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The sedentary office: the need for more pragmatic guidelines

26 Jun, 15 | by BJSM

Letter to the Editor by: Dr Kelly Mackenzie, Specialty Registrar in Public Health / Academic Public Health Fellow

In response to:  JP Buckley & A Hedge et al (2015). The sedentary office: a growing case for change towards better health and productivity.

We welcome the development of quantifiable targets relating to workplace sedentary.  However, given the low quality evidence, it was expected that the recommendations would have been more pragmatic.

For desk-based workers, an initial target of two hours per day of standing/light activity eventually progressing to four hours per day, would be difficult to accumulate without the use of environmental and/or ergonomic adaptations such as adjustable-height desks.  As these interventions have a relatively high initial cost (around £300-1000 for an adjustable-height desk1), this recommendation is unlikely to be achievable in most workplaces.  Financial gains due to increased productivity and decreased absenteeism can be made to offset these costs, but tend to only be realised in the longer-term, so will not provide a viable justification for many organisations.

Instead, initial recommendations need to provide realistic targets that involve no/low cost changes that can be accumulated incidentally throughout the working day e.g. by encouraging standing/walking meetings.  The recommendations could then be taken up by a range of organisations, hence promoting maximal public health benefits.


  1. Height Adjustable, (Accessed on 16th June 2015)

Authors of “”Load me up Scotty”: Mechanotherapy for plantar fasciopathy…” respond to Letter to the Editor by Dr. Nick Webborn and colleagues

27 Mar, 15 | by BJSM

Thank you for your interest in our editorial in the British Journal of Sports Medicine: ”Load me up Scotty”: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis)”. However, we find your letter to the editor (published in this recent blog) somewhat hit-and-miss with regards to the main “swings” (critique points) provided by you and your colleagues.

  • Your main critique was not related to our editorial, but more so to the original study published in Scandinavian Journal of Medicine & Science in Sports (SJMSS )(Read it HERE )
  • We were criticised for promoting our own work in an unbalanced way, and in an incomplete form.

In reverse order, our response to these 2 main “swings” are:

Yes, you can rightfully claim that we highlight some of our own work, but as this was an important part of the task given by the BJSM (in a requested editorial), your criticism seems a little off target. Point taken, although, we do not share you and your colleagues concern, as we believe that most BJSM readers will know that editorials are narratives (Expert opinion, Level 5), and therefore not high-level evidence, in itself. The BJSM editorial format limits of 800 words and 8-10 references, also plays a role as to why the comprehensiveness of most subjects is usually limited in some way, shape or form.

We therefore urge people to read the original study in SJMSS, as an a priori justification and rationale for the primary outcome and endpoint (including sample size justification) is provided in the methods section of this study, and the relevance of this is discussed in detail in the manuscript. Furthermore, this specific study has been referred to in this blog in BJSM, where the methodological issues are more thoroughly discussed.

We chose 3 months as the primary endpoint because the exercise protocol lasted three months, and therefore the effects of exercise were most relevant to that time point — when there is no wash-out of the exercise effect. We agree that most patients do not only care about their status at 3 months, but also at other time points. However, patients in both groups were better at 6 and 12 months (and not different as your blog suggests), than before initiating treatment, with no differences between the groups. So, if you your patients prefer to wait till 6 months, instead of 3 months, before a substantial improvement kicks in, then the traditional approach with stretching and inserts seems equally effective, as suggested by the secondary analyses of the study.

With this answer we have addressed the main points in your blog/letter. We agree that our work is only the first indication that high-load strength training is an effective treatment for plantar fasciopathy, and that replication studies should follow. We have no interest in panaceas, and have therefore extensively studied different musculoskeletal conditions and specific exercise interventions in several RCTs, during the past 5 years, and we will be the first ones to abandon interventions that show no clinically meaningful promise.

Finally, we are also admittedly very enthusiastic and passionate people, especially with regards to our clinical research and work, but the intention was never to offend you and your colleagues, only to promote a novel and interesting modality for people to consider to include in their clinical tool box. As previously stated in the blog post on the BJSM website “The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis.”

Who knows, maybe future randomised trials within fasciopathy or other tendinopathies will be initiated from an interest sparkled by this enthusiastic editorial on the importance of loading. If so, we believe ”Load me up, Scotty….” has certainly done it’s job, as the current level of evidence for the modalities often used in treating plantar fasciopathy is still low, and therefore often based upon low-level evidence, as documented in a recent Clinical Practice Guideline (Read it HERE).

