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Sleep as a recovery tool for athletes

17 Nov, 14 | by BJSM

Article originally published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital


By Charles Samuels and Lois James, Canada

The athlete sleep screening questionnaire©

“If your athletes go to bed, fall asleep within 30 minutes, sleep through the night with brief awakenings, feel refreshed within 60 minutes of waking most days (5/7 days/week) then congratulations: your athletes are normal sleepers!”

(Dr Samuels, 2013)


We know from decades of research that sleep is important for human performance1-3. So, why would we even think about screening athletes when it comes to sleep? Why not just apply basic principles of sleep and generalize from the research that’s been done in other areas such as law enforcement4-7, the military8-11 or aviation12-15? As a result of this research and knowledge athletes, coaches, sport medicine physicians and trainers are interested in understanding the relationship of sleep to training, recovery and performance in athletes. The complicating factor is that athletes, and elite athletes in particular, are very different than the average individual or members of occupational groups such as law enforcement and the military, on whom prior research is based. Athletes have unique physical and mental demands, have to accommodate rigorous competition and training schedules, and have to adapt to difficult travel regimes. So we have to be careful and specific about applying what we know about sleep to athletes. There is a clear need for developing valid, reliable tools to screen and monitor athlete sleep behaviours as the basis for understanding and developing effective interventions.

Most countries are developing high performance training programmes for National/Olympic team athletes and are committed to investing in every available tool to help them succeed. We know from the scientific study of sleep that it promotes physical and mental recovery16,17. However, the theoretical principles behind the relationship between sleep and recovery have only just started to be explored in athletic populations. Without a structured assessment of relevant sleep behaviours and the development of valid, reliable tools to acquire accurate data we will have nothing upon which to base useful research questions. Without these tools there will be no way to drive data collection, analyse the data and determine how sleep may affect training, recovery and performance. Finally, valid, reliable data collection methods are necessary to monitor the effectiveness of therapeutic interventions.

Over the past several years the University of Calgary Sport Medicine Sleep and Human Performance Research Initiative has developed the Athlete Sleep Screening Questionnaire (ASSQ) ©. This tool is designed to capture athlete sleep behaviours, identify athletes with abnormal sleep and primary sleep disorders, and determine the frequency with which athletes have difficulty with sleep when travelling. The ASSQ© screening system stratifies athletes into those who require basic sleep education, assessment with the sport medicine physician, and those who require a sleep medicine consultation and investigations. The goal of this article is to provide:

  1. A clear understanding of the relationship between sleep and recovery.
  2. An understanding of the ASSQ©, and how it can be used to benefit elite athletic teams.
  3. A summary of ASSQ© results collected from teams and athletes to date.


Sleep factors have been shown to have a direct effect on executive cognitive function18, metabolic control of energy balance, appetite and weight19,20 and tissue repair21. Cognition, metabolism and tissue repair are critical physiological processes that contribute to training capacity, recovery and performance. Recent research on athlete populations has provided objective evidence that confirms the importance of sleep in athlete development and performance16,22.

The relationship of sleep to post-exercise recovery and regeneration can be viewed in a structured fashion:

  1. Sleep length (total sleep requirement: hours/night, plus naps).
  2. Sleep quality (sleep disorders, environmental disturbance or sleep fragmentation).
  3. Sleep phase (circadian timing of sleep).

These three parameters of sleep are the key factors affecting the overall recuperative outcome of the sleep state23. They affect an athlete’s ability to train, maximise the training response, perform and recover24. Capitalising on the restorative power of sleep will help maximise energy, mood, decision-making skill and reflex response. In addition, attending to the importance of sleep will reduce the risk of overtraining/under-recovery, enhance resistance to illness and improve recovery from injury25.


For sleep to be recuperative it must be of adequate duration. This is a universal principle, but applies especially to athletes whose physical recovery may need to be greater than the average individual. Sleep requirements change over the course of an individual’s life; in particular the amount of sleep required. For example, 8 to 12 year olds need about 9.5 to 10 hours, 12 to 16 year olds need about 9 hours, and 16 to 22 year olds need about 9 to 10 hours per night. Naps can count towards total sleep time, should be restricted to 30 minutes and should be scheduled between 2 to 4 pm for the average sleeper. Strategic napping may be particularly beneficial for young athletes who, due to school commitments and training, may not be able to achieve the recommended amount of sleep per night.


Maintaining a regular sleep/nap routine, establishing a comfortable sleeping environment and monitoring for sleep disorders can maximise sleep quality. A key indicator of sleep disorders is excessive sleepiness, despite adequate sleep length. This is due to ‘non-restorative’ sleep, which is poor quality due to interruptions from sleep disorders such as insomnia, sleep apnoea or restless legs syndrome. Sleep disorders are common and treatable, but often remain undiagnosed. It’s especially important to find out if young athletes suffer from sleep disorders because intervention at a young age could make a huge difference for their long-term athletic development and performance. Travel can also affect sleep quality, so jet lag management and sleep scheduling while traveling is critical26.


The circadian system regulates the feeling of sleepiness and wakefulness throughout the day, which directly affects athletic performance. After awakening in the morning the average individual feels alert until about 2 pm, when the ‘afternoon siesta’ feeling kicks in. This tends to last for 30 to 60 minutes and then alertness rises again with a peak in the evening around 6 to 8 pm. After this point sleepiness increases, which facilitates the onset of sleep at bedtime. Each athlete has a preferred sleep schedule that suits his or her circadian phase; however, training, school, exposure to technology and work commitments can have a substantial impact on the athlete’s ability to match their circadian phase to the available time for sleep. If the circadian phase and sleep schedule are not matched (out of phase), the amount of sleep that can be achieved, as well as the quality of that sleep, will be affected. For example, adolescents have a natural tendency to become night owls, delaying bedtime. The delay in sleep onset (12 am to 1 am) in combination with having to get up for school (7 to 8 am) and the fact that adolescents need 9 to 10 hours of sleep per day results in a chronic sleep debt that affects daytime performance, alters mood, increases appetite and impairs post-exercise recovery23.

From a clinical perspective, we want information on athletes’ sleep behaviours to solve existing problems and help them improve post-exercise recovery and regeneration. However, it’s equally important to gather data from athletes at the aggregate level to start drawing some inferences or “best practices” that can apply to particular sports or athletes in general. The Athlete Sleep Screening Questionnaire© (ASSQ) has both strong clinical relevance, but also allows us to gather population-level data, learn about trends in athlete sleep behaviour, and start providing the athletes, coaches and support staff with some answers about how they should manage athletes’ sleep.


The ASSQ© has been about 6 years in the making. Our goal was to create a questionnaire that gathered information on athlete sleep behaviours to enable nationwide screening of a large population of athletes, provide efficient data gathering for research and validation, and to implement targeted clinical intervention. The ASSQ© is derived from standard sleep screening questionnaires and made up of 23 items representing four domains that capture the essence of the key sleep parameters of interest. The sleep difficulty score is used to categorise respondents into four meaningful categories that are associated with specific interventions:

  1. No clinical problem = education.
  2. Mild clinical problem = education and monitoring.
  3. Moderate clinical problem = see the sport physician.
  4. Severe clinical problem = sleep physician.

We wanted the tool we created to provide practical answers. We retain the theoretical concepts of sleep length, sleep quality and sleep phase; but translate results into simple ‘do this / don’t do that’ recommendations. In a nutshell, we are illuminating sleep problems, educating athletes that don’t suffer, finding the athletes that do and getting those athletes help.

The ASSQ© process is very straightforward. A team physician typically requests access to the questionnaire and is emailed a link to the online site. The athlete goes online and fills out the questionnaire, we download the response, review the results, and send a letter back to the doctor giving them advice for their athlete. If an athlete presents with a moderate or severe clinical problem a Skype consult is set up with the principal investigator, and a visit to a sleep doctor scheduled if necessary.


Between its launch in 2011 and the end of 2013, 307 elite athletes have completed the ASSQ©. Of these, 132 are male, and 168 are female. Athletes have participated from BMX, curling, rugby, alpine skiing, biathlon, bobsleigh, cycling, para-olympics, skeleton, speed-skating, swimming, volleyball, water-polo, and wrestling. Some athletes have also participated anonymously, where sport is not reported. Tables 1 and 2 below show the number of participating athletes where the team is known (248/307), the average hours slept per night and the average sleep difficulty score for each team. Sleep difficulty scores greater than 12 indicated clinically significant sleep disturbance and required follow-up consultation.

Within these teams, distinctive sleep profiles have started to emerge. For example, skeleton, swimming, and rugby athletes tend to sleep less and experience greater sleep difficulty, whereas curling and cycling athletes tend to sleep more and experience less difficulty sleeping than other sports.

Approximately 13% of athletes screened with the ASSQ to date have had sleep difficulty scores requiring them to have follow-up Skype consults. Females have tended to have slightly higher sleep difficulty scores than males, although not significantly so. Athletes’ increasing age and reduced sleep were significantly associated (P=0.01). Also, increasing age and increased sleep difficulty were significantly associated (P=0.03). Not surprisingly, a significant relationship was found between total sleep time and sleep difficulty score, with athletes who sleep less tending to have higher sleep difficulty scores (rho=-0.52).

Athletes who reported satisfaction with their sleep tended to have total sleep times averaging over 8 hours per night, whereas athletes reporting dissatisfaction with their sleep tended to have total sleep times averaging less than 7 hours per night. This finding is consistent with previous research demonstrating that extended hours of sleep are related to increased performance in intercollegiate athletes27. As dissatisfaction with sleep increased, so did average sleep difficulty score, suggesting that athletes are pretty good judges of their own sleep – if they are dissatisfied, chances are they are getting poor quality sleep.

Team case study:

The Canadian Women’s National Curling Program was very invested in sleep screening in preparation for the Olympic Trials and the 2014 Sochi Olympic Games. The national team coach initiated the screening, and 22 athletes were screened from across the country. The data from the athletes who were screened were analysed at the team level to provide a sleep profile for the team as a whole:

  • The median hours slept a night was 8 hours (with a range of 5.30 hours to 9.15 hours).
  • Comment: While the median was reassuring the range revealed that there was at least one athlete (possibly more) who was/were severely sleep deprived (<6 hours/night).
  • On average the athletes took 2 to 3 naps per week (average nap length 31 to 60 minutes).
  • Comment: This was encouraging that athletes napped, however routine napping for 20 to 30 minutes a day was recommended for all athletes.
  • On average it took the athletes 15 minutes or less to fall asleep.
  • Comment: This was a normal sleep onset latency.
  • Very few of the athletes had trouble staying asleep, or used medication to help them fall or stay asleep.
  • Comment: This was very encouraging. Inappropriate use of sedative medication is common amongst athletes and should be monitored and controlled.
  • The average level of satisfaction with sleep was “somewhat satisfied” or “neither satisfied nor dissatisfied”.
  • Comment: This question is the most predictive question for high probability of a clinically significant sleep disturbance.
  • The majority of the athletes did not snore or routinely gasp, cough or choke in their sleep.
  • Comment: While the likelihood of sleep apnoea is low in this population, the impact of the disease is significant and if treated can have substantial implications for the athlete.
  • The median sleep difficulty score for the athletes was 10.
  • Comment: The early validation data suggests that a score greater than 12 indicates clinically significant sleep disturbance and requires follow-up consultation.
  • 30% (n=7) of the athletes had a sleep difficulty score greater than 12, and required follow-up Skype consultation
  • The majority of the athletes experienced difficulty sleeping while travelling for their sport, however, the majority did not experience performance disturbance while travelling.
  • Comment: This indicated that there was value in developing a jet lag and travel fatigue programme to assist athletes with this disturbance.


