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An Open Letter to Tim Gabbett: Thank-you, I’m running harder and smarter.

27 Dec, 16 | by BJSM

By James Montgomery

RE: The training-injury prevention paradox: should athletes be training smarter and harder (Open access) Br J Sports Med doi:10.1136/bjsports-2015-095788

Dear Dr. Gabbett,

Thank you. Since reading your January 2016 article I can sincerely say I am running smarter and harder! You may ask ‘why did I decide to write a thank-you letter?’ Well there’s a story to that answer.

We (that is, my cobber and I) decided that we needed an adventure for 2016. As two dedicated fathers, the idea of a weekend run seemed as good a Father’s Day present as you’d ever get. We settled on one of NZ’s Great Walks – The Rakiura Track, Stewart Island, New Zealand.


Stewart Island, NZ

Stewart Island had me sold on the idealistic idea of running 30km through dense and ancient NZ bush, along rugged and majestic coast lines and finishing with a fine plate of fresh caught Blue Cod. However, the reality was much more daunting. I hadn’t completed anything longer than 5 km for months and nothing longer than 20 km for years. How am I going to get fit enough in 14 weeks to run that far and still walk from the accommodation to the restaurant and back? As a mid-40’s recreational runner the prospect of sore hips, knees, and ankles are at an even balance compared to the picturesque beauty of NZ’s deep south.

Luckily, the chance to manifest the ‘acute:chronic workload ratio’ sweet spot was possible. And so, training commenced.

Rooted with the knowledge that under training and overtraining were real possibilities, I began the intriguing prospect of building a steady base without overloading (figure 1). I have been able to use details of your article to educate patients on load management and planning. But sometimes there is a need for experience, either in the clinic or in life, to help with the hard sell of change (figure 2). How many experienced runners train using volume + volume + volume until they break – any then keep running on anyway hoping it comes right? Sometimes convincing an old dog about new tricks requires some fundamental facts. Hence, I am using the acute: chronic loading ratio to evaluate the progress of my own training plan for this pending Rakiura 30km delight.

I have included a couple of graphs to illustrate progress so far, I am currently at week 13.

Figure 1 – Acute loading per week (km) – currently training in week 13.

Figure 1 – Acute loading per week (km) – currently training in week 13.

Figure 2 – Chronic loading – the four-week average. Currently training in week 13.

Figure 2 – Chronic loading – the four-week average. Currently training in week 13.

I’m not going to introduce an intensity variable here Tim as speed is not an issue – I don’t want to miss any photo opportunities by running too quickly! But I think using an RPE factor may be adequate for the future.

At week 8 it was too early to decide if I was near an overuse risk. At week 11 things were still on track. By week 13 I had two unplanned missed trainings but my data below indicates I’m in a training sweet spot (figure 3).


Figure 3 – Acute:Chronic ratio – the sweet spot. Currently training in mid-week 13.

So, I say again – thank you Tim – I’m certainly running smarter and harder than before. There is a confidence in quantifying the process but now I’ll need to brush up on my exercise physiology because if this gets published the athletic trainers, strength and conditioning coaches and running coaches will be up in arms – where are the intervals, the Fartlek’s, the tempo’s and the recovery sessions? Maybe there’s an art to this smarter and harder stuff too?

Yours sincerely,

James Montgomery @gardensphysio

PS Don’t worry Tim, the recovery and strength work is being done too.


James Montgomery is the Director and Principal Physiotherapist at Gardens Physiotherapy, an independent musculoskeletal physiotherapy and sport medicine practice in Dunedin, New Zealand. James has worked in professional cricket for over six years, both nationally and internationally. He recently started his Masters in Sports Physiotherapy, is a keen recreational mountain runner and has two young daughters with a passion for the outdoors.



Bike Fitting – An introduction for physiotherapists

11 Nov, 16 | by BJSM

By Bianca Broadbent @Thecyclingphys 

The whole experience of a bike fit is highly complex. It is also an area of ongoing significance for injury prevention.  In this blog, I outline the scientific rationale behind bike alignment, and discuss noteworthy trends and how you might utilise these with your current clients.


A proper bicycle fit is essential for comfort, injury prevention, and performance. It optimises power output, aerobic efficiency, aerodynamics, and sustainability for the target event duration (Silberman et al. 2005). Cyclists average between 80-100 pedal revolutions per minute, which equates to around 5400 revolutions per hour. For cyclists riding anything from a few hours per week as a leisure ride, through to competitive cyclists doing 15-20 hours or professional riders doing 30-40  (STOP) hours per week, any ongoing asymmetries or mal-alignments can easily result in injuries and discomfort.

A combination of high training volume and mal-alignment is indicated as an anatomic risk factor for overuse injury (Ahonen 2008, Fousekis et al. 2010, Krivickas 1997). However, quantification of the contribution of asymmetric intrinsic and extrinsic factors to a dose response relationship within musculo-skeletal loading is problematic; norm values do not allude to the epidemiology of asymmetry. The introduction of technology to the bike fitting process through 3D kinematics is starting to produce this database of knowledge.

Use of technology to drive the decision making within bike fitting is a relatively new phenomenon within the cycling world. It has become more popular recently with bike mechanics, coaches, physios, and other health care professionals getting on board. However there is the risk of commercial bias, where companies will use the fitting tools to push their latest products, but do not always identify the most appropriate product for the consumer and their specific injury or complaint.


