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Fatigue, sport performance and hormones..more on the endocrine system

25 May, 17 | by BJSM

By Dr Nicky Keay

How do you feel on Monday morning, when the alarm wakes you at 7am with a day of work ahead after the weekend? A bit tired, slightly lethargic, sluggish, maybe a little bit down, perhaps a few regrets about somewhat too much alcohol/food over weekend, frustrated that the exercise training schedule didn’t go according to plan?

There are many causes of fatigue and sport underperformance: Endocrine, immunological, infective, metabolic, haematological, nutritional, digestive, neoplastic….. The adrenal gland in the Endocrine system in particular has come in for some bad press recently.

Adrenal woes

Undoubtedly the adrenal glands have a case to answer. Situated above the kidneys these Endocrine glands produce glucocorticoids, mineralocorticoids, androgens from the adrenal cortex and from the adrenal medulla adrenaline. Glucocorticoids (e.g. cortisol) have a metabolic function to maintain energy homeostasis and an immune function to suppress inflammation. Mineralocorticoids (e.g. aldosterone) maintain electrolyte and water balance. As mineralocorticoids and glucocorticoids are similar biological steroid molecules, there is some degree of overlap in their actions.

Addison’s disease and Cushing’s disease are serious medical conditions, corresponding respectively to under or over production by the adrenal glands of steroid hormones. Someone presenting in Addisonian crisis is a medical emergency requiring resuscitation with intravenous hydrocortisone and fluids. Conversely those with Cushing’s can present with hypertension and elevated blood glucose. Yet, apart from in the extremes of these disease states, cortisol metrics do not correlate with clinical symptoms. This is one reason why it is unwise and potentially dangerous to stimulate cortisol production based on clinical symptoms. Inappropriate exogenous steroid intake can suppress normal endogenous production and reduce the ability to respond normally to “stress” situations, such as infection. This is why the prescription of steroids, for example to reduce inflammation in autoimmune disease, is always given in a course of reducing dose and a steroid alert card has to be carried. Athletes should also be aware that exogenous steroid intake is a doping offence.

However, what is the “normal” concentration for cortisol? Well, for a start, it depends what time of day a sample is taken, as cortisol is produced in a circadian rhythm, with highest values in the morning on waking and lowest levels about 2/3am. Nor is this temporal periodicity of production the only variable, there are considerations such as tissue responsiveness and metabolism (break down) of the hormone. On top of these variables there are other inputs to the feedback control mechanism, which can in turn influence these variables. In other words, focusing on the steroid hormone production of the adrenal gland in isolation, could overlook underlying hypothamalmic-pituitary-adrenal (H-P-A) axis dysfunction and indeed wider issues.

Much maligned thyroid

That is not end of the possible causes of fatigue and sport underperformance: the H-P-A axis is just one of many interrelated, interacting Endocrine systems. There are many neuroendocrine inputs to the hypothalamus, the gate keeper of the control of the Endocrine system. Furthermore there are network interaction effects between the various Endocrine control feedback loops. For example cortisol towards the top end of “normal” range can impede the conversion at the tissue level of thyroxine (T4) to the more active triiodothyronine (T3) by enzymes which require selenium to function. Rather T4 can be converted to reverse T3 which is biologically inactive, but blocks the receptors for T3 and thus impair its action. This in turn can interfere with the feedback loop controlling thyroid function (hypothalamic-pituitary-thyroid axis). The physiological ratio of T4 to T3 is 14:1, which is why supplementation with desiccated thyroid is not advisable with ratio of 4:1. There are other processes which can crucially interfere with this peripheral conversion of T4 to T3, such as inflammation and gut dysbiosis, which can occur as result of strenuous exercise training. So what might appear to be a primary thyroid dysfunction can have an apparently unrelated underlying cause. Indeed amongst highly trained athletes thyroid function can show an unusual pattern, with both thyroid stimulating hormone (TSH) and T4 at low end of the “normal “range, thought to be due to resetting of the hypothalamic-pituitary control signalling system. This highlights that the “normal” range for many hormones comprises subsets of the population and in the case of TSH, the “normal” range is not age adjusted, despite TSH increasing with age. As described by Dr Boelaert at recent conferences, there is certainly no medical justification for reports of some athletes in the USA being given thyroxine with TSH>2 (when the normal range is 0.5-5mU/l). Although thyroxine is not on the banned list for athletes, it could have potentially serious implications for health due to its impact on the Endocrine system as a whole.

Endocrine system interactions

Symptoms of fatigue are common to many clinical conditions, not just dysfunction in an Endocrine control axis in isolation, nor even the network interactive effects of the Endocrine system in isolation. For example, the impact of nutrition relative to training load produces a spectrum of clinical pictures and Endocrine disturbances seen in Relative Energy Deficiency in Sport (RED-S) in terms of health and sport performance.

Underlying mechanisms of Endocrine dysfunction

There may be predisposing factors in developing any clinical syndrome, the usual suspects being inflammation: whether infective, dysbioses, autoimmune; nutritional status linked with endocrine status; training load with inadequate periodised recovery to name a few….


From population based norms to personalised medicine: Health, Fitness, Sports Performance British Journal of Sport Medicine 2017

Sports Endocrinology – what does it have to do with performance? British Journal of Sport Medicine 2017

Advanced Medicine Conference, Royal College of Physicians, London 13-16 February 2017, Endocrine session: Dr Kristien Boelaert, Dr Helen Simpson, Professor Rebecca Reynolds

Subclinical hypothydroidism in athletes. Lecture by Dr Kristeien Boelaert, British Association of Sport and Exercise Medicine Spring Conference 2014. The Fatigued Athlete

Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences British Journal of Sport Medicine 2017

Relative Energy Deficiency in Sport CPD module British Association of Sport and Exercise Medicine

Sleep for health and sports performance British Journal of Sport Medicine 2017

Inflammation: why and how much?

