compete through extreme pain, his medical support team continued to request his return to the competition despite being fully aware of the nature of his injury.

Our team, however, did all that was deemed appropriate at the time and eventually after a factual discussion with the athlete and his coaching team he decided to retire from competition. We further organised investigations and follow up as appropriate and achieved a favourable conclusion, or did we? Well, maybe not from the athlete’s perspective.

On reflection, and after discussion with other senior colleagues, I am convinced our approach was consistent with the best practice in similar presentations to an Emergency Department or outpatients Orthopaedic or Sports Injuries clinic. But we were dealing with completely different circumstances where the athlete, from a different cultural background, and at the peak of his sporting career was under immense pressure to perform. He had a medical support team which he trusted and which encouraged him to continue, with this probably being his only chance of getting an Olympic medal. This clearly was a very stressful situation.

The ethical issues arising from this case are complex considering that:

1) The objectivity of advice offered by an athlete’s own medical team, given their full knowledge of his medical history which they were reluctant to share.

2) The athlete’s ability to give informed consent or make decisions under such immense pressure.

3) The potential ‘conflict of interest’, given our role as an independent but responsible third party.

These are only but a few of the issues for clinicians who work in this setting to consider and discuss.

Suggested Further Reading:

1)  L Anderson. Writing a new code of ethics for sports physicians: principles and challenges. Br J Sports Med. 2009;43:1079-1082

2) Salkeld LR. Ethics and the pitchside physician. J Med Ethics. 2008 Jun;34(6):456-7

3)  Standaert CJ, Schofferman JA, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: conflict of interest. Arch Phys Med Rehabil. 2009 Oct;90(10):1647-51

4) Holm S, McNamee MJ, Pigozzi F. Ethical practice and sports physician protection: a proposal. Br J Sports Med. 2011 Dec;45(15):1170-3 (Free, Editor’s Choice)

5) Holm S, McNamee M. Ethics in sports medicine. BMJ. 2009 Sep 29;339:b3898 (not free)

6) FSEM Professional Code. V.1 – ©1st July 2010 FSEM (UK)


Dr Amir Pakravan is a Sports and Exercise Medicine Registrar in Cambridge who has worked with different professional and elite team sports.

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

Dr. Babette Pluim: Living the Olympic Dream

22 Aug, 12 | by Karim Khan

By Dr. Babette Pluim (@DocPluim)

To work at an Olympic Games is a dream for every sport physician. So, in 2011, I applied to LOCOG as a volunteer. The minimum commitment was ten days, with an option to do both the Olympics and Paralympics. Nothing could hold me back at the interview. Yes, yes, yes, put me down for everything that is going. Needless to say, every day of sunshine is followed by a cloudy day or two. I did not realise that there were possibly going to be a few spots of rain along the way!


The fact that I live in the Netherlands is not LOCOG’s fault but I had to fly back and forth from Amsterdam to London for: my orientation training (a 2-hour rah-rah bonding session), the role-specific training (some general pre-hospital care training and role play), the venue-specific training (in my case, a guided tour of the Olympic Stadium with role play), my GMC interview and accreditation, and finally for LOCOG accreditation and uniform collection. None of these could be squeezed into one visit so I had already visited London five times (along with all the other medical volunteers) and the Olympics hadn’t even started yet. But hey, if the athletes can show commitment and determination, so can I! Armed with my stylish purple/pink uniform, I was ready for anything!

There was a slight problem with scheduling. Working 7 days in a row is much easier to fit into a busy work schedule than 7 spread over 17 days. One day on duty, followed by three days off, two days working. 1 day off etc meant that I now had to take six weeks unpaid holiday to cover both the Olympics and Paralympics. Not an insurmountable problem, but slightly unexpected, so a gentle request and a flurry of e-mails resulted in a rescheduling of the Paralympics duties (consecutive days to 9), and I was down to only five weeks away from paid employment.

My first shift

For my first shift I was a bit nervous. It was on the 25th July before the Games had started – the day of the rehearsal for the Opening Ceremony. My shift started at 3pm but we had been told to arrive two hours early and to allow one hour for security. Security actually took three minutes and I never had a delay of longer than five minutes at any time during the Olympics – top marks to the military who were fast, friendly and forever courteous.

As a result, we all gathered in the dining area in good time and right at 1pm the LOCOG staff appeared and split us into two groups: first aid for the crowd and field of play recovery teams. I was in the field of play team (16), normally only responsible for athletes and officials, but today we would also be responsible for the 7,500 people participating in the opening ceremony.

