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Announcement of winners! 2017 BJSM PhD Academy Awards

21 Jul, 17 | by BJSM

By Alan McCall

The hard work of PhD candidates and their innovative findings are integral to moving our field forward. They provide evidence based practical recommendations for clinicians and practitioners. The BJSM PhD Academy Awards recognise and celebrate the contribution of younger and emerging leaders.

The ‘People’ and the ‘Editors’ have voted for the inaugural BJSM PhD Oscars! Thanks to all of you who engaged via the BJSM blog – we were delighted to see votes from all over the world for the People’s Choice award.

The People’s Choice Award:

Voted for by the BJSM readership through social media outlets, the winner is…

Dr Ryan Timmins for his thesis entitled: Biceps femoris architecture: the association with injury and response to training. (watch video HERE)

The Editors’ Choice Award:

For the Editors’ Choice Award, each PhD summary was graded based on 6 categories: 1) Novelty, 2) Rationale, 3) Methods, 4) Ambition, 5) Practical applications and 6) Perceived reach. The winner of the BJSM PhD Academy Award is…

Dr James O’Brien for his thesis entitled: Enhancing the implementation of injury prevention exercise programmes in professional football

(watch video HERE)



Here’s our interview with each winner:

Ryan Timmins

Congratulations! How does it feel to hold the People’s Choice ‘Oscar’?
It’s a big shock to be completely honest. I didn’t expect it at all. To be up against some amazing researchers and come out on top, is surprising. The work that Guus Reurink and James O’Brien are doing will have an impact on sports medicine for years to come. It’s a great initiative from BJSM to promote the work of some great PhDs within the field.

What’s the elevator pitch for your thesis?

Hamstring injuries are the most common injury in elite sport and although research in this area is increasing, injury rates aren’t dropping. I identified different factors, mainly muscle structural components, which are associated with an increased risk of injury;   interventions can alter these characteristics of muscle.

What was your most noteworthy finding? 

In elite soccer players, short muscle fascicles (a bundle of fibres – which can be assessed via ultrasound) increases the risk of future hamstring strain injury. This is a previously unidentified risk factor and one which is now being considered within injury prevention and rehabilitation programs.

What was your most significant personal or professional learning that came out of the project?

That research within elite sport medicine isn’t impossible, despite the common view here in Australia that it is. There’s moments where you need to consider all views etc, but being approachable and working well with the sporting clubs enables a mutually beneficial result. Sometimes egos need to be checked at the door and this takes a bit of time to get past for some.

What’s next for you? How can research progress further?

There’s plenty of space now to look at interventions to modify these variables and thus decrease the risk of injury. However, the big leap will be implementing these evidence based interventions within elite populations. It isn’t impossible, but one which will take a bit of massaging to happen. It’s an implementation challenge.

Where are you working now?

I’m at Australian Catholic University in Melbourne, still working closely with Dr David Opar (my PhD supervisor) in the area of hamstring injury prevention and rehabilitation. I also hold a position at the Melbourne Victory Football Club, which helps in understanding some of the limitations with implementing research within the sporting sphere.

Any special thank-yous / shout outs?

As always this is never an individual effort. This whole PhD and awards process wouldn’t have happened without a great team of people:

Anthony (Das) Shield: now an Associate Professor who always provided great insight and direction and is always a wealth of knowledge. Without him, a lot of the people in this thank you list wouldn’t even be in research (myself included); David Opar: one of the greats and one who will continue to change sports medicine research now and into the future; Morgan Williams: the magic man responsible for anything interesting in our papers. We have him to thank for his tireless hours with JMP and trying to bash our stats into something understandable. Also thank you to all my other co authors and ripper blokes (and Casey) from our research group: Christian Lorenzen; Nirav Maniar; Joshua Ruddy; Jack Hickey; Joel Presland; Matthew Bourne; Chris Pollard; Dan Messer; Steven Duhig; Casey Sims; Argell San Jose.

James O’Brien

Congratulations! How does it feel to be the Editors’ Choice? (for the grammar pundits, it’s Editors’ choice because there are 3 Editors of the BJSM)…

I’m really honoured to have my work recognised in this way, especially considering the strength of all the nominees’ projects. The positive feedback I’ve received this past week from both researchers and clinicians also means a lot.

What’s the elevator pitch summary of your thesis?

Football is the world’s most popular sport, but injuries are common. Specific exercise programs can drastically reduce the number of injuries, but a lot of teams choose not to use these programs, or don’t perform them correctly. I asked “Why is this?”, with the aim of improving use of these exercise programs, and hence preventing more football injuries.

What did you discover? 

The most important finding was the wide range of barriers and facilitators to implementing injury prevention programs. This is important because these factors directly influence the ultimate success of these programs, when teams employ them under real world conditions.

What was your most significant personal or professional lesson? 

As I come from a clinical background, the biggest lesson for me was that conducting and reporting high quality research is really hard work. I developed huge respect for top-level researchers in sport and exercise medicine, especially those few who manage to combine both research and clinical work at a high level.

What’s next for you? 

Important steps are understanding what components of injury prevention exercise programs are crucial to their success, along with the required dosage. There’s also a need for innovative ways of harmonising injury prevention with other important goals in the football environment, especially performance goals. Future injury prevention requires multi-faceted strategies that embrace the complexity of the environments in which they are delivered.

What are you doing now?

I’m extremely fortunate to be working in one of the world’s leading football academies at Red Bull Salzburg. My work involves a combination of injury prevention research and practice, along with physiotherapy treatments and supervision. In the academy, I’ve been able to directly apply the important lessons I’ve learnt from my PhD. We’ve enjoyed big injury reductions, along with significant sporting success, including winning the UEFA Youth League.

Any special thank-yous/shout outs?

Most of all I want to thank my wife and children  for supporting me through my PhD. The trials and sufferings of PhD students are well known, but those of their partners and families often go unheard. A huge thank you to my supervisors Professor Caroline Finch and Associate Professor Warren Young, along with the whole team at ACRISP, Federation University Australia, who are all conducting very important research. I also want to thank my colleagues in the medical team at the Red Bull Academy; I cannot imagine a finer group of people to work with. Finally, thanks to BJSM for drawing attention to the contribution PhD students make to sport and exercise medicine

Editors’ notes: Big thanks to BJSM Senior Associate Editor Dr Alan McCall who runs this part of the BJSM. Every element of BJSM takes a ton of work and we have sportsmedicine’s best team – by a mile!  Kudos to all whose work is published in this monthly BJSM feature, part of the new-look colour BJSM which launches in January 2018. 