Clusters of athletes

Enhancing Sport Performance: Part 1 British Association of Sport and Exercise Medicine 2017

Balance of recovery and adaptation for sports performance British Association of Sport and Exercise Medicine

Annual Sport and Exercise Medicine Conference, London 8/3/17 Gut Dysbiosis, Dr Ese Stacey

Adrenal fatigue does not exist: a systematic review BMC Endocrine Disorders. 2016; 16(1): 48.

A Controversy Continues: Combination Treatment for Hypothyroidism Endocrine News, Endocrine Society April 2017

World Health Organisation to develop Global Action Plan to Promote Physical Activity

22 May, 17 | by BJSM

By Charlie FosterTrevor ShiltonLucy Westerman, Justin Varney,  and Fiona Bull

More people moving more is central to a healthier world. Unfortunately, evidence tells us that people everywhere are less active than ever before, and the burden of chronic noncommunicable diseases rises unabated.

In response, the WHO has launched their strategy to develop a new Global Action Plan to Promote Physical Activity.

Years of advocacy have culminated in this unique opportunity; the development and comprehensive implementation of a global action plan to promote physical activity. This in many ways, will shape the future.

Why is WHO suddenly talking about physical activity?

WHO has encouraged member state governments to promote physical activity for over a decade. Since the 2004 WHO Global Strategy on Diet, Physical Activity and Health, and inclusion of physical activity as a key risk factor and opportunity in the 2013 Global Action Plan on NCDs, the International Society for Physical Activity and Health (ISPAH) has been a lead advocate to promote physical activity. Its numerous resources, including a policy framework (the Toronto Charter, 2010) and policy investment decision tool (What Works: The Seven Best Investments for Physical Activity, 2011) guide countries with the rationale and operational choices for physical activity promotion.

What’s helped get physical activity on the global agenda?

Recent progress toward a Global Action Plan to Promote Physical Activity comes thanks to the tireless work of various key individuals and organisations. This includes ThaiHealth. ISPAH, in partnership with the BJSM. These organizations, along with others, are leading the push for greater recognition of physical activity as a key component of health, and social and sustainable development. An inactive world is unhealthier, uneconomic and unsustainable.

Broader policy priorities have emerged highlighting the pivotal role of physical activity in: (i) achieving the Sustainable Development Goals (SDGs), (ii) making the Global Action Plan to Promote Physical Activity a catalytic opportunity across multiple sectors, and (iii) providing a framework for a truly embedded whole system approach to moving nations. The NCD Alliance, ISPAH and partners will mobilize civil society advocates from across sectors to contribute to the development of a strong Global Action Plan, to call for renewed commitment from governments to boost physical activity, and to enhance the feasibility, sustainability and accountability of its implementation.

How will the Bangkok Declaration on Physical Activity and Health help?

Actions on physical activity can contribute to achieving eight sustainable development goals

The BKKD will help more people from more sectors engage in elevating physical activity as a local, national and global priority. It:

  • advocates for investment and actions at country, regional and global levels
  • provides a case for partnerships with sectors inside and outside of health
  • details six actions which could advance progress toward achieving WHO targets of increasing physical activity and reducing NCD burden by 2025
  • contributes to mitigating climate change, reducing inequalities and supporting more sustainable cities and communities in a rapidly urbanising world.

Use the BKKD in your practice, teachings and advocacy, share it far and wide. Get it at

The more engaged we all are, the better the ultimate health of our planet.


Competing Interests

All authors were involved in developing and promoting the BKKD

Further Reading

  1. International Society for Physical Activity and Health. The Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. Bangkok: ISPAH; 2017 [cited 2017 May 14]. Available from:
  2. Bull F, Gauvin L, Bauman A, Shilton T, Kohl H, Salmon A. The Toronto Charter for Physical Activity: a global call for action. 2010;7(4):421-2.
  3. Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International Society for Physical Activity and Health (ISPAH). NCD Prevention: Investments that Work for Physical Activity. Br J Sports Med2012;46:709–712


Figure 1           Actions on physical activity can contribute to achieving eight of the sustainable development goals

Authors: Charlie Foster1  Trevor ShiltonLucy WestermanJustin VarneyFiona Bull5

  1. Nuffield Department of Population Health, University of Oxford, UK & President of International Society of Physical Activity and Health (2016-2018),
  2. National Heart Foundation, Perth, Western Australia, Australia & Global Advocacy for Physical Activity (GAPA),
  3. NCD Alliance, Geneva, Switzerland,
  4. Healthy People Division, Public Health England, UK,
  5. Prevention of Noncommunicable Diseases and Mental Health, World Health Organisation, Geneva, Switzerland, Past President of ISPAH (2014-2016)

Register now: Nutrition, Oral Health & Performance Symposium (July 28, 2017)

19 May, 17 | by BJSM

Friday 28 July 2017 • Torrington Place, London, WC1E 7JE

UCL Eastman Dental Institute and partners invite you to join us for a ground breaking, one-day symposium in sport and exercise medicine and oral health. Expert speakers will explore:

  • State-of-the-art developments and future of sport nutrition (Dr Kevin Currell & Prof. Ron Maughan);
  • Sport nutrition and health (Dr Dan Kings);
  • Eating disorders & RED-S in athletes (Dr Anna Katarina Melin)
  • Oral health & sport performance (Prof. Ian Needleman, Dr Paul Ashley & Dr Julie Gallagher).

We will discuss how to maximise performance and minimise negative performance impacts. The symposium will be highly relevant to sport and exercise medicine clinicians and scientists, nutritionists, performance directors, dental care professionals and researchers. See the full schedule

Reserve your

The Symposium will be held in collaboration with the NCSEM and ISEH who, together with the Centre for Oral Health and Performance, are collaborating members with the IOC.