Bicycle fitting methods can broadly be categorised into static (measurements taken at rest) and dynamic (measurements taken while riding). Taking from several sources, we may define it as “harmonisation between the rider and the bicycle, based on their goals, injuries and physical capabilities”.

Market leading companies are Specialized, Retül (which now comes under specialized), with alternative approaches include, Apex, Torke, and Gebiomized which also offer pressure assessment for saddles, feet and handlebars.

Like all tools and techniques it is the operator rather than the software who needs to make the fit decisions. Also, the clinical reasoning skills of an experienced clinician are essential when dealing with a multifactorial presentation.

A new theoretical model of factors associated with functional asymmetry in cycling sports



There are three contact points a rider has with the bicycle; shoe-cleat-pedal interface, pelvis-saddle interface, and hands-handlebar interface.


The cleats

There are many cleat systems available, Speedplay, Look, Shimano and others, which all offer varying degrees of adjustment, rotation, shimming and wedging. Certainly research seems to suggest allowing cleat float can reduce the incidence of knee pain (Gregor and Wheeler 1994).

There are also many studies linking a poor cleat set up with iliotibial band syndrome (Farrell, Reisinger and Tillman 2003), anterior knee pain (Asplund and St Pierre 2004), and foot disorders e.g. paraesthesia and “hot foot”.

Historically the cleat was positioned so that the first metatarsal head lies directly over the pedal axle, however more recently this idea has changed to suggest that positioning the pedal axle beneath the third metatarsal head allows a more efficient transfer of power.

If the rider has a leg length discrepancy then the shoe-pedal interface can be adjusted by inserting a shim between the shoe and the cleat or by having a custom orthotic insole manufactured. Research suggests that anything greater than 6mm is considered significant and needs correcting (Silberman et al. 2005) although some athletes may not be able to tolerate a difference of 3mm (Baker 2000).   If a rider has a leg length discrepancy then up to half the difference should be corrected.  Any excessive malalignment of the lower extremity, such as forefoot varus or over pronation, can be corrected with the use of canted shims or wedges (Sanderson 1990).

The saddle

A common and under reported phenomenon amongst cyclists is numbness (Leibovitch and Mor 2005). This can present complexly, or be resolved by means of simply correcting the bike fit – evidence suggests looking at saddle height (too high and forwards), saddle shape (cut out and removing the long nose) and maintaining an upright position (Lowe et al 2004) beneficial for reducing pressure on the perineum.

ISM, Cobb, Rido and Specialized are all leaders in providing ergonomic and carefully thought out saddles, but products can also be limited by many fit systems which place clients into “neutral fits”. As a result the saddle may be the “perfect” height for pedalling, but not for other complaints which they may have.

The cranks

A great deal of research discusses the physiological effects of crank length, less studies investigate outcomes related to running shorter crank on cyclists with hip, knee and ankle pathologies. Reducing crank length in these clients, does, however, seem logical. Anecdotally I can report great success from switching those struggling with a closed hip angle to shorter cranks e.g. labral pathology, FAI, arthritic hips. Commercially you will struggle to obtain anything shorter than 165mm. Research does not appear to show shortening the cranks adversely affects power (Tomas, Ross & Martin 2010) and it may help with rapid acceleration in some situations (Macdermid and Edwards 2009).


Bianca Broadbent MCSP ACPSEM, Physiotherapist at Physiokinetic, Spire & Fit Your Bike

With extra special thanks to:


Physiotherapist – Athlete Matters / Preston Physiotherapy & Sports Injuries Clinic

Academic lead – Clinical Biomechanics Salford University

Useful Links

Specialized BG






Medicine of Cycling Research Library –


GREGOR, R. & WHEELER, JB. (1994) Biomechanical Factors Associated with Shoe/Pedal Interfaces. Sports Medicine, Volume 17, Issue 2, pg 117–131

FARREL, K. REISINGER, K. & TILMAN, M. (2003) Force and Repetition in Cycling: Possible Implications for Iliotibial Band Friction Syndrome. The Knee, Volume 10, Issue 1, pg 103-109

ASPLUND, C & ST. PIERRE, P. (2004) Knee Pain and Bicycling – Fitting Concepts for Clinicians. The Physician and Sports Medicine, Volume 32, Issue 4

LEIBOVITCH, I. & MOR, Y. (2005) The Vicious Cycling: Bicycling Related Urogenital Disorders. Eur Urol, Volume 47, Issue 3, Pg 277-286

LOWE, B. SCHRADER, S. & BREITENSTEIN, M. (2004) Effect of Bicycle Saddle Designs on the Pressure to the Perineum of the Bicyclist. American College of Sports Medidine, Pg 1055-1062

TOMAS, A. ROSS, E. & MARTIN, J. (2010) Fatigue During Maximal Sprint Cycling: Unique Role of Cumulative Contraction Cycles. Medicine and Science in Sports and Exercise, Volume 42, Issue 7, pg 1364-1369

MACDERMID, P. & EDWARDS, A. (2009) Influence of Crank Length on Cycle Ergonometry Performance of Well Trained Female Cross Country Mountain Bike Athletes. European Journal of Applied Physiology, Volume 108

