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Highlights from The Barefoot Medicine Clinic

19 Mar, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine

By Rory Heath, Bethany Koh, Vera Wong and Anant Shah.

Two expert speakers were recently in session at the Barefoot Running Clinic, hosted by the London Sports and Exercise Medicine Society (LSEMS):

  • Mr Ioan Tudur-Jones, consultant foot and ankle surgeon at the Fortius Clinic, and;
  • Mr Ben Le Vesconte, a running technique specialist.

‘Barefoot’, or ‘minimalist’ running describes a step away from heavily padded conventional sports shoes, to wearing either a minimally supportive shoe, or no shoe at all!

It was a true multidisciplinary meeting, with medical students, doctors, physiotherapists and podiatrists from all universities London-wide. The fantastic talks were followed by diverse and lively discussion. Here are the learning points that we took away!

  • Humans evolved as “hunter-gatherers” who spent a lot of time on their feet, moving about. Mr Ben Le Vesconte suggested that standing, walking, running, and squatting are natural movement patterns of Homo Sapiens. Today’s society places us in unnatural habitats that encourage sedentary lifestyles, far removing us from these natural movements. We were not made to sit around on our bums all day!

GET ACTIVE!

  • We commonly promote the myriad health benefits of physical activity, however, it is important to consider that exercise may incur injury risk. Running is popular, but is associated with high rates of lower limb injury – 70% of runners are injured each year1!
  • One study of 54 competitive cross country runners at Harvard who ran a weekly average of 40-15 miles reported that runners who “heel strike” (land on their heels) were shown to have over double the amount of lower limb mild-moderate repetitive stress injuries vs runners who landed on their forefoot2.
  • Despite attempts by the running shoe industry to reduce injury, rates remain high. Daroud’s paper suggests cushioned shoes alter the biomechanics in the ankle, knee and hip joints, as well as encourage a heel-strike, therefore encouraging injury2.

Is it technique, footwear and improper loading that contributes to our large injury burden? We should be wary of this when prescribing activity to patients.

  • Leonardo da Vinci said ‘The human foot is a masterpiece of engineering and a work of art’. There are 200,000 nerve endings, and lots of muscles in the foot. Our curriculums rarely encourage us to learn the intricacies of our pedal anatomy. We think that to appreciate its complexity and function, we must look at it as a whole (as we do with any other part of the body!).
  • Most people only notice the long ‘extrinsic’ muscles because they provide power, propelling the foot forwards. Although it is easy to overlook the smaller ‘intrinsic’ muscles, they control the fine motor movements of the toes and joints. A small study of 20 experienced runners suggested that runners with plantar fasciitis have significantly smaller muscles in the rear of their feet in comparison to runners without the same pathology3.

Both speakers suggested actively training the intrinsic muscles for optimum function and performance.

  • Some research has shown that barefoot running may actually increase the incidence of injury4. Our event speculated this is due to poor transition from a rear-foot to fore-foot strike, due to inadequate education, improper technique or excessive and rapid loading of deconditioned tissues.

Coaching and follow up is key to ensuring a smooth transition.

Although both talks supported barefoot running, the discussion included varied opinions from both sides of the argument. Our main take-away is that the heart of barefoot running respects the ‘intended’ biomechanics and anatomy of the foot. It can offer benefits to individuals who are appropriately conditioned or can safely transition to a new running technique. It might not be for everyone; our sedentary modern world has shaped our bodies, making a switch to barefoot running difficult for some, and possibly dangerous if done rapidly. It is, however, an option to consider for those wishing to explore how to return their feet to their natural form, and run the way we were meant to run.

To hear more on this topic from Mr Ioan Tudur-Jones and learn more about the Fortius Clinic have a listen to this fantastic podcast conducted by Anant Shah (LSEMS Secretary)!

************************

Written by Rory Heath (@roryjheath), Bethany Koh (@bethanykoh) and Vera Wong. Podcast recorded by Anant Shah and Mr Ioan Tudur Jones, at the Fortius Clinic, London.

Find the London Sports and Exercise Medicine on Facebook and Twitter!

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee and Co-President of Birmingham University Sports and Exercise Medicine Society (BUSEMS).