Sleep is the foundation of recovery and critical to the management of athletic training regimens. Sleep is often ignored and compromised by athletes as a result of their busy schedules, other demands such as work and school, and most importantly by the intrusion of technology (cell phones, computers and tablets) into their life. This technology inhibits normal sleep physiology and fosters a heightened state of arousal, which acts as a barrier to the onset and maintenance of the sleep state. Understanding the actual sleep behaviours of athletes, how sleep parameters affect training and performance, and the impact of specific interventions on sleep and performance is important. This information will provide athletes, coaches and support staff with the tools necessary to manage sleep and improve athletes’ tolerance of strenuous training regimens. A better understanding of sleep behaviour and the effect of interventions will provide important solutions for the management of the negative impact of travel on athlete health and performance. The ASSQ© and global sleep screening of large populations of elite athletes will provide the information necessary to develop research methods, design informative studies and provide effective interventions. This article provides insight into how this can be achieved along with examples and early results of the work accomplished by the Canadian Own the Podium programme in preparation for the Sochi Winter Olympics.


Charles H. Samuels MD, CCFP, DABSM  is a Medical Director at the Centre for Sleep and Human Performance and a Clinical Assistant Professor, Faculty of Medicine, University of Calgary, Institute of Public Health

Lois James Ph.D is a Research Assistant Professor at the Department of Criminal Justice and Criminology, Sleep & Performance Research Center, Canada. Contact:


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  3. Cohen DA, Wang W, Wyatt JK, Kronauer RE, Dijk D, Czeisler CA et al. Uncovering residual effects of chronic sleep loss on human performance. Sci Transl Med 2010; 2:14.
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  8. Haslam, DR. Sleep loss, recovery sleep and military performance. Ergonomics 1982; 25: 163-178.
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Image via Jeff Rouk

Groin Pain in Athletes: First (Ever!), World Conference #Groin2014

11 Nov, 14 | by BJSM

By Ania Tarazi

On November 1-3, Aspetar Orthopaedic and Sports Medicine Hospital launched the inaugural World Conference on Groin Pain in Athletes at Aspire Zone in Doha, Qatar. International experts on groin pain convened during six sessions over three days to discuss developments in the field.

aspetarOn day 1 experts discussed groin pain epidemiology, risk factors and clinical examination and outcome measures. The day 2 presentations were on imaging and treatment of groin pain in athletes. The final day focused on the treatment of hip pain in athletes.

In this Groin Pain Storify, I compiled key themes and takeaways using the live feed from attendees and the audience that streamed the conference online from Aspetar’s website. For those not familiar, “Storify” allows you to capture all of the tweets, and other social media posts – including photos and graphs- in sequence.

We look forward to the conference consensus statement to be published in BJSM in 2015.


Post-exercise recovery: Effects of whole-body cryostimulation exposure in sport and medicine

6 Oct, 14 | by BJSM

Article originally published in the Aspetar Sports Medicine Journal as part of a Targeted Issue on Post-Exercise Recovery and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital


By Christophe Hausswirth, France

Elite athletes often train intensitively or compete over consecutive days. Cumulative fatigue over such periods of training or competition can reduce athletic performance. Adequate recovery between training sessions and/or competitive events is therefore essential to minimise the risk of fatigue and optimise performance. In this context, the use of whole-body cryotherapy (WBC) as a tool to aid recovery shows benefits on some inflammatory parameters, possible improvement of antioxidant status and improvements in mood and mild depression. Heating the body is supposed to be beneficial to athletes’ recovery, to treat muscle pain and as part of rehabilitation after injury. It has been already demonstrated that WBC stimulates the physiological reactions of an organism which results in analgesic, anti-swelling, antalgic immune and circulatory system reactions and could improve recovery after muscular trauma injury. Definition is needed as to the precise context in which athletes may use this tool to optimise recovery in relation to improving sleep patterns, optimising the parasympathetic system and increasing their general well-being.


Exercise-related stress is often increased due to environmental conditions, particularly those relating to temperature changes. For every sporting activity there is an ideal ambient temperature. Any deviation from this reference temperature will have a negative impact on performance.

Indeed, physical activity in a warm or cold atmosphere means that the body and the mechanisms involved in temperature regulation have to work harder. Although very effective, these thermoregulatory mechanisms may not be able to cope with extreme conditions.

They do, however, allow the body to adapt during chronic exposure. Artificial cooling of ambient temperature is an evolving technique, both to prepare athletes for competitions in difficult conditions and to improve the body’s recovery capacity.


The first very low temperature cold rooms appeared in Japan in 1989, when Yamauchi used a cryogenic chamber to treat rheumatism. The indications for WBC were subsequently extended to various inflammatory conditions. WBC was then offered to treat pain and prevent post-traumatic oedema, with exposure limited to to 2 to 3 minutes.

One of the most well-established physiological responses to cold exposure is triggered by the decrease in skin temperature, promptly stimulating cutaneous receptors and their sensory afferents to excite sympathetic adrenergic fibres, in turn causing the constriction of local arterioles and venules. The resulting decrease in blood flow to the periphery or injured/inflammed tissues reduces local metabolic processes, thereby attenuating the inflammatory response and the formation of oedema around the injured tissues1.

Reported reasons for using WBC include decreased joint pain and disorders, improved general well-being, decreased fatigue perception2 and reduced symptoms of psychiatric disorders such as anxiety and depression3. WBC is also extensively used in self-treatment or body hardening against respiratory tract infections and musculoskeletal pain4, as well as parasympathetic reactivation after intensive exercise5.


What is known today: a review of scientific data

How well WBC restores biological constants following intensive training remains unclear. Studies are therefore ongoing in the field of athlete recovery.

Although we still lack scientific hindsight on the link between recovery, sport and cryostimulation, this paper will summarise the effects of WBC on some relevant parameters and practical applications from our point of view. This will help to identify possible applications in the field of recovery in sport. The first parameter subjected to in-depth studies was inflammation; some studies associate recovery with the kinetics of appearance of inflammatory and/or muscle injury markers. At INSEP (French National Institute of Sport, Expertise and Perfomrance) we have been working for 4 years to help both the medical and the performance-related recovery process.

Sport and cold exposure

In the sporting realm, WBC (in this instance, more accurately defined as whole-body cryostimulation) has been used at temperatures ranging from -110°C to -160°C with the aim of limiting the spread of muscle lesions after training or competing6. It has also been offered as a prophylactic treatment to reduce the risk of muscle lesions during intense training periods and to increase the antioxidant status after multiple exposures7. Despite the increasing popularity of WBC in sports, few studies have assessed its efficacy in accelerating the recovery of the athlete2,8. Very recently, post-exercise cold water immersion has been shown to aid recovery by altering blood flow9, and improving perceptions of recovery10 which may be reflected by changes in cardiac autonomic activity. WBC may also exert important effects on post-exercise recovery at the cardiovascular level. As exercise causes an intensity-dependent parasympathetic withdrawal and sympathetic increase, a prompt recovery of parasympathetic activity is desirable after exercise. Changes in cardiac parasympathetic activity as assessed by heart rate variability (HRV) analysis have emerged in the literature as a global recovery index that reflects the acute response of the body to exercise; an elevated level of parasympathetic activity allows rapid cardiodeceleration and faster recovery10,11. While Stanley et al10 demonstrated that both cold water immersion (5 minutes in 14°C water) and contrast water therapy, consisting of three cycles alternating immersion in cold (1 minute, 14.2°C) and warm (2 minutes, 35.5°C) water, significantly aided post-exercise parasympathetic reactivation compared to passive recovery (PAS) in trained endurance athletes, they also reported that this effect was larger with cold water immersion than contrast water therapy, suggesting that combining a greater cold stimulus increased the effectiveness of water immersion. While various water immersion protocols have been shown to accelerate post-exercise parasympathetic reactivation, the effect of dry air whole-body cryostimulation (range from -110°C to -160°C) on post-exercise autonomic recovery is not well-documented, even though this recovery method has become increasingly used in high level sport3,8. Only one study reported a significant increase in the HRV indices of parasympathetic activity following a WBC session performed after exercise in elite synchronised swimmers5. Similarly, in resting conditions, Westerlund et al12 found that a single session of WBC significantly augmented HRV indices of parasympathetic modulation in healthy non-athletic women, with a mean increase of approximately 50% in root mean square of the successive differences and high frequency power. The resulting increase in central pressure in turn activates the baroreflex, responsible for reducing sympathetic nerve activity while shifting autonomic heart rate control toward a parasympathetic dominance. However, in the case of healthy, recreationally active men training only a few times per month, the autonomic response to WBC has not been investigated. Further, the influence of WBC on blood parameters and subsequent cardiac and thermal responses compared to partial-body cryostimulation (PBC) technique has not been thoroughly evaluated.

Comparison in different techniques of cold stimulation

Modern cryotherapy techniques involve local, partial-body and whole-body exposures. WBC and PBC have been developed very recently and many devices are commercially available. The major differences in the two systems are:

  1. the temperatures (-110°C vs -160°C for WBC and PBC, respectively),
  2. whether the head is exposed to the cold stimulus (yes vs no for WBC and PBC, respectively),
  3. the source of cold stimulation (compressor vs nitrogen gas for WBC and PBC, respectively).

The infrared studies of the temperature response to 3 minutes WBC exposure reported that cold air on the entire human body was responsible for an obvious drop off in skin temperature whereas central temperature did not exceed the thermoregulation range during cryotherapy sessions13. Thermal mapping of the body could be influenced by local blood flow, degenerative and inflammatory state of the tissue. It was therefore previously reported that an enhancement of skin temperature profile could increase the diagnostic sensitivity of infrared imaging in patients13. The use of several types of cryostimulation raises new questions such as:

  • What is the optimal modality?
  • What are the duration and minimal temperature required to elicit physiological responses?
  • Is head exposure needed to induce general modifications?

During WBC the entire body is exposed to cold, including the face and neck, as opposed to a PBC session. It has been shown that the direct effect of cold on the head alone, via face immersion in cold water (without breath holding) aided parasympathetic reactivation significantly following exercise11. The results of a recent study conducted at INSEP showed that whatever the cryotherapy technique used, a single 3-minute cryostimulation induced a strong autonomic response, as rising plasma noradrenaline, systolic and diastolic blood pressures reflected increased sympathetic activation and as the rise in HRV indices suggested an augmentation of the parasympathetic control of heart rate. A likely greater parasympathetic activation was observed with the greatest body cooling obtained by exposing the whole body (WBC) to cold.


Figure 1: Examples of thermograms obtained immediately before (a, b) and after (c, d) a partial-body cryostimulation session (A) and a whole-body cryostimulation session (B). The black shapes represent the different body regions of interests for the front and back facing subject (Hausswirth et al14).

Contrary to localised cryotherapy obtained by the application of ice packs, cold towels or cold air-pulsed on a small body region, the air-based cryotherapy modalities examined in the present study14 involved either complete body cooling (WBC) or whole-body cooling except the head and neck (PBC), inducing an important decrease in whole-body temperature (Figure 1). An almost certain very large reduction in Tskin (skin temperature) of all body regions of interests was recorded after the 3-minute cryostimulation, in greater proportion with the WBC. The mean decrease in Tskin was 13.7°C (i.e. -42.9%) for WBC and 8.3°C (i.e. -26.1%) for PBC. As previously reported by Cholewka et al13, a larger decrease in Tskin was recorded in the legs and arms when compared with the torso and back (Figure 1). These authors reported a significant positive correlation between the decrease in Tskin and the body mass index of individuals, indicating that the effects of cryostimulation may be influenced by body composition.


Cold-related stimulation of the autonomic nervous system

Hear Rate Variability (HRV) indices and blood catecholamines are classically used to evaluate the modulation of the autonomic nervous system (ANS) in response to various stimuli such as cold or physical exercise5,11. The parasympathetic and sympathetic activities refer to the cholinergic and adrenergic phases of the ANS, in reference to their respective neurotransmitters (i.e. acetylcholine for the parasympathetic component and catecholamines for the sympathetic component). Given the lack of consensus on the accuracy of HRV analysis in assessing sympathetic activity, we stated that the activity of this component of the ANS was studied only through plasma catecholamine concentrations, while the parasympathetic component was studied through HRV analyses. Plasma noradrenaline concentrations were likely and very likely increased after the PBC and WBC sessions, respectively, suggesting increased sympathetic nerve stimulation. This increase in plasma noradrenaline was accompanied by a possible small increase in plasma dopamine after WBC only, but no response in plasma adrenalinewas recorded after PBC and WBC sessions. Similar findings (cold-induced increases in plasma noradrenaline without any changes in plasma adrenaline) have been reported after different modalities of cold exposure15. Since noradrenaline mostly originates from the sympathetic nerve endings and adrenaline from the adrenal medulla, we can suggest that both cryostimulation techniques activate the sympathetic nerve system. In addition, since an increase in plasma dopamine is typically related to sensations of well-being and pleasure, we can suggest a slightly greater effect of WBC in generating positive feelings. A previous study reported a significant increase in sensations of well-being when an exhaustive treadmill running protocol was followed by a WBC session2.