At the barre Part 1: Ballet dancers – observation, principles of management and unique considerations

17 May, 17 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Luke Abnett @balletphysio

Observing dancers

Ballet is an interesting and challenging field of sports medicine, and to be optimally able to manage injury rehabilitation it is important to know your sport. In this case it is important to know your art, because ballet doesn’t see itself as a sport at all. In fact, the entry level position in the Corps de Ballet of the Royal Ballet company carries the title of ‘Artist’. However, these athletic artists require just as coordinated a sports medicine approach to perform at their peak as any other sport.

In this blog I will share my experience of working for six years in ballet medicine to demystify some of the quirks of this population. I will explore some basic principles of ballet, the habits of its artists, the specialised equipment they use, and a typical balletic body.

Basic Principles

Classical ballet is an aesthetic art form and the most important outcome is how a performer subjectively looks whilst performing, rather than any objectively measurable physical achievement such as speed or strength. By way of example, the dancer who jumps higher may be overlooked in favour of the dancer whose technique and alignment is more visually appealing. Ballet aims to please the eye of the observer by creating the illusion of weightlessness in making seemingly effortless shapes with dancers’ bodies. Additionally groups of dancers coordinate their movements to make patterns and lines on the stage. To achieve this precision of movement, and precision of prescribed balletic positions.

There are two features of classical ballet which distinguish it from other forms of dance. Firstly dancers dance in a ‘turned out’ position, that is the lower limb is externally rotated (with maximal contribution from the hip joint but additionally from joints at the knee and foot). This allows the audience to see the line of the leg as it is either bent, extended or in some cases hyperextended more clearly than if the leg is viewed in the anatomical position. Secondly female dancers frequently dance on pointe, or on the tips of the toes, to add to the impression of weightlessness and to lengthen the leg line.


Dancers’ technical practice involves a high degree of repetition of set positions in various sequences, with the intention of maximising precision and efficiency of movement and therefore minimising risk of injury. However, the extreme nature of some ballet positions at the end of a joint’s available range of motion increases this risk, and the low variability of very repetitive movements may increase this risk further.

There is also a relatively limited capacity for practising ballet technique whilst resting one body part. Dancers commonly report feeling the technique of ballet as a whole-body position or movement, with part-practice of these positions feeling confusing and counterproductive. For example if a dancer was avoiding end range ankle plantarflexion to rest a posterior ankle impingement injury, it would be difficult to practise a high leg extension (which demands hip abduction/external rotation, knee extension and ankle plantarflexion). Changing the ankle position would change the overall feeling of ‘stretch’ in the leg as a whole and, even though the knee and hip ranges would not be limited by the ankle injury, the whole manoeuvre would tend to be avoided.

This ‘all or nothing’ approach is culturally embedded within ballet and also tends to affect training as a whole. In fact this makes sense when considering that, during a performance, a dancer must perform every step of their role to the full, otherwise they would not be permitted on stage. The unfortunate side-effect of this approach is that ballet training periodisation historically lags behind that of other athletic pursuits.


Ballet generally uses little equipment. Footwear is designed either for flexibility, to enable the dancer full freedom of movement of all foot and ankle joints, or rigidity, to enable the dancer to maintain neutral metatarsophalangeal joints when dancing on pointe.

Dance floors are sometimes sprung to reduce the shock of impact of jumping on the feet, legs and lumbar spines of dancers, though some theatre floors may be concrete. Most studios have floors that are flat, but some older theatres’ stages may be ‘raked’ – meaning sloping up towards the rear of the stage to give the audience a better view of the performance. This angulation adds the additional challenge of trying to avoid ending up in the orchestra pit when dancing pirouettes!

Ballet Physique

Ballet favours aesthetically pleasing lines, so hyperextended knees, excessive hip external rotation, excessive lumbar extension and excessive ankle plantarflexion with a high medial longitudinal arch are all favoured characteristics. A significant proportion of ballet dancers is hypermobile1, though this brings its own challenge of having sufficient strength to control excessive movement at the end of joint range. Ballet dancers (especially females) also tend towards low BMI and other female athlete triad risk factors, which could partially explain risk of bone stress injury2,3.

If a healthcare practitioner working in sports medicine considers that the typical ballet dancer is naturally hypermobile, regularly practises positions of extreme flexibility, uses unsupportive footwear and trains with a high degree of repetition, it is unsurprising that overuse injuries form the majority of those sustained by professional dancers. In part two of this blog I will explore some of the more common ballet injuries and discuss their mechanisms.

Luke Abnett has specialised in ballet physiotherapy for six years, having managed healthcare provision at the Royal Ballet School and now working in private practice in central London and leading a Dance Medicine Clinic in Surrey.


Facebook: BalletPhysio

Twitter: @balletphysio

Instagram: balletphysiolondon


  1. J Rheumatol. 2004 Jan;31(1):173-8.

Joint laxity and the benign joint hypermobility syndrome in student and professional ballet dancers.

McCormack M1, Briggs J, Hakim A, Grahame R.

  1. Am J Sports Med. 2014 Apr;42(4):949-58. doi: 10.1177/0363546513520295. Epub 2014 Feb 24.

Higher incidence of bone stress injuries with increasing female athlete triad-related risk factors: a prospective multisite study of exercising girls and women.

Barrack MT1, Gibbs JC, De Souza MJ, Williams NI, Nichols JF, Rauh MJ, Nattiv A.

  1. J Sci Med Sport. 2014 May;17(3):271-5. doi: 10.1016/j.jsams.2013.07.013. Epub 2013 Aug 8.

Injuries in pre-professional ballet dancers: Incidence, characteristics and consequences.