References

 

  1. Van Gent RN, Siem D, Van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sport Med. 2007;41:469-480. doi:10.1136/bjsm.2006.033548.
  2. DAOUD AI, GEISSLER GJ, WANG F, SARETSKY J, DAOUD YA, LIEBERMAN DE. Foot Strike and Injury Rates in Endurance Runners. Med Sci Sport Exerc. 2012;44(7):1325-1334. doi:10.1249/MSS.0b013e3182465115.
  3. Cheung RTH, Sze LKY, Mok NW, Ng GYF. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport. 2016;19(9):713-715. doi:10.1016/j.jsams.2015.11.004.
  4. Ryan M, Elashi M, Newsham-West R, Taunton J. Examining injury risk and pain perception in runners using minimalist footwear. Br J Sports Med. 2014;48(16):1257-1262. doi:10.1136/bjsports-2012-092061.

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

27 Dec, 16 | by BJSM

By James Montgomery

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

Dear Dr. Gabbett,

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

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

silversea-cruises-australia-stewart-island-new-zealand-468x270

Stewart Island, NZ

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

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

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

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

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

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

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

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

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

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

acute-chronig

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

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

Yours sincerely,

James Montgomery @gardensphysio

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

*********************

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

E-mail: james.physio@gardenshealth.co.nz

 

Training error and achilles pain

29 Jul, 16 | by BJSM

Association of Chartered Physiotherapists in Sport and Exercise Medicine blog series @PhysiosinSport

By Tom Goom @TomGoom, Sports Physiotherapist at the Physio Rooms and the creator of Running Physio; lead on Running Repairs Course  http://www.running-physio.com/running-repairs-course/

Achilles tendinopathy is a common problem among runners and can be a challenge to manage. As clinicians, we want to help the patient find a balance between the load being applied to the tissue and its capacity to manage this load. This blog is the first in a series that will examine key factors in achieving this balance by assessing and modifying tissue load and increasing load capacity, and offer PRACTICAL applications of knowledge. We are, of course, more than just tissues being loaded and we have to keep the person at the very centre of a biopsychosocial approach. In this case that person will be Al…

Meet Al.

He’ll be joining us as the key figure in a multi-part blog series on managing achilles tendinopathy in runners. Al is a runner with a sore achilles. He will be our case-study to address all aspects of tendinopathy within a biopsychosocial approach. This first blog is about what training errors may have lead to Al’s symptoms. We’d like readers to join in and share their thoughts about it by tweeting @BJSM_BMJ and @physiosinsport using the hashtag #AchillesAl.

A bit more about #AchillesAl

Before we delve in, let’s learn a bit more about Al. Al is 49 year old runner with a 2 month history of right mid-portion achilles pain. He runs an IT company, is married with 2 teenage children and is generally fit and well. His main goal is to complete a marathon in 5 months time in under 3 hours and 30 minutes. His current PB is 3:36 and he’s determined to beat this before he turns 50 next summer!

He reports a gradual onset of achilles pain that began as a niggle then progressed over a couple of weeks to become swollen and painful. It has settled somewhat since, but hurts at the start of a run and then flares-up the following morning if he’s ‘overdone it’. He doesn’t usually get pain with activities of daily living, unless his symptoms have already been aggravated by a run.

Subjective history and objective examination leads to a diagnosis of right mid-portion achilles tendinopathy. Which leads us to an important question:

What factors/conditions have caused this to develop?…

Research suggests 60-70% of running injury occurs as a result of training error. It’s important to identify which training errors may have led to an injury so a runner can learn how to adjust their training to prevent a recurrence. The best way to do this is to get a thorough overview of a runner’s training structure and how it’s changed in the lead up to the injury. Particularly important is to identify relevant change. By this we mean changes to the training that would influence the load on the injured tissue or its capacity to manage that load.

Subjective history is vital in identifying training errors. There’s no recipe to this but it typically involves looking at weekly training structure,examining longer term changes (depending on chronicity of symptoms) and hunting, delving and exploring to see what’s changed!

Al’s a very modern runner. At a touch of a button he sends you his typically weekly training schedule;

image1 goom

What are your thoughts? Can you see any training errors that might be relevant?

This snapshot it useful but doesn’t tell you the whole picture so Al shares his training schedule in the weeks just prior to the onset of his pain;

image 2 goom

What do you think? Any relevant change that might have increased achilles load? Let us know on #AchillesAL.

So we have an overview but there’s still more to know! We need to hunt out those extra, key bits of information. A good subjective isn’t a box ticking exercise to ask pre-determined questions, it’s an exploration of a patient’s personal insights to see where it leads you.