Kind Regards,

Michael Skovdal Rathleff & Kristian Thorborg

‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy – “It may be science Jim, but not as we know it!” (Letter to the Editor)

24 Mar, 15 | by BJSM

Letter to the Editor by BJSM Associate Editor Dr Nick Webborn and colleagues

In response to: MS Rathleff and K Thorborg (2015) ‘Load me up, Scotty’: mechanotherapy for plantar fasciopathy (formerly known as plantar fasciitis)

feet tiptoesAlthough it’s good to see researchers putting forward hypotheses for improving rehabilitation protocols, I believe there needs to be a balance of promoting their own work published in another journal  (Scandinavian Journal of Medicine & Science in Sports) with incomplete presentation of the data in a BJSM editorial.

The original paper was titled High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Keep in mind the key point in the editorial was a significant difference between groups after THREE months of loading intervention – mechanotherapy.(Open Access Paper with 66,000 views here)

The authors found no differences between groups at 1, 6, and 12 months. There was no mention of this failure to find a difference at those time points in the editorial. At 12 months, the Foot Function Index score was actually worse in the stretch group. So if all our patients were just interested in how they functioned after 3 months of treatment the study findings are exciting. But there could be numerous reasons for this transient difference at 3 months including chance. There may have been no difference at 4 months and it was a transient blip in the data. Perhaps an explanation of reported improvements at 3 months but not at 1,6 & 12 should have been hypothesised in relation to the high-load’ model.

Too often we are told of the next great step in treatment based on limited science and then have to readjust it and confuse our patients yet again. If we are going to tell people “to boldly go where no one has gone before” we need to be clear, and honest, as to why. The authors need to temper their enthusiasm for their theory and accept the limitations of the study. There were only 24 subjects per group. We need to consider this before we all jump on the bandwagon that this is the next new panacea.

We all acknowledge that some form of loading is important during rehabilitation of injured structures but the evidence of this type of loading over other forms is still conjectural based on the current evidence. Maybe we need Dr ‘Bones’ McCoy’s medical tricorder device to assess it?

Common ground and continued debate: further response to “Strong evidence against PRP injections for chronic lateral epicondylar tendinopathy: a systematic review”

10 Dec, 14 | by BJSM

The rich academic discussion continues! Here is a Letter to the Editor from Renee Keijsers, Denise Eygendaal, Michel P. J. van den Bekerom that they wrote in response to a blog from RJ de Vos and colleagues (read it here), who wrote an initial Letter to the Editor (read it here) in response to: Robert-Jan de Vos, Johann Windt, Adam Weir. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956.  Have something to add? Send us your thoughts or comment below!


We thank RJ de Vos and colleagues for the response on our comments. We do agree that there is a lot of common ground between the two groups. This is probably the main reason for this lively discussion. The enthusiasm of the authors is reflected in both the original article as in the fast response to our comment.

The diagnostic terminology ‘tendinopathy’ is indeed substantively better than ‘epicondylitis’. The terms ‘lateral epicondylitis (LE)’, ‘lateral epicondylar tendinopathy’, ‘lateral epicondylalgia’ or ‘tennis elbow’ are often used interchangeably, where the same condition is meant. The Cochrane Library overcomes this by using the term lateral elbow pain; which is not an actual diagnosis, but only a description of the localization of the pain. The majority of cases are believed to be caused by a tendinous lesion of the common extensor tendon origin at the lateral epicondyle as a result of repetitive microtrauma. There are several hypotheses regarding the cause of the tendinosis in LE based on histopathological, biochemical and clinical findings. Cell apoptosis, angiofibroblastic features, or abnormal biochemical adaptations, largely suggesting that a failed healing response underlies the condition. (1,2)

We would also like to refine our criticism: we do agree that the design of the systematic review was performed correctly and with respect to the PRISMA guidelines. Nevertheless we think that the interpretations of these results are oversimplified. Due to the different techniques and the use of different concentrations of PRPs (with different platelet count, leukocyte concentration and activation of PRP) it is too hasty to definitively abort the use of PRPs. We do agree that a beneficial effect of PRPs (especially in relation to infiltration of whole autologous blood) in the treatment of LE has not been proven; therefore we need more placebo-controlled RCTs. Or to be more specific: we need more placebo controlled trials in which the technique is uniformly performed and controlled. We think that many of the infiltrations are not in the area of the ECRB tendon. When injection therapies are not performed in a standardized way by ultrasound guidance and with a well defined injection technique it is not possible to compare injection therapies with one another.

