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UK Physios in Sport

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).



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.

Top blogs of 2013 – Career Development – How to get the #DreamJob?

19 Mar, 14 | by Karim Khan

conc3 aussieYou know the job you’d love to have, sports physio or sports physician for a team of your choice. And/or working in a private clinic where you respect the clinical leaders and they provide terrific opportunities for developing your skills through working with teams, attending conferences, ensuring continuing professional development on site including workshops. How do you get such a job? Why would the Australian Cricket Team choose you as their physio? Why would Barcelona FC choose you as the head of sports medicine & sports science?

Leading sports clinicians have shared these 5 elements:

1. Differentiate This should be on every student/trainee’s mind. We often call it ‘specialisation’ in our disciplines but that word has specific meanings (e.g. Titled Sports Physio); the concept of ‘differentiation’ is a broader one. Being a ‘sports physio’ is not enough if you want to be considered for a cricket job. You’ll need to get experience in cricket of course. Or, even as a Titled Sports Physio, you might differentiate further into shoulder injuries. Sounds simple!

2. Add value I almost bundled this in with ‘differentiation’ because ultimately the point of differentiation is to provide special value. Extending the cricket example, you’ll get the cricket job not just because you have ‘experience’ in cricket but because you are better at treating backs, shoulders, and finger injuries.  By recognising this need, you might chase experience in treating shoulders and fingers by spending time with specialists in those roles – even if those clinicians are not expert in cricket. Gaining experience may not be a straightforward path but if you are clear on the goal, you know HOW your will ‘add value’, you can at least go after those skills.

3. Volunteer strategically The first job is the hardest and that is particularly the case in 2013. The Baby Boomers have the #DreamJobs and they aren’t marching away from them yet. Also, national unemployment is high the world over; youth unemployment – yes, that means new graduates — is at a record high. So, if you ever thought that after your final exams or graduation, you would be able so scan a long list of advertisements offering you and your peers full time work…. I’m sorry to be a bearer of bad news. But don’t be disheartened  – you have a valuable, practical, degree in hand or coming, so please adjust to the fact that you need to volunteer and network the way many graduates have done in many disciplines for decades.

Be patient, take care of the process and the outcome will take care of itself. You‘ll often have to start with part-time opportunities. As a volunteer, if you are confident of ‘adding value’ (see above) you may have some leverage – you are bright, prepared to work hard and you have acquired some skills. And nothing is ‘below you’. Need the water bottles? That’s OK. Fetching balls? OK too. Remember that the top team clinicians will also do a bit of that where needed. It’s a team. No-one is suggesting a trainee sports physician or physio agree to serve as a bowling machine as 100% of a volunteer experience. But it is invaluable to experience a 3-day training camp where you meet the key coaches and officials, see the sport first hand, and at least watch assessment, treatment and prevention programs first hand. This will definitely provide you skills you didn’t learn about at Uni.

4. Network This word has negative connotations for some young people – who may be confusing networking with nepotism. The words are very different and carry very different implications. Networking means you try to connect with people you think are influential in the field and who may be able to guide you. If you can have an appropriate ‘mentor’ agree to guide your career that will be invaluable. But mentors are busy and you may not have things to offer the mentor (money, time at your ski chalet, a drive in your Porsche) so it makes sense to have a few different mentors – so you don’t burden ‘one mentor’ too much. Sports Medicine events such as educational programs run by your local and national sports medicine organization can be excellent networking events. In Australia, Sports Medicine Australia, (one of BJSM’s 13 member societies) runs excellent networking events for members and non-members. In the US, the AMSSM conference is terrific for sports medicine fellows; there are specific ‘networking events’ within the program. Network young, network early. In many prestigious Business Schools they start the students networking in the first weeks. In sports, now you’ll need to network just to get your volunteer opportunity!

