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And the winner of the BJSM education content poll is…

16 Nov, 12 | by Karim Khan

…Groin pain/ hip pain!

That’s right, out of close to 100 respondents, nearly half indicated that they want more BJSM education content on groin pain / hip pain. We will be sure to take these results back to BMJ headquarters.

The full break down of poll results are:

  • Groin pain/ hip pain: 49%

  • Management of hamstring strain: 13%

  • Cardiac pre-participation assessment: 9%

  • Cardiac resuscitation at sporting events (what should be present at every game?): 12%

  • ACL management (conservative or operative?): 17%


Thanks to everyone who voted, we really value your feedback. Stay tuned  for new research articles, assessment techniques, and tutorials from the experts.

For now here are some great articles already free online:

Weir. 2011. Prevalence of radiological signs of femoroacetabular impingement in patients presenting with long-standing adductor-related groin pain

Thorborg. 2011. The Copenhagen Hip and Groin Outcome Score (HAGOS): development and validation according to the COSMIN checklist 

Noehren et all. 2009. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome.

‘Cool it!’… So is thermal perception a controller of exercise intensity during heat stress?

28 Apr, 12 | by Karim Khan

By  Drs. Zachary J. Schlader &  Toby Mündel 


In response to:  Barwood MJ, Corbett J, White D, et al. Early change in thermal perception is not a driver of anticipatory exercise pacing in the heat. Br J Sports Med 2011


Dear Editor,

We read with great interest the study by Barwood and colleagues published recently within BJSM  [1].  In this study, the authors aimed to explore the relationships between body temperature(s), thermal perception, and the voluntary control of exercise intensity in the heat.  For this they should be commended for although this area is quite topical, our understanding of these relationships remains virtually unknown.  By chemically activating peripheral cold thermo-sensors with menthol, Barwood et al. [1] have demonstrated that improvements in thermal comfort and reductions in sensations of warmth, independent of changes in skin temperature, both prior to, and during, the initial stages of self-paced exercise in the heat did not influence the selection of exercise intensity.  Although the conclusions drawn appear appropriate, we would like to further discuss their results in the context of others to explore this topic and perhaps allow a better understanding of our current base of knowledge.

As part of the rationale for conducting their study, Barwood et al. [1] state “It is presently unknown whether altered pacing strategy is regulated as part of behavioral thermoregulation driven by a conscious awareness of thermal state or if a central and subconscious homeostatic mechanism is activated when skin temperature rises above a threshold rate”. Furthermore, Barwood et al. [1] conclude that “This study addresses an as-yet unanswered question of whether the fatiguing mechanisms during exercise in the heat are primarily consciously or subconsciously mediated”.  Firstly, we would like to draw the authors’ attention to our recent work testing the hypothesis that voluntary reductions in exercise intensity in the heat are thermoregulatory behaviors [2].  Our results demonstrated that the observed reductions in power output during exercise in ~40°C compared to ~20°C were, at least in part, due to a conscious action that was inversely related to total heat body storage and thermal discomfort, and improved heat exchange [2].  Secondly, it is unfortunate that it was not possible to discuss two of our recent studies demonstrating that skin temperature and/or the perceptions of this temperature play a large role in the initial selection of [3] or sustained decrease in [4] exercise intensity.  Perhaps in “addressing [only] two current viewpoints on how exercise pacing is driven in hot conditions” Barwood et al. have unintentionally overlooked this recent evidence?

This notwithstanding, the results put forward by Barwood and colleagues [1] appear to be in stark contrast to those we obtained utilizing a similar methodology whereby menthol and skin cooling was used to independently alter thermal perception and skin temperature during exercise at a fixed rating of perceived exertion (RPE) [5]. These results showed that an improved thermal comfort and reduced sensations of warmth with menthol enhanced the capacity to maintain exercise intensity.  Thus, we concluded that thermal perception is a capable modulator of exercise intensity independent of any change in skin temperature [5]; so why, then, such opposing views?

As supported by Barwood et al. [1], it is becoming increasingly clear that RPE is perhaps the most dependable criterion dictating the voluntary selection of exercise intensity [6].  In such circumstances, it appears as though, independent of perturbation (e.g. hypoxia, heating, cooling etc.), the exerciser compares how they feel to how they expect themselves to feel at that moment in time and adjust their exercise intensity accordingly [6].  Thus, although the RPE response during self-paced exercise appears to be tightly controlled, the effect of a given perturbation is found in changes in the selection of exercise intensity (or pacing strategy).  Therefore, the sole manner in which pacing strategy can be altered is if the perturbation is large enough in magnitude to alter RPE.  Herein lies the difference between our studies.  It is unlikely that the cooling modalities (either skin cooling or menthol) utilized by Barwood et al. [1] were sufficiently sustained or large enough in magnitude to alter RPE.  In contrast, by utilizing a significantly different experimental design to address the same question, we were successful in altering RPE.