The authors state in their comment that ‘Comparison with autologous blood injections would only make sense if this would was “usual care” for tendinopathies’. A more recent review, than the one cited by the authors on the effect of different injectables in the treatment of LE, found a paucity of evidence from unbiased trials on which to base treatment recommendations for LE. However, this meta-analysis by Krogh et al. (2013) showed that injection therapy with autologous blood, PRP, hyaluronic acid and prolotherapy (injection with dextrose) were all more efficacious than placebo.(3) Therefore, we think there is still a place for injection therapy with autologous blood or (more expensive) PRP in the standard treatment of chronic tendinopathies of the elbow.

A hypothesis is that perforations of the affected tendon alone (without application of an injectable) could also have a therapeutic effect; the needle is used to either break up scars or poke holes in the injured tendon so that bleeding occurs. The blood cells carry precursors, which eventually develop into collagen to replace the damaged tendon. Therefore it is quite possible that all currently used injectables are not effective at all. As long as there is no consensus on the best treatment of LE, there will be many items to discuss about.

To our opinion the bottom-line should be that it is very important to remain critical about promising new developments in health care, and that results should be viewed in the right perspective.


1. Pitzer ME, Seidenberg PH, Bader DA. Elbow tendinopathy. Med Clin North Am. 2014 Jul;98(4):833-49.

2. Walz DM, Newman JS, Konin GP, Ross G. Epicondylitis: pathogenesis, imaging, and treatment. Radiographics. 2010;30:167-184.

3. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2013 Jun;41(6):1435-46

De Vos, Windt and Weir respond to: “Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy?”

19 Nov, 14 | by BJSM

One of the great things about social media (blogs, Twitter, etc.) is that it encourages dynamic dialogue and discussion. Academics and practitioners alike benefit from the new insights and ‘food for thought’ this generates. With this tenet in mind, here is a letter from Robert-Jan de Vos, Johann Windt and Adam Weir in response to the BJSM blog: Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy? that was written in response to de Vos, Windt and Weir’s publication:  Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956. …comprende? We hope so. 


With great interest we read the letter to the editor regarding our systematic review on the use of Platelet-rich Plasma (PRP) injections in patients with chronic lateral epicondylar tendinopathy.1 We compliment the authors on their efforts to improve scientific quality in this field. The BJSM Blog is a fantastic forum to host discussions like this and we would encourage other readers to share their thoughts as well. There is a lot of common ground between the two groups but we were surprised that our systematic review conclusions were described as being ‘not properly supported by recent literature’. We would like to emphasise that it was properly designed and performed according to the PRISMA guidelines. In response to this criticism we address some aspects of the letter and explain why we think our systematic review is of value in the field of tendinopathy.

Diagnostic terminology

We hope that we are on the same page regarding the diagnosis. The authors use a different terminology and refer to ‘chronic lateral epicondylitis’. We know that inflammatory theories in tendinopathy are currently popular, but the generally accepted term is “tendinopathy” for these conditions.2 This might sound as a semantic discussion, but if authors in a research field cannot agree on terminology and diagnostic criteria for a certain condition, it will be very hard to make comparisons in scientific literature.

Meta analysis

While meta analysis is generally accepted to be the highest level of evidence you should always consider if it is correct to use this technique. By presenting a meta-analysis in the way the authors have done, study design labels (e.g. RCTs or CCTs) are used to imply high study quality and low risk of bias. The assessment of risk of bias is a key step in conducting systematic review and possible meta analysis. It plays an important role in the final assessment of the strength of the evidence. The first question we should ask is whether the included studies have a low risk of bias. If not, it is questionable if the outcome really reflects the efficacy of PRP or the effect of studies with a high risk of bias. We feel that to present a meta analysis one must also first assess the risk of bias and argue the case as to why it is valid to perform a meta analysis. It is known that lower study methodological quality is associated with better treatment outcomes in patellar tendinopathy.3 To simply pool the outcomes of all RCTs performed in this field does therefore not automatically imply a ‘highest level of evidence’.


We fully agree with the authors that corticosteroid injections should not be used for control groups in PRP studies. We support the approach to leave these studies out of the final evaluation because of the detrimental effect of corticosteroids.4 Corticosteroid injections should be discouraged in the routine management of tendinopathy and they are not suitable as a control group because of the detrimental long-term effects.