5. Be prepared to travel – live in a different environment for a while. Finally for this short blog, remember that many folks have to travel beyond the backyard to make their dreams come true. Read biographies of your heroes on Wikipedia and see if they did everything they needed to do to become great in their birth city. Russell Crowe  (@RussellCrowe) famously had to move to make his career as a Rabbitoh’s spruiker. Think of folks like Roald Bahr (@RoaldBahr, Norway) and Timothy Noakes (@ProfTimNoakes, South Africa) who may seem the archetypal home grown talents and proud ambassadors for their country; both report pivotal years away which changed their lives. Concussion expert Prof Winne Meeuwisse moved from Vancouver to Calgary for better opportunities. The list is long. To share a personal story for illustration, I moved to Canada for love (without thinking about work, I am not as strategic as I am advocating in this blog!) yet it proved to be a boon for my development as a sports physician. (This principle of moving to a fertile environment is a key message in one of my favourite books – Outliers by Malcolm Gladwell but let’s not go there today.)   ******************************************************************

If you feel we have missed something about how to improve your career chances, just email me ( your comments or a blog post and we’ll add it to the conversation. If you want to make a point in <140 characters, tweet to @BJSM_BMJ. #TopJobs  Or suggest someone you’d like to hear share their thoughts on a BJSM podcast.

Archive: 20 min podcast re: Mechanotherapy paper (>89,000 views)

26 Oct, 13 | by Karim Khan

mechano picMany BJSM followers know about mechanotherapy – so skip this blog.

If you aren’t aware that you know about it, there is a BJSM podcast – here’s the link.

Relevant background —  I have a ‘competing interest’ – I’m blogging about a paper I coauthored. It’s my 2nd such post since we started blogging seriously at BJSM (2009). The objective measure is that the paper has been downloaded almost 90,000 times in full text and PDF. And I have been encouraged by colleagues – so here goes…

There is substantial level 1 evidence that exercise is a powerful therapy for musculoskeletal conditions – for muscle strains, joint degeneration, sciatica, tendinopathy. The historical rationale to explain the mechanism was ‘strengthening’.

‘Strengthening’ as a mechanism for tissue repair didn’t make sense to me when I was in my busy clinical phase. How did ‘strengthening’ the hip external rotators remove the pain of ITB friction syndrome? What was it about ‘strength’ that would remove the pain of a hamstring strain? There is more to tissue repair than ‘strength’.

Mechanotransduction is a well-recognized physiological principle that should have much more traction in physiotherapy/physical therapy courses and in sports medicine. This is how the body adapts to load. Why are Arnold Schwarzenegger’s muscles bigger than mine? His workouts signal his cells to hypertrophy and and multiply as needed and he gets bigger muscles. Why does an elite distance runner have  larger blood vessels than a sedentary academic about to have a cardiac arrest? Mechanotransduction is the process.

A negligent sawmiller – who has lost his distal phalanx — has a vastly smaller proximal phalanx than his or her proximal phalanges on the intact fingers. Same hand, same genetics — less loading. Mechanotherapy trumps genetics! Note examples from different tissues – mechanotherapy is a universal principle.

When clinicians prescribe exercise, the loading signals cell to repair and to function in response to load. Turning movement into repair.

Clinicians see the power of mechanotherapy daily. Mechanotherapy is when you apply the principle of mechanotransduction as a treatment – analogous to the use of ‘electotherapy’ or ‘pharmacotherapy’ (but way more powerful than either of those!). Medial ligament rehab – how does it work? Mechanotherapy. Normal physiology = mechanotransduction; Prescribing targeted exercise = mechantherapy. Simple.

Mechanotransduction has a very well-established scientific basis underpinning the success. Incontrovertible. (5077 citations in Pubmed). Stick with exercise loading– it can take time to work fully. Avoid the temptation to switch to snake-oil formulas or funky treatments. Trust in millions of year of evolution. The folks who couldn’t heal their own injuries while moving on to the next feeding grounds aren’t with us any more. Mechanotherapy provides a powerful survival benefit!

Click here for open access to the paper: Mechanotherapy–How physical therapists’ prescription of exercise promotes tissue repair

And I discuss this paper with BMJ MultiMedia editor @HarrietVickers on this podcast link:

And you can upload of the graphics from the paper for free as powerpoint slides.  If you enjoy the podcast or have tips as to how we can make it better – tweet @BJSM_BMJ

Turning movement into repair!

**BJSM has over 230 podcasts on SoundCloud with over 900,000 listens** Check them out at

Professor Michael Kjaer has a great podcast on pathology and treatment options: It’s much better than this mechanotherapy one but don’t tell anyone I said that.

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