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South African Sports Medicine Association (SASMA)

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

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

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

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

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

Tiger Woods has officially withdrawn from the Ryder Cup – a move that makes a lot more sense than his starting the PGA last week.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

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

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

  1. Correct Diagnosis (correction, hypothesis)

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

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

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

  1. Correct Treatment and Rehabilitation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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

3 Aug, 14 | by Karim Khan


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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



Prizes, excitement, legacy! 2013 BJSM Cover Competition

18 Nov, 13 | by Karim Khan

Welcome to the third annual BJSM cover competition. Where we get to do three things we enjoy: reflect on BJSM content (usually guided by one of our 13 member societies), celebrate the artistry of our covers, and solicit feedback from our readers.

Because BJSM had 16 issues in in 2014, you (and your friends) will have four preliminary rounds to vote for your favourite cover per ‘season’. First set of 4 covers below. The winner of each preliminary round will move to the final, sudden death round. The BJSM cover award ranks right up there with the Nobel Prize and an Oscar as a much vaunted and greatly valued award.

To refresh your memory about last years winners, READ THIS BLOG.

If you want to be eligible for a soon-to-be-revealed but definitely fabulous prizes you can do that too -but you can vote anonymously as well.

Voting starts…NOW:

January 2013 BJSM Cover

Cover 1: January 2013

Cover Jan 2

Cover 2: January 2013

Cover 2013 Feb 3

Cover 3: February 2013

Cover March 4

Cover 4: March 2013


























Congrats to the winners of the BJSM cover competition

27 May, 13 | by Karim Khan

untitledWe are happy to announce 3 different winners today.

First off, for the second year in a row the issue associated with the South African Sports Medicine Association (SASMA) (with guest Editors Jon Patricios and Wayne Viljoen) was victorious. Coincidence (or maybe it was the cute giraffe)? By coincidence, the current issue of BJSM celebrates SASMA again – and their conference in October 2013.

Secondly, the contest winners of either

1. The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr.


2.Brukner and Khan’s Clinical Sports Medicine, 4th Edition, 2012.


1. Xabat Casado

Xabat has been a physical therapist since 2005 and currently works in private practice in San Sebastian, Spain. He is passionate about the science and practice of manual therapy and looks forward to reading his new book to access updated information on sports medicine. When asked what about his favourite thing on the BJSM blog, he stated: ” The quality of the information published. Without a doubt, a reference blog.”

2. Loryn Turnock

Loryn recently graduated in Sports Therapy at the University of Hertfordshire. She aspires to work with a sporting team and also gain clinical experience (in Australia where she wants to live out her dreams). She is excited to have won either book as she views them as key resources for her career. Her favorite thing about the BJSM blog is that it keeps her up to date on current literature.

Seems like these book prizes will be put to good use.

Thanks to everybody who participated!

BJSM cover competition – round 2 (Vote now!)

21 Dec, 12 | by Karim Khan

The winner of round 1!

Thanks to everyone who voted in round 1 of our second annual BJSM cover competition. Perhaps due to flexibility envy, BJSM’s issue #2 (ECOSEP special issue) goes through to the final.

See the four awesome covers in this second round. To recap: You (and your friends) vote below for your favourite cover. One click and you would make Abe Lincoln proud. The winner of the remaining preliminary rounds joins the Hamstring Issue in the final.

We will have prizes (a draw from those who vote) in the final. Right now, vote for your favourite cover from April – June 2012. (There were 16 issues of BJSM in 2012 – because of our links with the IOC and their 4 issues dedicated to Injury Prevention and Health Promotion – see the Olympic Rings on those issue covers, e.g, Cover 7, below). If you want to vote along ‘party lines’ remember that issue 5 and 8 were guided by the AMSSM (US) and SASMA (South Africa) respectively. BJSM has 12 actively engaged member societies.

Cover 5

Cover 5

Cover 6

Cover 6













Cover 7

Cover 7


Cover 8

Modern Day Gladiators – A day at the Colosseum and thoughts of Super 15 at Kings Park.

22 Oct, 12 | by Karim Khan

Guest Blog by SASMA President –

Dr Glen Hagemann

Pollice Verso (Thumbs Down), Jean-Léon Gérôme, 1872.