Placebo as control

The authors present their analysis of PRP vs autologous blood injections. We would stress the need for more placebo-controlled RCTs, rather than comparison to another active treatment. Creaney et al. randomised patients to a PRP or autologous blood injection and found no significant differences in outcome.5 They then concluded that both autologous blood and PRP injections are useful second-line therapies to improve clinical outcomes. However, it would only be possible to draw this conclusion if a placebo-arm was used in the study. Comparison with autologous blood injections would only make sense if this would was “usual care” for tendinopathies. A previous systematic review showed that there was strong evidence that autologous blood injections are not efficacious6, so the use of autologous blood injections in routine care or as a control group cannot not be advised.

Should we abandon PRP?

In our opinion the authors do not present a case for the use of PRP in clinical practice. They provide us with a meta analysis where no difference is found between PRP and autologous blood injections.

We feel that at the current time there is strong evidence that both PRP and autologous blood injections are not efficacious. The fact that autologous blood is cheaper than PRP cannot be used to argue a case for it being preferred. In our clinical practice we prefer to use neither.

We are aware that the conclusion of our systematic review is not popular,7 as attention for PRP treatment is still growing. We still feel that our review conclusion is robust and it is also supported by other high-quality placebo-controlled studies in the field of musculoskeletal medicine.8-10 To end again on a positive note we agree with the authors’ final comment, where they advise for more placebo-controlled studies.


  1. de Vos RJ, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med 2014;48(12):952-6.
  2. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth. BMJ 2002;324(7338):626-7.
  3. Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD. Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 2000;10(1):2-11.
  4. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010;376(9754):1751-67.
  5. Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45(12):966-71.
  6. de Vos RJ, van Veldhoven PL, Moen MH, Weir A, Tol JL, Maffulli N. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull 2010;95:63-77.
  7. Gosens T, Mishra AK. Editorial in response to the systematic review by de Vos et al: ‘Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review’. Br J Sports Med 2014;48(12):945-6.
  8. de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010;303(2):144-9.
  9. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, et al. Platelet-rich plasma injections in acute muscle injury. N Engl J Med 2014;370(26):2546-7.
  10. Schepull T, Kvist J, Norrman H, Trinks M, Berlin G, Aspenberg P. Autologous platelets have no effect on the healing of human achilles tendon ruptures: a randomized single-blind study. Am J Sports Med 2011;39(1):38-47.


Should we really abandon PRP in the treatment of lateral epicondylar tendinopathy?

27 Oct, 14 | by BJSM


In response to:

Robert-Jan de Vos, Johann Windt, Adam Weir. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med. 2014;48(12):952-956. 

Dear Editor,

Recently a systematic review was published in your journal by de Vos et al (1) on the effect of PRP (Platelet rich plasma) injections in the treatment of chronic lateral epicondylar tendinopathy. They conclude there is strong evidence that PRP injections are not efficacious in the management of chronic lateral epicondylitis (LE).

In our opinion the conclusions drawn in this study are too firm and not properly supported by recent literature. In the review, PRP injections are compared to different other injection therapies as control group. In three of the included studies PRP injections are compared to corticosteroid injections (2,4,7). In current literature and stated by the authors of current review there are several studies that demonstrate a short term (4- 6 weeks) beneficial effect of glucocorticoid injections on pain in the treatment of lateral epicondylitis (11,12,13,14). The review by Krogh et al (11) found no long term benefits of glucocorticoid injection over placebo. After 12 months, conservative treatment appears more effective: 8 till 9 of 10 patients are pain free versus 7 of 10 patients having had corticosteroids. Therefore it cannot be used as a control group to investigate the efficacy of PRP injections, in fact it is even not ethical to use these as a comparison in future trials. The follow up of the study by Omar et al (7) was only 1.5 months. This may explain why there were no differences in outcome measures between the PRP and the corticosteroid group. The meta-analysis by Krogh et al (11) also showed that autologous blood, PRP, prolotherapy and hyaluronic acid were all more efficacious than placebo in the treatment of LE.

A relevant question in the discussion about the treatment of LE with injection therapies is the difference in effectiveness between PRP and autologous whole blood. The included study by Thanasas et al (5) shows a trend of decreasing VAS scores in favor of the PRP group (VAS improvement of 4.4 points (71%) compared to mean VAS improvement 3.4 points (58%)), no significant differences are found. The study by Creaney et al (6) showed no difference in VAS scores between PRP and autologous whole blood.