Ekegren CL, Quested R, Brodrick A.

A historic celebration of World Physical Activity Day 2017, and partnership for sustained dissemination of the EuroFIT program

13 May, 17 | by BJSM

By Dr. Marcos Agostinho

A historic celebration of World Physical Activity Day 2017 took place in The City of Football, home of the Portuguese Football Federation (FPF), with a formal public presentation of the National Program for the Promotion of Physical Activity. The program was coordinated by the Health Ministry, in Portugal’s Directorate-General of Health (DGS), and was presented by its Director, Professor Pedro Teixeira, from The Faculty of Human Kinetics – University of Lisbon (FMH).

With the participation of Portugal’s Ministers of Health and Education, the celebration was also marked by the signing of a unique formal partnership between the FPF, DGS and FMH for the dissemination of The EuroFIT program, derived from a EU H2020 funded project. EuroFIT uses some of the biggest national and European football clubs’ venues for the fight against sedentary lifestyles and related problems.

EuroFIT (European Fans In Training) is a social innovation program aimed at improving physical activity and sedentary behaviour through elite European football clubs. Its overall objective is to build new social partnerships between football clubs, fans and researchers that harness the power of football to deliver an innovative public health programme. The innovation will address the problems of physical inactivity, sedentary behaviour and poor diet. More can be found here:

As for Portugal’s recent National Program for the Promotion of Physical Activity (PNPAF), four primary strategic objectives were created for the 2017-2020 period:

  1. Promote awareness, physical literacy and the readiness of the entire population to practice regular physical activity and reduce sedentary time;
  2. Promote the generalization of assessment, counseling and referral of physical activity at the primary health care level;
  3. Encourage environments that promote physical activity in leisure spaces, in the workplace, in schools and universities, in transportation and in health services;
  4. Promote epidemiological surveillance and research, and value and disseminate good practices in the field of physical activity promotion and sport.

More information can be found here at the official program’s website:


Dr. Marcos Agostinho, MD, PGDip (SEM), BASc (MB)

Primary Care Sports Medicine Physician (CUF Torres Vedras Hospital), Family Physician & General Practitioner (USF Santa Cruz), Collaborator for The National Program for the Promotion of Physical Activity (DGS Portugal), Associate Editor British Journal of Sports Medicine (BJSM), Associate Editor BMJ Open Sport & Exercise Medicine (BMJ)

Mechanisms for optimal health…for all athletes!

11 May, 17 | by BJSM

Part-4 of the blog mini-series on RED-S

By Dr Nicky Keay

As described in previous blogs, the female athlete triad (disordered eating, amenorrhoea, low bone mineral density) is part of Relative Energy Deficiency in sports (RED-S). RED-S has multi-system effects and can affect both female and male athletes together with young athletes. The fundamental issue is a mismatch of energy availability and energy expenditure through exercise training. As described in previous blogs this situation leads to a range of adverse effects on both health and sports performance. I have tried to unravel the mechanisms involved. Please note the diagram below is simplified view: I have only included selected major neuroendocrine control systems.

Low energy availability is an example of a metabolic stressor. Other sources of stress in an athlete will be training load and possibly inadequate sleep. These physiological and psychological stressors input into the neuroendocrine system via the hypothalamus. Low plasma glucose concentrations stimulates release of glucagon and suppression of the antagonist hormone insulin from the pancreas. This causes mobilisation of glycogen stores and fat deposits. Feedback of this metabolic situation to the hypothalamus, in the short term is via low blood glucose and insulin levels and in longer term via low levels of leptin from reduced fat reserves.

A critical body weight and threshold body fat percentage was proposed as a requirement for menarche and subsequent regular menstruation by Rose Frisch in 1984. To explain the mechanism behind this observation, a peptide hormone leptin is secreted by adipose tissue which acts on the hypothalamus. Leptin is one of the hormones responsible for enabling the episodic, pulsatile release of gonadotrophin releasing hormone (GnRH) which is key in the onset of puberty, menarche in girls and subsequent menstrual cycles. In my 3 year longitudinal study of 87 pre and post-pubertal girls, those in the Ballet stream had lowest body fat and leptin levels associated with delayed menarche and low bone mineral density (BMD) compared to musical theatre and control girls. Other elements of body composition also play a part as athletes tend to have higher lean mass to fat mass ratio than non-active population and energy intake of 45 KCal/Kg lean mass is thought to be required for regular menstruation.

Suppression of GnRH pulsatility, results in low secretion rates of pituitary trophic factors LH and FSH which are responsible for regulation of sex steroid production by the gonads. In the case of females this manifests as menstrual disruption with associated anovulation resulting in low levels of oestradiol. In males this suppression of the hypothamlamic-pituitary-gonadal axis results in low testosterone production. In males testosterone is aromatised to oestradiol which acts on bone to stimulate bone mineralisation. Low energy availability is an independent factor of impaired bone health due to decreased insulin like growth factor 1 (IGF-1) concentrations. Low body weight was found to be an independent predictor of BMD in my study of 57 retired pre-menopausal professional dancers. Hence low BMD is seen in both male and female athletes with RED-S. Low age matched BMD in athletes is of concern as this increases risk of stress fracture.  In long term suboptimal BMD is irrecoverable even if normal function of hypothamlamic-pituitary-gonadal function is restored, as demonstrated in my study of retired professional dancers. In young athletes RED-S could result in suboptimal peak bone mass (PBM) and associated impaired bone microstructure. Not an ideal situation if RED-S continues into adulthood.

