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Considering psychological stress alongside training load – A reflection on the “How much is too much’” IOC Consensus Statement

8 Mar, 17 | by BJSM

By Pete Garbutt

I first read about the International Olympic Committee’s 2-part ‘How much is too much’’ Consensus Statement in BJSM 50(16/17), 2016 regarding injury and illness in athletes. It highlighted common roadblocks to athletic performance, and evidence informed insights to enhance the health of our athletic community. This was a landmark paper to shine light on a diverse and cumbersome topic, however it was clear that this IOC paper was targeted towards elite athletes. (Read the open access articles: part 1 HERE, and part 2 HERE).

Below are my reflections on psychological stress, otherwise known as psychological load – one of the less monitored issues raised in the IOC paper. I discuss how these ideals can fit amongst a modern SEM framework in an elite and non-elite setting. Psychological load or psychological distress is defined as ”the end result of factors eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with ‘significant others’ ”. This may impact on functioning and is likely to affect performance.

Loading and illness/injury

In the Consensus Statement, psychological load was discussed as one of the parameters in an athlete’s training load. Whilst not an entirely new concept, it is certainly one not often discussed. This is especially true outside an elite setting where a sports psychologist is becoming a more standard part of the team. Elite sport often includes daily measurement of psychological parameters with outcome measures such as Rate of Perceived Exhaustion (RPE) or forms such as the K10 for detecting anxiety and depression. This is to assess signs of early warning. The non-elite setting does not usually provide for this. Psychological stressors were noted as coming from a variety of external areas such as negative life events, daily stressors and sports related stress. It also covered internal variables such as personality type, anxiety, stress susceptibility and maladaptive coping strategies. These areas have been implicated in increasing athlete load, impacting areas such as timing and coordination, fatigue, muscle tension and immunity.

The conversation

The conversation surrounding psychological load and training, in elite and non-elite settings is one that needs to exist between three groups of people. The coaches, the athlete and the treating practitioners: physiotherapists, doctors, and other therapists. Without an openness to this topic, we close our eyes to a potential cause of injury.

Coaches program their training based on physiological factors in and around competition needs. They are experts on the physical requirements of the athlete within their sport, the technical and skill requirements of the sport, and the competitive mindset for achievement. It is important that the coach has a conversation with the athlete that creates an awareness of these off-field psychological loads which affect their training.

Although professional practitioners are often trained in Waddell’s biopsychosocial model, in my experience they often focus on the patho-anatomical side of injuries. They need to be cognisant of the impact of psychological load as a contributor to system overload in the first place, and as a confounder for return to play. The practitioner needs to instigate this discussion and this concept as they sort through the potential points of overload and initiators of breakdown in the system that results in injury.  If there is not a multidisciplinary team, including a sports psychologist, who are communicating between each other about the athlete’s welfare, such as exists in many elite settings, practitioners in private practice need to be this front line. Thus, for the non-elite athlete the conversation of psychological load ought to be held in the treatment room. It is also a conversation that must be monitored and maintained.

The athlete is the only person in this conversation that can make it work. Although in an elite setting psychological concerns may be attended to, it is especially important that non elite athletes are also aware of the importance of psychological load. The success of their training programs hinges on it. Giving them a safe, open environment to discuss these issues, and having them prepared to come to the table with this considered as part of their overall load, is essential. Only once the athlete understands psychological load and is engaged in this process can the potential outcomes be viable and useful.

Missed training and performance

Papers by the likes of Raysmith, Drew, Blanch and Gabbett demonstrate why it is so important to monitor and manage load. They show the usefulness of training smart so that trainings aren’t missed.

This research becomes an important part of our conversation with the elite and non elite athlete regarding psychological load. Notably, how it can tip the scales on injury and illness. This evidence is useful to reason with the competitive mindset of the athlete. Non elite populations additionally need to understand how crucial it is not to miss trainings. When injuries are reduced, we ultimately create better performance, and the competitive mindset is satisfied that taking the foot off the pedal can be a step forward.

Management strategies

The IOC papers focus very much on the elite end of sport. Here we see sophisticated monitoring of athlete well-being and suggestions on implementing resilience strategies and stress management skills.

For most coaches, docs, and therapists treating elite and non-elite athletes, the strategy is to consider psychological stress assessments, referral to a sports psychologist for the above, and/or have a discussion with the athlete, educating on importance of moderating training during times of increased psychological stress.

The first step to combating this silent injury risk is being aware, and having the conversation. It’s time that we all became a part of this conversation for not only our elite athletes, but our recreational athletes. The latter are quite possibly the most at risk due to their diminished support structure.

I hope that these thoughts have helped to raise the relevance of the IOC papers beyond elite sport and into private clinics and sports medicine practices around the world. Thank you to the BJSM blog team for letting me share my thoughts.


Pete Garbutt is in private practice at Enhance Healthcare in Canberra, Australia. With over 20 years of working with sports from indoor soccer to beach volleyball, pole dancing to water polo at all levels from local to international, Pete has a wealth of experience with managing sports injury and performance.Pete is the President of the International Sports Chiropractic Federation. In 2015 Pete was awarded a Fellowship with Sports Medicine Australia and Australian Chiropractor of the Year in 2016. You can follow him on Twitter (@Pete_Garbutt).