The reason for this is likely four-fold, but certainly other rationale cannot be discounted.  Firstly, in contrast to the entire skin surface we chose to manipulate the skin of the face, an area that is both of high thermal sensitivity during heat stress [7] and an area that has been directly demonstrated to modulate exercise duration [8].   Secondarily, we used a greater concentration of menthol (8% vs. 0.05%) which, together with the facial manipulation, likely elicited a larger change in thermal perception.  Thirdly, we chose to use fit but untrained subjects, as trained individuals have an altered perception of their physiological thermal strain during exercise [9].   Thus, our subjects were likely more sensitive to changes in thermal perception.  The fourth, and perhaps final reason for the observed differences between these two studies likely stems from the exercise protocols used, i.e. fixed-RPE vs. time trial.  For instance, anecdotal observations from our laboratory suggest that the fixed-RPE protocol may be more sensitive to a given thermal stimulus than a time trial; although to our knowledge there is no formal data suggesting this arrangement.  Other rationale that should probably also be considered include the heat stress compensability and modality, exercise duration, and suitable subject blinding to the experimental conditions, amongst others.

In conclusion, we would like to commend Barwood and colleagues for their study and the data it adds to the literature.  However, we would urge caution before readers draw conclusions based on this study alone.  As it currently stands, the relationships between temperature, thermal perception, and exercise intensity remain uncertain and further research is required before conclusions can and should be drawn.  The differences between our study [5] and that of Barwood et al. [1] further highlight that the choice of experimental methodology may greatly influence a study’s outcome(s).  Issues pertaining to methodology are not specific to perception and exercise.  For instance, this journal recently highlighted another (equally debated) area, i.e. exercise and fluid replacement, which suffers from similar methodological concerns [10, 11].  Nevertheless, these studies [1, 5] endorse (and encourage) the use of menthol and other chemicals capable of affecting thermal perception without changing skin temperature in providing a useful paradigm to study the interactions between thermal perception and the voluntary control of exercise intensity.  Finally, as is the case with nearly all areas of research, we would encourage further studies in this area to ensure a better understanding and therefore, perhaps, a resolution to this interesting and topical area.



1.         Barwood MJ, Corbett J, White D, et al. Early change in thermal perception is not a driver of anticipatory exercise pacing in the heat. Br J Sports Med 2011.

2.         Schlader ZJ, Stannard SR, Mundel T. Evidence for thermoregulatory behavior during self-paced exercise in the heat. J Therm Biol 2011;36:390-6.

3.         Schlader ZJ, Simmons SE, Stannard SR, et al. Skin temperature as a thermal controller of exercise intensity. Eur J Appl Physiol 2011;11:1631-9.

4.         Schlader ZJ, Stannard SR, Mundel T. Is peak oxygen uptake a determinant of moderate-duration self-paced exercise performance in the heat? Appl Physiol Nutr Metab 2011;36:863-72.

5.         Schlader ZJ, Simmons SE, Stannard SR, et al. The independent roles of temperature and thermal perception in the control of human thermoregulatory behavior. Physiol Behav 2011;103:217-24.

6.         Schlader ZJ, Stannard SR, Mundel T. Human thermoregulatory behavior during rest and exercise – a prospective review. Physiol Behav 2010;99:269-75.

7.         Cotter JD, Taylor NA. The distribution of cutaneous sudomotor and alliesthesial thermosensitivity in mildly heat-stressed humans: an open-loop approach. J Physiol 2005;565:335-45.

8.         Ansley L, Marvin G, Sharma A, et al. The effects of head cooling on endurance and neuroendocrine reponses to exericse in warm conditions. Physiol Res 2008;57:863-72.

9.         Tikuisis P, McLellan TM, Selkirk G. Perceptual versus physiological heat strain during exercise-heat stress. Med Sci Sports Exerc 2002;34:1454-61.

10.       Mundel T. To drink or not to drink? Explaining “contradictory findings” in fluid replacement and exercise performance: evidence from a more valid model for real-life competition. Br J Sports Med 2011;45:2.

11.       Goulet ED. Effect of exercise-induced dehydration on time-trial exercise performance: a meta-analysis. Br J Sports Med 2011;45:1149-56.