Because a meta-analysis has the highest level of evidence we performed a systematic search in Pubmed/Medline to identify trials comparing PRP with ABI in the treatment of LE. Four publications were identified (5,6,9,10). This first meta-analysis should be updated in the future to summarize the most up to date evidence.

To support these findings we have pooled data of the study by Thanasas et al (5) and data of  recent studies on the effect of Platelet-rich plasma versus autologous whole blood for the treatment of LE by Raeissadat et al (9, 10). This shows no differences in VAS painscores after six weeks (table 1) and 6 months (table 2) after treatment with PRP or autologous whole blood. Standard Deviations (SD) are estimated based on ranges or 95 % confidence intervals.

Table 1: VAS pain score after 6-8 weeks

Table 1: VAS pain score after 6-8 weeks


Table 2 PRP letter

Table 2: VAS pain score after 6 months


Creaney et al (6) and Thanasas et al (5) both used a (different) functional outcome score. Data of the two studies were pooled and showed no differences in functional improvement between PRP and autologous whole blood (table 3).

Table 3: Functional improvement at 3 months

Table 3: Functional improvement at 3 months

It is possible that the two studies by Raeissadat and colleagues (9, 10) used the same dataset, given the overlap in inclusion period. If this is the case, it would perhaps be better to consider them as one study. Due to the high level of heterogeneity, no firm conclusion can be drawn. Nevertheless, it is questionable to what extend there is a relevant difference in the treatment effect between PRP versus whole blood. When there is no difference in treatment effect, treatment with autologous whole blood is preferred due to the higher costs of preparation of PRP.

To answer this question, a high quality study is needed to compare the effects of autologous whole blood with PRP and placebo in the treatment of LE. In current literature the injections therapies are performed manually and blindly and are therefore not properly comparable (11). Future studies should be performed in a standardized way by an ultrasound guided reproducible and well defined injection technique to make the interventions comparable.


Renee Keijsers

Denise Eygendaal

Michel P. J. van den Bekerom


  1. de Vos, R-J, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic reviewBr J Sports Med doi:10.1136/bjsports-2013-093281.
  2. Peerbooms JC, Sluimer J, Bruijn DJ, et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med 2010;38:255–62.
  3. Gosens T, Peerbooms JC, van Laar W, et al. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 2011;39:1200–8.
  4. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41:625–35.
  5. Thanasas C, Papadimitriou G, Charalambidis C, et al. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: a randomized controlled clinical trial. Am J Sports Med 2011;39:2130–4.
  6. Creaney L, Wallace A, Curtis M, et al. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45:966–71.
  7. Omar AS, Ibrahim ME, Ahmed AS, et al. Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: randomized clinical trial. Egypt Rheumatol 2012;34:43–9.
  8. Mishra AK, Skrepnik NV, Edwards SG, et al. Platelet-rich plasma significantly improves clinical outcomes in patients with chronic tennis elbow: a double-blind, prospective, multicenter, controlled trial of 230 patients. Am J Sports Med 2014;42:463–71.
  9. Raeissadat SA, Rayegani SM, Hassanabadi H, Rahimi R, Sedighipour L, Rostami K. Is Platelet-rich plasma superior to whole blood in the management of chronic tennis elbow: one year randomized clinical trial. BMC Sports Sci Med Rehabil. 2014 Mar 18;6(1):12.
  10. Raeissadat SA, Sedighipour L, Rayegani SM, Bahrami MH, Bayat M, Rahimi R. Effect of Platelet-Rich Plasma (PRP) versus Autologous Whole Blood on Pain and Function improvement in Tennis Elbow: A Randomized Clinical Trial. Pain Res Treat. 2014;2014:191525. doi: 10.1155/2014/191525. Epub 2014 Jan 20.
  11. Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative Effectiveness of Injection Therapies in Lateral Epicondylitis: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2013 Jun;41(6):1435-46.
  12. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 Dec;68(12):1843-9. Epub 2008 Dec 3.
  13. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999;319:964-968.
  14. Smidt N, Lewis M, Van der Windt DA, Hay EM, Bouter LM, Croft P. Lateral epicondylitis in general practice: course and prognostic indicators of outcome. J Rheumatol. 2006;33:2053-2059.

Exercises to prevent sports injuries – lots of talk, but do they work?

20 Jul, 14 | by BJSM

Letter to the Editor

By Dr. Babette Pluim (@DocPluim)

In response to: Jeppe Bo LauersenDitte Marie Bertelsen, Lars Bo Andersen.