Raysmith B, Drew M, 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  Original Research Article. JSAMS 2016;19(10):778-783

Charlton P, Drew MK. Can we think about training loads differently? Canberra, Australia: Australian Institute of Sport; 2015

Schwellnus M, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. Br J Sports Med 2016;50:1043–1052

Soligard T, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury Br J Sports Med 2016;50:1030–1041

Definition “psychological distress”. McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc. URL: . Date accessed: 10/2/2017

Beyond Blue, Anxiety and depression checklist (K10). Date accessed 10/02/2016,


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

6 Mar, 17 | by BJSM

By Andy Rolls1, with contribution from Alan McCall

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


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


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


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

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

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

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


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

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

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

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

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


Corresponding author:

Andy Rolls, Arsenal Football Club,



World Sports PT Team Concept Conference in Las Vegas: much more than gambling!

24 Jan, 17 | by BJSM

By Mario Bizzini

The notorious slogan “What happens in Vegas stays in Vegas” certainly did not apply for the recent Team Concept Conference, which was held in the renowned resort city in Nevada, US. Please just re-live the Twitter buzz on #TCC2016 to get a feeling of three exciting days (December 1 to 3, 2017) when over >400 participants gathered at the Planet Hollywood Hotel.

For the 2nd time since 2012, this Sports PT congress was a joint cooperation between the Sports Physical Therapy Section (SPTS) of the American Association of Physical Therapy (APTA) and the International Federation of Sports Physical Therapy (IFSPT). SPTS dedicated the first day to a Golf Symposium with several US speakers such as Mike Voight, Lance Gill (both involved with the Titleist professional golfers), Russ Paine (former PT of the Houston Rockets) and Sue Falsone (the first women to hold an Head ATC/PT position in US professional sports with the LA Dodgers). These speakers provided excellent presentations of developments in testing and treating golfers; one clear innovation is the sophisticated biomechanical swing analysis systems now readily available.

Loading tissue for prevention and repair

The two main days of TCC featured several American and international speakers, covering lectures, debates and several courses & workshops. Karin Silbernagel (Sweden, and Delaware University, US) and Kristian Thorborg (Denmark) delivered an excellent overview on “Eccentrics or concentric exercise: is one better?” While Kristian illustrated the evidence behind the eccentric exercise to prevent and treat muscle injury (Nordic hamstring and Askling’s protocols), Karin stressed the importance to promote tendon healing (and reduce symptoms) by improving strength/endurance and function (using the different contraction types). Two particularly memorable quotes are: “Just handing out an eccentric exercise program is not appropriate” in tendinopathy, and it’s “time to focus on adjusting loading dose” individually to the specific tendon injury” (so Karin words).

ACL prevention – an uptake/compliance problem?

Holly Silvers (Santa Monica, US) and Mario Bizzini (Switzerland) summarized more than 20 years of research and dissemination of injury (focus on ACL) prevention (with programs as PEP, and 11+). The programs work! But we’d like to see more uptake by coaches. It seems the word has not reached all Sport PTs. Some audience members suggested that there may be a tendency for some clinicians to jump on “new” trends rather than to apply “old” evidence-based knowledge on injury prevention…

Return to play

Kevin Wilk (Birmingham, US), also among the authors of the BJSM Consensus paper on Return to Play, reinforced how the athlete who has been rehabilitated after ACL injury must be ready both physically and psychologically before returning to compete. The need to have valid/reliable sport specific (possibly also “position-specific” for team sports) is crucial, and there’s still “a long way to go on this”…

The former Wales Rugby professional player and now extreme environment athlete Richard Parks gave an inspirational talk on his rehab and training for extreme challenges. He also discussed his 15+ years work with his sports PT Nicola Phillips (Cardiff University, Wales, IFSPT President).

The last day of TCC saw a firework of stellar presentations in a special International Federation of Sports PT (IFSPT) Symposium “Return to Play” moderated by Mario Bizzini and based on the Bern 1st World Conference (2015) and on the BJSM Consensus paper published earlier this year.

It featured Nicola Phillips, Phil Glasgow (Northern Ireland), Clare Ardern (Australia, Sweden now), Kristian Thorborg , Karin Silbernagel  and Brandon Schmitt (US) in this together with Luciana de Michelis and Felipe Tadiello (Brazil), who were invited to present about the sport PT experiences at the Summer Olympics and Paralympics Games in Rio de Janeiro. This was the perfect occasion to welcome the Brazilian Sports PT Group (SONAFE) as the new Member Organization of IFSPT (Brazil being at the moment the only South American society among the 25 countries in IFSPT).

Clare Ardern underscored how much the mind matters in RTP, and that quality rehabilitation/training for an athlete should optimally comprise physical, psychological, social, tactical and technical aspects. Both questionnaires and performance tests should be evidence-based and relate to the athlete’s sports (the interdisciplinary cooperation with athletic trainers, coaches is therefore crucial). Kristian Thorborg highlighted-in his classical talk on RTP after groin injuries, that the “Copenhagen five-second squeeze test”, can add value in decision-making when dealing with athletes suffering from groin problems. (That paper was published online first in BJSM just a few days prior to TCC). Brandon Schmitt highlighted the lack of evidence for the use of MRI in the clinical exam of muscle injuries, and presented an interesting new approach in mapping the area of tenderness, which may help in determining the time to RTP after hamstring strain (this is an ongoing study at Scarsdale High School, NY).