Two weeks ago I attended the FIMS World Congress of Sports Medicine in Rome. I particularly enjoyed visiting the Colosseum and learning about the Roman gladiators, whose similarity to modern professional rugby players became more and more evident the longer I spent there! The Colosseum had a capacity of around 50,000, similar to that of our local rugby stadium , Kings Park, and the gladiators fought about three to five times every year (unlike our professional players who are expected to put their bodies on the line virtually every weekend). However, considering that the implication of losing a fight was potential death, this number of appearances was probably more than enough!

Contrary to popular belief, however, gladiators did not deliberately fight to the end. When a gladiator lost a fight, the crowd was encouraged to demonstrate whether he lived or died, but the final decision was left to the emperor; lives were often preserved as gladiators were considered valuable assets, just as our professional sportsmen are today. Seriously wounded gladiators, however, were killed by a hammer-wielding executioner (just picture the scene at the end of a Super 15 game…). Despite their value as athletes, gladiators were generally considered second rate citizens and had few if any social privileges. However, the most successful fighters were treated like modern day sporting celebrities. These trained gladiators also joined formal associations, called collegia (just like the South African Rugby Players Association) to ensure that they were provided with proper burials and that adequate compensation was given to their families.

Like the Lambies’ and the Carters’ of the world today, gladiators were often the object of female adoration. Only attractive men would be recruited as the spectators enjoyed good looking gladiators.

Gladiatorial combat was as much a science as modern rugby. Training involved the learning of a series of figures, which were broken down into various phases. Sometimes fans complained that a gladiator fought too mechanically, according to the numbers, something akin to rugby players being “over-coached” today.

Because of their value, gladiators were looked after by only the best doctors. The most famous of these was Aelius Galenus (Galen), the forefather of sports medicine. Galen learnt the importance of diet, fitness, hygiene and preventive measures. He became a master of living anatomy, and the treatment of fractures and severe trauma, referring to wounds as “windows into the body”.  His meticulous attention to gladiators’ wounds resulted in a significant reduction in their mortality rate when compared to his predecessor. In spite of this, he argued strongly against the immoderate lifestyle of athletes and their obsession with victory, which he believed was “unhealthy and potentially dangerous behaviour” (a bit unfair considering the consequences for the defeated gladiator!).  He was probably the most accomplished medical researcher of the Roman period and he later became the personal physician to Emperor Marcus Aurelius. His theories dominated and influenced Western medical science for over 1500 years.


The rest of the medical team included the equivalent of modern day physiotherapists, and the Romans understood the role of sports massage in improving recovery after bouts. Like today, gladiators were placed on high carbohydrate diets and consumed their own type of isotonic sports drink in the form of a foul-smelling bone- ash solution which may even have been a kind of primitive painkiller.



Dr Glen Hagemann is President of the South African Sports Medicine Association (SASMA). SAMSA is a BJSM member society. The next SASMA congress will take place in October of 2013. Watch for the special SASMA issue of BJSM in July of 2013.  (The 2011 SASMA issue won first prize in the BJSM cover competition for 2011)

The legality of Pistorius: why ethics is more relevant than biomechanics. Guest blog @DrJohnOrchard

5 Aug, 12 | by Karim Khan

by @DrJohnOrchard

I’m pleased to see Professor Lippi’s opinion piece on Oscar Pistorius in BJSM’s Online first [1], as it is a very important topic and the BJSM is a very appropriate forum to publish on this debate. Much of the article is a good neutral overview of the parameters of this debate. However I disagree very strongly with some of the conclusions made. In particular this section:

“If we all agree—as we do, indeed—that whatever artificial addition on athlete’s body shall be considered unfair or even illicit (the ban of the bathing suits that enhanced swimmers performance is a paradigmatic case), then, prosthetic technology should follow the same route. Beside the fact that Pistorious’s running performance may be higher, the basic dynamics has been definitely proven to be grossly different from that of intact-limb sprinters, and he should not be allowed to race in the Olympics, whereby his natural field remains the Paralympics.” [1]