We asked Al, “anything else that’s changed during this time? Did your type of training change, did you change your running surface?”

Al replies, “I’ve been pushing a bit harder to improve my pace and I also switched all my training to the treadmill a couple of weeks before it got really sore as the weather was shocking!”

We’re starting to see a couple of reasons how Al’s achilles may have become overloaded and sore but there’s another piece or two left in this puzzle! We know Al’s goal, a sub 3:30 marathon, we can use this to approximate what Al’s running pace should be at each training session. Al may have this information if he’s following a structured plan. However, questioning him further he says his training plan was provided by a friend and doesn’t have those details.

This final step is tricky. For many of us we might need some help approximating training intensity, we might feel it’s outside of our role. In an ideal world we’d work within an integrated, multi-disciplinary team and ask a running coach to help. Sadly for a lot of clinicians we can become quite isolated in clinics and may not have access to this.

**Action point** look to connect with local running coaches in your area to facilitate MDT working

If you feel confident to delve a little further there are some good online resources that can help. The Macmillan Calculator can be a useful tool. If we put Al’s goal time and a recent race time in to the calculator it gives us some approximations of his training paces;

  • Speed session: 400 metre intervals ~ 1:34 – 1:39, 800 metre intervals ~ 3:17 – 3:27 (i.e. Run an 800m interval in between 3 mins 17 secs and 3 mins 27 secs)
  • Tempo run: 7:21 – 7:37 minutes per mile
  • Easy run: 8:10 – 9:11 minutes per mile
  • Long slow run: 8:15 – 9:32 minutes per mile

We can then compare that to Al’s schedule;

image 3 goom

With all the information to hand, what training errors can you see and how might they affect the achilles?Share your thoughts by tweeting@physiosinsport and @BJSM-BMJ on hashtag #AchillesAl.

Once you’ve given it some consideration scroll down, past the humorous ‘error in loading’ image below to see our conclusions…

Al’s case is interesting because if all you knew was his training basics (e.g. how many times a week he runs, how far and on what days) it’s unlikely we’d identify the key training errors. His training volume (how much he does) is at a normal level for him and only increases very slightly from week to week (approximately 5%). His training frequency (5 sessions per week) remains constant. It’s only when we explore training intensity, pace and type that following the ‘training errors’ appear;

  1. Training structure – too much speed work
  2. Long runs are too fast
  3. Rapid change in training type – addition of treadmill
  4. ‘Failure to adapt’

Research by Stephen Seiler suggests that endurance athletes should do roughly 80% of their training at low intensity. Indeed even the world’s best distance runners do a lot of slow running in their training. Typically a marathon training schedule for a recreational athlete involves 1 speed session per week. Al has replaced a recovery run with a second speed session and not adapted his other training to accommodate this so his schedule now includes too much high intensity work.

When we examine the pace of each run in detail we see his speed sessions are at about the right pace, e.g. 800 metre intervals in around 3:25 which is well within his target pace of 3:17 to 3:27. His tempo runs are also on target, at around 7:25 to 7:35 minutes per mile. Al’s running a little fast during his easy runs at 7:50 minutes per mile when he should be 8:10 to 9:11.

The biggest issue though appears to be his long, slow run. Al should be doing these slowly according to his plan. His target is 8:15 to 9:32 minutes per mile and typically these runs are around a minute per mile slower than race pace. Al has been doing these at race pace (~8:00 per mile) in an attempt to improve his time. Some coaches recommend doing long runs close to race pace but you need to ensure your body is coping with it and strike the right balance between pushing performance and increasing injury risk. That makes the ‘failure to adapt‘ training error particularly pertinent; if you’re pushing yourself hard you need to monitor how well your body is coping and adapt your training if you start to struggle or you get pain. Al ignored his pain and barely changed his schedule until it reached a point where he couldn’t run.

Thoughts from the MDT

I asked my go to guy for training advice, Exercise Physiologist John Feeney from Pure Sports Performance for his views on Al’s training;

“From a coaching point of view, I don’t think I would ever advocate doing a ‘long run’ at race pace unless it was part of the athlete’s periodised training plan – i.e. a race pace half marathon as part of a marathon training plan. I always have trouble trying to get athletes to slow down during their long, aerobic runs. Its perhaps more a question of educating the athletes about the benefits of the long, slow runs so they don’t take them for granted and appreciate that these should be exactly what they say on the tin…..long and slow!