These were just some pearls from #TCC2016, where interestingly –but not surprisingly-BJSM publications were often used as key references in several presentations. Maybe a Socrates citation (brought up by Kristian Thorborg) illustrates at best the spirit of this conference: “I cannot teach anybody anything, I only make them think”…

It has been a truly International Sports PT conference in Las Vegas, and yet another important step towards Belfast 2017, place of the 2nd World Congress of Sports Physical Therapy (October 6-7, 2017)!


Mario Bizzini, Zürich, Switzerland, IFSPT Executive Board Member, BJSM Deputy Editor


Return to Play – BJSM Virtual Conference

15 Jul, 16 | by BJSM

A monthly round-up of podcasts and articles

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

Can’t keep up with what the latest research on return-to-play is saying? Need direction on where to find all the up-to-date literature and podcasts? This is your place! We’ve put together the greatest and latest RTP work from BJSM into this Virtual Conference to create ease of access – you can read or listen to all material via clicking the links or downloading the BJSM app.

So if you’re on your summer holidays at the moment (or wishing you were!) then get stuck into all your RTP goodness here!

  1. 2016 Consensus statement on Return to Sport

First up – This is the big one. Brand new consensus statement on return to play or ‘return to sport’ (RTS) as is used in the paper. It contains discussion on the definition of RTS and proposes a framework that incorporates the StARRT 3 step model ( and the Biopsychosocial model with appropriate load management. Great stride forward for return to play!

RTP infographic

  1. Criteria based return to play. Psychological readiness. How? Whose call? With Clare Ardern

This podcast is a close sibling of the consensus statement above! Clare Ardern explains and answers questions in regard to how fear and anxiety can affect return to play and how we as clinicians can become desensitised to the psychological stresses on an athlete post injury. There is a specific ACL example used to illustrate how we can examine a player’s psychological readiness.

  1. To risk, or not to risk: the return to play dilemma, with Roald Bahr

Where is the traditional RTP model letting athletes down? How can we be more holistic in our approach? Prof Roald Bahr explains by focusing on physical deficits and the danger of not customising your rehab to individual sport/position requirements. Finally the discussion dives into why sport and health are sometimes opposing entities. Not to be missed!

  1. “I can’t return to play” – When fear of re-injury dominates after ACL reconstruction, with Adam Gledhill

Now let’s get sport specific. Adam Gledhill brings his knowledge of sport psychology (particularly among top female football players) to the forefront in discussing the ACL injury example of ‘Joanna’. We hear about specific tools that address psychological readiness and their application and success in real life! Best results achieved with combined reading of this paper

  1. MRI findings and return to play in football: Hamstring injuries

Big paper here. Prospective analysis of 255 hamstring injuries within elite football was completed by Jan Ekstrand et al. (2016). Some interesting findings! Combine with this podcast if possible!

  1. ACL injuries in men’s professional football: a 15 year prospective study

Another ACL source here. This time it’s the work of Markus Walden et al. 2016 with their paper on return to play rates after ACL injury. This is currently a very popular paper and shows the startling finding that only 65% of players still play top level football 3 years post rupture. Vital information here.

  1. The brain and mind in chronic pain, with Lorimer Moseley

And finally we’ll tie up all the above with some pain science from the master – Lorimer Moseley. It’s a BJSM classic. As discussed in all of the RTP work in this virtual conference, one cannot underestimate the factor of psychological readiness. You’ll hear how Lorimer proposes clinicians working in sport can use pain science to further inform their athletes.

So that’s it. Another virtual conference with all the ingredients to make a RTP soufflé. As always, let us know your thoughts via our various social media channels – Twitter (@BJSM_BMJ), Facebook (BJSM) and Google + ( We value and appreciate Feedback!


Zachary Spargo (@ZachSpargo) MSc Physiotherapist working within NHS Betsi Cadwaladr, BSc (Hons) Sport and Exercise Science. BJSM Editorial Team and ACPSEM member.

Zurück zum Sport nach Verletzungen an der unteren Extremität  

10 May, 16 | by BJSM

By Keller Matthias

Ob Freizeitsportler oder Profiathlet – nach einer Verletzung stellt sich dem Sportler immer die gleiche Fragen. “Wann kann ich wieder zurück zu meinem Sport?”

Auch für Therapeuten ist es schwierig, diese Frage klar zu beantworten. Es zeichnet sich aber ab, dass Tests, welche Funktionen prüfen und sportartspezifische Belastungen simulieren als Entscheidungshilfe für eine sichere Rückkehr zum Sport dienen (1,2). Um die richtigen Assessments zu wählen muss das Ziel des Patienten definiert werden. Neben den spezifischen Anforderungen einer Sportart spielt auch das angestrebte Leistungsniveau des Sportlers eine entscheidende Rolle. Die Post Injury-Pyramide soll dabei helfen das angestrebte Leistungsniveau eines verletzten Sportlers zu bestimmen. Gleichzeitig stellt es ein Stufensystem dar, welches zur Steuerung der Rehabilitation bis zur Wettkampffähigkeit eingesetzt werden kann (2,3).