Firstly, I don’t think that there is universal agreement that “all artificial aids should be illicit”. What is a running shoe other than an artificial aid? It is simply an artificial aid that everyone is allowed to use (although different brands, which surely have different biomechanics, are allowed and chosen). Equestrians are allowed saddles, cyclists are allowed helmets that reduce drag and footballers can wear studs on their boots to improve grip on grass. Artificial aids are available in many sports and we debate and regulate depending on a combination of scientific argument and consensus opinion. We also debate whether caffeine, pseudoephedrine and salbutamol should be on the banned substances list and sometimes change our minds. Lippi points out that the decision was made to ban ‘fast swimsuits’ as if this was the only decision available, when of course it is easy to envisage a scenario where this decision could have been determined with the opposite outcome and we all just accepted better technology. We accept that modern golf balls and clubs allow the ball to be hit further than previous versions, even though many have made the argument to limit this technology. These are all decisions on artificial aids, not automatic choices where we have only had one option.

I don’t think it is an established ‘fact’ that Pistorius has biomechanical advantages over able-bodied runners which outweigh his disadvantages. Obviously there are respected biomechanics experts who have quantified advantages that he does have, but there remain multiple unknowns with respect to the disadvantages. The counter-argument that Pistorius and his supporters (including myself) make is: you can have as much ‘in vitro’ science as you like, but why do able-bodied runners post faster times in every discipline than amputees using artificial limbs over the same distance? In vitro science is fallible. I imagine that a motivated biomechanist could present an in vitro study suggesting that a running shoe would make you run slower compared to bare feet or a physiologist similarly that women had a theoretical advantage in the marathon than men. You wouldn’t need better science to mount a powerful counter-argument – why don’t barefeet athletes (since Abebe Bakila) win running events or women beat men? If amputee runners were consistently beating able-bodied runners then the science alleging an unfair advantage to Pistorius would have a lot more weight. Let’s face it, science can’t yet tell us whether Nike shoes lead to more injuries than Asics shoes or even lead to faster running (even though we could actually do RCTs on these hypotheses, which is not available in the case of amputee athletes) and we need to be humble about what the limits of scientific analysis are.

If the jury is still out on whether Pistorius has an unfair advantage then he deserves the benefit of the doubt. If he was a completely crazy second tier able-bodied athlete who had cut off his own legs in order to try to improve his times, then you could mount a very good ethical argument that he should be excluded (in order to discourage others from following suit). He is in fact the opposite – one of the most inspirational athletes of all time. Where biomechanics can’t give us a foolproof answer, we need to judge this based on our ethical preferences, just as it was decided to ban fast swimsuits, but to keep caffeine legal. Just as the golf authorities will decide whether or not long putters stay legal or become illicit. Just as we decide whether drug cheats should get a 1, 2, 4 year or life suspension. The key question is “what do we want the Olympics to look like?” We decide that you can’t compete in the Olympic marathon in a wheelchair because we don’t want the Gold, Silver and Bronze medals all going to wheelchair athletes. That is a value judgement. If amputee runners were winning every medal at the Olympics, I would be comfortable with a decision that banned them from the events before we did start to get lunatics chopping their legs off to compete. At the moment we have a single amputee runner (Oscar Pistorius) who is internationally competitive in the able-bodied 400m but nowhere near as fast as Michael Johnson, the world record holder. Do we want this sort of athlete in the Olympics? I can’t comprehend an ethical world where it could be determined, ethically, that LaShawn Merritt could return from a drug suspension in time to compete in the 400m at the Olympics, but that we decided to exclude Pistorius from the same event because we thought he had an unfair advantage that we weren’t comfortable with. I am very relieved that the IOC didn’t exclude him. It has already been shown, however, in the Pistorius case, that it is possible to change the rules (from Pistorius being ineligible in Beijing to eligible in London). The “thin edge of the wedge” argument can be countered with the obvious – if Pistorius, or any other amputee athlete, starts beating world records by huge margins, there is every opportunity to change the rules once again.

Personally I would rank Oscar Pistorius amongst the most significant Olympic athletes of all time, alongside Paavo Nurmi, Jesse Owens, Dawn Fraser, Abebe Bakila, Bob Beamon, Mark Spitz, Nadia Comanici, Cathy Freeman, Steven Redgrave, Michael Phelps and Usain Bolt.