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trialsBJSM. 201448:11 871877 .

Strength training was the big winner in a recent BJSM systematic review and meta-analysis of Lauersen et al.1 The authors carefully quantified the preventive effect of several different forms of physical activity programs. They differentiated between the effect on acute and overuse injuries. Previous studies on musculoskeletal injuries, have focused on one particular intervention, one injury type or location, one specific sport, or were narrative reviews. This is a quantum step forward.

The field is relatively mature with 25 RCTs to study, including 26 610 participants with 3464 injuries. The studies were grouped into strength exercises, stretching exercises, proprioception exercises and multiple exposure studies.

Strength training was the most effective intervention and reduced sports injuries to less than one third (RR 0.315 (0.207-0.480). Proprioception exercises were also effective and reduced the number to almost half (RR 0.550 (0.347-0.869). Contrary to my expectations multiple exposure interventions were less effective (RR 0.655 (0.520-0.286) and stretching had no beneficial effect at all (RR 0.963 (0.846-1.095). Outcome analysis showed that both acute (RR 0.647 (0.502-0.836) and overuse injuries (RR 0.527 (0.373-0.746) could be reduced by preventative exercise programs.

exposure plot

Clinical implications

1. There is great potential in strength training — we should utilize this more. The results from the strength training studies were consistent, despite different programmes being used and despite different outcomes of interest, which points towards a strong generalisability of results. This means that many types of strength exercise have the potential to prevent many types of injuries.

2. Was it a nail in the coffin for stretching exercises? Stretching did not prevent injuries, whether done before or after training. However, this analysis included only two studies on army recruits and one internet-based study on the general population, so more data are badly wanted.2-4 Stretching may serve other purposes, and it may still be relevant for the upper extremity, but NOT for injury prevention of lower extremity exercises. It may be helpful in specific cases if there has been a previous injury. But today, there is no evidence supporting stretching for injury prevention.

It makes intuitive sense to combine several interventions to prevent all injuries, and I was therefore surprised that see that multiple intervention studies had smaller effect size that strength training or proprioception alone. However, the authors point out that each component may be reduced quantitatively or qualitatively by designing a program with an array of exposures (the proportion of effective interventions may be smaller, compliance may suffer etc). They therefore suggest these type of programs should be built from well-proven single exposures and they stress the importance of further research into single exposures.

The take home message for me as a sports physician is that I will take strengthening exercises to prevent injuries even more seriously than I already did:

– hip abduction, lunges, squats, step ups and step downs to prevent ACL injuries and anterior knee pain
– leg curls and Nordic hamstring exercise to prevent hamstring injuries
– proprioception exercises for the ankle (the ankle app!)5 to prevent ankle injuries

The recent data of Clarsen et al. on the shoulder are promising,6 and as a tennis doctor, I would love to see an RCT on the effect of external rotator cuff strengthening as a follow up to their cohort study :-).


Dr Babette Pluim is a Sports Physician with particular expertise in Tennis Medicine (Chief Medical officer – Netherlands. She is Deputy Editor of BJSM. Follow her on twitter @DocPluim


1. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2014:48:871-7.

2. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sports Med 2010;44:1002–9. LaBella CR, Huxford

3. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother 1998;44:65–72.

4. Pope RP, Herbert RD, Kirwan JD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000;32:271–7.

5. Verhagen E. Easy to use mobile app for ankle sprains prevention and rehabilitation.

6. Clarsen B, Bahr R, Andersson SH, et al. Reduced glenohumeral rotation, external rotation weakness and scapular dyskinesis are risk factors for shoulder injuries among elite male handball players: a prospective cohort study. Br J Sports Med 2014. Published Online First 19 June 2014.



Cape Town Medical 10, running race for health professionals

25 Mar, 13 | by Karim Khan

Hennie Muller and grandson

Letter to the Editor

The 35th staging of the Medical 10 will take place in Cape Town, South Africa, in November 2013. It is a 10 kilometre running race for health professionals. The race started in 1978 after a physician, Hennie Muller (shown in the photo with his grandson), discovered that the doctors in Finland held a 10 kilometer race to show that they practiced what the preached about a healthy lifestyle. The aim was to run it in 40 minutes but allowed a handicap of a minute for each year of age over 40.

Race organizers cut the handicap to half a minute and made it open to all health professionals and walkers, however, the event continues to be held annually at the end of November.