Highlights from the 2017 future of football medicine conference

7 Jun, 17 | by BJSM

By Dr Chris Garnett

On 13-15th May 2017, the largest annual football medicine event in the world took place at the iconic Camp Nou in Barcelona.  ‘The Future of Football Medicine’ Conference, organised by the Isokinetic Medical Group in association with FIFA, brought together 2,500 delegates and 197 of the world’s most renowned speakers from 90 different countries. Over the 3 days, researchers, clinicians and sports scientists delivered talks and workshops on the latest sports medicine research, injury prevention, rehabilitation, and optimisation of player and team performance.

A top journalist meets an International Football Manager: Roy Hodgson

The footballer’s groin pain was a topic covered particularly well with expert guidance provided by Dr Per Holmich, Dr Ulrike Muschaweck and Andreas Serner. Groin pain is a common injury in football and can be challenging for clinicians to manage. In 2015 the ‘Doha agreement meeting on terminology and definitions in groin pain in athletes’ defined four clinical entities – adductor-related, iliopsoas-related, inguinal-related and pubic-related groin pain.1 Acute adductor injuries account for approximately two thirds of acute groin injuries in football and primarily involve the adductor longus muscle.2 The hip flexors, in particular the rectus femoris and iliopsoas, are the second most frequent. A similar pattern is seen in chronic groin injuries with adductor-related being the most common, followed by iliopsoas-related and inguinal-related injuries. Typically in sport, groin injuries occur during a change of direction, however, in football, kicking is the most commonly reported injury mechanism.2 For both adductor-related and iliopsoas-related groin injuries a conservative approach with an exercise treatment programme is usually effective.

Inguinal-related groin pain, previously termed sportsman’s groin or hernia, is a weakness of the posterior wall of the inguinal canal usually caused by overuse rather than a specific traumatic event. This leads to a localised protrusion of the posterior wall which compresses the genital branch of the genito-femoral nerve and can also displace the rectus abdominis muscle causing increase tension at the pubic bone.  Clinically, athletes complain of pain that is exacerbated with physical activity which can radiate to the inner upper thigh or scrotum. The pain is reported as sharp or sometimes burning in character which is a typical sign for nerve compression and disappears with rest. Dr Muschaweck recommends an initial conservative approach for managing inguinal-related groin pain focussing on rest, physiotherapy (massage, muscle strengthening and core stability training) and medication. This treatment approach should not exceed 8 weeks due to potential nerve damage. If conservative treatment fails, surgical reinforcement of the posterior wall of the inguinal canal should be performed. This can be achieved by a minimal repair technique, which is an open mesh-free technique that also allows exploration of the pain-causing nerve and replacement of the rectus abdominis muscle. Mesh implantation is not recommended due to the risk of an extensive foreign body reaction with local scar formation. The Minimal Repair technique has been shown to be an effective and safe way to treat inguinal-related groin pain and according to Dr Muschaweck can return athletes to full activity in 14 days.3

Further learning points from the conference

Hamstring injuries – Are exercises the best medicine? Askling


  • Indications for acute surgery in MCL injury – bony avulsion, intra-articular prolapse, knee dislocation and possibly combined cruciate/MCL injury and in an elite sportsperson – Professor Fares Haddad
  • Hamstring injuries that involve the intramuscular tendon result in a prolonged RTP and higher risk of re-injury – Dr Peter Brukner
  • Wait on average 7-10 days post-injury before ACL reconstruction to enable the knee to extend fully and bend freely – Mr Andy Williams
  • 80% of discogenic low back pain will resolve with conservative management within 8-10 weeks – Mr Damian Fahy
  • Avoid the use of ice and long-term NSAID use in Achilles tendinopathy as they may reduce muscle and tendon adaptation – Seth O’Neill
  • There is no evidence for the use of PRP in muscle injuries – Dr Gustaaf Reurink
  • Pubic bone oedema reflects load and not injury – Dr Per Holmich

Follow the link below for a highlights video of the conference


  1. Weir A, Brukner P, Delahunt E, et al. Doha agreement meeting on terminology and definitions in groin pain in athletes. B J Sports Med 2015; 49: 768-774
  2. Serner A, Tol JL, Jomaah N, Weir A, Whiteley , Thorborg K, Robinson M, Holmich P. Diangosis of acute groin injuries: a prospective study of 110 athletes. Am J Sports Med 2015; 43(8) 1857-1864
  3. Muschaweck U, Berger L. Minimal repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia; 14(1) 27-33

Dr Chris Garnett is a Sport & Exercise Medicine registrar (ST5) based in Yorkshire. He currently works at the National Centre for Sport and Exercise Medicine in Sheffield and provides medical support for the GB boxing squad at the English Institute of Sport and Huddersfield Giants Rugby League Club.

Dr Farrah Jawad is a Sport & Exercise Medicine registrar in London and coordinates the BJSM Trainee Perspective blog.

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

13 May, 17 | by BJSM

By Dr. Marcos Agostinho

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

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

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

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

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

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


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

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

No more poker face, it is time to finally lay our cards on the table

6 Mar, 17 | by BJSM

By Andy Rolls1, with contribution from Alan McCall

1 Arsenal Football Club, Research & Development Department, London, UK


‘Learning to share, sharing to learn’ is a title I have borrowed from an article published in the teaching literature.[1] It is based on the premise that unless individuals disseminate or share what they have learned, insights gained from action and reflection are not fully realised at the higher level.[2]In it’s strongest form, dissemination is more than a one-way relay of information, it is an extension of the reflective process, moving reflection from the individual to the group level.[1] I propose that this concept is also true in elite sports where, in order for us as medical practitioners to continue to learn and optimise our practice, we need to start sharing our experiences, our mistakes and how we learned from these.


Speaking from experience, I wonder why elite sport and in particular professional football is so secretive and adverse to sharing? And I fear this is stopping us from growing to the best we can. As outlined by Abraham Maslow,[3] regarding growth, every Human being has 2 sets of forces within – one set clings to safety and defensiveness out of fear, the other force impels him forward toward to the full functioning of all of his capacities. Perhaps it is a fear of being wrong, or a fear of being ridiculed that has been stopping us from sharing. Certainly, in the football industry, it has a reputation for being insular, secretive and protective, this may also be true for medical teams within the industry. It is my opinion that in any sporting environment, especially one that talks about the importance of gaining small margins and getting those extra inches and all such clichés, that we have actually become too insular in our quest to ‘show’ that we are better than others or at least market ourselves as being better/the best even if what we are doing is nothing special! Reputation is important, and of course everyone wants a good reputation for being world leading and good at what they do, however, often perception does not equal reality.[4] Perhaps, it is the fear of affecting our reputations that is stopping us from opening up and sharing with others and the safe option is remain behind our Wizard of Oz curtain. Such an insular and essentially selfish approach, may actually be halting us from making big strides in the care and management of our players.