Another consequence of metabolic, physiological and psychological stressor input to the hypothalamus is suppression of the secretion of thyroid hormones, including the tissue conversion of T4 to the more active T3. Athletes may display a variation of “non-thyroidal illness/sick euthyroid” where both TSH and T4 and T3 are in low normal range. Thyroid hormone receptors are expressed in virtually all tissues which explains the extensive effects of suboptimal levels of T4 and T3 in RED-S including on physiology and metabolism.

In contrast, a neuroendocrine control axis that is activated in RED-S is the hypothalamic-pituitary-adrenal axis. In this axis, stressors increase the amplitude of the pulsatile secretion of CRH, which in turn increases the release of ACTH and consequently cortisol secretion from the adrenal cortex. Elevated cortisol suppresses immunity and increases risk of infection. Long term cortisol elevation also impairs the other hormone axes: growth hormone, thyroid and reproductive. In other words the stress response in RED-S amplifies the suppression of key hormones both directly and indirectly via endocrine network interactions.

The original female athlete triad is part of RED-S which can involve male and female athletes of all ages. There are a range of interacting endocrine systems responsible for the multi-system effects seen in RED-S. These effects can impact on current and future health and sports performance.


Optimal health: including female athletes! Part 1 Bones British Journal of Sport Medicine

Optimal health: including male athletes! Part 2 Relative Energy Deficiency in sports

Optimal health: especially young athletes! Part 3 Consequences of Relative Energy Deficiency in sports

Keay N, Fogelman I, Blake G. Effects of dance training on development,endocrine status and bone mineral density in young girls. Current Research in Osteoporosis and bone mineral measurement 103, June 1998.

Jenkins P, Taylor L, Keay N. Decreased serum leptin levels in females dancers are affected by menstrual status. Annual Meeting of the Endocrine Society. June 1998.

Keay N, Dancing through adolescence. Editorial, British Journal of Sports Medicine, vol 32 no 3 196-7, September 1998.

Keay N, Effects of dance training on development, endocrine status and bone mineral density in young girls, Journal of Endocrinology, November 1997, vol 155, OC15.

Relative Energy Deficiency in sport (REDs) Lecture by Professor Jorum Sundgot-Borgen, IOC working group on female athlete triad and IOC working group on body composition, health and performance. BAEM Spring Conference 2015.

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A. The IOC consensus statement: beyond the Female Athlete Triad-Relative Energy Deficiency in Sport (RED-S).Br J Sports Med. 2014 Apr;48(7):491-7.

“Subclinical hypothydroidism in athletes”. Lecture by Dr Kristeien Boelaert at BASEM Spring Conference 2014 on the Fatigued Athlete

From population based norms to personalised medicine: Health, Fitness, Sports Performance British Journal of Sport Medicine


Handball medicine, a growing area of interest in SEM: Insights from the 1st Scandinavian Congress in Handball Medicine

8 May, 17 | by BJSM

Is there a growing interest for handball medicine?

The 1st Scandinavian Congress in Handball Medicine was held during the final weekend of the Women’s Euro 2016, December 17-18th in Gothenburg, Sweden. It was organized by the Medical Committee of the Swedish Handball Federation (SHF) under the patronage of the European Handball Federation (EHF) and the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA).

The Norwegian team receiving the gold medals during the prize ceremony at Women´s EHF EURO 2016.

The congress was held at the newly opened Kviberg Park Hotel & Conference. Home of the largest multi-sport arena in Scandinavia with e.g. artificial turf football pitches, handball courts, beach volleyball courts and a unique indoor ski hall.

Inspired by Ted Talks

Rod Whiteley demonstrating how to assess the ”handball shoulder” during the workshop ’Screening the handball shoulder – What does it bring to the table?

The main focus of the first day was on shoulder injuries starting off with a symposium on injury prevention. Martin Asker (Sweden) talked about the high prevalence of shoulder problems among elite adolescent players, highlighting the need for prevention strategies at an early age. Grethe Myklebust (Norway) nicely showed that we actually can reduce the amount of shoulder problems in handball players by using a weekly neuromuscular training programme. Merete Møller (Denmark), who just before the congress successfully defended her PhD thesis, highlighted that monitoring load is very important among the youth players ( Kajsa Johansson (Sweden) then rounded up with a talk for the future by describing the new injury surveillance possibilities through the smartphone app AIM Control.

Rod Whiteley (Qatar) then entered the stage and delivered a keynote lecture with the somewhat provocative title “Throwing out the nonsense in the handballer’s shoulder – what you should and shouldn’t be doing in the clinic”. Rod went through several myths around the shoulder pathologies and highlighted what one should focus a little bit extra on in terms of shoulder assessment in handballers. Thereafter, the former elite player Lior Laver (the UK) outlined the possibilities and limitations with doing arthroscopic surgery in handballers from an evidence-based perspective in his key note lecture.

Day 2 Professor Grethe Myklebust presenting the body of evidence on ACL injury prevention in handball. These findings published recently in BJSM

The main focus was now switched to the knee joint and the morning started early with a symposium on cruciate ligaments injuries. Markus Waldén (Sweden) highlighted a few important takeaways for the sometimes “forgotten” injury to the posterior cruciate ligament (PCL) which is believed to be relatively more frequent in handball compared with many other team sports. Next, Grethe Myklebust took us through her group’s excellent research over 15 years on the epidemiology and prevention of anterior cruciate ligament (ACL) injuries in handball. Tron Krosshaug (Norway) then described what really is going on inside the knee joint when the ACL ruptures.

Romain Seil (Luxembourg), the current chairman of ESSKA, then held a keynote about knee injuries in in the very young and skeletally immature players. He also highlighted how there is life after the handball career – we need to consider not only the injuries, but also the potential long-term problems that could occur later in life such as osteoarthritis.