Is this race still held in Finland? Or are similar events held in any other country? I am interested to know.

Please contact me at:

Yours sincerely,

Sydney Cullis (Race Director)

Research in Stretching- A Letter to the Editor

16 Nov, 10 | by Karim Khan


I recently read the article Jamtvedt et al on whether pre and post stretching prevents injury (1) with interest. I commend the authors for their well-conducted study and would like to comment on two particular issues.

First, the authors correctly point out that there was no difference in the primary outcome of all injuries, and that the analysis showing an absolute 22% reduction in muscle, ligament and tendon injuries with stretching should be interpreted cautiously. However, they then continue to say “Nonetheless, it is plausible that stretching reduces muscle, ligament and tendon injuries, and it may be implausible that stretching increases other injuries”. Moreover, in the conclusion, they only mention the “probable reduction in muscle, ligament and tendon injuries” and omit the absence of an effect on the primary outcome of overall injuries. This type of thinking appears to be gaining popularity. For example, Small et al (cited by the current article) emphasized the decrease in musculotendinous injuries they observed in their review of stretching and discounted the associated increase in stress fractures and “shin splints” (2).

In other areas of medicine, we have already learned the difficult lesson that “all- cause mortality” is generally a much more important outcome compared to “disease- specific mortality” because interventions can cause damage through unrecognized mechanisms. It would be a pity if the sport medicine world has to go through the same lessons. Plausible reasons why stretching would increase some types of injuries are already available from a review of basic science evidence (3). Because Jamtvedt et al do not actually detail the non muscle-tendon-ligament injuries, I will use the example from Small et al. related to stress fractures and “shin splints” (not defined, but presumably periostitis and compartment syndrome). An acute bout of stretching causes weakness, (4) which is expected to lead to 1) an increased force transmission to the bone (5), (6), which would lead to increased stress reaction and stress fractures and 2) a possible increase in compensatory muscle use, which could theoretically cause shin splints of any cause. Further, stretching-induced weakness would theoretically also decrease proprioception, although this remains to be studied. Authors who decide to report sub-group analyses need to show the same analyses for all the sub-groups created by the categorization.

Second, “stretching” as an intervention is intricately related to the timing of the stretch, and one expects different results from stretching before exercise compared to stretching at other times (7). In their conclusion, Jamtvedt et al suggest that “the results of this trial support the decision to stretch” (1), with no mention of the timing; reviews by Small et al (2), and Thacker et al (8) (cited by the current article) made the same error. In brief, the effects of “stretching” are similar to those of “weight lifting”. An acute bout of weight lifting or stretching will cause an immediate decrease in strength, power and endurance 4. However, if one weight lifts or stretches for weeks, there is an increase in strength, power and endurance (4). Based on this, one would expect that stretching before every exercise session would increase the risk of injury due the acute effects, but there would also be an expected decrease in injury risk as the body adapts and strengthens over time. If the two effects were relatively balanced, one would expect no effect on overall injury rate. However, if one stretched regularly but not before exercise, then one would expect only the benefits, with a decrease in overall injury rate. Indeed, there have been three randomized trials prior to this study and a meta-analysis of these (one study had subjects stretch before and after exercise as in the current study (9)) suggests regular stretching not before exercise reduces injury risk [OR=0.68 (95%CI: 0.52, 0.88)] (7).

Given these previous studies, it would be interesting for the authors to conduct a post-hoc analysis (with the appropriate cautious interpretation) comparing the injury risk among those who stretched only before exercise, those that stretched only after exercise, and those that stretched both before and after exercise.

In summary, there should be little controversy about 1) post-exercise stretching reducing acute muscle soreness, just as it reduces any chronic musculoskeletal pain (10), presumably due to its well-studied effects on stretch-tolerance (a form of analgesia) (11, 12), and 2) stretching not before exercise reducing injury risk given that both basic science and clinical science provide consistent evidence, although a couple more confirmatory studies could be helpful.

Future research priorities should focus on questions where there is little to no evidence such as 1) whether post-exercise stretching is as beneficial as stretching at other times, 2) what are the effects for high intensity sports, 3) the effects of stretching on rehabilitation of injuries, and 4) the effects on the performance in injured athletes (all published studies examined healthy subjects) (13).