During cryostimulation, cold-sensitive cutaneous receptors excite the sympathetic α-adrenergic fibres, responsible for a peripheral vasoconstriction mechanism through the release of noradrenaline. Consequently, blood flow is redistributed toward the core, resulting in increased arterial pressure16. INSEP data suggested that systolic and diastolic blood pressure were very likely increased after WBC, but not after PBC, pointing to a lower sympathetic stimulation that may be related to the smaller decrease in Tskin obtained after PBC. Further, the decrease in Ttymp (tympanic temperature )recorded with WBC, as well as the stimulation of cold trigemino-cardiac reflex receptors located in the face may have accentuated the parasympathetic response after WBC, augmenting vagal output to the heart. As expected, the increase in blood pressure was associated with a large decrease in heart rate, that was larger after WBC (-15.2%) than PBC (-10.9%) likely reinforced by the concomitant triggering of the baroreflex which lowers the sympathetic tone of the ANS, shifting to a predominance of the parasympathetic tone.

We published recently published a paper of the effect of WBC single exposure on recovery in elite athletes5. To our knowledge, this is the first time that WBC was investigated as a recovery technique between two closely scheduled, sport-specific maximal exercise bouts. The two most important findings of this study were:

  1. using WBC shortly after a full-length synchronised swimming ballet resulted in a strong parasympathetic reactivation in elite swimmers, yielding two- to four-fold increases in vagal-related HRV indices compared to pre-exercise values within only 1 hour;
  2. WBC exerted a significant influence on metabolic parameters of recovery and subsequent exercise, with a larger clearance of plasma lactate and an increase in maximal aerobic work output during the second ballet. The latter was only matched by the effects of active recovery.

Inflammatory marker responses

Some authors have measured various markers of inflammation in subjects exposed to very low temperatures. Banfi et al7 showed that treating top-level rugby players with WBC for 1 week led to reduced rates of pro-inflammatory cytokines (IL-2 and IL-8) and increased levels of anti-inflammatory cytokines (IL-10). This is the only study in which the results can genuinely be related to recovery after intense muscular exercise. According to the authors, WBC should improve muscle recovery, although they were not able to measure to what extent.

In this 5-day study, 10 top-level rugby players were placed in cryogenic chambers at -60 C for 30 seconds, then at -110 °C for 120 seconds. In addition, subjects followed their normal 3-hour daily training without changing their workload. While no significant difference was measured in terms of immunoglobulin or C-reactive protein levels (two markers of acute inflammation), the authors did show that creatine kinase and PGE2 prostaglandin concentrations were significantly reduced after 5 days of WBC (Figure 2). No control group was included in this study. The authors explain that the drop in creatine kinase is likely to result from the stimulation of noradrenalin secretion during exposure to cold, an effect demonstrated in Rønsen et al’s18 study. No assay of noradrenalin was performed in this study.


Figure 2: Variation in serum concentrations of muscle injury markers (prostaglandin and creatine kinase). The left panel shows a significant reduction in prostaglandin PGE2 (P <0.0001) “After WBC”. The right panel shows a significant reduction in creatine kinase (P <0.01) “After WBC”. Adapted from Banfi et al17 with permission from the Journal of Thermal Biology. WBC=whole-body cryotherapy.

Banfi et al17 observed a reduction in PGE2 associated with reduced creatine kinase levels. PGE2 is synthesised at the site of inflammation, where it acts as a vasodilator in synergy with other mediators, such as histamine and bradykinin. These mediators cause increased vascular permeability leading to oedema. Their reduction, after 5 days of WBC, seems to be a good indicator of improved muscle recovery. However, the absence of a control group in the study is a flaw which makes it impossible to reliably conclude on the efficacy of WBC in recovery. This research does, however, offer some suggestions as to the parameters likely to favour (or not) improved recovery.

In a recent study8 conducted in order to analyse the effect of two different recovery modalities on classical markers of exercise-induced muscle damage and inflammation obtained after a simulated trail running race. We chose to compare changes in immune cell mobilisation and C-reactive protein level because they are reliable indicators of acute performance deterioration, muscle damage and/or inflammation routinely evaluated in the general population and in athletes4,9. The major finding was that a single exposure to WBC significantly alleviated inflammation after strenuous exercise.

  1. Delta IL-1ra increased 1 hour after exercise following WBC compared to PAS
  2. Delta IL-1β was significantly suppressed 1 hour after exercise following WBC, compared to the PAS condition,
  3. WBC minimised the decrease of neutrophils 24 hours after exercise and
  4. C-reactive protein increase was strongly limited in the WBC group compared to the PAS group at 24 hours and until 48 hours after exercise. Data confirm that the treatment induces an anti-inflammatory protection effect and suggest that WBC reduced the time of recovery by positive effects on immunological parameters and the regeneration process for elite athletes.

Hormonal responses

Most studies of WBC have focused on the kinetics of biochemical markers and/or how various hormones evolve in response to exposure. It is widely believed that changes (or lack of changes) to endocrine parameters are relevant topics for research on improved athlete recovery. In this context, a recent study by Smolander et al19 compared WBC exposure (-110 °C for 2 minutes) to cold-water immersion (0-2 °C for 20 seconds). The two groups were subjected to either treatment weekly over a total of 12 weeks. Various hormones – growth hormone, prolactin and the thyroid hormones (TSH, T3, T4) – were analysed. The authors concluded that there were no significant variations in hormone levels for the WBC group. Prolonged exposure to cold seems to have no effect on the concentrations of these hormones. Based on this lack of effect of WBC on hormone levels, we can conclude that this procedure conforms to sporting ethics. These results are supported by those of another recent study by Banfi et al17, who indicated that, for a group of 10 athletes, none of the haematological parameters (e.g. red blood cells, white blood cells, haematocrit, haemoglobin, platelets etc.) were affected by five 2-minute exposures over 1 week. In an earlier study, Leppäluoto et al15 showed that exposure to WBC (three times per week for 12 weeks) induced a significant increase in plasma noradrenalin levels (Figure 3). The authors explain that the increases in noradrenalin levels recorded over the twelve weeks could play a role in relieving perceived pain, an effect seen in other studies using traumatising exercise. However, no scale of pain perception was offered in this purely descriptive study, which involved straightforward cryostimulation by WBC exposure.


Figure 3: Variations in plasma noradrenalin concentrations after 1, 4, 8 and 12 weeks of whole body cryotherapy. *Significant difference from initial value (P <0.01). Adapted from Leppäluoto et al15 with permission from The Scandinavian Journal of Clinical and Laboratory Investigation.

Immune responses

For a number of years, the immune system has been of particular interest to sports physiologists. The incidence of sore throats in very fit athletes initially helped doctors to detect overtraining syndrome. These intuitions were confirmed more recently by some very well-run American and UK studies.

In this context, Nieman20 observed that the immune response was impaired during repeated phases of prolonged high-intensity exercise, and that athletes responded poorly to bacterial and viral attacks, thus delaying recovery. Excessive sensitivity to respiratory tract infections seems to set in gradually, although it is well-described that the risk of respiratory infection follows a ‘J-shaped’ curve when plotted against training intensity, and that moderate exercise results in a low risk. Training is known to improve the immune response to a certain degree, while overworked athletes have reduced immune responses, in particular for immunoglobulins, ‘Natural Killer’ or ‘NK’ lymphocyte subgroups. While no study deals with the kinetics of how the immune system evolves after exposure to WBC, mainly because the procedure is so new, models involving swimming and immersion in cold water have been used for the last few years in Nordic countries and have provided indications on how the immune system is affected. This practice, which was developed more on a cultural than on a scientific basis, has always been empirically linked to improved resistance to infections. In this context, Dugué and Leppänen21 showed, in a study comparing populations swimming regularly in cold water or not, that plasma IL-6 levels, monocytes and leukocytes were all higher in cold-water swimmers. The authors concluded that the immune system of cold-water swimmers was controlling the inflammatory response better and that repeated exposure to cold (by immersion or not) could explain the improvement in defence against infections. It could therefore be suggested that repeated exposure in cold rooms (i.e. WBC) stimulates the immune system and reduces susceptibility to infections in acclimatised individuals. New studies on WBC should shed light on these hypotheses and offer insights into the relationships between immunity, cold and athlete recovery.

Antioxidant status responses

Physical exercise is known to be characterised by an increase in oxygen consumption, and consuming high levels of oxygen is associated with increased free radical production. Modulation of oxygenated free radical production plays a clear role in muscle recovery after exercise. High intensity exercise and/or exercise involving many eccentric movements are a true stress, producing metabolic by-products with significant effects on cellular structures. Oxygen-derived free radical species involved in oxidative stress are of various structures, but all are extremely reactive compounds which, once produced, will oxidise various cellular components. This oxidation can lead to cellular dysfunction and, among other things, to inflammatory disorders. A recent study by Dugué et al22 showed increased total plasma antioxidant capacity after 36 cold room sessions over 12 weeks (three times per week). These results contradict the authors’ initial hypothesis that values would be significantly reduced, and explain the improved protection. A single study investigated the effects of a WBC session (at -130°C) on the pro-oxidant/antioxidant ratio7. Plasma total oxidant status was significantly lower 30 minutes after exposure to WBC for 3 minutes (Figure 4). The next day, the total oxidant status level was still significantly lower compared to the basal level before WBC exposure. In addition, total antioxidant status values were significantly lower 30 minutes after exposure to cold, but did not differ from basal values the next day. However, in the case of athletes, cryostimulation is combined with physical exercises as part of regular training, and it is therefore difficult to know to what extent lipid peroxidation is the result of training and/or cryostimulation6.


Figure 4: a) Variations in plasma total oxidant status in resting subjects 30 minutes after cryostimulation and the next morning. *Significant difference between 30 min after cryostimulation and Next morning (P <0.05). b) Variation in plasma total antioxidant status in resting subjects 30 minutes after cryostimulation and the next morning. *Significant difference between Resting and 30 minutes after cryostimulation (P <0.05); **Significant difference between 30 min after cryostimulation and Next morning (P <0.01). Adapted from Lubkowska et al7 with permission from the Journal of Thermal Biology.

Responses for depressive symptoms

Some studies investigated the somatic and psychological effects of cold and seemed to reach a consensus on mood alterations. Even if somatic and psychological parameters seem somewhat removed from the topic of recovery in sport, they can obviously play an indirect role. Thus, the first studies on the subject showed that a short exposure to WBC improved sleep, sense of relaxation and mood, and that these effects can persist for hours or even days. In a more recent study, Rymaszewska et al3 studied the effects of WBC (-150 °C, 160 seconds, 10 times over 2 weeks) in 23 depressed patients on anti-depressant treatment. Using the 21 items on the ‘Hamilton Rating Scale for Depression’ (HRSD), the authors concluded that WBC exposure had a positive effect on HRSD scores, and thus helped alleviate symptoms of depression. Given these results, the authors very recently published another study, similar to their previous work, which included a control group of 34 patients3. After 3 weeks, the HRSD scores for the 26 patients suffering from depression were reduced by 34.6% in the WBC group, against only 2.9% in the control group. One neurobiological hypothesis states that depression results from a deregulation of the hypothalamic-pituitary-adrenal axis (hypothalamo-hypophyso-adrenergic axis). The authors relate the improved mood regulation and HRSD scores to this axis. In addition, it seems that WBC also has positive effects on patients’ biological rhythms. All these results could provide some help for the temporary psychological problems frequently encountered by athletes during training.