Verschiedene Experten haben zum Thema “Zurück zum Sport” Begrifflichkeiten eingeführt. Eine einheitliche Darstellung existiert nicht. Grundsätzlich lassen sich die verwendeten Begrifflichkeiten hierarchisch als Pyramide darstellen (Abbildung 1).

Return to Activity

Unter “Return to Activity” versteht man das Wiedererlangen von Basisfunktionen oder grundlegenden Bewegungsmustern, wie beispielsweise dem Einbeinstand, einem Ausfallschritt oder einem Sprung. Das Beherrschen dieser Muster kann als minimale Voraussetzung für alle (dynamischen) Sportarten angesehen werden.

Return to Sport

Kann der Patient wieder beginnen sportartspezifisch zu trainieren, dann kann dies als “Return to Sport” bezeichnet werden. Dabei finden Teile des Trainings in der gewohnten Trainingsumgebung statt. Das volle Leistungsniveau ist noch nicht erreicht.

Return to Play

Als “Return to Play” bezeichnet man das Wiederlangen der vollen Sportfähigkeit. Der Athlet hat keine posttraumatischen Einschränkungen mehr und kann als gesund bezeichnet werden. In Teamsportarten bedeutet dies die uneingeschränkte Teilnahme am Mannschaftstraining.

Return to Competition

Wenn ein Sportler wieder über die gesamte Dauer oder den gesamten Umfang am Wettkampf teilnehmen kann, wird dies als “Return to Competition” bezeichnet. Ob der Athlet die physische und psychische Leistung erbringen kann um einem Wettkampf erfolgreich standzuhalten, obliegt meist der Entscheidung des Trainers oder des Trainerstabs.


german pyramid

Abbildung 1: Post Injury-Pyramide



  1. Keller M, Kotkowski P, Hochleitner E, Kurz E. Der Return to Activity Algorithmus für die untere Extremität – ein Fallbeispiel. manuelletherapie 2016; 20: 19–29
  1. Keller M, Kurz E, Schmidtlein O, Welsch G, Anders C. Interdisziplinäre Beurteilungskriterien für die Rehabilitation nach Verletzungen an der unteren Extremität: Ein funktionsbasierter Return-To-Activity Algorithmus. Sportverletzung Sportschaden 2016; 30 ( 01 ): 38-49
  1. Keller M, Kurz E. Zurück zum Pre Injury Level nach Verletzungen der unteren Extremität – eine Einteilung funktioneller Assessments. manuelletherapie 2016; 20: 16–18


Hamstring highlights from Arsenal FC SEMS March 2016 Conference

13 Apr, 16 | by BJSM

By Dr. Ronan Kearney (@KearneyRonan)

The Arsenal FC Sport and Exercise Medicine conference (FC SEMS) brought together world experts to advance the knowledge base in muscle injury prevention, treatment, rehabilitation, and return to play in football.

The topic of hamstring injury (HSI) featured strongly. Here are 6 ‘take home messages’ for sports and exercise medicine professionals.


  1. Mechanism of injury

Understanding the mechanism of action of the injury can help identify whether the HSI was obtained during sprinting or stretching. A more proximal HSI with tendon involvement generally means a longer return to play (RTP) for the injured athlete.

  1. Communication is key

Comprehensive communication between medical and coaching staff is vital to ensure the injuried athlete is managed appropriately. The player and manager should be informed of the risk of re-injury following a HSI. The risk of HSI re-injury is greater when there is intratendonis rather than musculotendinous involvement. Mode and methods of communication will differ depending on the managers preference, as eluded to by Dr. Nigel Jones, England Rugby Union Team Doctor. Dr. Jones also highlighted the important ability to adapt to the needs of the coaching staff.

  1. Importance of hamstring lengthening

Prof. Karim Khan highlighted recent evidence suggesting a faster RTP following acute HSI with a lengthening type hamstring rehabilitation programme (‘L’ protocol) rather than a conventional hamstring rehabilitation programme. The ‘L’ protocol as described by Carl Askling (1) involves three core hamstring lengthening exercises: ‘The Extender’, ‘The Diver’, and ‘The Glider’.

The benefits of lengthening the biceps femoris muscle fascicles (BF) were also mentioned by Dr. David Opar, who noted that short BF and weak knee flexion lead to an increased risk of HSI. Ultrasound estimation of BF length has potential for practical use in helping to identify high risk HSI players who would benefit from a hamstring lengthening programme. Or should hamstring lengthening programmes be advised to all players regardless of fascicle length? Nonetheless BF length is a modifiable risk factor in HSI.

  1. Do we really need MRI for hamstring injuries?

Shorter RTP times are noted in players with a normal MRI HSI than a HSI with abnormal findings on an MRI. The need for MRI in HSI is questionable, however it can be argued that the knowledge of a shorter estimated window of RTP could prove benficial to both player and team for both footballing and rehabilitative decision making. Interestingly during the conference a vote was running on the BJSM Plus Twitter page: “Hammy injury to star striker – MRI to determine RTP time? Would you?’ 66% of voters agree that they would get an MRI. Would you?