AHONEN, J. (2008) Biomechanics of the foot in dance. Journal of Dance Medicine & Science 12:3 99-109

FOUSEKIS, J. TSEPSIS, K. & VAGENAS, G. (2010) Multivariate Isokinetic Strength Asymmetries of the Knee and Ankle in Professional Soccer Players.  Sports Medicine and Physical Fitness. Volume 50, Issue 4, Pg 465-474

KRIVICKAS, L. (1997) Anatomical Factors Associated With Overuse Sports Injuries. Sports Medicine Volume 24, Issue 2, Pg 132-146

SILBERMAN, M. WEBNER, D, COLLINA, S. & SHIPLE, B. (2005) Road Bicycle Fit.  Clinical Journal of Sports Medicine. Volume 15, Issue 4, Pg 271-276

BAKER, A.  (2000) Medical problems in road cycling.  In Gregor RJ, Conconi F, eds. Road Cycling, Oxford, UK. Blackwell Sciences Ltd, Pg 68-120

SANDERSON, D. (1990) The Biomechanics of Cycling Shoes. Cycling science. Pg 17-30.


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).


Work It. Make It. Do It. Sports injuries at the Olympics: an overview from past games and future directions

27 Sep, 16 | by BJSM

 Engagement, Evidence, & Practice Blog Series

By Nirmala Perera (@Nim_Perera)

Examining the changing profiles of injuries provides opportunity for insight, and potential to better embed innovative injury prevention strategies and advances in sports medicine.


Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Athletes from over 200 nations gather every four years for the Olympic and Paralympic Games to celebrate sport, culture, fair play and international cooperation on sport’s biggest stage. I like many of you BJSM blog readers who watched the Rio Olympic (#Rio2016) coverage saw the myriad of injuries and illness captured and broadcast by the media, from fractures and dislocations to diarrhoea and subsequent collapse. At elite level, top players and teams are separated by a very small margin. Injuries and illness affect athletes’ ability to train, complete and can even shatter their dreams of gold. Injury prevention therefore, could be considered ‘legal’ performance enhancement.1 2

Work It. Make It. Do It. Makes Us: Faster. Higher. Stronger.

The Olympic motto Citius, Altius, Fortius (Latin for “Faster, Higher, Stronger”) inspires athletes to reach new heights, changing the nature of the sport over time. The Olympic Games are the pinnacle of many athletes’ careers. They aspire to successfully compete at the games. Injuries and illness can be the cost of striving for athletic greatness. Protecting athletes’ health is therefore, important to maximise performance and chances of success. Current profile of injuries in a sport might be different to injuries suffered by athletes participating the same sports in the past as rules, techniques and equipment evolve. Additionally, elite athletes enter sports much earlier and some continue to compete for longer. Consequently, sports medicine and injury prevention has to evolve with the athlete and their sport.

Injury and illness surveillance of Olympic athletes

The number one priority for the IOC and its Medical and Scientific Commission is protecting the health of the athletes3. Injury surveillance therefore, was initially established by the IOC during the 2004 summer games in Athens and was limited to team sports4. In 2008  injury surveillance was expanded to include all athletes participating in the  Beijing Summer Olympics5 and subsequently the 2010 Winter Olympics in Vancouver6; 2012 London Summer Olympics7, and 2014 Sochi Winter Olympics8. For the first time, injuries in 2012 London Paralympics were reported9 10.

The overall injury rate has remained similar over the last two summer Olympics (9.6% in Beijing5, 11.0% in London7). In addition, 7.2% athletes suffered an illness such as infections to respiratory and gastrointestinal tract during London Olympics. Female athletes were 1.6 times more likely to be ill than their male counterparts7. It is likely that these figures will remain comparable in #Rio2016.

Olympic pains:  the most common injuries by sport, nature and mechanism of the injury

Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Photo courtesy of Mario Bizzini (@SportfisioSwiss)

Football, taekwondo and handball topped the injury list in both Beijing and London. Field hockey and weightlifting, also in the top 5 sports with the most frequent injuries in Beijing5 were ousted by BMX and mountain biking in London7.

Fractures, ligament ruptures and dislocations were the most common types of injury during the Beijing games5. The most common injuries for the London games were ligament sprains, muscle strains, fractures7. Head/neck/face, hand/wrist/fingers and lower back were the most frequently injured regions at #London2012. Interestingly, most of the diagnosis examinations performed at  #Rio2016 Polyclinic at the Athletes Village were to the knee, lumber region and ankles.

Overuse was the second common cause of  injuries in Beijing5. And, it was the most common injury mechanism in London. However, 68% of the reported overuse injuries did not require time-loss from the sport7.  High prevalence of overuse injuries signals to the repetitive nature of elite sport. Elite players are selected on the strength of the key sports specific skill. Many hours of practice are required for athletes to achieve mastery, which necessitate repetitive activities potentially associated with overuse and recurrent injuries. Particularly if training regimes are poorly managed.

Cupping: why athletes use it?

Techniques to manage pain of overexertion such as myofascial decompression (i.e. cupping) to improve healing and release muscle stress attracted a heightened media coverage in #Rio2016. Cupping has shown to provide effective pain management but the evidence is of poor quality and subject to bias. Exact mechanism of cupping is unclear; it may work by ‘counter irritation’ or by ‘placebo effect’. Yet, athletes turn to drug-free methods such as cupping as an alternative to medications possibly because the anti-doping regulations.