The published studies concentrate on physiological, biochemical and haematological parameters affected by WBC. It reduces proinflammatory responses, decreases pro-oxidant molecular species and stabilises membranes, resulting in high potential beneficial effects on sports-induced haemolysis, and cell tissue damage, which is characteristic of heavy physical exercise. Conversely, it does not influence immulogical or hormonal responses, with the exception of testosterone, estradiol, noradrenaline and myocardial cell metabolism. Interleukin concentrations are modified by WBC, which induces anti-inflammatory responses.

In the context of recovery between two training sessions, it has showed that a single session of WBC performed shortly after a maximal exercise exerted a strong influence on parasympathetic reactivation, yielding a two- to four-fold augmentation of in pre-exercise vagal-related HRV indices, only 1 hour post-exercise. In addition to the desirable effects of WBC identified in sport, future research should aim to determine whether the strong influence of WBC on parasympathetic reactivation at the cardiac level could present additional benefits over longer periods, as fatigue accumulation during periods of intensified training has been associated with changes in the autonomic modulation of heart rate in athletes.

The published data are generally not controversial, but further studies are necessary to confirm the present observations. Standardisation of exposures times and the number of treatments during each cycle could improve data comparison. Due to the impact on the parasympathetic reactivation, we hypothesised that further studies conducted on sleep efficacy are needed in order to speed-up the recovery of elite athletes.


Christophe Hausswirth, PhD is the Head of the Research Department and the Director of the Laboratory of Sport, Expertise and Performance, INSEP – French National Institute of Sport, expertise and Performance, Paris, France.



  1. Paddon-Jones DJ, Quigley BM. Effect of cryotherapy on muscle soreness and strength following eccentric exercise. Int J Sports Med 1997; 18:588-593.
  2. Hausswirth C, Louis J, Bieuzen F, Pournot H, Fournier J, Fillard JR et al. Effects of whole-body cryotherapy vs. far-infrared vs. passive modalities on recovery from exercise-induced muscle damage in highly-trained runners. PLoS One 2011; 6:e27749.
  3. Rymaszewska J, Ramsey D, Chladzińska-Kiejna S. Whole-body cryotherapy as adjunct treatment of depressive and anxiety disorders. Arch Immunol Ther Exp (Warsz) 2008; 56:63-68.
  4. Banfi G, Lombardi G, Colombini A, Melegati G. Whole-body cryotherapy in athletes. Sports Med 2010; 40:509-517.
  5. Schaal K, Le Meur Y, Bieuzen F, Petit O, Hellard P, Toussaint JF et al. Effect of recovery mode on post-exercise vagal reactivation in elite synchronized swimmers. Applied Physiology, Nutrition, and Metabolism 2013; 38:126-133.
  6. Swenson C, Swärd L, Karlsson J. Cryotherapy in sports medicine. Scand J Med Sci Sports 1996; 6:193-200.
  7. Lubkowska A, Chudecka M, Klimek A, Szyguła Z, Frączek B. Acute effect of a single whole-body cryostimulation or prooxidant-antioxidant balance in blood of healthy, young men. J Therm Biol 2008; 33:464-467.
  8. Pournot H, Bieuzen F, Louis J, Mounier R, Fillard JR, Barbiche E et al. Time-course of changes in inflammatory response after whole-body cryotherapy multi exposures following severe exercise. PLoS One 2011; 6: e22748.
  9. Vaile J, O’Hagan C, Stefanovic B, Walker M, Gill N, Askew CD. Effect of cold water immersion on repeated cycling performance and limb blood flow. Br J Sports Med 2011; 45:825-829.
  10. Stanley J, Buchheit M, Peake JM. The effect of post-exercise hydrotherapy on subsequent exercise performance and heart rate variability. Eur J Appl Physiol 2012; 112:951-961.
  11. Al Haddad H, Laursen PB, Ahmaidi S, Buchheit M. Influence of cold water face immersion on post-exercise parasympathetic reactivation. Eur J Appl Physiol 2010; 108:599-606.
  12. Westerlund T, Uusitalo A, Smolander J, Mikkelsson M. Heart rate variability in women exposed to very cold air (-110°C) during whole-body cryotherapy. J Therm Biol 2006; 31:342-346.
  13. Cholewka A, Drzazga Z, Kajewski B, Bogucki R, Wisniowska B. Thermal imaging of skin body surface die ti whole-body cryotherapy – preliminary report. Phys Med 2004; 1:81-83.
  14. Hausswirth C, Schaal K, Le Meur Y, Bieuzen F, Filliard JR, Volondat M et al. Parasympathetic activity and blood catecholamine responses following a single partial-body cryostimulation and a whole-body cryostimulation. PlosOne 2013; 8:e72658.
  15. Leppäluoto J, Westerlund T, Huttunen P, Oksa J, Smolander J, Dugué B et al. Effects of long-term whole-body cold exposures on plasma concentrations of ACTH, beta-endorphin, cortisol, catecholamines and cytokines in healthy females. Sca J Clin Lab Invest 2008; 68:145-153.
  16. Lubkowska A, Szyguła Z. Changes in blood pressure with compensatory heart rate decrease and in the level of aerobic capacity in response to repeated whole-body cryostimulation in normotensive, young and physically active men. Int J Occup Med Environ Health 2010; 23:367-375.
  17. Banfi G, Melegati G, Barassi A, Dogliotti G, Melzi d’Eril G, Dugué B, Massimiliano M et al. Effects of whole-body cryotherapy on serum mediators of inflammation and serum muscle enzymes in athletes. J Therm Biol 2009; 34:55-59.
  18. Rønsen O, Børsheim E, Bahr R, Klarlund Pedersen B, Haug E, Kjeldsen-Kragh J et al. Immuno-endocrine and metabolic responses to long distance ski racing in world-class male and female cross-country skiers. Scand J Med Sci Sports 2004; 14:39-48.
  19. Smolander J, Leppäluoto J, Westerlund T, Oksa J, Dugué B, Mikkelson M et al. Effects of repeated whole-body cold exposures on serum concentration of growth hormone, thyrotropin, prolactin and thyroid hormones in healthy women. Cryobiology 2009; 58:275-278.
  20. Nieman DC (1994) Exercise, infection, and immunity. Int J Sports Med 1994; 15:S131-S141.
  21. Dugué B, Leppänen E. Adaptation related to cytokines in man: effect of regular swimming in ice-cold water. Clin Physiol 2000; 20:114-121.
  22. Dugué B, Smolander J, Westerlund T, Oksa J, Nieminen R, Moilanen E et al. Acute and long-term effects of winter swimming and whole-body cryotherapy on plasma antioxidative capacity in healthy women. Scand J Clin Lab Invest 2005; 65:395-402.

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.



Osteoarthritic changes in the knee in handball players

31 Jul, 14 | by BJSM

This article was originally published in 2013 in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital

Written by Daichi Hayashi, Frank W Roemer and Ali Guermazi

**Note that you can subscribe (free) to the Aspetar Sports Medicine Journal by following this link (right margin, simple!):


Image courtesy of the Qatar Handball Association

Handball involves running, turning and jumping which cause high levels of mechanical stress to the knee. The vigorous nature of the ball game predisposes handball players to develop osteoarthritic changes in the knee including, for example, cartilage damage, meniscal tear, ligamentous damage and bone marrow oedema-like lesions.

A recent large-scale European research study involving 15,783 athletes who had primary unilateral anterior cruciate ligament reconstruction showed male team handball players (n=1,392) had an increased risk of full-thickness cartilage damage compared to male team football (soccer) players (n=6,473)1. Another epidemiological study demonstrated playing handball was associated with symptomatic knee osteoarthritis (OA) in 295 men aged 25 to 70 seen at orthopaedic clinics2.

While knee OA is generally thought to be a major public health problem that primarily affects the elderly, handball players can have OA of the knee from a relatively younger age than persons who do not play handball or other vigorous sports that can have a similar level of mechanical stress to the knee joint. In particular, trauma-induced damage of cartilage, meniscus and ligaments can trigger acceleration of degenerative OA-related changes within the knee joint, potentially leading to the need for knee arthroplasty at a relatively young age.

The joint as an organ – not just articular cartilage!

Sports physicians should also be aware of imaging characteristics of knee OA in vigorous sports such as handball. Currently, conventional radiography is still the gold standard imaging technique for the evaluation of known or suspected knee OA in clinical practice and research. It has many important limitations that were revealed as MRI became more and more widely available3.

Traditionally, it has been thought that articular cartilage is the central feature and the primary target for evaluation and therapy. However, in reality, OA-related pathological changes may affect all structures of the knee joint. Of the commonly deployed imaging techniques, only MRI allows visual assessment of all structures of the joint, including cartilage, meniscus, ligaments, subarticular bone marrow and synovium. MRI also allows evaluation of the knee as a whole organ in a three-dimensional fashion and directly aids in the assessment of cartilage morphology and composition.

In this narrative review article, the advantages and disadvantages of conventional radiography, MRI and other techniques including ultrasound, nuclear medicine, computed tomography (CT) and CT arthrography in the imaging of knee OA are described, in the context of sports medicine and musculoskeletal radiology.


Radiography is the most readily available, least expensive and simplest imaging modality. It enables detection of OA-associated bony features such as osteophytes, subchondral sclerosis and cysts. OA is radiographically defined by the presence of marginal osteophytes3. Radiography can also determine joint space width (JSW), which is a surrogate marker of cartilage thickness and meniscal integrity4. However, precise measurement of each of these articular structures is not possible because one cannot actually visualise cartilage or meniscus on radiography unless they are abnormally calcified i.e. normal hyaline cartilage or meniscus cannot be directly evaluated using radiography. Variations in semiflexed knee positioning, which occur during image acquisition despite standardisation, can also be problematic, since such variations can affect the measurement of various radiographic parameters of OA including JSW. In the OA research field, despite these notable drawbacks, slowing of radiographically detected joint space narrowing (JSN) is the only structural end point currently recommended by the U.S. Food and Drug Administration to demonstrate efficacy of disease-modifying OA drugs in phase-III clinical trials4. Progression of JSN is the most commonly used criterion for the evaluation of structural knee OA progression, and the total loss of JSW (‘bone-on-bone’ appearance) is one of the indicators for knee arthroplasty3.

The severity of radiographic OA can be assessed semi-quantitatively or quantitatively. For semi-quantitative assessment of knee OA, the Kellgren and Lawrence (KL) grading system is a widely accepted scheme used for defining radiographic OA based on the presence of a definite osteophyte (grade 2)3. However, KL grading is limited by the fact that KL grade 3 includes all degrees of JSN, regardless of the actual severity. Alternatively, the Osteoarthritis Research Society International (OARSI) atlas uses a different approach and grades tibiofemoral JSW and osteophytes separately for each compartment (medial tibiofemoral, lateral tibiofemoral and patellofemoral) of the knee. Using either method, it should be kept in mind that centralised radiographic reading is important from the view point of observer reliability, as even expert readers seem to apply different thresholds for semiquantitative grading of JSN3.

In contrast, quantitative JSW measurements can be performed either manually or by using a semi-automated software application. JSW is the distance between the projected femoral and tibial margins on the radiographic image. Quantification of JSW using image processing software does require a digital image either digitised plain films or images acquired using fully digital modalities such as computed radiography and digital radiography. Measurements of JSW obtained from knee radiographs have been found to be reliable, especially when the study lasted longer than 2 years and when the radiographs were obtained with the knee in a standardised semiflexed position. For further details of the measurement techniques, interested readers are directed to a recent publication by Guermazi and colleagues3.

The abovementioned semiquantitative and quantitative analyses of knee radiographs are particularly relevant for clinical and epidemiological OA research. In daily clinical practice of sports physicians treating handball players, evaluation of knee joint using radiography alone is insufficient since it does not allow comprehensive assessment of the joint as a whole organ. For example, a small focal cartilage defect with intact meniscus in the same compartment may not cause JSN, and thus radiographic appearance will be normal. Moreover, assessment of menisci and ligaments are very important since those structures can potentially affect the performance of handball players. Indeed, a recent population-based study in the USA involving 710 persons aged >50 years demonstrated that MRI shows OA-related pathologies in the knee joint in most people in whom knee radiographs do not show any features of OA, regardless of pain5. Conversely, cartilage loss is not the only contributory factor to JSN but changes in the meniscus such as meniscal extrusion, subluxation or meniscal root tear can also cause JSN3. Based on these limitations of conventional radiography, there is an ongoing debate regarding of the choice of modality for imaging-based definition of OA, as well as inclusion criteria and outcome measures for knee OA clinical trials4.