Prof. Khan mentioned a recent study considered controversial by some (2). The study suggests that MRI does not add value over and above patient history and clinical examination in predicting time to return to sport in acute HSI. Score of maximal pain at onset, forced to stop playing within 5 minutes of injury, length of palpable tenderness, and painful resisted knee flexion can account for 29% of a time to RTP prediciton following acute HIS whereas the addition of MRI only adds 2% to the prediciton. In the words of Dr. David Opar; “if the scan and other investigations are normal but the player still feels injured, then the player is injured.”

  1. The mind matters for RTP

Dr. Clare Ardern highlighted that readiness to RTP not only deals with physical and functional readiness but also encompasses psychological readiness (3) and suggested the Injury-Psychological Readiness to Return to Sport scale (I-PRRS) (4) as a potential simple to use measure of RTP readiness. Prof. Khan noted that physical readiness for RTP in HSI can be estimated using a simple yet effective Askling ‘H’ test (5)

  1. Training the skilled athlete

Mr. Shad Forsythe, head of performance at Arsenal FC, spoke passionately about the importance of player specific training where one-size-fits all really doesn’t fit-all as teams consist of mesomorphs, endomorphs and ectomorphs or ‘stubbies, chubbies, and beanpoles’. Maybe if this is taken into consideration we can reduce the incidence of HSI among elite football players from its 4% increase in recent times.


Dr. Ronan Kearney is a postgraduate M.Sc. Sport and Exercise Medicine student at Trinity College Dublin, Ireland. Ronan works with a number of sporting teams and is a senior house officer at the Sports Surgery Clinic, Dublin. Ronan will commence his General Practice specialty training in July with a view to Sport and Exercise Medicine specialisation.  (@KearneyRonan)


(1) Askling CM, Tengvar M, Tarassova O et al. Acute hamstring injuries in Swedish elite football: a prospective randomised controlled clinical trial comparing two rehabilitation protocols. Br J Sports Med 2014;48:532–539

(2) Wangensteen A, Almusa E, Boukarroum S et al. MRI does not add value over and above patient history and clinical examination in predicting time to return to sport in acute hamstring injury. Br J Sports Med 2015;0:1–10

(3) Ardern CL, Osterberg A, Tagesson S et al. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med 2014;0:1–8

(4) Glazer DD. Development and Preliminary Validation of the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Journal of Athletic Training. 2009;44(2):185-189.

(5) Askling CM, Nilsson J, Thorstensson A. A new hamstring test to complement the common clinical examination before return to sport after injury. Knee Surg Sports Traumatol Arthrosc 2010;18:1798–803.

Football Medicine Strategies: Return to Play Conference, major value for both seasoned SEM pros and students

31 Jan, 16 | by BJSM

Undergraduate perspective on Sports & Exercise Medicine – a BJSM blog

By Sean Carmody (@seancarmody1)

When will they be able to get back playing?”

..That is the question that the medical staff of football clubs attempt to answer most days of their working lives. The question may come from coaches, journalists, agents, supporters, club owners and most importantly, the affected players themselves.

The theme of this year’s Football Medicine Strategies Conference  is centered on identifying the factors determining a footballer’s successful Return to Play following injury. As such, the conference will benefit sports medicine personnel who want to give more accurate responses to the perennial question regarding the readiness of a player to return to competition.


The Queen Elizabeth II Conference Centre in London will once again play host to the Conference on the 9th to 11th of April. Last year over 2000 delegates attended from all over the world, representing some of the most famous clubs and influential organisations in football. The Conference is set to grow once again in 2016, maintaining its position as one of the world’s leading sports medicine events.

What can we expect from this year’s conference?

Since its first international event in 1992, Isokinetic have developed a reputation for presenting innovative and cutting-edge research at their annual conferences. Dr Alicia Tomkinson, a Clinical Fellow in Sports Medicine, believes one of the strengths of the Conference is “the opportunity to gain a snapshot of how multidisciplinary management works in elite sport”. This was particularly true of 2015’s event which saw the medical departments of Europe’s top clubs; Bayern Munich, Real Madrid, AC Milan, Juventus, Chelsea and Arsenal, describe in detail how they organise their sports medicine provision. Ted Caplan, a fourth year medical student at Bristol University singled that stream out for praise; “It was extremely inspiring to hear and learn from some of the world leaders in sport and exercise medicine”. Another particular highlight from last year’s conference was the constructive debate that took place between clinicians and researchers on the use of PRP during the rehabilitation process.

Isokinetic’s commitment to innovation and pushing the boundaries is set to continue this year with the programme featuring topics such as the role of regenerative medicine in RTP and psychological considerations in RTP. The Science of Football Summit on the third day of the conference will focus on athletic development in youth footballers, an important, but often overlooked population. Once more, there are world class speakers scheduled for each day of the conference.

What will students gain from attending?

Students can often feel intimidated by conference programmes, deeming that they lack the requisite knowledge to participate fully in the occasion. This certainly isn’t the case with FMSC, where 27% of the delegates in 2015 were students.