Zachary J. Schlader, PhD, Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA

 Toby Mündel, PhD, School of Sport and Exercise, Massey University, Palmerston North, New Zealand


Injury prevention in high level snowboard: A need to return to first principles?

17 Apr, 12 | by Karim Khan

 Guest blog by @CarolineFinch

In the recent BJSM blog Is high level snowboard too dangerous to allow your children to participate? Prof Engebretsen raises an important question, namely how to prevent injuries in a sport where pushing the extremes of physical performance in challenging and harsh environments is both an individual athlete and sporting organisation goal.[1]

Most recent advances in sports injury prevention have tended to focus directly on the athletes, themselves, with the aim of making them more resilient to the injury risks they are faced with in their chosen sport. I wonder if, for sports such as snowboarding where most injuries result from acute energy exchange beyond the body’s tolerance, it is time to go back to first principles for injury prevention and revisit the application of Haddon’s 10 countermeasure strategies.[2] In this hierarchy of injury control, “Make what is to be protected more resistant to damage from the hazard” is only the eighth strategy. There are seven higher order control strategies that could (and should) be applied to also reduce injury risks and hazards.

Engebretsen [1]also queries whether leaders of the sport really have true awareness of the risks in elite snowboarding. The fact that so little ongoing attention seems to have been given to identifying and implementing solutions meeting many of the higher-order Haddon countermeasure strategies would seem to support this. Interestingly, a recent blog by Laura Robinson at also queries whether “sports officials’ tendencies to put the fight for new viewers by making the sports more dangerous and exciting” are more favoured than the safety of the athletes of snow sports.[3]

We published a review of the evidence for preventing snowboarding injuries in 1999, with the main focus on recreational participants of this sport as it was still a very new activity in Australia.[4] At that time, the sport was considered similar to other snow sports and so most safety advice was derived from that for more general snow/ski safety. One of our conclusions was:

“the rapid international growth of the sport has not been matched by a detailed epidemiological evaluation of the injuries specific to snowboarding or of the countermeasures to prevent them” (page 118).

It would seem that the situation has not changed that much. All sports injuries occur within an ecological context in which multiple levels of the sports delivery system interact with the physical environments in which sports are undertaken and the specific characteristics of the athletes who participate in them.[5] This applies equally well to high performance and professional sport as it does to the more recreational forms. Future safety gains for snowboarding, as indeed other sports, will only be achieved if all stakeholder groups:

  1. are engaged and united from the outset;
  2. share common goals for the ongoing development of the sport;
  3. prioritise the safety of their athletes; and
  4. jointly invest in the development, implementation and evaluation of cost-effective injury prevention solutions according to Haddon’s hierarchy of control as translated to this sport.


1.         Engebretsen L. Is high level snowborrd too dangerous to allow your children to partcipate? Posted 1/03/2012.: BJSM blog – social
media’s leading SEM voice; 2012.

2.         Haddon WJ. Energy damage and the 10 countermeasure strategies. 1973;13:321-31.

3.         Robinson L. Faster, Higher … Deader. Posted 23/03/2012.; 2012.

4.         Finch C, Kelsall H. Preventing snowboarding injuries – what is the evidence? 1999;6:117-26.

5.         Finch CF, Donaldson A. A sports setting matrix for understanding the implementation context for community sport. Br J
Sports Med. 2010;44:973-8.



Caroline Finch is an injury prevention researcher from the Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) within the Monash Injury Research Centre, Monash University, Australia.  She specialises in implementation and dissemination science applications for sports injury prevention.  She is the Senior Associate Editor for Implementation & Dissemination for the British Journal of Sports Medicine and a member of the Editorial Board of Injury Prevention; both journals are
published by the BMJ Group.

Caroline can be followed on Twitter @CarolineFinch

Injury surveillance on young elite athletes participating in the 1st Winter Youth Olympic Games in Innsbruck/Austria

27 Dec, 11 | by Karim Khan

BJSM e-letter by:

Gerhard Ruedl and Wolfgang Schobersberger

E-letter for: Kathrin Steffen, Lars Engebretsen. The Youth Olympic Games and a new awakening for sports and exercise medicine. BJSM. 2011; 45: 1251-1252 (Warm up)

Photo courtesy of IYOGOC

Do we really want to see our young promising talents go through a major injury at one stage into their career?

Definitely no!