Injury prevention research into practice

Nine IOC research centres of excellence work alongside sporting organisations and key stake holders, striving to develop and implement effective preventive and treatment measures for injuries 3. For example, in Beijing5 49.6% of the injuries resulted in an inability to compete, this was reduced to 35.0% in London7. This might be due to advancement in sports medicine where management strategies such as activity modifications/restrictions and analgesia may have delay treatment or prolong recovery until the end of the games, particularly for overuse injuries. The latest research innovations developed by preeminent international authorities in sport injury and illness prevention will be showcased at the IOC World Conference on Prevention of Injury and Illness in Sport in Monaco (#IOCprev2017). In addition, the IOC supports the #BJSM Injury Prevention and Health Protection issues to further enhance knowledge translation to protect the health of both professional and amateur athletes.



  1. Raysmith BP DM. Performance success or failure is influenced by weeks lost to injury and illness in elite Australian track and field athletes: A 5-year prospective study. J Sci Med Sport 2016;19(10):778-83. doi: 10.1016/j.jsams.2015.12.515
  2. Hägglund M WM, Magnusson H, et al. 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(12):738-42. doi: 10.1136/bjsports-2013-092215
  3. Engebretsen L BR, Cook JL, et al. . The IOC Centres of Excellence bring prevention to Sports Medicine. Br J Sports Med 2014;48(17):1270-75. doi: 10.1136/bjsports-2014-093992
  4. Junge A LG, Pipe A, et al. . Injuries in Team Sport Tournaments During the 2004 Olympic Games. Am J Sports Med 2006;34(4):565-76. doi: 10.1177/0363546505281807
  5. Junge A EL, Mountjoy ML, et al. . Sports injuries during the summer Olympic games 2008. Am J Sports Med 2009;37(11):2165-72.
  6. Engebretsen L SK, Alonso JM, et al. . Sports injuries and illnesses during the Winter Olympic Games 2010. Br J Sports Med 2010;44(11):772-80.
  7. Engebretsen L ST, Steffen K, et al. . Sports injuries and illnesses during the London Summer Olympic Games 2012. Br J Sports Med 2013;47(7):407-14.
  8. Soligard T SK, Palmer-Green D, et al. . Sports injuries and illnesses in the Sochi 2014 Olympic Winter Games. Br J Sports Med 2015;49(7):441-47.
  9. Willick SE WN, Emery C, et al. The epidemiology of injuries at the London 2012 Paralympic Games. Br J Sports Med 2013;47(7):426-32. doi: 10.1136/bjsports-2013-092374
  10. Derman W SM, Jordaan E, et al. . Illness and injury in athletes during the competition period at the London 2012 Paralympic Games: development and implementation of a web-based surveillance system (WEB-IISS) for team medical staff. Br J Sports Med 2013;47(7):420-25. doi: 10.1136/bjsports-2013-092375


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.


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Injury Prevention Virtual Conference: Summary of papers and podcasts that address key issues and debates

2 Mar, 16 | by BJSM

A monthly round-up of podcasts and articles

By Zach Spargo (@ZachSpargo) & Steffan Griffin (@lifestylemedic)

Welcome back to another BJSM Virtual Conference. This month’s edition hones in on the holy grail of SEM – injury prevention. As usual, our aim is to provide you with the most recent and very best of BJSM content all in one easy to access location. There has been some huge papers/podcasts in this area recently so here, we’ll help you find what matters.

The training-injury prevention paradox

virtual podcast injury prevention

PODCAST: Heavy Training vs injury risk – Tim Gabbett

We start with a brilliant podcast with load management expert Tim Gabbett. Tim talks about how physiotherapists and S&C coaches can work together to create a more resilient athlete. A main focus of Tim’s is regarding the relationship between quantity of load and injury risk. He proposes that load needs to be increased slowly so that the ratio between acute load (last week of training) and chronic load (last 4-6 weeks of training) remains similar.

PAPERS: Has the athlete trained enough to return to play?

Train smarter and harder

Following on from above, these two papers need no introduction. Two game changers here from Tim Gabbett and Peter Blanch. They will change how you manage a player’s load!

Sport Specific

PODCAST: Keeping runners running

Wondering what a running assessment might consist of? Need ideas for how you might prevent running injuries? Andy Cornelius a previous sport rehabilitator and head running coach at Premiership Football clubs, gives offers suggestions in this area, and identifies what makes a great runner like Mo Farah.

PODCAST: Preventing catastrophic injury at the rugby world cup

Now we head to the world of rugby – with Dr James Brown and Dr Sharief Hendricks from the University of Cape Town. We hear of recent advances in rugby such as doctors being given real time video access to assess potential injuries. This podcast also illustrates how players should be exposed to tackling without pads in training in order to reduce injuries related to contact in matches.

Muscle Injuries

PAPER: Hamstrings – Prevention better than a cure?

Peter Brukner gives his expert analysis of all things new in hamstring literature. In short the paper highlights a hamstring lengthening exercise programme with definite inclusion of Nordics!