All of these athletes make the list because of the Gold medals performance that they have put in. Pistorius is possibly the only non-Gold medallist who belongs in such an esteemed list. Most importantly I believe he will have a greater impact on the world than any of the other legends, in that he may lead to a completely different vision we have of ‘disability’. I will explore this possibility in my upcoming Dr J. column in Sport Medicine Australia’s magazine Sport Health and co-publish it on the BJSM Blog in the near future.

Lippi G. Pistorious at the Olympics: the saga continues. Br J Sports Med doi:10.1136/bjsports-2012-091545

See also medical student Abhishek Chitnis’ BJSM Blog on this topic. (Retweeted 21 times in first hour it was up)


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


Professor Lippi whose article in Italian can be found here

Guest blog: Do athletes with prosthetic limbs have an unfair advantage over able-bodied athletes?

5 Aug, 12 | by Karim Khan



Abhishek Chitnis

3rd Year Medical Student

Keele University


The use of prosthetic limbs in medicine has helped many patients over millennia lead a more comfortable life, enabling them to continue their activities of daily living as well as to compete in sport. In developing countries, prosthetic limbs are mainly used because of amputation due to trauma related injuries such as those suffered in conflict or road traffic injuries.[1] By contrast, in developed countries, the main cause of lower limb amputation is atherosclerosis, which may be affiliated with diabetes.[2] In the UK alone there are about 5000 new major amputations yearly, usually occurring in those who are sixty years old (or above),[1] making the use and development of prosthetics vital in the 21st century.

For athletes, this may be especially important as it could help them lead a normal life having being born with congenital limb problems. Other athletes who have suffered major trauma related injuries may want to continue competing in sports, and the development of prosthesis helps them achieve their goals. However, technological developments in sport can be controversial and this article aims to review any discrepancies as to whether or not technology creates an unfair advantage for the Paralympian, when competing against able-bodied Olympic athletes.

The history and development of prosthetics

Prosthetics have been used for over 3000 years, from the Egyptians where a prosthetic toe made of wood and leather has been discovered, to armoured knights who used prosthetic arms and legs in battle. In the sixteenth century Ambroise Paré invented prosthetics with joints, allowing prosthesis to become more functional.[3] And its not only humans who use prosthesis; elephants and horses that have been injured in accidents have also been given prostheses to help them move around!

Prosthetic limbs have evolved over time to use more advanced materials such as plastics and carbon-fibre composites. These materials make the prosthesis lighter, stronger and more realistic enabling the patient to engage in a full range of normal activities.[3]

Prostheses for athletes; the Flex-Foot

For athletes, possibly the most important development in prosthetic limbs has been the development of the energy-storing Flex-Foot, a carbon-fibre prosthesis with a heel component. Studies have shown the Flex-Foot provides amputees with a natural ankle motion and gives up to 84% of energy return rate to every step taken,[4] resulting in lower energy expenditure and an enhanced gait efficiency.[4] This value may seem high, but in comparison, the energy return rate of a natural limb is about three times higher at 241%.[4]

The Flex-Foot however only conserves energy at higher walking velocities and it does not seem to provide any major advantages for less active amputees. In a recent study to find the benefits of the Flex-Foot when compared with a conventional prosthesis, results showed that amputees had a lower induced disability when walking in a variety of different situations with the Flex-Foot than with conventional prostheses.[5]

Another study showed that amputees walking with the Flex-Foot had a lower heart rate and a lower VO2 (maximal oxygen uptake) than amputees walking with normal prosthesis[4], enabling them to walk for longer distances before tiring.

Case study; Oscar Pistorius

The above studies show that the Flex-Foot was the best type of prosthesis for athletes but the application of this technology has been controversial, as demonstrated by the much-heralded Oscar Pistorius or ‘Blade Runner’. The double amputee Paralympic runner who uses the “Cheetah” Flex-Foot (Figure. 2), a sprinting variant of the Flex-Foot without the heel, was eligible to qualify in the men’s 400 m sprint in both the 2008 Olympic and Paralympic Games. This begged the question; do Pistorius’ Cheetahs provide him with any advantage over biological limbs?  Or are they needed to maximise his performance and to overcome any compensatory consequences his disability creates?