However, in competitive alpine skiing, snowboarding and freestyle, the risk to get major head and anterior cruciate ligament injuries is indeed high [1-4]. Therefore, training focussing on injury prevention should start at an early age and should go along with the athletes’ career. To implement evidence based preventive measures, however, it is of utmost importance to investigate first of all data on occurrence and severity of injuries according to the 4-step model of injury prevention research [5].

At this point of time, there is little data available concerning the injury risk of youth elite athletes competing in winter sports [6, 7]. Therefore, we will conduct a systematic injury and illness surveillance on young elite athletes participating in the 1st Winter Youth Olympic Games in Innsbruck/Austria in January 2012.  Let us work together to get meaningful data as a basis for further research on injury risk factors and injury mechanisms and finally on injury prevention strategies among young elite winter sport athletes.

We are glad to welcome you in Innsbruck!

(1) Pujol N, Blanchi MP, Chambat P. The incidence of anterior cruciate ligament injuries among competitive alpine skiers.  Am J Sports Med 2007; 35: 1070-4.
(2) Florenes TW, Bere T, Nordsletten L et al. Injuries among male and female World Cup alpine skiers. Br J Sports Med 2009; 43: 973-8.
(3) Florenes TW, Nordsletten L, Heir S et al. Injuries among World Cup freestyle skiers. Br J Sports Med 2010; 44: 803-8.
(4) Florenes TW, Nordsletten L, Heir S et al. Injuries among World Cup ski and snowboard atlethes. Scand J Med Sci Sports. 2010 Jun 18 [Epub ahead of print].
(5) Bahr R, Krosshaug T. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med 2005; 39: 324-9.
(6) Steffen K, Engebretsen L. The Youth Olympic Games and a new awakening for sports and exercise medicine. Br J Sports Med 2011; 45: 1251-52.
(7) Steffen K, Engebretsen L. More data needed on injury risk among young elite athletes. Br J Sports Med 2010; 44: 485-9.


Gerhard Ruedl is a Senior Researcher at the Department of Sport Science, University of Innsbruck, Austria

Wolfgang Schobersberger is the Chief Medical Officer of Winter Youth Olympic Games in Innsbruck; Institute for Sports Medicine, Alpine Medicine & Health Tourism Innsbruck/Austria

Confusion/difference of opinion on investigating compartment syndrome. BJSM poll results are in!

4 Nov, 11 | by Karim Khan

The results of the latest BJSM home-page poll are in. We had a split!! Folks can’t agree on a very common procedure in sports medicine. Yikes!! Out of 120 respondents, 57% preferred that all 4 compartments are measured in both legs to diagnose chronic compartment syndrome. Unless both methods have equal outcomes a large proportion of sportspeople are getting suboptimal investigation and treatment!  Please submit your thoughts as a comment below or as an email to and we’ll post it as a Guest Blog. Hot topic!

What do other experts have to say about this topic? Read these related BJSM articles:



Check out the BJSM homepage to contribute to the new online survey.

Educating ALL Medical Specialists to consider exercise as the fifth vital sign – Dr. Danica Bonello Spiteri comments

20 Jul, 11 | by Karim Khan

Guest blog by Dr. Danica Bonello Spiteri

I read with great interest your article  ‘Developing healthcare systems to support exercise: exercise as the fifth vital sign’ (Sallis R. Br J Sports Med May  2011 45;6:473-4 – Free online).

My main concern is whether we should also be educating the physicians. I recently was involved in a discussion with 3 diabetes consultants and was suggesting that whilst working in their department, an exercise and nutrition section should be opened up. Eager to be part of such an initiative, I explained how this can reduce health care costs, morbidity and mortality in the long term for both patient and the health care system.

To my dismay, the idea was quickly shot down. Although they agreed that the evidence is there and there is a good positive outcome, the manpower, expertise and cost to the health care system to initiate such a programme was difficult to obtain.

This made me think deeply, and my main concern is whether we should be also educating the specialists who are not in the field of exercise medicine. The long term benefit clearly outweigh the initial costs, yet lack of initiative about an exercise programme makes me wonder where the problem lies.

We want to know what you think about developing healthcare systems to support exercise as the fifth vital sign!

Please leave comment below or


or Tweet @BJSM_BMJ

Dr Danica Bonello Spiteri graduated from the University of Malta in medicine and surgery in 2004 and obtained her MRCP in 2009. She is pursuing the Masters level degree in sports and exercise medicine at Bath University. She is also a Specialty Registrar in Sports and Exercise Medicine in Leeds, UK. Dr. Spiteri is very active in the triathlon scene on a national and international level, and was the Malta National Sportswoman of the year in 2010.