Because of high cost per examination, MRI is not routinely used as an initial assessment or during disease follow-up of OA patients in the general population. However, in the field of sports medicine, MRI of the knee is an essential imaging examination to be performed. MRI is a key imaging tool thanks to its ability to visualise pathologies that are not detected on radiographs i.e. articular cartilage, menisci and meniscal roots, ligaments, synovium, capsular structures and bone marrow oedema-like lesions3. All these structures are important to maintain normal function of the knee joint and high levels of performance during handball games. MRI enables the following:

  • the joint can be evaluated as a whole organ,
  • multiple tissue changes can be monitored simultaneously over several time points,
  • pathologic changes of pre-radiographic OA can be detected at a much earlier stage of the disease,
  • physiologic changes within joint tissues (e.g. cartilage and menisci) can be assessed before morphologic changes become apparent.

A list of knee OA features that can be evaluated using MRI are shown in Table 1. An important point to note is that one needs to select appropriate MR pulse sequences for the purpose of each study. For example, focal cartilage defects and bone marrow oedema-like lesions are best assessed using fluid-sensitive fast spin echo sequences (e.g. T2-weighted, proton density-weighted or intermediate-weighted) with fat suppression (Figure 1). 3D gradient recalled echo sequences (e.g. DESS, SPGR, FLASH) should not be used since these will underestimate the size of the lesions or may completely miss them7. Also, meniscal tears are better visualised on standard fast or turbo spin echo sequences compared to 3D gradient recalled echo sequences.OA table 1

OA knee Figure 1

Figure 1

Synovitis should ideally be evaluated by using T1-weighted fat-suppressed sequences before and after intravenous administration of gadolinium to enable differentiation of inflamed synovium and effusion within the joint cavity. Both synovium and effusion show high signal intensity on non-gadolinium enhanced fluid-sensitive fast spin echo sequences and the accurate extent of synovitis cannot thus be evaluated without the use of gadolinium (Figure 2). On non-enhanced MRI, the presence of joint effusion or signal abnormalities within the Hoffa fat pad can be used as a surrogate marker of synovitis when contrast-enhanced MRI is unavailable, but these are indirect and considered less accurate than the evaluation based on contrast-enhanced MRI. Evaluation of synovitis is clinically relevant since synovitis detected by contrast-enhanced MRI is known to be associated with pain3. Another point to note is the fact that bone marrow oedema-like lesions is a non-specific finding on MRI and can represent pathologic processes that are not related to OA, such as bone contusion, spontaneous osteonecrosis of the knee and bone marrow oedema syndrome. Thus, MRI should always be interpreted in the appropriate clinical context and the interpreter needs to have knowledge of a wide range of potential differential diagnoses that bone marrow oedema-like lesions may represent. Furthermore, MRI may sometimes be affected by artifacts which degrade image quality and mimic pathological findings. For example, so-called susceptibility artifacts can be misinterpreted as cartilage damage or meniscal tear if the observer is unaware of this phenomenon.

OA knee Figure 2

Figure 2

Gradient recalled echo sequences are known to be particularly prone to this type of artifact (Figure 3). In general, experienced musculoskeletal radiologists are aware of these facts and unlikely to make misinterpretations. However, it would also be beneficial for sports physicians and orthopaedic surgeons to know these important pieces of knowledge so that when they review the images themselves in reference to diagnostic reports issued by musculoskeletal radiologists they can fully understand the implications of these artifacts. To ensure optimal assessment of MRI-derived data, trained expert musculoskeletal radiologists should be consulted when designing imaging-based clinical or epidemiological OA studies and interpreting data generated in those studies.

OA knee Figure 3

Figure 3

An MRI-based definition of OA has recently been proposed for the purpose of OA research. Tibiofemoral OA on MRI is defined as either:

a) the presence of both definite osteophyte formation AND full thickness cartilage loss OR

b) the presence of one of the features in (a) AND one of the following:

  • subchondral bone marrow lesion or cyst not associated with meniscal or ligamentous attachments,
  • meniscal subluxation, maceration or degenerative (horizontal) tear,
  • partial thickness cartilage loss and
  • bone attrition6.

In addition, with MRI, OA can be classified into hypertrophic and atrophic phenotypes, according to the size of osteophytes. These newly proposed definitions and classifications are still in their infancy and are not utilised in routine clinical practice. However, given the limitations of the conventional radiography as described earlier, an MRI-based definition of OA may eventually become applicable to clinical practice in the future.

Semiquantitative and quantitative analysis of knee OA features

For research purposes, MRI features of knee OA can be evaluated using semiquantitative or quantitative approaches3. In semiquantitative assess-ment, each OA feature is graded using a defined scale (e.g. grade 0, 1, 2 and 3). A detailed review article focusing on semiquantitative MRI assessment of OA has been published recently7, and we will give an essential summary of this approach herein. There are three well-established scoring systems based on non-contrast enhanced MRI i.e. the Whole Organ Magnetic Resonance Imaging Score (WORMS), the Knee Osteoarthritis Scoring System (KOSS), and the Boston Leeds Osteoarthritis Knee Score (BLOKS), but in addition a new scoring system called the MR Imaging Osteoarthritis Knee Score (MOAKS) has been published. By integrating expert readers’ experience with all of the available scoring tools and the published data comparing different scoring systems, MOAKS was developed as a refined scoring tool for cross-sectional and longitudinal semiquantitative MR assessment of knee OA, and includes evaluation of OA features that are listed in Table 1. WORMS and BLOKS have been most widely disseminated and used, while MOAKS is new and needs more data to demonstrate its validity and reliability when applied to OA studies. For the purpose of synovitis evaluation, separate scoring systems based on contrast-enhanced MRI are available7. While WORMS, KOSS, BLOKS and MOAKS all include evaluation of synovitis using a surrogate marker, contrast-enhanced MRI-based scoring systems offer more accurate assessment because of the aforementioned reason. These scoring systems are not used in routine clinical practice and readers of this article who are not dedicated OA researchers may be unfamiliar with these, but in the field of OA research these semiquantitative scoring systems are commonly applied in both clinical and epidemiological research studies3,7. It should be noted that application and usage of these scoring systems should be done by trained expert musculoskeletal radiologists to ensure the validity and reliability of readings.

Quantitative assessment of knee OA features involves measurement of tissue dimensions such as thickness, volume, area or other numerical values. Each tissue to be analysed needs to be segmented manually or using a semi-automated or automated computer programme, and this is a labour-intensive process. For quantitative analysis of cartilage morphology, high-resolution 3D imaging sequences that delineate the bone-cartilage interface and cartilage surface with adequate contrast is required e.g. SGES and DESS sequence3. Quantitative analysis can be applied for evaluation of various knee OA pathologies, including cartilage, bone marrow oedema-like lesions, meniscus, synovitis and joint effusion, and has been used in clinical and epidemiological OA studies. However, it should be kept in mind that using segmentation approaches for ill-defined lesions such as bone marrow lesions is more challenging than segmentation of clearly delineated structures such as cartilage, menisci and effusion.

Compositional MR imaging

Compositional MR imaging allows visualisation of the biochemical properties of different joint tissues. It is therefore very sensitive to early, pre-morphologic changes that cannot be seen on conventional MRI. The vast majority of studies applying compositional MRI have focused on cartilage, although this technique can also be applied to assess other tissues including menisci and ligaments. Compositional imaging of cartilage matrix changes can be performed using advanced MRI techniques such as dGEMRIC, T1 rho and T2 mapping. For interested readers, more descriptions of these sophisticated research techniques are described elsewhere3.

Today, compositional MR imaging techniques are not used in routine clinical practice and remain sophisticated research tools that are only available at a limited number of research institutions. Nevertheless, the application in clinical trials and observational studies has been ongoing. It has been shown that composition of cartilage measured by dGEMRIC indices, T1 rho and T2 relaxation times may be related to the amount of mechanical stress to the knee joint imposed through regular exercise3. These techniques may be particularly relevant to evaluation of the knee in handball players, since a large amount of mechanical stress is regularly imposed to their knees and therefore physiological changes before morphological changes occur may be more commonly observed compared to sedentary persons in the general population. Additional novel compositional techniques include in vivo diffusion tensor imaging of cartilage based on a 7T MR system and T2* mapping of cartilage and menisci. These techniques show promise, but they will need to be practical and deployable using standard MRI systems before they can be widely used as a research or a clinical diagnostic tool.


Ultrasound is a technique that enables multiplanar and real time imaging at a relatively low cost without radiation exposure. It has the ability to image soft tissue and to detect synovial pathology without contrast administration. Thus, it is widely used in the setting of sports medicine clinics. Limitations of ultrasound include operator-dependency and the fact that physical properties of sound limit its application to assess deeper articular structures and the subchondral bone.

In inflammatory arthritis ultrasound is more sensitive than radiography in detecting cortical lesions (erosions) and has reasonable sensitivity compared to MRI. There is no reason to believe the ability to detect cortical bone pathology should differ in OA. In contrast, subchondral bone changes (e.g. bone marrow oedema-like lesions) are not readily demonstrable by ultrasound, because the interface between soft tissue and bony cortex is highly reflective, preventing sound waves from penetrating the cortex and hence preventing visualisation of pathology deep to the cortex.

Cartilage is easily identified and ultrasound is sensitive to physical properties of cartilage. However in actual clinical practice, non-invasively visualising the cartilage in central load-bearing areas of a joint is difficult in vivo, and the clinical relevance of visible articular cartilage is questionable.

The ability to detect synovial pathology is perhaps the major advantage ultrasound has over radiography. Ultrasound-detected grey scale synovitis has been validated against arthroscopy, MRI and histology in large joint OA and ultrasound appears to be more sensitive than clinical examination in detecting synovial hypertrophy and effusions. Additionally, Doppler signal is an indirect measure of increased synovial vascularity in large joint OA. Ultrasound-detected inflammatory features seem to be correlated with knee pain in motion in patients with knee OA. Ultrasound has also been used to assess clinical response to steroid injection but further research studies are needed to demonstrate the utility of ultrasound for this purpose3.


CT is a valuable tool for the characterisation of OA especially when imaging of osseous changes or detailed pre-surgical planning is required for knee arthroplasty. Development of helical multidetector CT systems enabled acquisition of isotropic voxels and multiplanar reconstructions in any given plane with equal quality to the original plane. Depiction of cortical bone and soft tissue calcifications by CT is superior to that by MRI. A high sensitivity was shown for CT in detection of intra-articular loose bony fragments in peripheral joints. Drawbacks of CT are low soft tissue contrast and relatively high dose of ionising radiation3.


CT or MR arthrography enables assessment of articular cartilage with a high anatomical resolution in multiplanar fashion. CT arthrography can be performed using a single (iodine alone) or double-contrast (iodine and air) technique. To avoid beam-hardening artifacts, the contrast material can be diluted with saline or local anaesthetics. For MR arthrography, gadolinium-DTPA is injected intra-articularly to visualise superficial cartilage defects. These arthrographic examinations have a low risk of infection from the intra-articular injection. Other potential risks include pain and vasovagal reactions, and systemic allergic reactions. CT arthrography exposes patients to radiation but MR arthrography does not.

Currently, CT arthrography is considered to be the most accurate method for assessing articular cartilage surface damage. It offers high spatial resolution and high contrast between the low attenuating cartilage and high attenuating superficial (contrast material filling the joint space) and deep (subchondral bone) boundaries. Meniscal tear can also be visualised due to the presence of contrast within the tear. CT arthrography is also ideally suited to depict subchondral bone sclerosis and osteophytes. As for subchondral changes, MR arthrography, but not CT arthrography, allows delineation of bone marrow oedema-like lesions on the fluid-sensitive sequences with fat suppression. Both techniques enable visualisation of central osteophytes, which are associated with more severe changes of OA than marginal osteophytes.