Pistorius was born with absent fibulas in both legs due to a congenital condition and at the age of 11 months he had a transtibial (below-knee) amputation to remove both legs. During his time at school, Pistorius competed in a number of different sports, including rugby, water polo, tennis and wrestling. At 17 he discovered athletics and he went on to win gold in the men’s 200m during the 2004 Paralympic games.

However in 2007, the International Association of Athletics Federation (IAAF) asked for an assessment to be carried out to find out whether the prostheses Pistorius used gave him any undue advantage. The study[6] found that at a given speed, the Cheetahs he used consumed 25% less energy than the runners he was compared to. This would mean Pistorius would have a much lower muscular demand, enabling him to run faster and for longer periods of time before he got tired.

Interestingly, as the normal Flex-Foot was found to give an 84% energy return compared to 241% of a natural limb, it was found that the Cheetahs energy return was three times higher than of a natural limb. The consequence of this would mean that Pistorius would be able to run at the speed with much lower energy expenditure.

The study also found Pistorius displayed a much lower vertical motion than able-bodied runners, meaning he lost less energy during the landing and take-off phase of running. This lead to the finding that the Cheetahs only lost 9.3% of energy during the stance phase of running compared to 41.4% in the biological leg. This meant that Pistorius had a much lower physiological and metabolic workload, giving him a large mechanical advantage over a biological leg. Pistorius argued the case stating the disadvantages he faced with his prostheses including running in the rain (giving him lower traction on the track), wind (which blew his prostheses sideways) and the fact that he needed more energy to start running than other competitors. However, the IAAF found him to breach rule 144.2 “any technical device … that provides a user with an advantage over another athlete not using such a device”,[6] subsequently barring him from competing in any IAAF events including the 2008 Olympic games.

He consequently appealed and in May 2008 just before the Olympics, the Court of Arbitration for Sport (CAS) overturned the IAAF’s ban stating that there was insufficient evidence that Pistorious’ prostheses provided him with any sort of metabolic advantage over able-bodied competitors. It also concluded that the IAAF did not consider Pistorius’ disadvantages through the race.  This allowed Pistorius to try and qualify for the Olympics, but however in the end he could not meet the required qualifying time.

However in November 2009, a new study[7] concluded that athletes with a Flex-Foot, similar to one Pistorius used had no advantage over able-bodied competitors. The running mechanics of a number of athletes was tested as they sprinted on a treadmill and the results showed that prosthetic limbs didn’t generate as much force against the ground as biological legs.

Only single amputees were tested so that their prosthetic and biological limbs could easily be compared. The treadmill that the athletes ran on measured the force, called ground reaction force (GRF), each limb generated as it struck the belt; the greater the force, the higher the speed. It was found that at all speeds, athletes produced a 9% lower GFR in their prosthetic limb than their biological limb. In an able-bodied competitor this would mean a 9% drop in their top speed. It was also found that there is no difference in swing times between the prosthetic and biological limbs, meaning that even though prostheses are lighter than biological legs, amputee sprinters don’t move their legs any faster than able-bodied sprinters. To back up this data, the men’s 100m Olympic and Paralympic finals were analysed and again no significant difference in the swing times of their legs was found.

Pistorius argues that thousands of other runners also use the same prosthetic legs as him, without getting anywhere near his times, and that his times have been steadily improving since 2004 since he first got his Cheetahs blades not because of advances in technology, but due to his relentless training and improved technique. His sporting motto is “You’re not disabled by the disabilities you have, you are able by the abilities you have”. This tells us Pistorius feels his impairment does not affect his physical functioning and that to him; competition is as much mind, as it is matter.

In 2011 Pistorius qualified for the world athletics champions in South Korea with a time that would have placed him in fifth place the 400-metre final at the Beijing Olympics. He is currently contesting for a place in the South African sprinting team that will compete in London 2012 Olympics.

Pistorius is not the first disabled athlete who attempted to compete in both the Olympic and Paralympic Games; several have done so before. Natalia Partyka, a table tennis player, was born without a right hand and forearm and competed in the 2008 Olympics and Paralympic games in Beijing and the wheelchair archer, Neroli Fairhall, the first ever paraplegic competitor, participated in the 1984 Olympic Games in Los Angeles and has also competed in several Paralympic Games.