One of the key factors that attracts undergraduates to the Conference is the ability to meet potential mentors, as Liam Newton, a recent graduate in physiotherapy reflected; “The most valuable aspect of the conference was to network with the biggest and best names in sports medicine. Everyone was extremely approachable and encouraging of students”. Dr Liam West, who founded the Undergraduate Sport and Exercise Medicine Society (USEMS), agreed with that sentiment,  and emphasised how a chance meeting at the Football Medicine Strategies Confrence “may help students take their first step into working within football medicine either on a medical elective or more permanent basis”. Additionally, Dr West cites the unique learning opportunities, stating “the educational programme is unrivalled in terms of expertise and breadth of topics”.

Student Discount

After the impressive undergraduate turnout at last year’s conference, USEMS have again teamed up with Isokinetic to provide a significant discount to students looking to attend. The discount includes both days (Saturday and Sunday) plus FREE Monday SUMMIT for £150 (instead of the full price of £390). To register at this discounted price email Alexia Sotiropoulou – referencing ‘USEMS’.

To learn more about the conference and to register:

See you in London!


Dr. Sean Carmody is a junior doctor working in the South Thames deanery. He has built on his passion for SEM and is now one of the key players in the Undergraduate movement in SEM alongside the advocating of physical activity education for students.

Dr. Liam West  (@Liam_West) coordinates the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series.

If you would like to contribute to the “Undergraduate Perspective on Sports & Exercise Medicine” Blog Series please email LIAMWESTSEM@HOTMAIL.CO.UK for further information.

Return to Play 2015 (#RTP2015) conference highlights – part 2 of 2

6 Jan, 16 | by BJSM

By David McFall @DynamicSCT

Here is the second instalment of the exciting #RTP2015 highlights. In case you missed our first blog you can find it HERE. And let us remind you that you can view all the presentations HERE.

Theme Three (cont.) – #TimeHeals 

Linked to the last take-home point of #TimeHeals, and a main RTP issue, is atrophy. Nicola Maffiuletti explained how large, fast muscle fibres are the last to be recruited and are therefore hard to train during impairment, which in turn leads to their atrophy. He also outlined a number of ways to combat this during rehab:

  • Normalising sensory feedback
  • Brain activation
  • Muscle activation
  • Rapid activation

Part of normalising sensory feedback is to constantly surprise the nervous system with new and varying stimuli. However, we should be careful not to descend into ‘circus training’ with our athletes. Stephen Mutch described the difficulties of finding this balance whilst showing us some of the amazing movement patterns performed by his rugby players.

The points regarding muscle and rapid activation were interesting as a basic tenant of strength and conditioning programming is that the whole of the force-velocity curve needs to be trained. Yet despite this, how often can a therapist genuinely say that they cover both ends of the curve in their RTP plan?

doha prt 2 img1

Theme Four – #LoadManagement

doha prt 2 img 2Ben Clarsen (@BenClarsen) demonstrated that overuse injuries result from a fluctuating pattern of overload rather than a single event. Overuse injuries are often blamed on an internal (anatomical) or an external factor, but in many cases the reason is overloading and insufficient recovery between training sessions, leading to reduced resilience.

Again we come back to the equation Injury = Load>Capacity emphasised by Glasgow, Mutch and Shrier. Maurizio Fanchini provided a case study of a footballer recovering from Achilles tendon repair;  including easier periods in the program was necessary for recovery. Load management is a huge topic (see @TimGabbett) and the Theme for the 2nd International Congress in Sports Physiotherapy in Belfast October 2017. (@BJSM_BMJ is one way of getting first, and regular, conference updates).

To avoid making the same mistakes when returning to sport, many speakers agreed that it is crucial to involve coaches. Whilst medical staff tend to have a large say in regard to RTP, coaches are considered experts in sport specific movements and demands, and play a key role in designing a well-structured training programme. It is therefore important to involve coaches in the RTP decision, which loops us again to Phillip’s initial questioning of how the RTP decision is made and by whom.

Theme Five – #NoSingleRecipe

McGill University’s Professor Ian Shrier (who is also teaching a Massive Open Online Course, MOOC, google it!) spoke passionately about the need for RTP to be individualised for every athlete and that risk is counteracted by risk tolerance – with some people willing to accept greater risk than others. The risk they are willing to take can be affected by the rewards for deciding to play and the decision should never purely be based on medical factors. Dr Boris Gojanovic @DrSportSante showed a model of the interactions between the parties involved in the RTP decision.

doha part 2 image 3

One point that was agreed by all at the event was that the athlete has to be a central part of the RTP decision. The one exception to this rule is with a concussed athlete, who sometimes needs to be protected from him/herself, as pointed out by Tony Schneiders.

Theme Six – #MRI

One question athletes, coaches and clubs will ask as soon as there is an injury is how long will it take to RTP? Abstract award winner Arnlaug Wangensteen presented her paper on whether MRI helps in predicting time to RTP in hamstring injuries and the answer was a resounding no.


doha prt 2 last image

Professor Karim Khan (@BJSM_BMJ) facilitated the closing discussion. He re-emphasized 5 key questions that the conference consensus statement will address:

  • How does the clinician determine when the athlete is ready to RTP?
  • Is physical recovery alone enough for RTP?
  • What is ‘successful’ RTP?
  • What are the sports medicine clinician’s responsibilities within the team and to the athlete?
  • Should athletes even return to play?

The consensus statement is in progress under the guidance of Dr Clare Ardern (@Clare_Ardern) and Dr Mario Bizzini and (@SportfisioSwiss) will be published in BJSM in July 2016.