The role of sports medicine research is to help guide practitioners to implement evidence based strategies[5] and while we can and should learn from research to enhance our practice, this is only one piece of the puzzle. The reality is that in elite football, re-injuries are still an issue for teams and something we as individual medical teams are battling day in day out. Despite the exponential increase in published research, and the wide acceptance that previous injury is a major issue for not only a re-injury but also an unrelated injury,[6] we are still a long way off understanding what has actually changed due to previous injury that increases susceptibility for another. Indeed we are even a long way off knowing much about the entire return to play process.

In my experience the majority of us all want and appreciate advances in research that will and already do help us move our medical practice forward. However, research is not always cutting edge: it has been estimated that it can take up to 1 to 2 decades for original medical research to be translated into routine medical practice.[7] And creating confusion in the practitioners mind is that the results of these research can often be conflicting and riddled with biases. This is why we must use our practice-based experience and review current practice and intuition in combination with the best available research evidence to optimise what we actually do. A no secrets, no holds barred, open and honest approach of dialogue with our peers working at the coal face implementing both research and practice based evidence can only help us to advance. The key here is that this dialogue poses no risk of ridicule or humiliation. While this can help guide our immediate clinical practice, giving such a big voice to those operating at the coal face, we can guide researchers to do meaningful research that will actually be useful to us in practice.

Perhaps, as Prof Jan Ekstrand[8] has recommended it is time to start ‘thinking bigger and working together’. We need to begin sharing in order to learn, BUT first we need to learn to share.

To kick off (pun intended), this process I am going to lead the way and lay my cards on the table; In this blog you will find my global approach to a hamstring injury rehabilitation, no poker face, no small print, everything laid bare and I invite the world to analyse, critique, criticise and add their thoughts so that we can start learning from each other and finally make a meaningful impact based on our combined knowledge and experiences in the field.


To give us a starting point and context; A Player running at approximately ¾ pace in a competitive game pulls up suddenly holding the back of their leg, as the physiotherapist approaches the player says ‘he felt his hammy go’ he has to be helped from the field of play

As most of you reading this will relate to, the first question we get is “how long will I/he/she be”?

I have worked in professional football for a long time now and if I had £1 for every time I have heard that question above, I would have retired yesterday. Yet I fully understand that if certain individuals ask for a prognosis, we have to give them something. However I will stress as often as possible to as many people as possible that ‘you/he/she will be ready when specific pre-defined objective markers have been hit and the player can safely progress through the rehabilitation program’ in fact I used to say this so much that staff would finish the sentence for me.

I wholeheartedly believe that objective markers whatever they may be are essential for the successful rehabilitation of all injuries because without them how do we know when the player/athlete can run, when they can sprint, when they can decelerate, when they are strong enough, when they can kick etc. However what to use, when and for which injuries are the million dollar questions, because our knowledge of what we think is the best approach lags behind what may actually be the best, and we don’t know yet which markers are optimal or even appropriate for specific injuries and certain players but unless we try how will we get better? I do not currently know if such an approach to an objective marker led rehabilitation pathway leads to less reoccurrences. I would postulate currently not, but, I do feel that I return players back better using objective markers than when I never used this approach. Another advantage in my opinion is that if a setback occurs it is easier to look back and work out why. While I focus heavily on objective markers for the reasons highlighted above, I must mention that this goes hand in hand with subjective measures provided by the player. Involving the player in the process is critical to understanding better what these objective markers are actually telling us i.e. is a player coping or not, these are often critical in telling me can I progress or not, so when going from a double leg exercise to a single leg exercise I will use a RPE to compare the sides, also RPE will be used not for ever session (This piece is all about be honest!!) but I will use them if I am changing a rehabilitation emphasis or making a larger than normal step forward. When these are used especially to gauge outside work I think they are a big help in assessing is this player ready whether it be psychologically or physically.

So here goes, cards on the table. By following this link:, you will be directed to a step by step rehabilitation program for a hamstring strain injury incurred by a professional football player (as in the example above). Please review step by step and I welcome and look forward to your feedback!


Corresponding author:

Andy Rolls, Arsenal Football Club,



Football injuries and their prevention with Swedish football injury warriors Martin & Markus

2 Nov, 16 | by BJSM

By Nirmala Perera (@Nim_Perera) with contributions from Martin Hägglund (@MHgglund) and Markus Waldén (@MarkusWalden)

What are the most common/’costly’ football injuries?

Hamstring Injuries

Hamstring injuries are the most common injuries in football. The findings are consistent across studies. In fact, hamstring injury rates seem to be increasing in elite football.1 The long head of biceps femoris is most at risk, sustaining more than 80% of the hamstring injuries/strains. Approximately every eighth injury leading to time-loss in football is associated with hamstrings. Hamstring injury affects more than one fifth of elite players over a season. Additionally, hamstring injuries are one of the most ‘costly’ injuries in football in terms of time-loss. The median time-loss from a hamstring injury is about two weeks, but due to their high incidence they comprise approximately 14% of the total days lost from the sport.

ACL Injuries


Denis Doyle/Bongarts — Getty Images for DFB

Anterior cruciate ligament (ACL) injuries are not as common as hamstring injuries in football. It is, however, well-known that female players are up to three times more likely to incur an ACL injury compared with male players.2  The underlying reason for this remains unclear. Men’s professional football clubs are faced with an ACL injury every other season, whereas female elite clubs can expect an injury every season. A recent 15-year follow-up study of men’s professional footballers reported that ACL injury rates have unfortunately not declined since 2000s in spite of substantial research on prevention of these injuries.3

Although not being among the most frequent injury types, ACL injuries are a significant time-loss injury. Few players with a total ACL tear go back to the pitch before six months. The average time-loss in Waldén and colleague’s aforementioned study was almost seven months to the release to full team training and another month to match play.3

What are the most important risk factors and injury mechanisms?

Previous injury is the number one risk factor for most football injuries.4,5 Low (eccentric) muscle strength and higher age are other factors associated with hamstring injury occurrence. Acute posterior thigh pain during high speed running is the most common hamstring injury situation in football.

The most common ACL injury mechanism in male elite players is pressing, where a player makes a side-step cut during a defensive playing situation. In addition, landing awkwardly on one leg after a heading duel is another established non-contact injury mechanism.6 Studies on women’s football are scarce and, therefore, it is not fully clear if the same injury mechanisms are at play.7

Short-term and accumulated fatigue seem to play a crucial role in hamstring injuries.8 For instance, accumulated fatigue over a congested playing period has been associated with increased hamstring injury rates. In addition, more hamstring injuries tend to occur towards the end of matches. In contrast, most ACL injuries occur early in the game, typically just after kick-off or after substitution, and it is, therefore, more likely that these injuries might be the result of accumulated fatigue over time rather than game-related energy depletion.