Hamstring injury prevention – a 10-minute update

This podcast addresses questions related to (i) the inclusion of lengthening exercises, trunk stabilisation, Nordic curls or PRP injections, and (ii) a comprehensive, evidence-based update on hamstring injury prevention.

So there you have it! We hope you find these resources valuable. It’s a massive topic and of course prevention has many associated factors such as sleep quality and previous injury. These resources will hopefully be a great starting point! We really love to hear your thoughts/questions at BJSM and you can do this on Google+ SEM community, Facebook and Twitter. We are always open to suggestions. See you next time!

Zachary Spargo MSc Physiotherapy student at York St John University, BSc (Hons) Sport and Exercise Science (@ZachSpargo). BJSM team member, Yorkshire and Humber CSP Communications Lead. ACPSEM student member.

Mixed Martial Arts: Understanding the athlete and the need for research

30 Jul, 15 | by BJSM

Mixed Martial Arts (MMA) is arguably one of the world’s most rapidly growing sports and many sports medicine practitioners will be exposed to these athletes. While the sport may seem foreign to some sports medicine specialists and elicit an unsubstantiated negative response, the participants still require quality care, just as any patient would be expected to receive. Furthermore, the MMA athlete of today is a well-rounded, multi-dimensional athlete with his or her own needs.

To adequately treat the MMA athlete, a sports medicine specialist should understand the needs of the sport and its culture as well as the medical issues the athletes faces. Many of these athletes do not have insurance, do not have an “off-season” to recover, and seek out what they believe to be more holistic approaches to treatment. By better understanding where the athlete is coming from, we can better address the athlete’s needs. Furthermore, through dedicated research and discussion, we can bring the science of sports medicine to this evolving sport.

The Modern MMA Athlete


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Today’s MMA athlete focuses on a wide variety of martial arts disciplines as well as strength and conditioning. Sometimes, he or she will also employ a nutritionist as many other athletes do. MMA involves both stand-up and ground-work. Stand-up fighting entails punches with light gloves, kicks, knees and elbows (elbows to the back of the head and kicking/kneeing a downed opponent in the head are illegal). During the fight, an MMA athlete may experience lacerations, orbital fractures, metacarpal fractures, or other striking related injuries. The fingerless aspect of the gloves may also lead to inadvertent eye-pokes. Shoulder dislocations and tibial fractures have also been seen inside the cage.

MMC fighter 2

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Ground-work is often a combination of wrestling and jiu-jitsu or other submission based martial art. While on the ground, the fighters will attempt to lure their opponents into a position that will allow them to apply a joint-lock or choke-hold leading to a tap or stoppage by the referee before a significant injury can occur. However, the hyperextension nature of a joint lock can often lead to injury during training or before a fighter can tap out. Elbows and knees are most at risk for hyperextension injuries as well as shoulder dislocation or labral tears from cranking the shoulder in an awkward position. In addition, like any athlete cutting or pivoting quickly, as well as scrambling from standing positions to ground positions, MMA athletes often suffer ACL or meniscal injuries.

The MMA Culture – not surrounded by too many SEM professionals

As MMA is still a growing sport, and due to the individual nature of the sport, it’s athletes are not surrounded by a team of athletic trainers, physical therapists, or team physicians. As a result, much of the advice an MMA athlete seeks may be from fellow fighters, boxing or jiu-jitsu coaches, or health professionals who train at the same gym. Often times, these athletes do not have health insurance and therefore seek out cheap, often temporizing treatments that may not be in their best interest. In addition, the MMA athlete has no off-season to recuperate and often loses site of long-term recovery in the face of an upcoming bout, especially if that bout means moving up the ranks, whether it be amateur or professional. The lure of a bigger payday and being discovered by the world’s largest MMA organization, the Ultimate Fighting Championship (UFC) often pushes these athletes to seek more fights within a given year, sometimes ignoring the advice of ringside or clinic doctors. In fact, since each state regulates its own MMA events and there is no centralized record base, an athlete may be handed a suspension by a ringside doctor only to fight in a new state before the suspension is completed.

Many MMA athletes arrive in the sport from wrestling or other backgrounds where more “holistic” approaches are stressed to limit the interventions by doctors and also to avoid surgery. As a result, many of these athletes favor chiropractors or more Eastern medical practitioners. While there is certainly a role for alternative treatments, it is the responsibility of the sports medicine specialist to educate the MMA athlete on the safety of these alternative treatments as well as the important advances available today in more traditional sports medicine.

MMA Sports Medicine Issues

Besides musculoskeletal issues, today’s MMA athlete faces other medical issues, particularly the abuse of Performance Enhancing Drugs (PEDs), rapid and unsafe weight-cutting, and concussion/mild traumatic brain injury. Like any professional athlete, MMA fighters often will seek any advantage over their opponent they can find. Unfortunately, that sometimes leads them to abuse PEDs. Anabolic steroids and HGH are of particular concern, but the abuse of Testosterone has also been a hot topic over the last few years. As television marketing and doctor prescription of testosterone has increased, so has the abuse of Testosterone Replacement Therapy (TRT). Some MMA athletes may seek out a physician to approve a Therapeutic Use Exemption (TUE) to allow them the use of TRT by the state athletic commission. In many cases, the athlete has abused anabolic steroids in the past, thus limiting the level of testosterone measured on testing. The athlete will then use this as “proof” that they require a TUE. State commissions understand the need to test athletes for TRT abuse, but they often have limited resources for funding these tests. It is therefore easier and more cost-effective for the physician to educate the athlete directly on the dangers of PEDs and TRT abuse. In response to the widespread use of TUEs, some state commissions such as Nevada and California have effectively banned the use of TRT by its athletes.