Save the dates (‘October’) for the 2017 2nd International Sports Physiotherapy Conference in Belfast.  To close, a huge thank you for such a great conference must be extended to the organising committee and particularly Mario Bizzini, Stephan Mayer and Nicolas Mathieu.


David McFall is a Sports Therapist working in Pforzheim, Germany. He can be contacted via Twitter: @DynamicSCT or e-mail:

2015 Return to Play Conference Highlights (there were so many this blog is part 1 of 2!)

7 Dec, 15 | by BJSM

By David McFall @DynamicSCT and Steffan Griffin @lifestylemedic

November’s Return to Play (#RTP2015) Conference in Bern, Switzerland, saw a stellar line-up of speakers engaging with >800 well-informed clinicians and researchers from over 50 countries. BJSM will publish a consensus statement in July 2016 ( and you can watch all the presentations here:!). In the meantime, here are highlights and talking points:

RTP image 1

Nicola Phillips from the IFSPT, opened the conference. She reported on a recent survey on aspects affecting the RTP decision, mainly based around Creighton et al’s (2010) model (#KeyReading). The survey looked at the perception and implementation of the RTP modifying factors and interestingly there were many differences according to both sport and country – especially in regard to who actually makes the RTP decision.

This talk set the scene for the conference; whilst each speaker would focus on a specific injury type, they would always relate to the general RTP setting, constantly coming back to Creighton’s model and Ian Shrier’s StARRT framework, from which many common themes emerged.RTP 2

Theme One – #TheMindMatters

Clare Ardern introduced the first of these common themes. She spoke about the RTP rates following an ACL injury and the crucial role that psychological factors play in a successful RTP. These points were reinforced by many others throughout the day. There were some stand-out quotes which made a huge impact on social media:

Havard Moksnes

  • “ACL training is long and boring. Doing it in a group and having fun provides a big psychological boost and better outcomes”
  • “We should be telling our returning athletes that ‘You are not patients anymore, now you have to become an athlete again’”

Ian Shrier @IanShrier

  • “Treat people, not injuries”

Robin Sadler

  • “Injured players need a lot of support, we need to ‘HU-MANage’ the situation”

Mary Lundberg

  • “Pain related fear affects physical performance”
  • “Be careful with what we say and how we say it”

One of the most salient points of the day was the demonstration of the ACL_RSI questionnaire, available as an iOS app for easy clinical implementation, which can be used to quantify psychological readiness to RTP.

Theme Two – #NoSingleTest

Mark de Carlo demonstrated a criterion based RTP progression, and provided example time frames for when criteria can expect to be met. The topic of performance criteria and testing was expanded on by the following speakers.

6 pack RTP 3Both Witvrouw and Moksnes argued that no single test can determine RTP but rather we need to use a battery of tests. Symmetry in testing between the injured and uninjured side was an oft-quoted return criteria, usually with a 90% threshold, but as mentioned by Ardern & Ann Cools – where are the symmetry figures for non-injured athletes? Benchmarking against others of a similar age, level etc. is useful, but do we have valid/reliable measurement tools for this?

RTP 4When symmetry is reached there is a further point to consider, that in many cases the pre-injury level of coordination/endurance/strength/skill was not good enough – the athlete got injured. We therefore need to return them to sport better than they were and closer to what could be considered appropriate/above their level of participation. Similar points were made by Phil Glasgow, Stephen Mutch and Ian Shrier: injury occurs when load is greater than capacity and that we therefore need to improve an athlete’s load tolerance to reduce their injury risk. However, as Mutch showed in his entertaining videos sport can be highly unpredictable, so how do we train for these complex, reactive and often unforeseeable movement patterns?

Theme Three – #TimeHeals

rtp 5We heard a lot about various RTP criteria over the course of the conference but Erik Witvrouw also importantly commented that we must not forget the issue of time, and that tissues need time to heal. He showed scans that demonstrated that knee cartilage was incompletely healed at RTP following an ACL injury. To reinforce this point, Mosksnes stated that from 6-9 months post ACL injury, the risk of re-injury is reduced by 24% for every month RTP is delayed. Similarly, Wagensteen (more on her in part 2!) presented evidence that 50% of hamstring re-injuries occur within 25 days of RTP. So even though the pressures may be enormous, delaying RTP and providing some time for further healing may be worth it in the long run!

Keep your eyes out for Part 2 in the next few weeks. For further highlights, you can see the tweets from the conference by Twitter-searching #RTP2015


David McFall is a Sports Therapist working in Pforzheim, Germany. He specialises in strength and conditioning as part of the RTP process and also provides competition/pitch-side support to teams and events. David has worked with professional rugby since 2006 and is a World Rugby certified Medical Educator. He can be contacted via Twitter: @DynamicSCT or e-mail:

Hamstring Rehabilitation: Criteria based progression protocol and clinical predictors for return to play

22 Nov, 15 | by BJSM

By Nicol van Dyk, Physiotherapist, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital and;

Rod Whiteley, Assistant Director, Rehabilitation Department, Aspetar Orthopaedic and Sports Medicine Hospital


(presented at the ASICS Sports Medicine Australia conference 2015 – find all the slides here)

“It’s tough to make predictions, especially about the future.” Yogi Berra

It is still one of the most difficult questions clinicians have to answer: “When can I play again?”  Not only the player, but also the coach and/or family members will push you for an answer.  And then we all rub our crystal ball, get out the magic wand, and give them something we feel is sort of close to the mark.  But in reality, we still have very little on which to base our predictions.  Most of the time we’re guessing.  (Educated guessing maybe, but guessing nonetheless.) But before that happens, we first have to get them through the rehab.  Rehabilitation has moved away from time, and grown into criteria-based progression – the paradigm has begun to shift.