Scintigraphy utilises radiopharmaceu-ticals to visualise skeletal metabolism, to contribute to the localisation of disease and to assess severity of pathologic changes in OA. 99mTc- hydroxymethane diphosphonate scintigraphy shows increased activity during the bone phase in the subchondral region and is thought to reflect osteoblastic activity of early cartilage loss. While scintigraphy has excellent sensitivity, is relatively inexpensive and is readily available, limitations of the technique for the assessment of OA include its poor specificity and radiation exposure.

Positron emission tomography (PET) demonstrates metabolic changes in target tissues and can detect foci of inflammation, infection and tumours. PET utilises 2-18F-fluoro-2-deoxy-D-glucose (FDG) and reflects glucose metabolism in different tissues. Increased FDG uptake in areas of subchondral bone marrow corresponding to MRI-detected bone marrow oedema-like lesions may be seen. However, the value of FDG-PET for the assessment of OA in a clinical and research setting remains to be shown. Limitations of this modality are its limited availability, radiation and costs.


With many current ongoing research efforts for imaging evaluation of knee OA, more advanced imaging techniques such as compositional MRI for evaluation of physiologic changes in cartilage and menisci may eventually find their role in clinical management of patients with knee OA in athletes. Currently, without any effective disease modifying drugs being available, radiographic evaluation is considered sufficient for managing most patients and CT is used for preoperative planning before knee arthroplasty. MRI is implemented mainly for reasons of differential diagnosis and to evaluate for concomitant muscular, ligamentous or other soft tissue pathologies as well as to rule out complications of disease. As MRI findings may not necessarily translate into clinical symptoms, interpretation of these images always needs to be done in the appropriate clinical context for each patient5. When preventive strategies become more widely implemented it is to be expected that potentially more advanced techniques such as compositional MRI will find their way into clinical practice.


Radiography is the initial imaging examination to be performed for the assessment of knee OA. However, in the context of sports medicine MRI is the most important imaging tool for accurate and detailed assessment of the knee joint as a whole organ. CT and MR arthrography are also useful for detailed assessment of cartilage surface damages. Sports physicians need to be aware that the choice of appropriate MR pulse sequence for the purpose of each type of pathological feature is essential for accurate and valid evaluation. Experienced musculoskeletal radiologists should be consulted to avoid potential misinterpretation of artifacts as pathological findings.

Daichi Hayashi M.D., Ph.D.1,2

Frank W Roemer M.D.1,3,4

Ali Guermazi M.D., Ph.D.1


1. Quantitative Imaging Center (QIC), Boston University School of Medicine, Boston, USA and Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.

2. Bridgeport Hospital, Yale University School of Medicine, Bridgeport, USA

3. University of Erlangen-Nuremberg, Erlangen, Germany

4. Klinikum Augsburg, Augsburg, Germany



  1. Røtterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Årøen A. Effect of gender and sports on the risk of full-thickness articular cartilage lesions in anterior cruciate ligament-injured knees: a nationwide cohort study from Sweden and Norway of 15 783 patients. Am J Sports Med 2011; 39:1387-1394.
  2. Vrezas I, Elsner G, Bolm-Audorff U, Abolmaali N, Seidler A. Case-control study of knee osteoarthritis and lifestyle factors considering their interaction with physical workload. Int Arch Occup Environ Health 2010; 83:291-300.
  3. Guermazi A, Hayashi D, Roemer FW, Felson DT. Osteoarthritis: a review of strengths and weaknesses of different imaging options. Rheum Dis Clin North Am 2013; 39:567-591.
  4. Guermazi A, Roemer FW, Felson DT, Brandt KD. Motion for debate: osteoarthritis clinical trials have not identified efficacious therapies because traditional imaging outcome measures are inadequate. Arthritis Rheum 2013; 65:2748-2758.
  5. Guermazi A, Niu J, Hayashi D, Roemer FW, Englund M, Neogi T et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ. 2012; 345:e5339.
  6. Hunter DJ, Arden N, Conoghan PG, Eckstein F, Gold G, Grainger A et al. Definition of osteoarthritis on MRI: results of a Delphi exercise. Osteoarthritis Cartilage 2011; 19:963-639.
  7. Guermazi A, Roemer FW, Haugen IK, Crema MD, Hayashi D.MRI-based semiquantative scoring of joint pathology in osteoarthritis.Nat Rev Rheumatol. 2013; 9:236-251.


Novak Djokovic shares his sportsmedicine secrets for success

28 Jun, 14 | by BJSM

This interview was originally published in 2013 in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Orthopaedic and Sports Medicine Hospital

You can subscribe for free and have the Aspetar Sports Medicine Journal delivered to your door – yes, full colour, hard copy to your door. Google ‘Aspetar Sports Medicine Journal’ and enter your address. Easy. No spam. Just good quality sports medicine content.

DvorskyInterview by Dr Bane Krivokapic

Whether he’s on court or off, Novak Djokovic gives 100% of himself. His fitness and flexibility have helped him climb to the World No. 1 ranking. His humanitarian projects and on-court antics have made him a crowd favourite. Not only can he play and win the longest matches the game has ever seen (remember the 2012 Australian Open Final? Or Wimbledon 2013?), but he can play up to an international audience across dozens of media channels. And then return to do it all again in the next tournament in a different country, on a different surface.

The 26-year-old Serbian has taken the art of recovery to a whole new level, but the secret to his success, he says, is his team and family. They are the ones who have helped him become a 6-time Grand Slam Champ. Well, that, and eliminating gluten and sugar from his diet, as he tells us here.

How do you feel after playing a match that lasts for many hours? E.g. Australian Open final against Nadal

If you win the match, then you feel fantastic, no matter the amount of hours spent on court. But if you lose, then you can feel really bad, which is normal – you know you gave it all, you fought to the last drop of strength on court, and you lost. That is not easy to handle every time, especially in Grand Slams. But, this is a sport where you can always get another chance, every week there is a new tournament, new challenge. So, you learn from what happened, and turn to what’s coming.

How much time do you need to recover from such an extreme effort?

Tennis trains your body and mind to recover fast from a very early age. Because the season is so long and we play week after week, we don’t really have time to recover our energy to its fullest. You have to factor in different time zones, different climate, food, courts, balls… So your body is always adjusting to something and recovering from something. Not to mention your mind – you have to be able to resist the temptation to just stay in bed and give in to laziness after a long flight, training or match. You have to resist the urge to give up when you lose a point, a game or a set because in tennis, you always get another chance. If not in this game, then in next one; if not in this set, then in the next one. If not this week, then there is the next one. So we get one or two times per year to fully recover. Everything else is just grinding, and not giving up when going gets tough.

What is your recovery routine?

I have a great team of people around me that do the best they can with their expertise to make me feel physically, mentally and emotionally ready for every match and every challenge, and they then help me to recover later on. We have a standard routine after the matches which I don’t like to talk about, but it’s not a big secret. We do the stretching part, ice-baths, massage and similar things that are common in our sport. The main thing is to find the right balance and to understand the true limits of your body.

You give the impression that you are always physically prepared. What advice can you give to other athletes about fitness?

Every player is different, and there is no unique rule or advice. My team and I, as an example, love to be in nature so most of the things I do, I try to do out of the gym if I can. I bike ride, swim, run, play football, basketball. Every day we focus on different parts of the body. My advantage is my flexibility. My muscles are elastic and I spend a lot of time on stretching because that prevents injuries and keeps my body fresh.

How do you personally maintain your health?

I have to thank my diet for that. Eating healthy food helps me stay energised, healthy, pain free and injury free. I talked a lot about this in my book Serve to Win. We are all different and one rule cannot apply to all of us, but I did give some advice on how to find the right formula for your body that will help you stay healthy and happy.

What motivates you?

Love. Love is what keeps me going every day. Love for life, for this beautiful sport, for my family and fiancé and my team. I enjoy playing tennis and love competing. The fact that I am successful at what I do gives me an incredible opportunity to help others less fortunate than I am. I am never lacking motivation to go out there and give my best.

What is the mental game of tennis like? How do you prepare yourself in terms of psychology?

I have certain techniques that help me such as visualisation, meditation, relaxation or quite simple things like walking through a park which does miracles sometimes, I must say.

You often joke around on court – does this help your mental game?

One of my mottos is to be who I am and not pretend to be somebody else. I think that kind of thinking got me to where I am. Apart from being very serious and business-like when I go out on court to play, at the same time I really enjoy those moments and sometimes I like to show it and share it with the crowd.

Who makes up your medical staff?

I don’t really have a medical staff. I mainly visit doctors who have high expertise in working with professional athletes and I’ve been very fortunate not to need any medical assistance in the past few years.

Who do you travel with? A physiotherapist? A doctor?

I don’t travel with a doctor. We do all the necessary tests several times a year, so there is no need for him to be with me at tournaments. On the other hand, a physiotherapist is a crucial part of my team. I work with Miljan Amanovic, my close friend. We have been working together since 2007, when I was number three in the world. He helps me to recover, to prevent injuries and to get my physical condition in the best possible shape. He knows exactly what I need in every moment, which is not an easy task. But, he does it in a magnificent manner, as you can see. We are together for 9 months of the year, and when Miljan is not able to travel with us because of his family, I work with another physio, Saša Jezdic, a great professional and expert. I also travel with Marijan Vajda, my tennis coach, and Gebhard Phil-Gritsch, a fitness coach. We are a team with a capital T.

Who makes the decisions when it comes to your health, you, your doctor or your coach?

I never try to make decisions on my own because even though it’s an individual sport, it’s a team effort in the end that really counts. So the whole team discusses everything that is affecting my game and career, including health.

How much do you believe in the doctors you see?

I am very fortunate to be surrounded by great people who are excellent at what they do. I am certain that doctors I meet during the tournaments and between tennis events are all professionals, therefore there is no reason for me not to trust them. Thank God I am still healthy and young so I don’t need their assistance that much. But I am definitely not the person who will take ‘a pill for every ill’. I strongly believe that our body is able to heal itself if we give it time, and if we eat the right food. On top of that, I observe my body as a whole and don’t think that a headache is just a headache. I always try to understand and respond to the signals my body is sending to me.

You are obviously very close to your team. How does that contribute to your playing?

Without their support I would never be so successful. They mean the world to me. Each member of my team has its own obligations, but we work best as a team. We talk about everything, listen to what everyone has to say and we respect each other. It is a co-operation based on trust, hard work and professionalism, which is a winning formula in my opinion.

What is your relationship like with your coach?

My coach, Marian Vajda, is like my second father. We are more than a coach and a player. He is a very emotional guy and we have a lot of fun off the court which is very important to me. Marian is a good spirit of the team who brings positive energy.

He has contributed a lot in my career. Since we started working together I have won every singles title with him. We have gone through highs and lows, not just in my tennis career but also in my private life. He is the person I can talk to and he is like a part of my family.

Now that you eat gluten free, how do you keep your energy up without large carbohydrate loads?

Being gluten free today is so much easier than couple of years ago. Everywhere you turn you can find gluten free products so I am not really missing out on carbs. My diet is thoroughly explained in my book, so I definitely encourage you to read it.

How do you feel now that you’ve given up gluten?

I feel great. I feel more relaxed, more focused and more in control of my life in general. I’ve learned to sync food with my body’s needs, giving it exactly what it wants, when it wants it. It probably sounds strange to say I feel more relaxed and at balance but it’s true. I am at one with my body – I feed it with the right energy and in return I get a healthy and energised body. My mind and body are now more focused on performance than on masking or fighting pain.

Are you strict about any other foods? Have you cut out anything else?

I am strict about being healthy. I don’t enjoy feeding my body with junk food. It’s funny how after a while of eating right, your body immediately detects the wrong food and rejects it. In the past, every time I ate something ‘sinful’ and took something that was not a ‘healthy’ choice, my body reacted immediately and I would regret going that way. So, I cut out gluten from my life and it was the best decision ever! I also cut sugar and dairy to certain extent. The bottom line is that I am not missing anything, I am replacing junk with good and that cannot feel bad to me or my body.