What are the most effective injury prevention strategies?

Injury prevention is most effective when it starts in youth football. These programs can improve motor control, therefore potentially reduce injury risk. Neuromuscular training programs such as FIFA 11+ and FIFA11+ for kids ( and Knäkontroll ( are efficacious in reducing lower limb and knee injury rates, respectively.9,10

For instance, the overall ACL injury rate was reduced by two-thirds in adolescent female football players who used the Knäkontroll program during one season.10 An important note is that adherence to training is a key factor for successful prevention, where players who were in the top adherence tertile in the Knäkontroll RCT had a 88% lower rate of ACL injury compared with players in the bottom tertile.11

The most effective hamstring injury prevention measure to date is the Nordic hamstring exercise (NHE). Football players who adhere to eccentric training programs are they shown to reduce hamstring injury rates by 50%.12 Still, a recent survey study from European professional football suggest that adoption and implementation of the NHE was poor among the teams.13

How can we boost adherence to injury prevention programs?

As discussed above, neuromuscular injury prevention programs and hamstring exercises are beneficial when players adhere to the programs and when they perform the exercises as prescribed. Coaches’ involvement, having high self-efficacy and being in control of the intervention are key factors to increase adherence. Better team success is evident when clubs ‘buy-in’ to invest in injury prevention.14 Similarly, buy-in from coaches boost the self-efficacy.

Organisational factors such as time constraints, worry that the exercises are not sports specific, not adapted to environment are barriers for adherence. Therefore it is important to have a clear plan of implementation, understand the context and provide support to coaches and empower players.


Looking for more cutting-edge information on this topic? The IOC World Conference on Prevention of Injury and Illness in Sport in Monaco (#IOCprev2017) will showcase the latest research innovations in football injury prevention. Notably, Martin and Markus will share their latest research during several symposiums.


  1. Ekstrand J, Waldén M, Hägglund M. Hamstring injuries have increased by 4% annually in men’s professional football, since 2001: a 13-year longitudinal analysis of the UEFA Elite Club injury study. Br J Sports Med 2016;50:731-7.
  2. Waldén M, Hägglund M, Werner J, Ekstrand J. The epidemiology of anterior cruciate ligament injury in football (soccer): a review of the literature from a gender-related perspective. Knee Surg Sports Traumatol 2011;19:3-10.
  3. Waldén M, Hägglund M, Magnusson H, Ekstrand J. Anterior cruciate ligament injuries in men’s professional football: a 15-year prospective study on time-trends and return to play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med 2016;50:744-50.
  4. Hägglund M, Waldén M, Ekstrand J. Previous injury as a risk factor for injury in elite football – a prospective study over two consecutive seasons. Br J Sports Med 2006;40:767-72.
  5. Hägglund M, Waldén M, Ekstrand J. Risk factors for lower extremity muscle injury in professional soccer: the UEFA injury study. Am J Sports Med 2013;41:327-35.
  6. Waldén M, Krosshaug T, Bjørneboe J, Andersen TE, Faul O, Hägglund M. Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football: a systematic video analysis of 39 cases. Br J Sports Med 2015;49:1452-60.
  7. Brophy RH, Stepan JG, Silvers HJ, Mandelbaum BR. Defending Puts the Anterior Cruciate Ligament at Risk During Soccer A Gender-Based Analysis. Sports Health 2015;7:244-9.
  8. Bengtsson H, Ekstrand J, Hägglund M. Muscle injury rates in professional football increase with match congestion – an 11-year follow up of the UEFA Champions League injury study. Br J Sports Med 2013;47:743-7.
  9. Soligard T, Myklebust G, Steffen K, Holme I, Silvers H, Bizzini M, Junge A, Dvorak J, Bahr R, Andersen TE. Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. BMJ 2008;337:a2469. doi: 10.1136/bmj.a2469.
  10. Waldén M, Atroshi I, Magnusson H, Wagner P, Hägglund M. Prevention of acute knee injuries in adolescent female football players: cluster randomised controlled trial. BMJ 2012;344:e3042 doi: 10.1136/bmj.e3042.
  11. Hägglund M, Atroshi I, Wagner P, Waldén M. Superior compliance with a neuromuscular training programme is associated with fewer ACL injuries and fewer acute knee injuries in female adolescent football players: secondary analysis of an RCT. Br J Sports Med 2013;47:974-9.
  12. Goode AP, Reiman MP, Harris L, DeLisa L, Kauffman A, Beltramo D, Poole C, Ledbetter L, Taylor AB. Eccentric training for prevention of hamstring injuries may depend on intervention compliance: a systematic review and meta-analysis. Br J Sports Med 2015;49:349-56.
  13. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. Br J Sports Med 2015;49:1466-71.
  14. Hägglund M, Waldén M, Magnusson H, Kristenson K, Bengtsson H, Ekstrand J. Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 2013;47:738-42.


Nirmala Perera (@Nim_Perera) is a health practitioner, an epidemiologist and a PhD scholar at the Australian Centre for Research into Injury in Sport and its Prevention (@ACRISPFedUni). She is the @IOCprev2017 #SoMe campaign coordinator.

Markus Walden (@MarkusWalden) is an orthopaedic surgeon, researcher at the Football Research Group (@frgsweden), team physician for IFK Kristianstad (@IFKKristianstad), and @IOCprev2017 scientific committee member.

Martin Hägglund (@MHgglund) is a physiotherapist and associate professor at Linköping University (@liu_university) and researcher at the Football Research Group (@frgsweden).


Thoughts and impressions midway through the FIFA Sports Medicine Diploma

4 Sep, 16 | by BJSM

By Nash Anderson

I first heard about the FIFA Sports Medicine Diploma in 2015 and was impressed to hear that a free course existed from the sporting organisation body FIFA.1 I started the course in June 2016 for two reasons. Firstly, I had more free time this year and I was curious to see this new course created by world leading clinicians. Secondly, I have worked on the sideline for various sporting codes over the years however never football specifically. I hoped this course would help me to develop my knowledge and confidence in football medicine for not only any potential sideline work in football but also for dealing more proficiently with my football playing patients. Below I share some pertinent information and my personal experience thus far.

ref standing footballWhat is the FIFA Sports Medicine Diploma?