There are many excellent rehabilitation protocols of course, and you can find some of them in landmark papers such as Sherry and Best 2004.  Reurink et al published an updated SR investigating different interventions for hamstring strain injury rehabilitation. Not wanting to be left out, we developed a hamstring rehabilitation protocol at the Aspetar Orthopaedic and Sports Medicine Hospital, based on available literature and clinical experience (that magic combination that doesn’t always like each other, but oh how sweet when they do).  Our initial assessment and treatment includes elements that will form part of most protocols.  So I will focus on three critical elements that we were able to identify:

  • The most important measurement is strength, especially outer range strength
  • A running progression protocol that includes volume, intensity, mechanics, and is sport specific
  • Criteria based progression between different stages in the rehabilitation

First things first – measure the strength.

With the use of standardized measurement procedure using hand held dynamometers, we measure inner, mid, and outer range strength of the injured and uninjured hamstring muscles.  The most valuable measurement has been the outer range strength, as this has tracked well with return to play.  In other words, by the time the player was discharged, he had regained his outer range strength fully when compared to the uninjured side.  Mid-range strength was also tracking well, while inner range strength normalized much more quickly – often as fast as a few days, so it was less helpful to measure if your aim was to get a “progress bar” for this athlete’s rehabilitation. (Video of how to do this testing).  We were fortunate to see patients 5 days a week, but if that is not possible, use the outer range strength measurement to keep track of the progression.

figure 1 hamstring 15.11.18
In our experience, nearly all of the hamstring injuries were due to running. If you see dancers (and maybe martial artists) you probably need to take our advice with a grain of salt. We agree with Askling that stretch type injuries are a different beast, but we can’t help you there as we really hardly ever see these. However for our patients, all rehab protocols must include running. Specifically, running as close as you can get to what would be required of the player and their sport.  At our facility, players would typically run from stage 2 and run 3 sets of 4 laps on an indoor track (8 “sprints”) approximating 700m.  We asked the player to rate their running on a scale from  0-100%, and timed their running.  This was also an excellent way to keep track of their progression (another great tip if you don’t have running facilities or can’t see your patient daily).  Finally, in stage 3 we included direction changes by modifying the T-drill a bit (in our version, keep running forwards, but with direction changes to run around the markers).

Modified T-drill to facilitate direction change

Modified T-drill to facilitate direction change

When the player was able to run at 100%, and do direction changes at 100%, he/she was allowed to go out on the field and perform sport specific rehabilitation with our sports rehabilitators.  After they successfully complete 3 sessions, each one harder than the last, we performed some discharge tests (including isokinetic testing) and recommendations to the club to allow a gradual return to play.

Here is our criteria based progression algorithm:

hamstring figure 3 11.18

And now, the magic question – when are they ready?  Considering the outcome reported in the literature, it varies considerably.  One thing we do know is that MRI parameters cannot help us to determine return to play, and adds no value above our clinical assessment.  See this article by Arnlaug Wangensteen, who has contributed enormously to our rehabilitation programme.

So why is the outcome for return to sport so variable? Here’s a thought – perhaps because everyone is employing “conventional rehab” for their control groups, but no one knows what that is?  In a soon to be published article in BJSM by Philipp Jacobsen, with some excellent work by co-author Rod Whiteley, they have investigated the things that we measure, and found some clinical predictors of return to play.  So you will have to wait for the full length version to appear in an upcoming addition of BJSM, but here is the teaser:

Using a regression analysis, a combination of features you can easily measure in your clinical examination on day 1 and day 7 the week 1 examination could predict return to play within a 10 day window, explaining 97% of the variance!  And here are the more important parameters to look out for:

  • Length of pain on palpation
  • Single leg bridge
  • Hamstring strength (compared to the uninjured side) and whether it is painful or not
  • Change in outer range strength over the week

Now, the data is over-fitted (which means it is too good to be true, and won’t stand up when they finish their replication study that’s nearly half way done), but even with that said, how good is a 10 day window?  The coach, the player, the media – they want to know if the player will be ready for the final, and maybe now we can be confident ± 5 days.  That is a pretty specific time point, and the reality is, even when I am using an equation set up to win, the best I can do is “Uh, yes, plus or minus 5 days.”  Is that good enough? I have a sneaky suspicion that it will still not satisfy.  But for now, it’s the best we can do!

So the next time you’re faced with the all impossible question, perhaps you have some better answers.  Not easy answers, but we can say it will take about 3 weeks (give or take 5 days); we have a really good rehabilitation plan, which is measuring what you can do and your progression is based on that; and we will keep track of your progression based on what you need to return to play.

That’s probably as good as it gets!


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