Free communications

The congress was also open for abstract submissions and the scientific committee accepted eight high-quality abstracts for oral presentations. After deliberation from stiff competition, the award of 500 Euros for the best presentation was given to Sebastian Skejø (Denmark) for his talk on estimating throwing intensity by using small accelerometers.

What can handball learn from other sports?

The closing of the congress consisted of a symposium dedicated to what handball can learn from other sports. Lars Bojsen Michalsik (Denmark) opened up with a talk about the physiological actions and demands in handball. Martin Hägglund (Sweden) underscored how the neuromuscular training programme “Knäkontroll” (Knee control) has been successfully implemented in Swedish football clubs. Fredrik Johansson (Sweden) gave an inspiring talk on training strategies for developing young tennis players and highlighted the importance of training in overhead positions. Markus Waldén argued for improving the overall medical support and arena safety in handball in order to resemble the guidelines in other big team sports. Finally, Lior Laver pointed out the importance of initiating injury surveillance research in high-level handball within the near future such as the studies being carried out in football (

Swedish Christmas carols and Norway (again)

A sports medicine congress is never better than what the associated social programme is. A lot of effort was therefore put on this aspect, kicking off with a pre-congress “Get together” followed by the semi-finals (Denmark vs. Netherlands and Norway vs. France) on Friday 16th. The official congress dinner on Saturday 17th started with bubbles and mingling and then the toastmaster Johan Sandberg (Sweden) took the lead by arranging a smartphone-based quiz during the buffet and a hilarious guide on why and how to sing Swedish Christmas carols.

The congress finished off with the fantastic final on Sunday 18th between Norway and the Netherlands in the classic Scandinavium Arena in front of more than 11,000 in the crowd. After some thrilling final seconds of the match, Norway claimed the title with a 30:29 win. Congratulations Norway!

SoMe reach out

With more than 800 individual posts, the congress managed to reach over 400.000 people through Twitter, Instagram and Facebook. If you missed the congress, you can still re-live through Twitter on the account @SCHM2016 and the hashtag #SCHM2016.


Martin Asker is a sports medicine therapist with more than 15 years of experience in handball. He is currently undertaking his PhD at the Karolinska Institutet, Stockholm, Sweden, with the aim to deepen the knowledge in shoulder function and risk factors for shoulder injuries in elite adolescent handball players.  He also has a special interest in throwing biomechanics and its relationship to performance and injuries in overhead athletes.  

Rod Whiteley, RPT, PhD, is a specialist sports physiotherapist from Australia who has worked extensively at the international level in e.g. rugby league and rugby union as well as in baseball. He has published in a wide range of areas of his clinical interest including throwing injury, muscle injury, and load management. He is currently working at the Aspetar Sports Medicine Hospital, Doha, Qatar.

Markus Waldén, MD, PhD,  is an orthopaedic surgeon who is involved in several research projects in football and handball. He is a senior researcher in the Football Research Group, Linköping University, Sweden and his main research interest is knee injuries and return to play issues. He is currently working as a team physician for a men’s professional handball team.

7th Annual London Sports & Exercise Medicine (SEM) Conference: Stand Tall, Talk Small, Play Ball

4 May, 17 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr. Robin Chatterjee

Last month, the 7th Annual London Sports & Exercise Medicine Conference took place at the KIA Oval. This yearly event is organised by the Sport and Exercise Medicine registrars who are based in the London area. The event doubles as one of the four National Training Days for Sport and Exercise Medicine trainees. The aim is to showcase a wide variety of topics via experts working throughout the field. This year’s conference, entitled ‘ Stand Tall, Talk Small, Play Ball’, examined the key issues in Sport and Exercise Medicine for all ages and at all levels.

Sport and Exercise Medicine (SEM) is a holistic specialty with various facets that are all equally important in the overall management of a patient, including but not limited to: musculoskeletal (MSK) medicine, exercise medicine, public health and population medicine.  The conference reflected this by having lectures in some of the different fields that make up SEM.

The speakers were comprised of internationally renowned medical, surgical and public health consultants, sports scientists and professors in sports medicine. Their work has ranged from preparing elite athletes for the pinnacle of their sport to strategies to increase activity amongst the general population in order to combat an array of chronic diseases.

The keynote speaker was Dr Ese Stacey who talked about gut dysbiosis causing MSK pain. She spoke about how diet and nutrition were important factors to include in the management of MSK pain as the balance of good and bad gut microorganisms had an impact on joints and tendons and in turn general well being and performance. Other speakers included Dr Justin Varney who discussed the peer-to-peer physical activity ‘Clinical Champions programme’. This is a service created by Public Health England, which provides free structured training, to health professionals by health professionals, to improve the understanding of PA in clinical practice so they can integrate very brief advice into their day-to-day clinical practice. Other highlights included: Dr Roger Wolman who described how short term bisphosphonate treatment may improve healing in selected athletes with stress fractures or bone marrow lesions; Dr. Richard Sylvester who shared his insights into complicated and unusual cases of concussion and Professor John King who spoke about past, present and future management of exercise-induced limb pain. All in all, there was something for everyone in the 170-strong audience, which comprised medical students, doctors, physiotherapists and scientists.

The event allowed networking opportunities for the delegates as well as a chance to learn new information and challenge old beliefs. We are very thankful to the speakers for taking time out of their busy schedules to talk and make the conference a success.