The Diploma is a free course by FIFA covering major medical and musculoskeletal issues in football. It also covers ‘special topics’ including: event planning, team travel, female athletes, anti-doping and more. More modules are added regularly. The aim is to provide a total of 42 modules, one from each of the FIFA Medical Centres of Excellence. 1

The course shares clinical experience and evidence from lead researchers as well as the theoretical knowledge amassed by F-MARC over the last 22 years.

Who is F-MARC?

The FIFA Medical Assessment and Research Centre (F-MARC), established in 1994, is a prestigious independent research body of FIFA uniting an international group of experts in football medicine.2 They are world leaders in football medicine and have produced hundreds of publications in peer-reviewed journals. 3

Besides research and educational courses,3 they have been involved in many initiatives including: improved screening for sudden cardiac arrest; the FIFA Sudden Death Registry;4 5 the FIFA 11+, an effective programme to prevent football injuries in various player groups worldwide; 6 as well the FIFA 11 for Health program. 7 The FIFA 11 for Health program illustrates the health benefits of football for population groups. One such recent example is that small-sided football in schools and leisure-time sport clubs improves physical fitness, health profile, well-being and learning in children. 8

Why is the FIFA Sports Medicine Diploma essential to clinicians interested in football medicine?

“Education is the key to prevention and therefore FIFA supports the “Diploma in Football Medicine” for doctors, physiotherapists and paramedical staff”

– Prof Jiří Dvořák. FIFA Chief Medical Officer & F-MARC Chairman.1

After completing these modules, participants will be better able to identify and treat injuries and illnesses as well as be more aware of injury and illness-prevention programmes. Due to the great breadth of topics there is something to learn even for the most experienced football medicine clinicians.

The FIFA Sports Medicine Diploma is essential to create an education platform for multidisciplinary cooperation. In turn, football will become a more safe 6 and rewarding pursuit for patients, athletes, clinicians and football associations.

I have currently completed a number of modules. Here are some of thoughts thus far:


  • Free. A free resource from a leading sports medicine organisation.
  • Comprehensive resource. This course covers a variety of topics. This is not just a course but also a brief online sports encyclopaedia.
  • All-star line up. In addition to up to date topics, modules are written by international experts with a wealth of practical and academic experience. The curriculum also includes insights from high-profile players.
  • Multidisciplinary depth of topics. MSK topics are generally broken down into initial presentations, radiological investigations, physical therapies, reasons for referral and surgical options. This helps to establish clear roles for football organisations and clinicians.
  • Excellent testing and feedback. Knowledge is tested using multiple-choice questions; however, if you do not select the correct answer, it prompts constructive feedback.
  • Web based course. Being entirely web based, participants can engage in content through multiple platforms, such as PCs and smartphones. There is also synchronisation between devices.
  • There are no deadlines! The course can be completed online at your own pace.

Constructive feedback

  • Technical. I have thoroughly enjoyed the depth of the content. Although one website comment suggested that the course was for “anyone with an interest in sports medicine”. I believe that may be a stretch. The original target audience was sports physicians and, although somewhat simplified, it is still very technical for “anyone with an interest”.
  • Where to go for practical skill growth? Although this course is very accessible and the practical assessment videos hugely helpful, I am interested to see what steps or courses FIFA recommends for clinicians for further practical skill development beyond the FIFA Sport Medicine Diploma, the FIFA Sports First Aid and their FIFA Nutrition Course.
  • Football Medicine Manual, web version please! 9
  • The key resource for this course is currently only in PDF form. On smaller devices it is difficult to read. A web enabled version would enable enhanced readability on all mediums such as PC and smartphone. This is, however, only a criticism to user friendliness of the manual and not its content.

Thank you to the F-MARC Team for producing an excellent and free resource. Kudos in particular to Dr Mark Fulcher, the New Zealand team doctor and editor-in-chief of the project. I look forward to viewing more modules in the future including as of yet unreleased modules.

I would also like to thank Dr. Reidar Lystad @RLystad for his assistance with this blog and the support of the BJSM @bjsm_bmj dream team for letting me share my thoughts.


For further information and to sign up for the course please visit:

You can download the Football Medicine Manual from here:

Also here you can also read the BJSM Course review on The FIFA Sports Medicine Diploma from Adam Culvenor. 10



Nash Anderson is a Chiropractor in private practice in Farnham. He has a special interest in sideline care, sports medicine and created, an open access health and sports medicine resource for clinicians and the public. He enjoys working pitch side and has recently finished up with the Farnham Knights American Football team but still works to provide care at cycling events with @roadsideteam. You can follow him on Twitter (@sportmednews).



  1. F-MARC. Football Medicine Diploma | FIFA Diploma in Football Medicine 2016 [Available from:
  2. Excellence FMCo. FIFA Medical Centre of Excellence – FIFA & F-MARC: FIFA Medical Centre of Excellence; 2016 [Available from:
  3. F-MARC. FOOTBALL MEDICINE the complex medico-social milieu 2016 [Football Medicine Courses provided]. Available from:
  4. Kramer EB, Dvorak J, Schmied C, et al. F-MARC: promoting the prevention and management of sudden cardiac arrest in football. Br J Sports Med 2015;49(9):597-8.
  5. Scharhag J, Bohm P, Dvorak J, et al. F-MARC: the FIFA Sudden Death Registry (FIFA-SDR). Br J Sports Med 2015;49(9):563-5.
  6. Bizzini M, Dvorak J. FIFA 11+: an effective programme to prevent football injuries in various player groups worldwide-a narrative review. Br J Sports Med 2015;49(9):577-9.
  7. F-MARC. FIFA 11 for Health 2016 [Available from:
  8. Krustrup P, Dvorak J, Bangsbo J. Small-sided football in schools and leisure-time sport clubs improves physical fitness, health profile, well-being and learning in children. Br J Sports Med 2016.
  9. (FIFA) FIFA. Football Medicine Handbook. In: FIFA Medical Assessment and Research Centre (F-MARC) FMOc, Production F, eds.
  10. Culvenor AG. FIFA Diploma in Football Medicine: free knowledge from expert clinicians to improve sports medicine care for all football players (continuing professional development series). Br J Sports Med 2016.


Evidence based medicine in elite sports – why go for the “1%ers”?

4 Aug, 16 | by BJSM

By Chris Morgan @chrismorgan10

I am a big advocate of Twitter and its role in promoting clinical discussion and professional disagreement!

I recently had a discussion on Twitter regarding the use of evidence based medicine in the treatment of elite athletes. This was just after Usain Bolt posted a picture of himself receiving treatment for his hamstring injury in the form of two electrotherapy modalities. The question asked was “anybody know if there is any useful evidence for this type of treatment?”

medical tapeElite Sport’s Medicine is a unique branch of Medicine and as such we often push the boundaries. Notably, in terms of novel treatments and the use of interventions which, whilst perhaps not being evidence based, come with anecdotal evidence or belief from the athlete that this is what they need; this falls within the spectrum of ‘shared decision making’, a process recently advocated in the 2016 Consensus Statement on Return to Sport (Open Access HERE).