Concussion in sport: The Consensus

3 Nov, 10 | by Karim Khan

Concussion is certainly hot this week! Lots of news stories of variable quality. Today we review the International Consensus statement itself.

This practical resource was established, using a consensus-based approach, at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. It updates the recommendations of the 1st (Vienna) and 2nd (Prague) International Symposia on Concussion in Sport. Click here to read the full document.

Key areas include:

  • Management of acute simple concussion,
  • complex concussion and long-term issues,
  • Return to play,
  • Paediatric concussion.

BJSMs podcasts also include 3 interviews with concussion guru Professor Paul McCrory, one of the leads on the Consensus statement.  See also this systematic review on helmets.

What do You Think? How has the Consensus Statement on Concussion in Sport shaped how you view and treat concussion?

Keep an eye on our homepage as an opinion poll will be posted shortly.

Reader Response: Rotator cuff tendinopathy

7 Feb, 09 | by Karim Khan

Hutch checks the shoulder
Photo by Lisa Bettany.

By Nicola Maffulli, Umile Giuseppe Longo, Vincenzo Denaro, Consultant Trauma and Orthopaedic Surgeon, University Hospital of North Staffordshire, Keele University School of Medicine

We read with interest the Review Article “Rotator cuff tendinopathy: A review”, by Lewis.

This manuscript may have been submitted before the publication of our investigations. Nevertheless, we would like to call your attention to the fact that we have performed several studies on the aetiology, histopathology and management of rotator cuff tendinopathy.

We investigated supraspinatus tendon samples obtained from patients undergoing arthroscopic repair of a rotator cuff tear to examine the distribution of tendinopathic changes associated with this condition. At arthroscopy, a full thickness supraspinatus tendon biopsy was harvested close to the tear edge. We found more frequent tendon changes on the articular side of the rotator cuff 4.

We found more cartilage-like changes in patients affected by rotator cuff tears, but not in our control group.Recent biomechanical data suggest that the stress-shielded and transversely-compressed side of the enthesis has a distinct tendency to develop cartilage-like or atrophic changes in response to the lack of tensile load 2,7,9,10. Over a long period, this process may develop into a primary degenerative lesion in that area of the tendon. This may explain why the tendinopathy is not always clearly activity related, and can be strongly correlated with age. In this manner, it could almost be considered an ”underuse” injury rather than an overuse injury as a result of stress-shielding 7,9,10. The formation of cartilage-like changes in the enthesis in many ways can be considered a physiological adaptation to the compressive loads 12-14. It may not allow the tendon to maintain its ability to withstand high tensile loads in that region of the tendon.

As the stress-shielding may have led to tensile weakening over time, an injury may occur more easily in this region. In this manner, insertional tendinopathy could be considered an overuse injury, but predisposed by pre -existing weakening of the tendon 12-14.

In another study 3 to evaluate the histopathological features of macroscopic intact tendon portion of patients with rotator cuff tears, we demonstrated that the supraspinatus tendons of patients undergoing arthroscopic repair for a rupture show profound histopathologic changes, while the tendons of aged persons with no known tendon abnormalities have, as a group, little histological evidence of pathological changes.

Moreover, tendon changes are not only localized at the site of rupture, but also in the macroscopic intact tendon portion.

Several centres are undertaking studies on tendinopathy 11,16,17, and the individual studies are unlikely to be large enough to result in adequate power for reliable evaluation. Therefore, combining the data from those studies with a similar study design will be essential. Consistent high- quality pathology data are thus remarkably important for the success of the studies. Two scoring systems can be used for classification of the histopathological findings of tendinopathy: the Movin score 15 and its validated modifications 4,6,12, and the Bonar score 1. We performed a study to answer the question whether these two scores of abnormal tendon tissue were comparable 8. In our hands, Movin and Bonar scores assess the same characteristics of tendon pathology.

In an frequency-matched case-control study we determined the plasma glucose levels in non diabetic patients with rotator cuff tear 5. We found that normal, but in the high range of normal, increasing plasma glucose levels may be a risk factor for rotator cuff tear.

Lastly, although it is likely that the histopathology of tendinopathy is similar, of not the same, regardless of its location, this has only been shown in a formal fashion in the Achilles and patellar tendons 12: we were slightly surprised of the fact that a number of papers dealing with pathology of other tendons (i.e., patellar tendon, Achilles Tendon, and extensor carpi radialis brevis tendon (tennis elbow) are quoted referring to rotator cuff tendinopathy (references n°23,24,25,26,81,94,96,97,98, 147,148).