We were taken to the venue medical area under the stadium. The 16 of us were split into 4 groups of 4. My group consisted of a sports physician (me), an anaesthetist, an A+E specialist and a paramedic. The arena field of play had 5 major entrance/exits, referred to as VOMs, one at each corner and an extra one under the Olympic flame. We were evenly divided over the 4 VOMs, and every group had to cover his/her quarter of the track.

Working as a team 

For the first two hours, we did pre-hospital care training (role play) as a team, and practiced resuscitation and recovery scenarios. How would you handle: an official who was hit on the head by a discus, or three hurdlers who collided and ended up with one shrieking loudly, one lying silently, flat on his stomach, and one with his lower leg angled in a funny way? We were rapidly drilled into a smooth running team and got to know each other very well.

Why do you need to train a highly skilled group of professionals? All I can tell you is that it worked extremely well. The nervousness disappeared completely and we rapidly became a ‘front line’ unit that could cope with anything that the event had to throw at us. We were all from different backgrounds, and the training ensured that all our skills and competencies were fully utilised. Hence the make up of each ‘quadrimed’ – a sports physician (to evaluating sport injuries), a traumatologist or anaesthetist (to establish good airway access), and front-line emergency support (paramedic, A+E nurse, ambulance technician etc).

Action in the field!

Did we have anything to do? Certainly – but not a lot! During the 400m relay heats, as documented in every daily paper, the American athlete broke his fibula and continued his leg of the race, the South African tripped  and fell onto his shoulder, and a Jamaican third athlete had an upper leg injury – all in the same race series! Our teams were always located on the outside of the running track so the process was simple – check that it was safe to move onto the field of play, despatch a pair to review the injured athlete (one with a radio), assess the athlete, treat if necessary and rapidly remove to the medical facility (in our case by wheelchair). Easy enough you say, but with 80,000 people screaming at the top of the lungs while you are assessing an injured athlete, the adrenaline is in overdrive.

Every day we had a pre-shift briefing and a post (8-12 hour)-shift debriefing. The topic of one of these briefings was: make sure that you are noticeable, and it is noticed when you offer medical assistance to an injured athlete. Hang on, you say, aren’t you meant to be nearly invisible out there and do you job as inconspicuously as possible?

It turned out that one of the commentators doing an overseas broadcast had mentioned, live on TV, that an athlete had not received prompt medical attention. In fact, the hurdler had been offered a wheelchair immediately (within 20 seconds) but had refused assistance and hopped towards the finishing line. After the end of the race, he was helped off the track by two fellow athletes and medical personnel were finally able to take over.

In our briefing the next day, it was suggested that the visibility of the medical teams should be slightly raised – without going to the extreme of offering a wheelchair to every 10,000m runner when they finish and lie down on the track.

Collapse management

Another gem to come out of our training and briefing sessions included a review of collapse. A collapse before the finish line is abnormal and the athlete requires immediate attention. A collapse after the finish line is more common and is generally innocent – athlete bending over, hands on the hips or knees, athlete lying on the ground on their back with the knees bent, athlete kneeling on the ground with the head touching the ground. Abnormal postures that should sound alarm bells are – athletes lying flat on their back with their legs straight or lying flat face down on the stomach.

All equipment and supplies at the Games were standardised and provided by LOCOG. The medical professionals were not even required to bring their own stethoscopes. Every medical volunteer had a small green waistbag that contained gloves, paracetamol, sticky plasters, scissors etc, for the immediate care of small wounds and minor medical problems. The team leader of every quadrimed (group of four) carried injectable morphine and every group had two radios, a scoop stretcher, a basket stretcher, a gurney, a wheelchair, an AED and a big red medical bag with resuscitation equipment.

Most event doctors are used to carrying their own bag of equipment and supplies. So before every shift we each had to familiarise ourselves with the content the LOCOG provided in the Standard Red Bag. In addition, the 2 hour, pre-shift training and role play sessions enabled the teams to practice using the stretchers, gurney and AED.

One of the best weeks of my life!

I will never forget being on the track the evening that Mo Farah won the 10,000m and Usain Bolt, and the Jamaican Team, set the world record in the 100m relay. I have never heard such an incredible noise, or seen 80,000 spectators stand up and encourage one man home like they did that night!

Elite athlete care is just one part of the sports physicians role but it provides a great opportunity to help athletes who have spent many years training to achieve their goals. Their single minded focus, and continual commitment to improve, is inspirational not only for other sportspeople but for all of us who are aiming for excellence in our vocation.

Volunteering is a crucial part of the Olympic Movement and the LOCOG are to be congratulated on delivering the London 2012 Olympic Games superbly. I am now preparing for my role as the LOCOG venue doctor at Eton Manor, the home of wheelchair tennis during the Paralympic Games – bring it on!


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

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