The need to look at the intensity of training is crucial as this will impact on the overall training load for that session. I have no problem in incorporating 2 HIT sessions for athletes (even novice athletes) in a periodised training plan. Whilst this will lead to short-term fatigue and overreaching, it often results in high levels of adaptation and super-compensation. However, having said that these twice weekly sessions are well controlled, separated by at least 48 hours and form part of a 4-6 week training block, which itself is part of the periodised programme. The overall training load across a week tends to remain the same as other sessions are adapted accordingly.”

How does this influence the achilles?

When identifying training error it’s important to try to reason through how it might influence the load on the injured tissue. Neilsen et al. (2013)reported that injuries to the achilles, calf and plantar fascia are more likely to occur with an increase in training pace (rather than volume). Hamner et al. (2010) found the calf complex to be the greatest contributor to propulsion and load on the gastrocnemius, soleus and achilles tendon increases as we increase running speed (Schache et al. 2014). Some runners will move towards a more forefoot strike as they accelerate (Forrester and Townend 2015) and this has been found to increase achilles load (Almonroeder et al. 2013).

It follows then that the load on Al’s achilles is likely to increase if he increases training intensity. This isn’t necessarily an issue unless the increase is too rapid and excedes Al’s load capacity. Perhaps it might not have done until he added another variable into the mix…

Recent research by Rich Willy et al. (2016) compared overground and treadmill running and found peak achilles tendon force was 12.5% greater on the treadmill. The rapid introduction of treadmill running in addition to increased training intensity may well have tipped the balance and overloaded the tendon.

It’s important to discuss these findings with Al and explain how we think his training may have caused his achilles pain……Al takes on the key messages but, understandably, has some questions…

“What training should I be doing now then?”

“How could I modify it to help my achilles?”

Over to you guys…what do you think? What else might you want to know from Al?

Tweet your answers to @physiosinsport and @BJSM_BMJ on hashtag #AchillesAl and we’ll feature the best suggestions in part 2!…

*********************************************

Tom Goom @tomgoom, is a Sports Physiotherapist, Physio @thephysiorooms, creator of Running Physio and lead on Running Repairs Cours http://www.running-physio.com/running-repairs-course/

Distance Running Part II: Landmark Research Projects and Science-Based Books

7 May, 16 | by BJSM

By Phillip B. Sparling

In part I of my retrospective, I featured pioneer researchers in distance running. In part II, I’ll first flashback to two notable projects on elite runners, and then share thoughts about books on the science of running.

Men's_Study_1975 (1)

40 Years Ago – Elite Men’s Project: In 1975, Michael Pollock, director of the Institute for Aerobics Research in Dallas, Texas, led a group of researchers in a multi-day study of 20 elite distance runners. Frank Shorter and Steve Prefontaine led the all-star ensemble of the best runners in America. Previous research had been limited by a small number of test variables or few subjects. This project was unique in incorporating a research team, a large sample and a more comprehensive test battery administered by experts in different domains: for example, muscle biopsies and fiber typing by David Costill (Ball State University), biomechanical analysis by Peter Cavanagh (Penn State University), psychological characterization by William Morgan (University of Wisconsin), and cardiorespiratory, metabolic and body composition measures by M. Pollock. The next year (1976) in New York City, findings from this project along with a host of other papers by notable investigators from far and wide were presented at a conference on the marathon runner. Sponsored by the New York Academy of Sciences, the published proceedings, a large volume at over 1,000 pages, has become a classic reference (1).

Dallas_study

Caption: Elite Men’s Study, Dallas, 1975. Back row, from left to right – Michael Pollock, Kenny Moore, Steve Prefontaine; Kenneth Cooper is at far right. Front row – Frank Shorter is at far right.

30 Years Ago – Elite Women’s Project: In 1985, I organized a study on elite women distance runners modeled after the 1975 study on men. My friend Russ Pate (University of South Carolina) was co-director of the project. Interestingly, as a 2:15 marathoner, he had been a subject in the men’s study. Key investigators from the project a decade before – Drs. Cavanagh, Costill, Morgan, and Pollock – joined us at Georgia Tech in Atlanta for 3 days of testing. Among our elite group of women runners (n=16), Canadian Jacqueline Gareau and Brit Priscilla Welch, both marathoners, were perhaps the best known. Three of the athletes were 1984 Olympians, 6 were USA national champions, and all were nationally ranked (top-10). At the time of this study, it had been 13 years since the passage of Title IX and the Boston Marathon’s acceptance of women competitors, and one year since the first Olympic Marathon for women. Papers from this project were published as a set in a special issue of the International Journal of Sports Medicine (2). Many papers from the 1975 and 1985 projects allow direct comparisons between measurements in elite men and women as well as with those of good runners (well-trained men and women but not elite) (see examples, 3-14).