How tough is it to be a high level tennis player?

It is not easy, I can tell you that. It has its ups and downs. You have to sacrifice a lot in life to be on top. High level tennis players are like Spartans, in a way. From early morning till evening we have a strict schedule of things we must do – four to five hours of practice each day, no matter if it’s 50 degrees outside. Fitness work, gym, running, ice-baths and a controlled diet are just a small part of it. Not to mention commitments to sponsors and tournaments. We travel so much, that sometimes we wake up not knowing which city or country we are in. When you are a top player, there is enormous pressure that you must win every single tournament and beat every opponent. But, I guess that’s the case with every job. If you want to be the best at something, you have to work hard; pressure is a privilege that we must earn. I enjoy tennis – it’s my life and it has given me everything. I breathe tennis and I must say it’s the best thing that has happened to me, so far. So all these things I mentioned I accept as a toll on the road and I keep going straight.

To be a high level tennis player, what percent is talent and how much is hard work?

It depends a lot from person to person, but I would say 10% is talent, 85% is hard work and 5% is luck.

The ATP tour is played on many surfaces. As an athlete, is changing surfaces good or bad for you?

It is always a challenge to change surface in a very short period of time. You have to adapt to different conditions, which is not easy, both physically and mentally. But tennis-wise, I guess the game would be quite boring if we constantly play on clay, for example. Different surfaces give opportunities to different players to show what they know, and this variety is always a good thing in sport.

When are we going to see you in Doha?

I play in Abu Dhabi every year in the Mubadala World Tennis Championship. If I find free time, I would be more than happy to visit Qatar, too. I respect all that the Al Thani family is doing for the country, and I have heard great things about Doha and its marvels. I am sure I will visit Qatar much before the FIFA World Cup in 2022.

Call for abstracts: First, world conference on groin pain in athletes, Aspetar, Qatar

5 May, 14 | by BJSM

groin aspetar blog

Dear Colleagues,

We are pleased to announce that Aspetar will host the 1st World Conference on Groin Pain in Athletes. This major conference will be held at the Academy Auditorium, from 1st to 3rd November 2014.

The scientific committee is currently accepting Abstract and Poster submissions in the topics related to the Groin Pain.

 The deadline for submissions is June 20th, 2014. 


For further information on abstract and poster submissions, please click here.

For further information about the conference, please go to the website.

Ramy Ashour, an interview with the squash superstar

17 Feb, 14 | by BJSM

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

– Interview by Cristiano Eirale, Qatar

R Ashour Palmer_5Every sport has its star. In squash, it’s Ramy Ashour. It’s not that he has the highest point average in the history of the professional tour. It’s not that he went unbeaten for nearly 2 years (or 49 games). It’s not that he has reached the final in more than half the events that he’s ever played in. The appeal of Ashour lies in his unique playing style and off-court charisma which have undoubtedly contributed to increasing the global appeal of squash. 

But it’s not just his shots that are unique. Ramy Ashour has gone his own way and taken his health and training into his own hands. He doesn’t have a coach and he doesn’t have an entourage. He teaches and trains himself, using an innate creativity that has led him to be described as ‘the artist’ and ‘mesmorising’. His fluid movements mask the dynamic speed at which he flies across the court; his humble nature masks a passionate fighter. But this has come at a great physical cost; here he tells Dr Cristiano Eirale about his training routine and what it feels like to be told he might never play squash again.

The first time I saw you play, the announcer told the crowd that they were very lucky to witness you playing squash that day because if you played to your full ability, there was no chance that your opponent would win. I have never heard this said about any other champion.

Are you, or do you feel like, a legend of sport?

To be honest, sometimes I don’t feel like a legend at all. I’m grateful and blessed to be called that and to be thought of as a good athlete, but at the end of the day I can’t think too much about that kind of thing, I can only think about being bad or not. I can’t think about how ‘good’ I am because otherwise it will go to my head. That’s happened to me before – once or twice my success got to my head and my level of play actually started going down. I learnt a lot from that so now I just do my best and play squash and surround myself with the best people that I can. I try to be myself, I try to be as genuine as possible and then just leave the rest to a greater power because I know I can’t control everything.

To be a champion athlete, how much is talent and how much is hard work?

I think talent and hard work have to be equal and work parallel to each other. I can’t just be more talented or skilful than I am a hard worker. I believe that to stay on top in squash, which is such a physically and mentally demanding game, you have to find that fine balance as much as you can. That’s what I’m trying to achieve now. I’m trying not to overdo it with squash so that I can leave enough room for my fitness and vice versa. I believe they have to work parallel to each other and that if I keep this balance, I’ll probably be able to stay at the top for a while.

How much time do you dedicate to squash every day?

I’ve always thought it’s a quality thing rather than quantity. There has been a revolution recently around fitness and conditioning that doesn’t focus on training for 5, 6, 7 hours a day. Rather, it’s about how affective you can be in the time you’re training, even if it’s just for 1 hour. So I’ve based my training around this philosophy for the last 2 years. I’m really interested in nutrition and physical fitness con-ditioning so I read about that a lot and I base by squash and fitness sessions on the latest information. These days, my fitness sessions don’t last more than an intense 1.5 hour session and never less than 45 minutes of intense training. My squash sessions are 1 to 1.5 hours in the morning and anything up to 1.5 hours in the evening.

I was impressed that you once told me that you like to put music on and to just play. Does this count as training?

Yes this is true – I try to imagine myself singing on court! I love music and I’ve always been involved in music since I was young. My grandfather and father both used to sing a lot – just for themselves – but it meant that I was raised in a musical atmosphere. I sing too and even hope to release a single soon! It will just be for my own pleasure and for the love of music, not a career move. I would never take music on as a career because I know that to start a new career, you have to begin at the bottom and I’m not sure if I could do that again.

When I started using music, I thought about how much I love squash and how much I love singing, so I thought I would link the two. No one really knows a lot about the connection between physical movement and music but I’ve found that it actually helped me come up with a lot of new shots. I started staying on court with my iPod and the more I did that, the more I found I was ‘high’ on music. It made me feel so liberated when I discovered that I could have not just one pleasure in squash but two pleasures with music too and I just felt like I had so much room in my head that I could come up with new shots. Basically, once I started listening to music and playing squash at the same time, I found myself being more creative.

At what age did you discover your talent?

My dad was the first one who got me to try squash as a new sport. At that time there was a glass court behind the three pyramids of Giza in Egypt and that was quite a scene! They used to black out the dessert and the only thing that was lit up was the glass squash court – it looked amazing. I was 6 years old at that time. My sports were horse riding and swimming so I decided to play squash and I never left the court since. I’ve always felt comfortable being on a squash court, like that’s where I belong. I know it’s not as big as tennis but it’s a great game. We’re trying to get squash into the Olympics and I will support that because I believe in this game. Wherever squash takes me I’m going with it because it is the thing I know the most in my life.

How important is sports medicine in your success e.g. nutrition, fitness, physio?

If I had to say a percent, I would say it has contributed 100% because I would never be where I am now without the help of my doctors, nutritionists and physios that I have worked with at Aspetar. The way I function on court has everything to do with my success and sports medicine takes care of that. I think sports health is very important and our game is very demanding, physically, so if you are not in the good hands of someone you trust, who trusts you and someone you feel comfortable with, you don’t stand the same chance as someone who does.

Sports medicine professionals also help me on a mental level. Sometimes I call my doctors in Doha at a time of intense stress and they just treat me calmly and give me advice. I know all my doctors are busy but they are still keen to connect with me on more of a personal level. They know how important squash is to me and what a big deal an injury can be. To be honest, I rarely received this level of care with any doctor in my life apart from my recent doctors. They have made me feel that I could not let them down because they have put so much effort into me. I just have to do well! When you have people working with you who genuinely want the best for you, you have to do your best for them.

Have you ever had an injury that threatened your career?

Yes, I have been told a couple of times that I won’t be able to play squash again and these were the most devastating moments of my life. I have never been able to imagine my life without sports. I love squash so much but not playing sports at all? I wouldn’t feel right living that way. But yes, I had an ACL operation when I was 16 years old and a doctor that I saw in Germany helped me a lot with that injury. He operated on me and I’m proud that I have come back after that operation even stronger. You never know how strong you are until you’ve been put in a situation where you don’t have any other option but to be strong. My mother was one of the people who helped me the most during this time because she is very strong, mentally. She’s always positive and I have learned that attitude from her and now use it on court. She is a good balance with my dad who is pretty relaxed and takes things very easily.

I’m proud to have overcome my injuries. I wasn’t necessarily rehabilitated well after my first operation and after that I didn’t do much prevention training. I also never paid attention to nutrition or physiotherapy treatment and my current doctors can see today what a beating my body has taken over the years.

What is the most common injury in squash?

I believe it is the hamstring, so I always take care to focus on this area. In the last 2 or 3 years there have been a lot of players who have had a lot of hamstring problems. Some have started contacting me asking where they should go for treatment and I found out through this contact that, surprisingly, there are a lot of players who have suffered from hamstring injuries. A lot of players take care of their quadriceps but no one really pays attention to their hamstrings or to the ratio of strength training that they should be doing to balance these muscles. I’m speaking about players who mainly come from Egypt – I can’t be sure about players all around the world.

Ankle sprains are also common.

Do you believe in prevention?

Yes, I definitely believe in prevention. I don’t refer to it as ‘prevention’ specifically, but I do work out in the gym and do the exercises I’m prescribed.

Do you think that a coach can help to improve a squash player’s performance?

I have always believed that the word ‘coach’ is a big deal. You can’t just call anyone a coach. To be a coach you have to earn it. I was coached in squash until I was about 19 years old. After that, I haven’t had a coach in that sense of the word, I’ve had training partners.

I have to give full credit to everyone who helped me because without them I wouldn’t be where I am but at the end of the day, I’ve had an unbelievable season, one of the best of my life where I haven’t lost a game since May 2012. I never expected that doing my fitness programme on my own with just one training partner would give such good results. I think that because I’m interested in fitness conditioning and I’ve seen so many fitness trainers, I can tailor my training myself. It was a risk, of course, but you have to be risk-taker in squash. You can’t be too safe. If you’re too safe you’ll be an ordinary player. If you want to be a little bit different you have to take risks and you have to accept the consequence of these risks, good or bad. So that’s what I applied to my fitness and it worked 100%. So of course I would say that a coach can make a difference but a real coach should be an inspiration who will stay close to you mentally and will train with you physically. There are a lot of important aspects to being a coach and unfortunately I wouldn’t say that I’ve met someone who is all of those things. But, at the same time, I’ve had people who have helped me throughout my whole career so I’ve benefitted from that.

Is there a process of testing for doping in squash?

Yes. We follow the WADA protocol so we have to be tested. I’m in the top 10 players in the world so I am tested every 3 months. I have to give them my whereabouts throughout the year and when it’s time for testing, I have to give them an hour in that day. So the anti-doping protocol is quite rigorous.

Do you think there are squash players who dope?

A couple of squash players have been caught. The doping programme in squash is relatively new. We never thought that squash players would dope but actually a couple of them were found to be positive and they were banned from playing for a while.

I think that the doping programme might seem like a bit of a hassle, since you have to constantly update your information online etc but it ensures that what we do is totally fair and transparent and that whoever is at the top has earned it 100%. Everyone knows that he didn’t do it with any illegal substances in his body, and that’s a good thing.

You have tournaments all over the world. Do you find a big difference between the medical care in each country?

Yes. One of the best places that I’ve found that has a lot of good institutes with good sports physicians, physiotherapists etc is New York. They’re very good and sports medicine is so big over there. In Egypt, where I have been treated for my whole life, I have a lot of respect for the doctors there but I got a lot of injuries when I was being treated there and I was mis-diagnosed a lot. I suffered from this and I could have avoided a lot of negative side-effects to my body if I hadn’t had that incorrect advice.

What are the ideal characteristics of doctors and physiotherapists working in squash?