Programme: 7th Annual London Sports & Exercise Medicine (SEM) Conference:

Stand Tall, Talk Small, Play Ball

Sports injuries in the paediatric patient. Dr Matthew Barry (Consultant Orthopaedic Surgeon, Royal London Hospital)

Bisphosphonates in the athlete. Dr Roger Wolman (Consultant Rheumatologist, Royal National Orthopaedic Hospital)

Complicated cases of concussion. Dr Richard Sylvester (Consultant Neurologist, National Hospital of Neurology and Neurosurgery)

Asthma in the athlete. Dr John Dickinson (Head of Exercise Respiratory Clinic and Senior Lecturer, University of Kent)

Exercise induced limb pain. Prof John King (Honorary Chair at the Centre for Sport and Exercise Medicine at Queen Mary University of London)

Gut dysbiosis and MSK problems. Dr Ese Stacey (Consultant in Sports & Exercise Medicine, London West End Bupa Health and Dental centre)

Collapse during endurance training. Dr Courtney Kipps (Consultant in Sports & Exercise Medicine, Consultant to Institute of Sport, medical director of London and Blenheim Triathlons)

Physical activity promotion and the Clinical Champions service. Dr Justin Varney (National Lead for Adult Health and Wellbeing, Public Health England)

Getting people active through sport: overcoming inactivity. Prof Tess Kay (lead for sport, health and well-being research group, Brunel University) & Dr Laura Hills (Lead for Sport, Health and Exercise Sciences, Brunel University)

Safeguarding in sport issues and initiatives. Dr Daniel Rhind (Senior lecturer in social psychology, Brunel University)


Dr Chatterjee is a Specialist Registrar (ST4) in Sports & Exercise Medicine (SEM), a GP with a Special Interest in SEM and chairperson for the 7th annual London SEM conference . He currently works as a medical officer at the Defence Medical Rehabilitation Centre at Headley Court, London Broncos Rugby League club and Musculoskeletal Interface Clinical Assessment Service (MICAS) at Battersea Health Centre and is a regular contributor for Co-Kinetic Journal.

Twitter: @sportsdocrob


Farrah Jawad is a registrar in Sport and Exercise Medicine and co-ordinates the BJSM Trainee Perspective blog.

Sudden victory, BJSM finalists for best cover of 2016 – vote now and win a prize!

1 May, 17 | by BJSM

Do you wonder what Instagram is valued at? To save you googling — it’s $40-50 billion. Snapchat? (formally ‘Snap Inc.’ now) –$20-25 billion. Images are valuable and for BJSM, the cover is the valuable single piece of real estate. Kudos to our cover page designer, Vicky Earle – – and our 25 member society leads who collaborate to build BJSM covers.

My favourites of all time include 2013’s striking concussion issue cover, the cartoon of the doctor prescribing physical activity in 2009 and 2013 (the prescription pad became a mobile device), award-winning South African covers, the Dutch-themed hamstring issue of 2014 and of course Barcelona FC’s gift of the night shot of the packed Camp Nou (2015).

The BJSM community has voted for 4 worthy finalists among the 2016 covers. In chronological order, they include; (i) a cover drawn by the BMJ cartoonist, Malcolm Willett, to reflect that ‘risk’ can be in the eye of the beholder, (ii) the crowning of an Olympic champion for the IOC Expert Group’s statement on exercise in pregnancy, (iii) the Swiss Alps on the issue that celebrated the Swiss Sports Medicine Society partnering with the BJSM, and (iv) a contemporary take on spinal pathology in the BASEM-focused issue.

But I know you are reading this to find out about the prizes. “What’s in it for me?” How does a choice of one of the ‘Big 3’ sports medicine and sports physio books sound?


  1. Brukner and Khan’s Clinical Sports Medicine, 5th Edition, 2017
  2. Grieve’s Modern Musculoskeletal Physiotherapy, 4th edition, 2015
  3. The IOC Manual of Sports Injuries: An Illustrated Guide to the Management of Injuries in Physical Activity, Edited by Roald Bahr, 2012.

Here’s how to qualify for the prize:

1. Vote below for your favourite BJSM 2016 cover – polls open until May 07th.

2. Include your email address for us to contact you if you win – we will delete it after the competition. Your email will not be used for list serve or promotional purposes.

3. Tweet this blog post: mention @BJSM_BMJ and hashtag #BJSMCoverComp

AND/OR (if you are not on Twitter)

4. Like our Facebook page, like the link to this blog, share the link on your own Facebook wall, and hashtag #BJSMCoverComp

If you share this post on both Twitter and Facebook you double your chances of winning. But just one prize per person. Fast, fun, and (potentially) a great reward!


January-50-2: Sports Cardiology: Lowering Risk in Athletes

May-50-10: IOC Exercise & Pregnancy in Athletes Expert Group

September 50-18: Swiss Sports Medicine national conference

November 50-21: Focus on spine


Sports Endocrinology – what does it have to do with performance?

28 Apr, 17 | by BJSM

By Dr Nicky Keay

The Endocrine system comprises various glands distributed throughout the body that secrete hormones to circulate in the blood stream. These chemical messengers, have effects on a vast range of tissue types, organs and therefore regulate metabolic and physiological processes occurring in systems throughout the body.

The various hormones produced by the Endocrine system do not work in isolation; they have interactive network effects. The magnitude of influence of a hormone is largely determined by its circulating concentration. This in turn is regulated by feedback loops. For example, too much circulating hormone will have negative feedback effect causing the control-releasing system to down regulate, which will in turn bring the level of the circulating hormone back into range. Ovulation in the menstrual cycle is a rare example of a process induced by positive hormonal feedback.

In the control system of hormone release, there are interactions with other inputs in addition to the circulating concentration of the hormone. The hypothalamus (gland in the brain) is a key gateway in the neuro-endocrine system, coordinating inputs from many sources to regulate output of the pituitary gland, which produces the major stimulating hormones to act on the Endocrine glands throughout the body.


The Endocrine system displays complex dynamics. There are temporal variations in secretion of hormones both in the long term during an individual’s lifetime and on shorter timescales, as seen in the diurnal variation of some hormones such as cortisol, displaying a circadian rhythm of secretion. The most fascinating and complex control system is found in the hypothalamic-pituitary-ovarian axis. Variation in both frequency and amplitude of gonadotrophin releasing factor (GnRH) secretion from the hypothalamus dictates initiation of menarche and the subsequent distinct pattern of cyclical patterns of the sex steroids, oestrogen and progesterone.