Women's_Study_1985

Looking Back, Moving Forward: Many people beyond those mentioned – other researchers, clinicians, graduate students, lab assistants and support staff – were instrumental in making these multidisciplinary projects possible. The primary scientists who formed the core teams went on to conduct research in other areas. Except for Michael Pollock who died in 1998, the main players are still around. Our experiences during these projects were uplifting and rewarding. With a synergy among investigators and with the runners, it was a special opportunity to combine passion, curiosity and science in the quest to learn more about distance running. Olympic marathoner and journalist Kenny Moore recounted his experiences as a subject in the Dallas study in a Sports Illustrated article (15). Findings from the women’s project, along with studies of researchers worldwide, clearly dispelled the lingering notion that “the fairer sex” is unsuited to the rigors of strenuous training and intense competition. Mary Decker (Slaney), Grete Waitz, Joan Benoit and their contemporaries blazed the trail; scientists simply confirmed their capabilities. Investigators today – using research tools from molecular biology, genomics and neuroscience – continue to probe deeper. The search continues to better understand what combinations of factors contribute to the success of the world’s best distance runners.

HowTheyTrain

Applying the Science: Introspective and analytical, distance runners have always sought answers. A half-century ago, athletes and coaches were primarily empiricists. In 1959, Fred Wilt published How They Train, a detailed compilation of training programs of the world’s best distance runners. Updated and retitled Run, Run, Run in 1964, his books set a new standard. A two-time Olympian (1948, 1952), Sullivan Award Winner, and prominent coach, he believed runners should study widely and through careful trial and error determine what training suits them individually. Today, after decades of research studies, an ongoing question is: What can science tell us about how to train better and run faster? Translating research findings into sound, practical advice, a seemingly simple task, is in fact difficult. Many books have tried to fill the gap but few have met the mark with lasting success. Among the top-tier books of perhaps a dozen in the USA, I’ll mention three: The Lore of Running by Tim Noakes (16), Daniels’ Running Formula by Jack Daniels (17), and Running Science by Owen Anderson (18). These authors, all venerated authorities, share an uncommon blend of attributes. Each is a highly-regarded scientist, accomplished athlete, sought-after coach/adviser, and superb writer for professional and general audiences alike. These books connect the dots between science, training and performance, with sage advice and fascinating stories of runners and races.

*************************

Phil Sparling is a Professor Emeritus of applied physiology at the Georgia Institute of Technology (Georgia Tech) in Atlanta, Georgia, USA. Decades ago he was a competitive distance runner and marathoner. He still runs several days a week. phil.sparling@gatech.edu

References

(1) Milvy P (ed) The Marathon: Physiological, Medical, Epidemiological, and Psychological Studies. Ann NY Acad Sci 301: 1–1046, 1977 http://onlinelibrary.wiley.com/doi/10.1111/nyas.1977.301.issue-1/issuetoc

(2) Sparling PB (ed). A Comprehensive Profile of Elite Women Distance Runners. Int J Sports Med 8 (suppl 2): 71-136, 1987 www.thieme-connect.com/products/ejournals/issue/10.1055/s-002-9118

(3) Pollock ML. Characteristics of elite class distance runners – overview. Ann NY Acad Sci 301: 278-282, 1977

(4) Sparling PB, Wilson GE, Pate RR. Project overview and description of performance, training and physical characteristics in elite women distance runners. Int J Sports Med 8 (suppl 2): 73-76, 1987

(5) Pollock ML. Submaximal and maximal working capacity of elite distance runners: cardiorespiratory aspects. Ann NY Acad Sci 301: 310–322, 1977

(6) Pate RR, Sparling PB, Wilson GE et al. Cardiorespiratory and metabolic responses to submaximal and maximal exercise in elite women distance runners. Int J Sports Med 8 (suppl 2): 91-95, 1987

(7) Costill DL, Fink WJ, Pollock ML. Muscle fiber composition and enzyme activities of elite distance runners. Med Sci Sports 8: 96–100, 1976

(8) Costill DL, Fink WJ, Flynn M et al. Muscle fiber composition and enzyme activities in elite female distance runners. Int J Sports Med 8 (suppl 2): 103-106, 1987