When debating technological developments in sport, it is also important to consider equal access to the technology. For example, Abebe Bikila, an athlete from Ethiopia who ran barefoot, won the Olympic marathon in 1960. How much faster could he have run with the technology to absorb the ground reaction forces and improve friction? Similarly, who knows how much faster other amputees could run if they had access to Pistorius’ Cheetahs, of which access is limited due to their expense. This situation is more problematic for athletes in developing countries, where the funding for new technology is hard to obtain.

Another issue to consider is have the technological development of Pistorius’ Cheetahs lead to his steadily improving times, or it down to his sheer grit and determination as he so claims. If this is due to the former, one can argue: ‘Who’s going to win the gold medal, the athlete or the scientists who have developed and improved the prosthesis?’

Some have reasoned that historical continuity is crucial, so current athletes can be compared to past athletes and achievements can be understood in context. Allowing Pistorius to compete with his existing Cheetahs does not allow this, as he cannot be compared to past sprinters, which represents a break in historical tradition. Others have made the point that “Natural” athleticism should be exhibited, to preserve the essence of a sport. Using a prosthesis represents a much more significant change than using contact lenses or improving your diet.

Psychological issues must also be contemplated; amputees have often gone through stressful and life changing events, often at an early age, which may put a strain on their psychological well being. For example, they may have issues surrounding their body image, self-pity and frustration. Does the use of a prosthesis help amputees overcome any disadvantage that they have suffered psychologically?

Final thoughts

The evolution of prosthetics has led to specialised limbs being developed for athletes, causing controversy to develop as amputees strive to compete against able-bodied athletes with their specialised limbs. Despite the debate, the ruling regarding Oscar Pistorius’ case was the right one. The prosthesis was primarily developed to attempt to restore loss of function in the Paralympian and there have been both studies for and against whether this prosthesis provides him with any advantage over able-bodied athletes. The fact that studies have not shown irrefutable evidence that Pistorius’ Cheetahs give him an advantage, allowing Pistorius to compete in able-bodied competition would constitute providing him fair opportunity to compete. Because of this uncertainty, Pistorius has rightly been given the sporting ‘benefit of the doubt’ and has been eligible to compete in the Olympic Games, given that he meets the required qualifying time. However, more research is required before any conclusive evidence is drawn as to whether prostheses do in fact give amputees an advantage or not. Until then, the question as to whether Pistorius is disabled, or too abled, remains.

The technological development of prosthesis has had a far-reaching impact worldwide, including in war stuck Sierra Leone where people regularly play amputee football. As prosthesis get more functional and advanced, it can be questioned as to whether or not using a prosthesis completely removes an amputees disability, as they now provide the opportunity for amputees to perform activities to the normal range (or even to a greater range), than a normal human being. This can be debated, but one thing is clear; prosthesis are bridging the gap between the disabled and able bodied.


Abhishek Chitnis is a 3rd Year Medical Student at Keele University. He has a keen interest in Sports and Exercise Medicine and hopes to pursue it as a future career. Abhishek can be contacted via email at

All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.


  1. Marks LJ, Michael JW. Science, medicine, and the future – Artificial limbs. BMJ 2001;323:732-735.
  1. Kelly BM, Pangilinan PH, Rodriguez GM, et al. (2009) Lower Limb Prosthetics <> (Accessed 04.05.2012).
  1. Thurston A. Pare and Prosthetics: The Early History of Artificial Limbs. ANZ Journal of Surgery 2007;77:1114-1119.
  1. Nolan L. Carbon fibre prostheses and running in amputees: a review. Foot and Ankle Surgery 2008;14:125-129.
  1. Alaranta H, Kinnunen A, Karkkainen M, et al. Practical Benefits of Flex-Foot(TM) in Below-Knee Amputees. JPO 1991;3:179-181.
  1. IAAF. Oscar Pistorius – Independent Scientific study concludes that cheetah prosthetics offer clear mechanical advantages. 2008.  <,newsid=42896.htmx>  (Accessed 04.05.2012)
  1. Grabowski AM, McGowan CP, McDermott WJ, et al. Running-specific prostheses limit ground-force during sprinting. Biology Letters 2010;6:201-204.

Figure 1. Oscar Pistorius running against able-bodied athletes at the Norwich Union British Grand Prix 2007. Adapted from,2933,289450,00.html, 2012.