So what have the Endocrine system and hormone production got to do with athletes and sport performance?

  1. Exercise training stimulates release of certain hormones that support favourable adaptive changes. For example, exercise is a major stimulus of growth hormone, whose action positively affects body composition in terms of lean mass, bone density and reduction of visceral fat.
  2. Disruption of hormones secreted from the Endocrine system can impair sport performance and have potential long term adverse health risks for athletes. This picture is seen in the female athlete triad (disordered eating, amenorrhoea and low density) and relative energy deficiency in sport (RED-S) with multi-system effects. In this situation there is a mismatch between dietary energy intake (including diet quality) and energy expenditure through training. The net result is a shift to an energy saving mode in the Endocrine system, which impedes both improvement in sport performance and health. RED-S should certainly be considered among the potential causes of sport underperformance, suboptimal health and recurrent injury, with appropriate medical support being provided.
  3. Caution! Athletic hypothalamic amenorrhoea, as seen in female athletes (in female athlete triad and RED-S) is a diagnosis of exclusion. Other causes of secondary amenorrhoea (cessation of periods >6 months) should be excluded such as pregnancy, polycystic ovary syndrome (PCOS), prolactinoma, ovarian failure and primary thyroid dysfunction.
  4. Unfortunately the beneficial effects of some hormones on sport performance are misused in the case of doping with growth hormone, erythropoeitin (EPO) and anabolic steroids. Excess administered exogenous hormones not only disrupt the normal control feedback loops, but have very serious health risks, which are seen in disease states of excess endogenous hormone secretion.

So the Endocrine system and the circulating hormones are key players not only in supporting health, but in determining sport performance in athletes.


Sport Performance and RED-S, insights from recent Annual Sport and Exercise Medicine and Innovations in Sport and Exercise Nutrition Conferences British Journal of Sports Medicine 17/3/17

Teaching module on RED-S for British Association of Sport and Exercise Medicine as CPD for Sports Physicians

Optimal Health: Including Female Athletes! Part 1 – Bones British Journal of Sport Medicine 26/3/17

Optimal Health: Including Male Athletes! Part 2 – REDs British Journal of Sport Medicine 4/4/17

Optimal Health: Young athletes! Part 3 Consequences of RED-S British Association Sport and Exercise Medicine 13/4/17

Optimal Health: All Athletes! Part 4 Mechanisms of RED-S British Association Sport and Exercise Medicine 13/4/17

Enhancing sport performance: part 1

Enhancing sports performance: part 3

From population based norms to personalised medicine: Health, Fitness, Sports Performance British Journal of Sport Medicine

Sleep for health and sports performance British Journal of Sport Medicine

Balance of recovery and adaptation for sports performance British Association of Sport and Exercise Medicine

Clusters of athletes

Inflammation: why and how much?

Successful ageing

Keay N, Logobardi S, Ehrnborg C, Cittadini A, Rosen T, Healy ML, Dall R, Bassett E, Pentecost C, Powrie J, Boroujerdi M, Jorgensen JOL, Sacca L. Growth hormone (GH) effects on bone and collagen turnover in healthy adults and its potential as a marker of GH abuse in sport: a double blind, placebo controlled study. Journal of Endocrinology and Metabolism. 85 (4) 1505-1512. 2000.

Wallace J, Cuneo R, Keay N, Sonksen P. Responses of markers of bone and collagen turover to exercise, growth hormone (GH) administration and GH withdrawal in trained adult males. Journal of Endocrinology and Metabolism 2000. 85 (1): 124-33.

Keay N. The effects of growth hormone misuse/abuse. Use and abuse of hormonal agents: Sport 1999. Vol 7, no 3, 11-12.

Wallace J, Cuneo R, Baxter R, Orskov H, Keay N, Sonksen P. Responses of the growth hormone (GH) and insulin-like factor axis to exercise,GH administration and GH withdrawal in trained adult males: a potential test for GH abuse in sport. Journal of Endocrinology and Metabolism 1999. 84 (10): 3591-601.

Keay N, Logobardi S, Ehrnborg C, Cittadini A, Rosen T, Healy ML, Dall R, Bassett E, Pentecost C, Powrie J, Boroujerdi M, Jorgensen JOL, Sacca L. Growth hormone (GH) effects on bone and collagen turnover in healthy adults and its potential usefulness as in the detection of GH abuse in sport: a double blind, placebo controlled study. Endocrine Society Conference 1999.

Wallace J, Cuneo R, Keay N. Bone markers and growth hormone abuse in athletes. Growth hormone and IGF Research, vol 8: 4: 348.

Keay N, Fogelman I, Blake G. Effects of dance training on development,endocrine status and bone mineral density in young girls.Current Research in Osteoporosis and bone mineral measurement 103, June 1998.

Keay N, Effects of dance training on development, endocrine status and bone mineral density in young girls, Journal of Endocrinology, November 1997, vol 155, OC15.

Keay N, Fogelman I, Blake G. Bone mineral density in professional female dancers. British Journal of Sports Medicine, vol 31 no2, 143-7, June 1997.

Keay N. Bone mineral density in professional female dancers. IOC World Congress on Sports Sciences. October 1997.

Keay N, Bone Mineral Density in Professional Female Dancers, Journal of Endocrinology, November 1996, volume 151, supplement p5.

Key words: adaptationamenorrhoeadoping in sport ,Endocrine systemendocrinologyexercisefemale athlete triadfitnessgrowth hormonehealthhormonesinjury, REDssporttraining

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