This raises the important question: is it ever acceptable to utilise a treatment which isn’t evidence based?

As a clinician in elite sport you are blessed with “time to treat” which in other SEM arenas you could only dream of; you also have a budget in place to maintain availability and a player and club who are willing to try “everything possible” to get the athlete back for the next game or event.

What is a 1%er?

My personal opinion is that treatment at the elite level requires a strongly evidence based approach complemented by what I call “1%ers” – which “may” enhance the players recovery from a physiological and psychological point of view. The use of the term “1%ers” came about after a discussion with Jill Cook when she spoke of the myriad of treatment options available to the clinician when treating Tendinopathy. With Tendinoapthy, it referred to the multitude of interventions which claimed results (or showed weak evidence for effectiveness) but are totally redundant without the main stay of Tendon treatment – effective load management.

Shared Decision Making

At the heart of this approach, should be a shared decision making process based on available treatment options and associated evidence for risk versus benefit, married alongside the patients values and preferences. In the sporting world this often splits into combining the benefits of active rehabilitation and appropriate exercise (in my opinion the cornerstone of rehabilitation), with passive interventions.

Although 1%ers often lack evidence, the athlete may place a lot of value on the particular modality. In my experience, it’s a trade-off between athlete and clinician – in effect “we have a lot of time here, let’s commit to a thorough rehabilitation program and use every available minute to throw the 1%ers at it too”.

The athlete will want to feel everything is being done to help them recover as quickly as possible, as will the club who pay the wages. I agree that sometimes a “less is more” approach is the key is to optimising the body’s environment for healing. However, there are also numerous treatment modalities that you can use in the early stages of recovery that ‘may’ enhance the process and won’t cause “harm” (the creation of psychological reliance is for a whole new blog!).

Maintain your principles

The challenge in sports medicine is to maintain your principles of injury management and rehabilitation whilst being open-minded enough to consider alternative options which could complement the recovery. In the early stages of recovery this could include pain reducing modalities (including cryotherapy and TENS) or those aimed at limiting the effects of muscle atrophy (Disinhibitory modalities) such as Muscle Stimulation.

Most importantly, we need to be open with the athlete about what those 1%ers can bring to the recovery process. The danger is when clinicians take these 1%ers and suggest that the importance of them is much higher than can ever be the case, or even worse that only they can apply that intervention in a very special way to get the desired, dare I say it, “healing” effect.

The fundamentals underpinning any form of rehabilitation is clinical reasoning and gradual re-loading of injured tissue in an accelerated but controlled way, whilst utilising 1%ers to complement but not dictate this process; this for me is what working in elite sport is all about.


Chris Morgan is a Sports Physiotherapist with a special interest in Football. He recently left Liverpool FC after 10 years at the club. You can follow him on Twitter (@chrismorgan10)


  1. Consensus statement:

2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern

Clare L Ardern, Philip Glasgow, Anthony Schneiders, Erik Witvrouw, Benjamin Clarsen, Ann Cools, Boris Gojanovic, Steffan Griffin, Karim M Khan, Håvard Moksnes, Stephen A Mutch, Nicola Phillips, Gustaaf Reurink, Robin Sadler, Karin Grävare Silbernagel, Kristian Thorborg, Arnlaug Wangensteen, Kevin E Wilk, Mario Bizzini

Br J Sports Med 2016;50:14 853-864 Published Online First: 25 May 2016 doi:10.1136/bjsports-2016-096278

Team doctors have authority over managers to make medical decisions #PlayerSafety1st

10 Jun, 16 | by BJSM

ApologyWe’ve all caught wind of the recent media flurry after last Tuesday’s unreserved apology (and settlement) by Chelsea FC to former sports physician, Dr. Eva Carneiro (@EvaCarneiro). The team’s management were explicit that Dr Carneiro had acted completely appropriate when she ran on to the pitch to treat Eden Hazard in last August’s opening day match of the Premier League season (read more here).

This incident raises two critical issues: (i) Gender discrimination in sport; Dr Carneiro, also reached a discrimination settlement against the club’s former manager Mr Jose Mourinho, and (ii) A team doctor’s authority to make medical decisions, not the manager.

To applaud and celebrate all SEM practitioners who have a commitment to player welfare, we made football physiotherapist Lisa O’Neil’s editorial FREE (for one month only). Please read and share via this free link to spread good practice:

“No way Jose!” Clinicians must have authority over patient care: the manager’s scope of practice does not cover medical decisions  Please read and share via this free link

Please use the hashtag: #PlayerSafety1st

PS: Want even more more insight and expertise on best practice for team physicians? Check out @PeterBrukner’s BJSM editorial: Surviving 30 years on the road as a team physician. Here’s the free link.

PPS: And one more? Managing the health of the elite athlete: a new integrated performance health management and coaching model by Sports Physicians @PaulDijkstra and @DrNoelPollock, Dr Rob Chakraverty, @DrJuan MAlonso.



Geeking Out at the Football Medicine Strategies Conference (BJSM’s 2015 Cover competition winner shares the story of her prize, and 5 take home messages)

30 May, 16 | by BJSM

What a bloody brilliant week I had in London. I remember starting this blog while enjoying a warm cup of tea at The Wolseley. I fondly recall staring blankly at my computer and an expensive basket of assorted croissants for a solid 15 minutes. But before I get ahead of myself, let’s backtrack to the very beginning. I was born a cute bundle of joy to a loving mum and dad. One day, a mean old wizard killed my parents in front of me and I became a really popular and powerful witch who saved the world… JK! Sounds like a good book idea though, someone should write it.

How about we start with the two things that brought me to London: Twitter and the British Journal of Sports Medicine (BJSM).

Screen Shot 2016-04-24 at 11.15.42 PMBefore I start rambling on, I should warn the general public that I am a huge nerd. Fact: every third tweet of mine includes the hashtag “#nerdtweet”. Usually, the only people who read my blog are my family (when relentlessly encouraged) and friends (n=4). So forgive me for any upcoming corny jokes.

Oh Twitter. Everyone who knows me is completely aware of my addiction to this social media app. I spend far too much time on my mobile reading sports headlines, laughing at Simpsons quotes, and trying to keep up with current physiotherapy research.