See also BJSM Online First paper by Professor Lippi – click here

See @ScienceofSport on Twitter and blog: TheScienceofSport for detailed discussion

See website ‘Only a Game’ discuss the topic: Argues for Pistorius running.




Designer Bodies: Anabolic steroid use in high schools

2 Aug, 12 | by Karim Khan

By Dr Glen Hagemann

Sports Physician and President of the South African Sports Medicine Association (SASMA)


Last year Discovery Sharksmart  anonymously surveyed 9824 male pupils attending 20 high schools in South Africa regarding various lifestyle behaviours.  One section of the questionnaire related to the use of anabolic steroids, the results of which proved both interesting and somewhat surprising. The response rate to the survey was in excess of 85% meaning that the results could be seen as representative of the high school population surveyed. In the survey approximately 5% of the respondents acknowledged having tried steroids at some stage in their lives – this figure was lowest for grade 8’s (1.2%), as expected, and highest for grade 12’s (9.5%). It is possible that these figures are indeed an underestimation of the real situation as a result of under-reporting.

The results of the survey are not only surprising in that they reveal the relatively frequent use of anabolic steroids, but also because the main reason reported for steroid use is for self-image reasons, and not for enhancing sporting performance, as is the common perception. Two thirds of the pupils who had used steroids stated that they did so primarily to “look good”, while only a third did so to perform better on the sports field. Incidentally, the main source for obtaining steroids by schoolboys was reported to be from gyms.

We then looked at the association between steroid use and other lifestyle factors, using a statistical measure called “the odds ratio”. This ratio measures the strength of the association between two behaviours; the higher the odds ratio, the stronger the association.  We found that steroid use and a perceived excessive pressure to perform on the sports field had an odds ratio of 2.5. Other associations with steroid use in order of increasing strength are: physical violence (odds ratio = 4.2), suicidal thoughts (odds ratio = 4.4), recreational drug use (odds ratio = 5.5) and hard drug use (7.2).

The finding that steroid use has the strongest association with recreational and hard drug use, and the weakest association with sports performance, suggests that steroid use in our schools is a “lifestyle” or social problem; it is more of a social behaviour undertaken for social reasons, similar to the use and abuse of mind altering drugs like marijuana, ecstasy and cocaine. With this in mind then, it was easier to understand why half of the nearly 10,000 respondents indicated in the survey that they did not consider the use of steroids as “cheating”; the notion of cheating is only relevant to a sporting context.

In this material world of designer clothes, shoes, accessories and electronics, have some of our youth reached a point where the use of body altering drugs like anabolic steroids to produce designer bodies is just an extension of this culture?

The South African Sports Medicine Association (SASMA) is one of 8 international member societies that partners with BJSM. See the South Africa focussed issue of BJSM (June 2012) by clicking here.


Congrats to Louise Kent – winner of the BJSM cover competition!

6 Jul, 12 | by Karim Khan

Thanks again to everyone who participated in the 1st annual BJSM cover competition. It was a close call, down to the final round where the South African Sports Medicine Association (SASMA) Congress took the lead to win best cover of 2011. As promised, we randomly selected a voter to receive a $133 book voucher to

Who won it?

Photographer: Daniel Morcos. Dancers (L - R): Faye Esterhuizen, Christy Giesler, Faith Giesler, Sasha Fourie, Milanje Jooste

What’s your name?

Louise Kent

What do you do for work?

Dance Scientist

Where do you live?

Port Elizabeth, Eastern Cape, South Africa

What cover did you vote for in the final round?

I voted for the South African Sports Medicine Association’s Congress Issue (June 2011).


I really wanted the South African cover to win for its colourful design.

How long have you been reading the BJSM blog?

I began following the BJSM blog at the end of last year (2011).

What do you like the most about the blog?    

I really enjoy the feature: The UK trainee perspective.

What are your future aspirations in the world of Sports and Exercise Medicine?

My goal is to continue educating and providing a service to the dancers of South Africa, who are so often overlooked as athletes in this country. I aim to continue to prevent and reduce injuries through the use of knowledge gained through Sports/Dance Medicine and Science communities and aspire to add to the knowledge base through research.


Thanks Louise, for your commitment to Sports and Dance Medicine. 


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