Ian Shrier MD, PhD, Dip Sport Med, FACSM Centre for Clinical Epidemiology and Community Studies SMBD-Jewish General Hospital 3755 Cote Ste-Catherine Rd Montreal, Qc H3T 1E2 Tel: 514-340-7563

Fax: 514-340-7564


1. Jamtvedt G, Herbert RD, Flottorp S, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. Br J Sports Med. 2010;44:1002-1009.

2. Small K, McNaughton L, Matthews M. A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury. Res Sports Med. 2008;16:213-231.

3. Shrier I. Does stretching help prevent injuries? In: MacAuley D, Best T, eds. Evidence-based sports medicine. London: BMJ Publishing Group; 2007.

4. Shrier I. Does stretching improve performance: A systematic and critical review of the literature. Clin J Sport Med. 2004;14:267-273.

5. Mizrahi J, Verbitsky O, Isakov E. Fatigue-related loading imbalance on the shank in running: a possible factor in stress fractures. Ann Biomed Eng. 2000;28:463- 469.

6. Christina KA, White SC, Gilchrist LA. Effect of localized muscle fatigue on vertical ground reaction forces and ankle joint motion during running. Hum Mov Sci. 2001;20:257-276.

7. Shrier I. Meta-analysis on preexercise stretching. Med Sci Sports Exerc. 2004;36:1832-1832.

8. Thacker SB, Gilchrist J, Stroup DF, et al. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc. 2004;36:371-378.

9. Amako M, Oda T, Masuoka K, et al. Effect of static stretching on prevention of injuries for military recruits. Mil Med. 2003;168:442-446.

10. Law RY, Harvey LA, Nicholas MK, et al. Stretch exercises increase tolerance to stretch in patients with chronic musculoskeletal pain: a randomized controlled trial. Phys Ther. 2009;89:1016-1026.

11. Magnusson SP, Simonsen EB, Aagaard P, et al. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Arch Phys Med Rehabil. 1996;77:373-378.

12. Halbertsma JPK, Mulder I, Goeken LNH, et al. Repeated passive stretching: acute effect on the passive muscle moment and extensibility of short hamstrings. Arch Phys Med Rehabil. 1999;80:407-414.

13. Shrier I. Stretching perspectives. Curr Sports Med Rep. 2005;4:237-238.

Letter to the Editor: Separating fatness from lack of fitness

14 Feb, 09 | by Karim Khan

pilates bjsm
By Sarmax.

In many practical situations such as the treatment of hypertension, it is important to determine whether an improvement of condition following exercise prescription is due to an increase in aerobic fitness, or whether it simply reflects a reduction in body fat content (1) A previous review of 61 studies of training-induced changes in resting blood pressure (2) concluded that any reduction in resting pressures could not be attributed to concomitant weight loss, since the changes in systolic and diastolic readings showed very small and statistically non-significant correlations with changes in body mass.

In their recent paper, Barrone et al. (1) wished to test whether the same was true of exercise hypertension, and in support of such a conclusion they claim to have demonstrated independent correlations of delta fitness and delta fat with changes of pressure through the use of generalized estimating equations. A variety of valid measures of body fatness were obtained on their subjects, but unfortunately an inappropriate measure of aerobic fitness was chosen for the analysis. The outcome is reported as a change in peak oxygen transport, expressed in ml/kg/min. This is dimensionally incorrect, but let us assume that the authors intended to indicate a relative change of oxygen transport, expressed in ml/[kg.min]. Aerobic fitness is in fact the overall ability of the cardio-respiratory system to transport litres of oxygen to the working tissues. Any accumulation of body fat reduces the utility of this transport in terms of daily activities (including treadmill running). To take a practical example, a man with a body mass of 70 kg and an aerobic fitness of 3.5 l/min has a relative VO2max of 50ml/[kg.min]. If that same person accumulates an extra 14 kg of body fat, the aerobic fitness may remain at 3.5 l/min. but the relative VO2max decreases to 41.7 ml/[kg.min]. Plainly, the relative units of oxygen transport confound the influence of fitness and fatness, and cannot be used to distinguish the importance of changes in fitness relative to changes in fatness.

The authors must have the data to make a more convincing independent analysis of the two variables, and I would encourage them to do so.


1. Barone BB, Wong N-Y, Bacher AC et al. Decreased exercise blood presure in older adults after exercise training: contributions of
increased fitness and decreased fatness. Br J Sports Med 2009; 43: 52-56.

2. Hagberg JM, Park J-J, Brown MD. The role of exercie training in the treatment of hypertension. An Update. Sports Med 2000; 30: 193-206.

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