Over the years I have been treated by a lot of doctors so I feel like I understand this role quite well. The main quality of a good doctor in squash is that he or she should understand the player’s movement. They should want to watch the player play to understand the mechanisms involved. This is rare, I haven’t found it much. A good doctor tries to really understand the squash player and apply their expertise to me as an individual, not just treat everyone the same. A good doctor also tries not to complicate things too much. They try not to make things bigger than they need to be, especially when the athlete is panicking. This is the way that the doctor can connect with a patient. I believe a big part of the curing is mental, not just physical.

Do you believe in sports psychology? Have you ever used it?

Yes, I believe in it. I used it for a while from when I was about 16 years old and until I got to the stage where I didn’t want to analyse things too much. Eventually I just felt that I didn’t need my personality analysed anymore. I know what I think about and I can address this myself.

My father once told me not to be superstitious about anything, whether it’s a piece of clothing or a day of the week, and not to pay attention to good or bad omens, just focus on the game and success. This helped me a lot. In terms of psychology, I tried to break every hurdle in my head and just be as free as I can.

I also live by the saying “if in doubt, work out”. There are times when I’ve woken up in the morning in the worst mood ever and I know that nothing will get me through the day unless I put 100% into what I do. I have always found life to be hard, not easy, but I have found that the good part comes after the hard part – that’s what I have always experienced and hopefully when I get older things will get a bit easier.

Do you use sports supplements?

I wouldn’t say I believe in supplements too much but I do use them a bit. I never used to take them but my nutritionist has given me a simple regimen to follow which involves a few supplements. He thinks they might help enhance my health and thus my perform-ance slightly. The effects won’t be anything major – I won’t end up like a body builder or anything like that – but these supplements can just help me get the right things to my muscles and help me perform. To be honest, I don’t want to get into supplements too much. At the end of the day I still want to feel natural. I don’t want to feel that I’m putting anything unnatural in my body or that I’m focussing too much on the elements outside of the court because squash is already such a big part of my life. I don’t want to overdo it.

Interview by Cristiano Eirale, M.D.

Aspetar – Orthopaedic and Sports Medicine Hospital Doha, Qatar

Paul McGinley – an interview on 21 years in pro golf, and lessons learned from knee injury recovery

8 Nov, 13 | by Karim Khan

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

If you want the excellent Aspetar Sports Medicine Journal sent to you just email your address to:

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Paul McGinley

Aspetar Cover Issue 6

–       Interview by Velvet Garvey

Paul McGinley’s entrance into the world of professional golf was unconventional. While he showed early potential, it was for a different sport – Gaelic football. But as a rising star, a knee injury excluded him from the sport he loved. With a need to channel his passion and athletic talent he turned to golf and quickly rose up the ranks from amateur to pro.

But the ethos of football never left him, and throughout his career he has excelled in the team events and earned a reputation as a good sportsman and great leader. Thanks to this reputation he has recently been awarded one of golf’s highest honours: the captaincy of the European Ryder Cup team. Known as a quiet achiever, here he talks about his constant injury, the changing game and the one thing on tour he can’t live without.

Firstly, congratulations on your recent captaincy.

Thank you. I am thrilled. Absolutely thrilled!

You started golf with an injury which is quite rare in an athlete. Tell us about your time playing Gaelic football and the injury you suffered?

Gaelic football was what I started with. If you had asked me as a young boy, would I have been a professional golfer by the time I was 18 years old, I would have said absolutely no way. There’s more chance of me going to the moon than being a professional golfer. I wasn’t bad at golf – about an 8 handicap – but I was really good at Gaelic football. I was going to play in the very top level but then I broke my knee cap and I did a lot of damage around it. I have had 8 operations on it since. Well, 6 on one knee, 2 on the other.

That injury and being told that I could no longer play football meant that I had to redirect my desire and my competitiveness in a completely different direction. It was going to be all Gaelic football and all of a sudden all that energy that I was putting into football got driven into golf. I started to play golf 12 months of the year and got down to scratch handicap quite quickly.

It also meant that I could study. With a degree in Marketing already, I studied International Business at a college in America where I could study and play. At the time I didn’t know if I was going to be good enough to turn pro but I knew that after 2 years in America I would either go into business or be good enough to play golf. I needed that time to prove to myself that I was good enough as a golfer and I did. I dominated the amateur scene in Ireland and had a good college career in America and that’s why I turned pro.

Has that injury affected you throughout your golf career?

Yes, no doubt.

Do you have a regimen that you follow for your knee injury?

For me, it’s about maintenance now. I do a lot of swimming and have cut back on my gym work. Over the years I have done a lot of work building up the muscle around my knee and getting it strong. But the bottom line is, the debris still breaks off the patella every now and again and floats around, so every 2 years I have to go in for an arthroscopic procedure and have it cleaned out and tidied up. So there is no cartilage left, it’s just bone on bone. Right now, as I’m sitting, I can feel it. On the golf course it’s fine. It’s not pain that is the problem, it is the anticipation of pain that makes me get in bad positions with my swing and basically back off it. It is my left knee. So it’s the same as Tiger’s (Woods), same as Ernie’s (Els). If you’re a golfer and you’re going to have a knee injury, the right is the one to have it on, not the left because all the impact goes through the left.

You must have a really good relationship with your surgeon if you have to go back every 2 years!

Yeah! There are two surgeons that I have used: one in Ireland and one in England. One of them especially, I know very well. I’m at the stage where they can help me in an emergency, like last year I had to pull out of a tournament because my knee was inflamed, which it does now and again when the fluid builds up. Usually I have to get that fluid drained off but last year I had a cortisone injection just to calm it down a bit. If there is any problem at all I get onto my surgeon and he sees me straight away, even if it is 7 am before his clinic opens. He will get me in, do an MRI, check it all out and see where we are at and give me advice on what to do.

Would you say that has affected your attitude towards preventing injuries?

Yes. Although I worked with a trainer, I think a lot of the damage I did over the years was when I was doing stuff of my own. It was when I wasn’t paying enough attention to form or to technique in terms of lifting weights and that kind of stuff. It was more about getting in, getting the reps done and getting out. One of the lessons I learned is that I should have paid real attention to getting the technique 100% correct. Some of my injuries were caused by poor technique and going through the routine, rather than being really specific about getting the technique perfect.

You have been playing for 21 years. How has the game changed from a physical point of view?

Massively. The physical change and the physical specimens of the guys on tour nowadays are completely different. Body shapes are so different. Guys are so much younger, so much more athletic and so much more powerful. The guys spend so much more time in the gym. When I came on tour 5% of players, maybe less, worked in the gym. Now, I would say 97% of players work in the gym.

What do you think it takes for those young guys to become number 1?

Well there is no doubt about it: a power game is essential. The game is so much easier if you’re powerful nowadays and a lot of the modern technology is very much allied with fast club head speed. So, the better you swing the club and the faster you swing the club, you get more out of modern technology. Having said that, the shorter hitters can still compete and some shorter hitters do, but you need to have a very strong short game and strong mind if you’re going to compete when you’re a shorter hitter, whereas it is a distinct advantage if you can hit the ball a long way in the modern game.

Charlie Beljan drew some attention to his nutrition this year and said that he is going to start focussing on eating well. What is your attitude to nutrition?

My grandmother used to say to me, “a little bit of everything won’t do you any harm”. So, if I fancy an ice cream, I have an ice cream. If I fancy a bar of chocolate I have a bar of chocolate, but I won’t overdo it. From my own experience (this isn’t everybody’s opinion) but for me, if I punish myself by never having any chocolate and I eat and go to the gym and do everything 100% and my whole life revolves around my golf, then I become a poorer player because I don’t have the ‘feel good’ factor.

I don’t have any hard or fast rules, except when it comes to breakfast. I have porridge every single morning. I travel with it on tour. If I’m going to somewhere like China, where I know they don’t have porridge, I bring my own sachets. Also, my cousin makes great oatmeal cookies so I take them with me to snack on. They are pure oatmeal with some raisins in them, no sugar or anything. I had them this morning for breakfast. They’re great because they’re easy and I have to base my eating times around my tee time.

Do you have anyone who gives you nutritional advice?

Yeah, I have sought advice in the past and used nutritionists so I am aware now what is best for me. The only problem is that if you listen to a nutritionist, their advice is so strict so I take a little bit from it but also focus on just feeling good.

As a golfer you shine in the team events. Do you think that Gaelic football had something to do with that?

No doubt. The team ethos of Gaelic football was instilled in me from when I started playing at about 4 years old. Gaelic football is an Irish game played only in Ireland, except for Irish expats who play it abroad. It is deeply ingrained into the Irish culture and it’s all about the team – the closeness of the players and the bonds that they form is what makes a great team.

Do you think there is an argument for athletes specialising in more than one sport?

Definitely. I have a 12-year-old son who is very good at golf and cricket and rugby and soccer. I want him to play every kind of sport. I don’t want him to specialise. If he gets to 15 or 16 and he starts getting serious about becoming competitive, maybe then he can specialise.

Growing up in Dublin, I played a wide variation of sports like golf, Gaelic hurling, soccer, running and swimming. All of those sports were very important in my development. Also, I think it’s kind of sad if a kid specialises in one sport from an age of 10 or 11 to the exclusion of every other. I don’t think that’s the right thing to do and I never encourage it when people ask me for advice about if kids show a good skill level in golf. I always say to just keep playing other sports, keep forming bonds with other people and be competitive in different arenas. Because the competitiveness you learn in different arenas can still be brought to your golf game. Golf is not just about hitting the golf ball around – it’s the ability to compete and you can learn that by playing other sports too.

You famously conceded a putt to J.J. Henry at the Ryder Cup in 2006. How important is good sportsmanship to you?

Of course it’s important. I feel that I live my life being a very fair and open person and I like to think that I play sport in the same way. The putt that I conceded in the Ryder cup was for no other reason than a fan ran onto the green and obstructed the other golfer’s line as he was trying to line up the putt. The match was all over and I was done, but more importantly, Henry wasn’t getting a fair chance to hole his putt because this guy was grabbing all of the attention and damaging his line. That’s why I conceded it. I wasn’t very popular because a lot of people had me backed to win and I only had a half game instead of a win! A lot of people have mentioned that to me since but I don’t regret it. It was the right thing to do under those circumstances.

When you are on tour do you travel with a medical team?

No, I use the physios on tour. They’re very good and they know my knee as well as anybody by this stage. We also have a doctor that travels with the tour and he is very familiar with my injuries as well. The main thing now is avoiding making it worse. I’m never going to make it any better; it is never going to be 100%. So I need to maintain it through proper physio, making sure that the muscles around it remain strong, and doing low impact stuff like swimming. I do very little gym work now, so stretching and swimming are the two things that maintain me.

Do you have a coach who travels with you?

My coach is Bob Torrance but he doesn’t travel with me because he is in his 80s now. He has coached me all my career and he will be my coach until one of us goes to the ‘fairways’ in the sky!

I have a great relationship with him. He’s a very strong character. I really admire him and love being in his company. We have a personal relationship. There are a number of people I seek advice from and get their opinions too, but ultimately Bob is my coach and he will always be so.

How do you train for the mental side of the game?

I don’t think you train for it. I think you have that instinct in you from a young age. I think what you need to do is remain fresh. You want to prepare your mental game so that when you get on the golf course, you feel like a greyhound. You want that ‘freshness’ as a golfer.

What does it take to be a good golfer?

A wide variety of things. You have to be physically fit, mentally fit and mentally tough. You’ve got to have a good technical golf game and you have got to be well-managed and have good council around you from friends and family. It is the whole package – it’s not just one or two things. As great as we think we are, we are not good enough to do it on our own. We need good people around us.

Editor’s note: Just a reminder that you can see examples of past Aspetar Sports Medicine Journals by clicking here.

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

22 Oct, 13 | by Karim Khan

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

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


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

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

Tell us about some of your career highlights.

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

What is your current training programme?

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

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

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

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

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

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

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

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

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

Every aspect of it is challenging.

Have you ever had an injury that threatened your career?

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

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

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

How do you treat an acute injury?

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

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

Who makes up your medical support team?

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

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

Who makes the decisions around your health?

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

What is your relationship like with your coach?

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

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

Do you follow any injury prevention programmes?

No, not at the moment.

Do you follow a nutritional strategy?

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

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

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

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

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


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