One wintery day in Edmonton, I came across a BJSM contest on my beloved Twitter. They were giving away free registration to the Football Medicine Strategies Conference in London (as in London, England for all the Canadians who asked me if I was going to London, Ontario… C’mon mate!). My coworker and I entered and proceeded to immediately practice our English accents in the off chance one of us would win. Then a few minutes went by and my small hamster brain forgot about the whole thing.

Then with a lot of luck and zero talent or skill, I received an email from the BJSM… I had won the contest! I was pretty much the living and breathing version of Charlie with his golden ticket to the chocolate factory. Except replace chocolate with lectures by sport medicine experts. Which is a thousand times better than chocolate, am I right?!Screen Shot 2016-04-23 at 12.13.42 AM

Full disclaimer: this was my first big conference (and my first time in London). What a rookie! I knew it would be amazing but I wasn’t aware of the degree of its amazingness. (Feel free to use that as a direct quote when sharing this on social media.)

Screen Shot 2016-04-23 at 2.44.48 PMI was ridiculously excited from day one. So excited that I took the wrong bus and ended up walking 20 minutes to the Queen Elizabeth II Centre. Pro: I got to see Big Ben and Westminster Abbey without a million tourists around. Con: I would have been kicked out if it were the Amazing Race.

Fortunately, I still got there with a few minutes to spare and parked myself in a seat with a good view for some live tweeting. For all the poor chaps who were unable to attend, you can relive the weekend by checking out Twitter (my feed or the official conference feed) or Adam Meakins’ review. Alternatively, you can just keep reading this blog..

On to the main act! Without further ado, here are my top 5 take home messages:

  1. Jill Cook on loading tendons. Wow. What an innovative way of dealing with tendon injuries, eh? To load them! Evidence it works in treating tendon injuries! It’s a modern day miracle. This one shouldn’t be Screen Shot 2016-04-23 at 4.28.18 PMearth shattering to anyone but it never hurts to really hammer home an important message.

@ProfJillCook focused on progressive loading as the key to victory when treating tendon injuries. Rest is detrimental. It causes detraining and weakens tendons. And on the other end of the spectrum, excessive loading is not the solution either. Overloading can cause bleeding, inflammation, structural changes, and eventually tendon thickening.

When loading a tendon (and the person to whom that tendon belongs), find the optimal load and slowly increase that over time. Heavy loads can take a few days for a tendon to recover from. The ultimate goal is to safely increase tissue capacity. Don’t listen to anyone who says they have a quick fix for tendon injuries. Toss the ultrasound, injections, and PRP. Be patient and load!

  1. Tim Gabbett on training load. I was gutted to have missed this talk. It was definitely my biggest regret of the conference, if not my life. But I was lucky to have fellow Twitterati kept me up to date. Even better, Aspire Academy uploaded a presentation Tim gave at their training load conference in March. @TimGabbett ‘s  research on training smarter and harder isn’t rocket science which is perfect for muppets like me!

Screen Shot 2016-04-28 at 12.10.04 AMTrain at low loads? Higher injury risk. Train at very high loads? Higher injury risk. We have to find that “sweet spot” where optimal training loads improve fitness and performance yet the odds of sustaining a non-contact soft tissue injury are minimized.

It’s important to train your athletes at safe (i.e. smart) but demanding levels (i.e. hard). If you can get them to these high loads on a consistent basis, they can develop a resistance to soft tissue injuries. Chronic high workloads should be the target of training programs.

Alright, makes sense so far but how do we get our athlete to that consistent high load without putting them at risk of injury? Enter the acute:chronic workload ratio. If your athlete’s acute workload (e.g. hours of training in one week) is much higher than his/her chronic workload (e.g. hours of training over the average of the last 4 weeks), then this athlete is more susceptible to injury.

In rugby players, the magic ratio number was 1.5 (i.e. acute load greater than chronic load by 1.5 times)2. A spike in training in one week greater than the 1.5 workload ratio puts players at risk of injury. The lesson here is to avoid these spikes in training load. Spikes are bad. Almost as bad as your favourite pub running out of fish and chips and lagers.Screen Shot 2016-04-23 at 4.42.45 PM

  1. Carl Askling @CAskling on hamstring injuries. I found this talk particularly great because there was lots of practical information. Stuff you can take home with you and try straight away. There was heavy emphasis on the long head of biceps femoris (the most commonly affected hamstring muscle) and even heavier emphasis on loading it eccentrically.

From one of his recent papers, Carl showed us the benefit of eccentric exercises over conventional exercises. Using the “diver” and “glider” lengthening exercises, elite sprinters were able to return to sport faster than their mates doing conventional exercises – on average, 37 days faster to be exact3! That’s almost a whole month and a fortnight!

He also implemented the use of the Askling H-test. When a sprinter had no positive signs of injury on clinical exam, they underwent the H-test (see video below and guess which is the injured side). The athlete is instructed to perform a straight leg raise as fast as possible. If the athlete reports any insecurity during the test, then the return to full training was delayed 3 to 5 days. This test of confidence likely prevents the risk of reinjury which has been shown to be an issue with hamstring strains3.

  1. Seth O’Neill on calf injuries. @Seth0Neill Calf injuries are the 4th most common musculoskeletal injury in soccer! Seth’s calf talk is also known as a public service announcement for soleus. Yes, soleus! The unsung hero in the posterior chain.

Screen Shot 2016-04-24 at 10.27.42 PMDid you know most calf strains happen in the last 15 minutes of the match? And that old geezers (like me) are at higher risk of injury? So when your veteran player sustains a calf injury in added time, paying attention to soleus is vital! Soleus plays a big role in our lower limb. Not only does it make up 50% of our calf musculature (picture from Seth’s slides), it also contributes 50% of our body’s vertical support force5 6! Seated calf raises FTW!

The trick for strengthening soleus – and the calf in general – is heavy loading. The long term goal is 1.5 times body weight for calf strengthening! Elite athletes aim for 2 to 3 times! Essentially, if you can do a calf raise with an elephant on your back, you’re set. Like I said, heavy.

  1. Andy Rolls on conservative management for an ACL injury. There has been lots of discussion about research in my previous 4 highlights. Screen Shot 2016-04-24 at 10.35.19 PMBut now we turn our attention to a rather interesting case study.

Andy is a first-team physio that works for (my favourite club) Arsenal. He presented a case of a professional soccer player who tore his ACL and made an informed decision to decline surgery. Andy was very honest about the medical team’s apprehension about the player choosing conservative treatment. If it failed, would they be scrutinized for not encouraging surgery? In a weekend filled with science this and science that, it was refreshing to hear about personal experience and emotion. All the feels!

Using a criteria-based return to play model (hooray!), the athlete gradually regained strength and control of his knee. Subjectively, he was asked the simple question, “Do you trust your knee?” following different exercises and graded this answer on a Likert scale. Objectively, he performed hop tests every 3 days. Using these simple measures, the staff was able to appropriately guide his progressions in rehab.