Another major medical issue the MMA athlete faces is rapid and unsafe weight-cutting practices. Rules on when a fighter weighs-in vary by state for amateurs, but professionals usually weigh-in the day before a fight. As is seen in wrestling, boxing, and judo, even on the Olympic-level, athletes will dehydrate themselves 5-7 days before a fight to weigh-in under the limit and then use the ensuing 24 hours to rehydrate, often gaining anywhere from 5 to 20 pounds. This rapid weight loss and dehydration puts them at significant risk for kidney failure, cardiovascular strain, neurocognitive dysfunction, and a host of other pathologies. Studies have even shown that many athletes are still dehydrated by the time the fight starts, and very few are fighting at a weight encompassed within the weight class for which they weighed in. Several weight-cutting related deaths in the 1990s actually led the NCAA to move wrestling weigh-ins to the same day as the event and regulate how quickly and how much weight a wrestler can cut. Furthermore, there is some thought that dehydration may limit the amount of fluid in the blood-brain barrier, thus reducing the cushion for impact from head blows.


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When compared to boxing, MMA gloves are lighter and the fights are shorter, but MMA fighters are still at significant risk for concussion and long-term mild traumatic brain injury. In fact, most of the accumulated brain injury may occur in the weeks preceding a fight as the athlete trains daily during training camp. Many athletes may not even know that a knockout involves a concussion. Education on the long-term risk of hard sparring as well as the accumulation of sub-concussive episodes is of paramount importance as more young athletes are entering the sport. Further research is required before we have begun to fully see the effects of long-term exposure in the earlier generation of MMA fighters.

The Need for Research

As the sport of MMA evolves, so too must the science of sports medicine. Currently, the care for the MMA athlete is very splintered. Treatment practitioners may range from nutritionists and strength and conditioning coaches to athletic trainer, physical therapists, and physicians. In addition, many labs around the world are performing research on very important issues related to MMA and other combat sports including head trauma and weight-cutting.

The major roadblock to bringing this high-level education and research to the athlete is that there are not any significant MMA research groups to promote collaboration and discussion among researchers and practitioners. Major sports such as American football and FIFA soccer have countless study groups and panels focused on analyzing safety, promoting research, and educating those team members around the athlete. Currently, MMA does not have such a research body.

As a result, I have founded the Mixed Martial Arts Research Society (MMARS) to help promote research, collaboration, and education among researchers, athletic trainers, physical therapists, and physicians. It is my hope that through research and the MMARS we can make the sport of MMA safer, prolong the careers of these athletes, and bring the science of medicine to this rapidly evolving sport.

 For more information visit


Jonathan Gelber, MD, MS is a sports medicine fellowship-trained orthopedic surgeon. To get involved in the Mixed Martial Arts Research Society (MMARS), you can visit

Fortius International Sports Injury Conference (FISIC) – A conference you can’t afford to miss…

11 Jul, 15 | by BJSM

Wimbledon is well underway, cricket season is in full flow, football season is commencing and 20 national rugby squads are preparing to compete in the 2015 Rugby World Cup – needless to say it is another exciting summer of sport.

With the home Rugby World Cup tournament fewer than three months away, the 50-man England squad are in boot camp at Pennyhill Park, then on to high altitude training in the Rocky Mountains, with the aim of being the fittest team in the tournament by the time the action kicks off in September.

The squad will be pushing themselves to their limits, while their medical teams will be working hard to minimise injuries. Perfect timing then for the Fortius International Sports Injury Conference (FISIC) which coincides with a brief interlude in play before the Quarter Finals, and gives team medical personnel a unique opportunity to participate in a world-class, multidisciplinary congress.

fisic june 2015

The full two-day conference, which takes place on October 13th-14th in central London, offers a unique multi-disciplinary approach, and a strong international faculty including many leading experts in Sports Orthopaedics, Elite Sports and Sports Exercise Medicine.

The theme of FISIC ‘15 is Treatment, Recovery and Return to Play, and the programme covers a wide range of key issues and hot topics in sports injury treatment and recovery, as well as specialist sessions from the World Rugby faculty and joint specific presentations.

All sessions will have a multidisciplinary element but are named plenary, surgical, MDT or GP according to their primary target audience. Speakers will emphasise themes of “from science to clinical practice”, “optimising recovery” and “clinical excellence”.

The surgical sessions will involve a series of short lectures with approximately half the session time allowed for debate and discussion. Although some of the MDT sessions will follow this format, others may involve lengthier talks but will still allow ample time for debate.

Some of the programme highlights for Sports Exercise Medicine professionals

The Future of Cell Therapies – Fact or Fiction: covering the current status of stem cell therapies in cartilage repair, bone marrow aspirate and cell therapies, and the PRP debate

Bone Health: covering the biology of bone repair; Bone health in the female athlete; Vitamin D deficiency, supplements & use as a hormone to enhance injury recovery; medical treatments to aid bone repair, and the use of exogen.