1. Cook, J.; Feller, J.; Bonar, S.; and Khan, K. Abnormal tenocyte morphology is more prevalent than collagen disruption in asymptomatic athletes’ patellar tendons. J Orthop Res 2004;22:334-338.
2. Gardner, K.; Arnoczky, S. P.; Caballero, O.; and Lavagnino, M. The effect of stress-deprivation and cyclic loading on the TIMP/MMP ratio in tendon cells: An in vitro experimental study. Disabil Rehabil 2008:1-7.
3. Longo, U. G.; Franceschi, F.; Ruzzini, L.; Rabitti, C.; Morini, S.; Maffulli, N.; and Denaro, V. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med 2008;36:533-8.
4. Longo, U. G.; Franceschi, F.; Ruzzini, L.; Rabitti, C.; Morini, S.; Maffulli, N.; Forriol, F.; and Denaro, V. Light microscopic histology of supraspinatus tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2007;15:1390-4.
5. Longo, U. G.; Franceschi, F.; Ruzzini, L.; Spiezia, F.; Maffulli, N.; and Denaro, V. Higher fasting plasma glucose levels within the normoglycemic range and rotator cuff tears. Br J Sports Med 2008;
6. Maffulli, N.; Barrass, V.; and Ewen, S. W. Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med 2000;28:857-63.
7. Maffulli, N.; Khan, K. M.; and Puddu, G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy 1998;14:840-3.
8. Maffulli, N.; Longo, U. G.; Franceschi, F.; Rabitti, C.; and Denaro, V. Movin and Bonar scores assess the same characteristics of tendon histology. Clin Orthop Relat Res 2008;466:1605-11.
9. Maffulli, N.; Reaper, J.; Ewen, S. W.; Waterston, S. W.; and Barrass, V. Chondral metaplasia in calcific insertional tendinopathy of the Achilles tendon. Clin J Sport Med 2006;16:329-34.
10. Maffulli, N.; Sharma, P.; and Luscombe, K. L. Achilles tendinopathy: aetiology and management. J R Soc Med 2004;97:472-6.
11. Maffulli, N.; Testa, V.; Capasso, G.; Bifulco, G.; and Binfield, P. M. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med 1997;25:835-40.
12. Maffulli, N.; Testa, V.; Capasso, G.; Ewen, S. W.; Sullo, A.; Benazzo, F.; and King, J. B. Similar histopathological picture in males with Achilles and patellar tendinopathy. Med Sci Sports Exerc 2004;36:1470-5.
13. Maffulli, N.; Waterston, S. W.; and Ewen, S. W. Ruptured Achilles tendons show increased lectin stainability. Med Sci Sports Exerc 2002;34:1057-64.
14. Maffulli, N.; Wong, J.; and Almekinders, L. C. Types and epidemiology of tendinopathy. Clin Sports Med 2003;22:675-92.
15. Movin, T.; Gad, A.; Reinholt, F.; and Rolf, C. Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 1997;68:170-5.
16. Murrell, G. A. Oxygen free radicals and tendon healing. J Shoulder Elbow Surg 2007;16:S208-14.
17. Murrell, G. A. Using nitric oxide to treat tendinopathy. Br J Sports Med 2007;41:227-31.

Reader Response: Inactivity in the 21st Century

2 Feb, 09 | by Karim Khan

By Fergus Joseph Dignan, Civilian Medical Practitioner, MOD

I very much enjoyed reading the ‘warm up’ article by Steven N Blair in the January edition of BJSM. The first study that he quoted on attributable fractions for all cause deaths was a real eye popper!

I was very surprised to see that low cardiorespiratory fitness was a greater attributable risk factor (in both sexes) than obesity, smoking, high cholesterol, and diabetes, as well as hypertension in women.

The second study was almost equally as fascinating. This illustrated that the risk of cardiovascular mortality in Type 2 diabetes in the obese category who took moderate to high levels of exercise, was half that of diabetics in the normal weight category who took no exercise. There was one thing that puzzled me and that was the histograms illustrated that for the type 2 diabetics who took low levels of exercise the cardiovascular risk was the same for those in the obese category as in the normal weight group.

This article will certainly alter the way that I communicate health promotion to my patients, and I would like to congratulate Steven Blair for such a stimulating article.

Hot Topic: Current Anti-Doping Policies

7 Aug, 08 | by Karim Khan

legs bjsm

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.

swimmer bjsm

“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.

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“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.


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.

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