Screen Shot 2016-04-24 at 11.57.31 PMThe best part of this story is that it has a happy ending. The player returned to training at 8 weeks post-injury and played 60 minutes in a reserve match at 9 weeks! Furthermore, he has been fully fit for over 2 years now and has started 26 games in the Premier League!

Pretty amazing considering our immediate instinct is to refer athletes in high demanding pivot and twisting sports, like soccer, for surgery. Can all players do this? No. So how do we identify copers from the non-copers? That is the million dollar question, folks.

And there you have it! Five solid messages from Isokinetics Football Medicine Strategies Conference to chew on, spit out, chew on some more, and then perhaps implement in practice. At the very least, I hope they get your wheels turning.

Screen Shot 2016-04-24 at 10.54.52 PMThe weekend was jam packed with great presentations and exhibits. I even got to fulfill my dream of testing out a NordBord and then walk around for the rest of the day with hamstring soreness! But my absolute favourite aspect of the conference was having the opportunity to chat with these wonderful speakers. Everyone I spoke to was top class. All very friendly and, thankfully, irrespective of my obvious fangirling.

I even made a few new friends (n=9)! Colleagues who share the same passion and desire to learn more about sport medicine and become better practitioners. It’s nice knowing I’m not the only geek out there!

Massive thanks to Isokinetic and FIFA putting on such an incredible conference. And a huge shout out to BJSM for sending me to it! I’ve already started saving for Barcelona in May 2017. (Picture below with the Conference President – Dr Stefano Della Villa)

Screen Shot 2016-04-24 at 11.23.04 PM

– Chris









  1. Cook, J.L. & Docking, S.I. (2015). “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ’tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine49, 1484-1485.
  2. Gabbett, T.J. (2016). The training-injury prevention paradox: should athletes be training smarter and harder? British Journal of Sports Medicine, 0, 1-9.
  3. Askling, C.M., Tengwar, M., Tarassova, O., & Thorstensson, A. (2014). Acute hamstring injuries in Swedish elite sprinters and jumpers: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. British Journal of Sports Medicine48, 532-539.
  4. Ekstrand, J., Hägglund, M., & Waldén, M. (2011). Epidemiology of muscle injuries in professional football (soccer). The American Journal of Sports Medicine39(6), 1226-1232.
  5. Albracht, K., Arampatzis, A., & Baltzopolous, V. (2008). Assessment of muscle volume and physiological cross-sectional area of the human triceps surae muscle in vivo. Journal of Biomechanics41(10), 2211-2218.
  6. Dorn, T.W., Schache, A.G., & Pandy, M.G. (2012). Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance. The Journal of Experimental Biology215, 1944-1956.


Christina Le @yegphysio is a Physiotherapist at the Glen Sather Sports Medicine Clinic in Edmonton, Canada

Time to bring in pitch-side medical video replays in football – more important than goal line videos?

25 May, 16 | by BJSM

By Andrew Massey @andy_massey

I listened with interest at the 2016 Isokinetic Conference where attendees discussed the importance of a medical team within the football community, and return to play. The event lived up to its reputation of creating a space for cutting edge science and practice innovation.

Discussions of ‘best practices’ made me think about a quandary I am currently
facing as Head of Medical Services for liverpool FC. Early in my training I was taught the acronym SALTAPS, which I still commonly use to assess an injury pitch side as a physiotherapist:liverpool

See – the mechanism of injury.

Ask – the patient what happened.

Look – at the affected area.

Touch – palpate the affected area.

Active – can the patient move the affected area actively?

Passive – can you take the affected area through its full passive range?

Special tests – to assess the affected area.

It is a crude way of examining a musculoskeletal injury, but served and continues to serve me well.

When looking at resuscitation, everyone is taught airway, breathing, circulation, in that order. My old Emergency Department consultant used to say, “you better have a damn good reason for not following a protocol that someone much cleverer than you has developed.” This advice has encouraged me not to deviate from my simple ABC approach to resuscitation. So why is it OK for me to stray from my SALTAPS approach?

Patient assessments on the pitch often involve very quick decision making on a management approach to any injury, without full access to as much information as possible. Lots can happen in a football match, a doctor or physiotherapist can have their view obscured by a manager, linesman, substitute or combination of all three. Or even if they can see every incident from where they sit, they may simply miss a mechanism. This is not bad practice, it’s just the reality of being a pitchside medic. So what happens when you can’t follow the first step of the SALTAPS approach, when you cannot see the mechanism of injury?


fuzzy tvVideo technology exists but we are not allowed to use it!

We are fortunate to have the technology that allows us to view replays of mechanisms of injury pitch side via portable devices, However, medics are constrained by the current laws of the game. The rules prevent us from providing the safest care for players. UEFA have informed me that no official is allowed to view any replays during a match (this is straight from their big book of rules, Match organisation, Rule 14.17. Page 24. Accessed 17th May 2016). FIFA suggests that the rules governed by IFAB do not permit the use of video technology for medical purposes (The Players equipment, Rule 4. Page 42. Accessed 17th May 2016). The FA Premier League have relaxed their rules this season, but request that the viewing of video replays for medical issues must be done in a designated area (often near the changing rooms). A practical implication of this rule is that if there is a serious injury, I either have to follow FIFA and UEFA rules and hope that I had a perfect view past the manager, past the linesman, past the 4th official and past the 6 substitutes warming up, or ask the seriously injured player to wait a moment or two whilst I run down the tunnel to see a replay before running back up the tunnel and administering treatment.

What are the reasons for not allowing such technology to aid medical management? I have been quoted everything from “it gives a performance advantage”, to “it would be a distraction, and take away from your clinical assessment”. My answer is always this, it is a welfare issue. The only performance it gives an advantage to is that of the treating medic. It does not distract. It adds to the initial assessment.

If we are looking to create a level playing field when it comes to medical management, or limit distractions, then perhaps we should insist on all doctors and physiotherapists keeping their eyes closed during a match. How would a radiologist react if we told them they were not allowed to look at the x ray they were reporting on? How would a physiotherapist feel if they were told you can only assess a patient using your left hand? At the moment we are making the best from a bad situation when treating on field injuries. We have the technology now to improve player care and safety, but it is being stifled by rules. From my perspective, if a rule puts a player’s health at risk, then it is wrong. These rules need to be changed and the governing authorities need to press ahead to put the health of the players in the forefront of everyone’s mind.



Andrew Massey @andy_massey is a Doctor, Physiotherapist, and Head of Medical Services Liverpool FC

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