Dr Bob Cantu, Dr Caroline Finch, Dr Jon Patricios and Dr Willie Stewart from the World Rugby advisory board discuss the science of concussion, how to recognise and remove it, including management of the difficult case and what we know of the potential long-term consequences.

The science of muscle injuries & repair going on to Acute injuries: Best medical management for successful RTP; imaging acute lower limb muscle injuries: Predicting return to play; best management & optimising RTP following contusion injuries & myositis ossificans; chronic recurrent tears and return to function; surgical indications for hamstring injury.

World Rugby leads a session on player anthropometrics, the demands and current trends in injury in Professional 15 a side Rugby, Community & age-group rugby; skills needed to work pitch-side in rugby union and how practitioners can reduce the risk of injury to a team.

A session on return to play covering: the psychology and nutritional aspects of return to play; RTP post max-fax injuries; the environment needed to facilitate smooth RTP; objective criteria for safe return to play.

A session on disability sport will cover sports science and coaching in sports medicine; performance physiotherapy for disability sport; the athlete/ paralympian perspective; complexity of sports psych in disability sport; Athlete classification and ethical issues in disability sport

The Adolescent Athlete: will cover spinal pain in adolescent sports, strength and conditioning training; apophysitis and soft tissue injuries; CL tears and reconstruction in children & adolescents; Osteochondritis Dissecans and imaging the Adolescent Athlete.

There will also be a wide range of joint specific sessions including: Knee sessions on the Meniscus, Cruciates, Patellofemoral Syndromes In Sport; Foot & ankle sessions on Mid Portion Tendinopathies, Insertional Tendinopathies, The difficult mid- season foot injuries, Ankle & Midfoot Injuries, Ankle Instabilities; Shoulder and elbow sessions on Gleno humeral instability, Spectrum of Shoulder Injuries, Elbow Instability, dislocations, MCL, biceps and triceps injuries and tendonitis; as well as specialist Spine, Hip and Groin and Wrist and Hand sessions

CPD points have been applied for and it’s expected that there will be 6 points for each day of the conference.

You can find out more on the conference website,


Video resources for running injury management and prevention, courtesy of @runningreform

31 May, 15 | by BJSM

By Dr Kevin Maggs (@runningreform)

The majority of patients in my clinic are runners. As a chiropractor, this may seem strange, but I have developed a niche due to my background in biomechanics and a penchant for running.

I see a wide variety of conditions during a typical day, but at the same time, certain scenarios become repetitive.

“Are these shoes good for me?”

The question, “Are these shoes good for me?” or any variation of that theme is certainly one of the most commonly repeated questions. When you have a “Groundhog day” moment like that on a daily basis, you start looking for more efficient ways to handle it.  Many patients respond well to visual learning, so I often search the web for appropriate media that fits with current evidence.  Unfortunately, I am usually unable to find anything suitable.

So, when I see a need for something, I try and fill that need.

I’ve dabbled in 3D animation and use a free program called “Blender”, to make short, evidence based videos for my patients to watch. My hope is that these videos offer a well thought out visual explanation/ representation–  and an improvement on what I could do “off the cuff” in the office.

Here is a sample of these videos:

1. Tendon Compression: Tendons are particularly vulnerable at sites where they wrap around and are compressed by bony protuberances. During the initial stages of treatment, it is often important that patients understand this concept and try to avoid positions or exercises that may increase compression.

Here’s a BJSM review by Jill Cook and Craig Purdam that examines the potential role of compressive loads in the onset and perpetuation of tendinopathy and more: Is compressive load a factor in the development of tendinopathy?

2. The Science?? of Prescribing Running Shoes: an article in the BJSM asked if prescription of distance running shoes is evidence based? This video is a patient friendly version that everyone should understand.

3. Increasing Anterior Ankle Impingement by Limiting Pronation: In order to fully understand this video, I would highly recommend reading the accompanying blog post (found here) which fully explains the concepts.

I frequently encounter patients suffering from anterior ankle impingement, running in zero drop shoes or shoes and orthotics that limit midfoot pronation.  I use this video to explain why this is probably a poor choice.

4. Craigs Test:The idea of femoral anteversion isn’t easy to understand without some visuals.  This video is very helpful.

5. Hamstring Tension During Running This video explains various factors of sagittal plane position of the pelvis will affect hamstring tension during running.

This BJSM Hamstring podcast cluster gives you the opportunity to hear from the hamstring experts.  I would highly recommend these!

6. The Forward Lean Reducing PFPS ForcesThis is one of the first videos I ever made, and so the quality isn’t that great, but it still does the job. There are studies that report increased trunk flexion angle will reduce patellofemoral joint forces.  While this is true, this video demonstrates an alternative.  Since I published this video and related blog in 2012, further studies have supported the notion that a forward lean reduces knee forces, but increases hip/low back forces.

In addition to above, have a listen to present-day expert in PFP, Associate Professor Kay Crossley on treatment for patellofemoral pain in this BJSM podcast. She discusses (i) the outcomes of the 3rd International Patellofemoral Retreat (BJSM 2014, see below), (ii) the best PFP treatments and evidence for them as well as (iii) new insights into knee pain after ACL reconstruction.

Ideas for further videos?  I’m open to suggestions. Contact me here.


Kevin Maggs is a chiropractor in Virginia, USA and operates the website  He studied Kinesiology at the University of Waterloo in Canada and is experienced and trained in running mechanics and running injuries.  He is also an instructor for Active Release Techniques and spent many years travelling and treating the professional triathletes for the Rev3 triathlon series.  He is an avid runner and has completed many marathons and full Ironman races.



The FSEM calls for a National Sporting Injury Register to encourage safe sporting and exercise practices for the general public

18 Feb, 15 | by BJSM

News Release – The Faculty of Sport and Exercise Medicine

fsem_v_Variation_1The Faculty of Sport and Exercise Medicine (FSEM) UK supports the need for a National Injury Register to cover all sports in order to identify and inform activities that may pose injury risk. Such a Register would provide key data for Governing Bodies in developing and assessing the effectiveness of injury prevention strategies including, when necessary, changes to the rules of a sport. The Faculty also acknowledges the need to apply accepted sporting risk management principles to age- group sport, including rugby union 1.

The lack of comprehensive injury statistics is a feature of almost all youth sports. Sport related hospital-treated injuries are more than five times more common than road traffic injuries for children aged 15 or younger 2. Road traffic injury prevention is a well-resourced public health issue in the UK, but sports injury identification and prevention is not. The FSEM welcomes opinion and debate on this, including the BMJ article, The unknown risks of youth rugby 3. However, it should also be noted that a growing number of individual sports governing bodies and sporting leagues are currently completing high-quality peer reviewed work in this field 4.

Dr Roderick Jaques, President of the Faculty of Sport and Exercise Medicine comments:

“There is a clear need in the UK to work towards the set-up of a National Injury Register for sport. This is essential not only for established sports, clubs and teams, but to also encourage and manage sporting and exercise practices for the general public within safe limits. The challenge is identifying how this can be done and how it can be delivered. “The barriers to developing a National Injury Register are principally outside the influence of national governing bodies for sport, therefore we need to look towards relevant organisations, regulatory bodies, colleges, faculties and public health authorities to collaborate and create a solution. Funding will also be an important part of this.”

The FSEM is already supporting and developing research strategies with key partners, such as the National Institute of Exercise and Health, to demonstrate the risks and benefits of sport and exercise to the health of the population.

Funding is now needed to support initiatives like this and the creation of a National Injury Register, in order for popular sport and exercise to be developed and encouraged within safe limits, including youth sport.


1 Fuller and Drawer Sports Med. 2004;34(6):349-56.

2 Finch CF, Wong Shee A, Clapperton A. Time to add a new priority target for child injury prevention? The case for an excess burden associated with sport and exercise injury: population-based study. BMJ Open 2014;4:e005043. doi:10.1136/bmjopen 2014-005043

3 The unknown risks of youth rugby, M Carter, Published 08 January 2015: BMJ 2015;350:h26

4 Palmer-Green DS et al Am J Sports Med. 2013 Apr;41(4):749-55. doi: 10.1177/0363546512473818. Epub 2013Feb 4


Follow FSEM on Twitter @FSEM_UK Linkedin and Facebook Web:

For further information contact Beth Cameron, PR & Communications for the Faculty of Sport and Exercise Medicine;

Email:, Tel: 0131 527 3498, Mobile: 07551903702

More skiers, less injuries, and the characteristics of ‘risk-takers’: A brief research update on injuries in alpine sports

8 Jan, 15 | by BJSM

Is skiing less dangerous than we may think? With the winter sport more popular than ever, there is a downward trend in injuries. What are the reasons? Why do injuries still occur?

skiingMartin Burtscher and Gerhard Reudl, two leading professors in the field, share their thoughts on the striking downward trend in injuries associated with alpine skiing in a CMAJ Blog. They state “Assuming a death rate of 1 per 1 million skier days and an injury rate of 1-2 per 1,000 skier days a total of 400 fatalities and 400,000 to 800,000 injured skiers would result. That may be enough to fill newspapers daily but they actually represent a relatively low death and injury risk… Put another way, for the individual who skis for 20 days per winter season on average, 1 death would occur within 50,000 years and 1 injury within 25 to 50 years.”

Still, injuries do happen. We highlight some key findings from BJSM research below.

Who is more likely to be a risk taker?

Risk taking behavior is associated with younger ages, higher skiing ability, male sex, lower body mass index and those with a higher than average speed. Read more in the BJSM Original article on Factors associated with self-reported risk-taking behaviour on ski slopes.

Snowboarders injuries when listening to music are less frequent but more severe. 2014 Original Article in BJSM: Listening to a personal music player is associated with fewer but more serious injuries among snowboarders in a terrain park: a case-control study.

Skiing safely

Although head injuries account for 9–19% of all winter sport injuries reported by ski patrols and emergency departments, the use of ski helmets has been shown to reduce the head injury risk up to 60% among children and adults. Learn more on the successes and challenges of helmet-use uptake in this BJSM Editorial: Is ski helmet legislation more effective than education?

Taken together, the evidence suggests that a fear of serious injury should not prevent you from being active on the slopes, and skiing is safer than ever before. Still, some basic safety precautions may help you experience none of the hazards and all of the health benefits associated with skiing.

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