(9) Pollock ML, Gettman LR, Jackson A et al. Body composition of elite class distance runners. Ann NY Acad Sci 301: 361-370, 1977

(10) Graves JE, Pollock ML, Sparling PB. Body composition of elite female distance runners. Int J Sports Med 8 (suppl 2): 96-102, 1987

(11) Cavanagh PR, Pollock ML, Landa J. A biomechanical comparison of elite and good distance runners. Ann NY Acad Sci 301: 328-345, 1977

(12) Williams KR, Cavanagh PR, Ziff JL. Biomechanical studies of elite female distance runners. Int J Sports Med 8 (suppl 2): 107-118, 1987

(13) Morgan WP, Pollock ML. Psychologic characterization of the elite distance runner. Ann NY Acad Sci 301: 382-403, 1977

(14) Morgan WP, O’Connor PJ, Sparling PB. Psychologic characterization of the elite female distance runner. Int J Sports Med 8 (suppl 2): 124-131, 1987

(15) Moore K. Watching their steps. Sports Illustrated May 3, 1976 www.si.com/vault/issue/43339/75/2

(16) Noakes T. The Lore of Running (4th ed). Human Kinetics, 2002

(17) Daniels J. Daniels’ Running Formula (3rd ed). Human Kinetics, 2013

(18) Anderson O. Running Science. Human Kinetics, 2014

Runners with red pee = red alert?…The answer to MOOC’s question of the week

4 Apr, 16 | by BJSM

Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. We call on our ‘world expert panel’ for the answers, and profile select responses on the BJSM blog.  

This week’s question: What are the possible causes for first time gross hematuria in a female runner who experiences some abdominal pain during running?

The scenario presented occurs rarely, and most sports physicians would only see a few cases in their career. Haematuria is frightening for the athlete, so most present promptly for advice.

red runnerThe history, duration, frequency and type of exercise is important. Lots of downhill running provokes cell break down in the quadriceps due to eccentric loading, and this may result in myoglobinuria. Old shoes with poor cushioning have less shock absorption and can lead to foot strike haemolysis.
Anit-inflammatory medications can reduce renal blood flow, and studies on hyponatremia have found increased creatinine in the serum. However, we know these medications are commonly used by distance runners with relatively few suffering severe complications.

On physical examination, the athlete’s general condition is usually well unless there is a rare case of rhabdomyolysis. In collision sports, flank tenderness may be present. In the vast majority of cases, the diagnosis is Runners’ Haematuria, which was initially termed “10,000 metres haematuria” by the urologist Blacklock back in the 1970s. It is caused by abrasions of the bladder wall against the trigone, analogous to caecal slap in the gut. The only routine investigation necessary is a simple urinalysis to look for RBC and casts, plus protein.

Although the vast majority of cases are Runner’s haematuria, physicians still need to ensure the less common possibilities from the differential diagnosis are ruled out based on history, physical and investigations:

  1. Renal or ureteric stone will cause pain. The condition is uncommon in young athletes, but the first episode can occur in youth. A detailed metabolic work up is required if this condition is diagnosed.
  2. Foot strike haemolysis with haemaglobin pigment causing red urine. This is common when old or worn shoes are used, and the running occurs on a concrete surface.
  3. Urinary tract infections classically presents with dysuria and frequency rather than severe abdominal  pain. Haematuria is uncommon in UTI.
  4. In a female athlete, the bleeding may actually be coming from the reproductive tract, i.e. uterus or cervix, but admixed with urine. Most women will be able to distinguish the two sources, but a pelvic examination may be required to clarify things in some circumstances.
  5. Myoglobinuria from damaged muscle can also change the colour of urine and appear similar to hematuria. This usually occurs after unaccustomed eccentric exercise and was originally termed the ‘squat jump syndrome’ within military settings. This condition can cause rhabdomyolysis and this would require an emergency work-up if suspected.
  6. Malignancy in the renal tract classically presents with painless haematuria. It is rare in young people, but should not be forgotten.
  7. In repeated cases of haematuria, a cystoscopy may help identify sites of bleeding, but these are usually just abrasions in the bladder wall opposite the trigone.

If the history and physical condition suggest any of the more serious differential diagnoses, further investigations are warranted. The only condition that needs urgent work up is rhabdomyolysis, which presents very differently from Runners Haematuria and needs hospital admission because an associated hyperkalemia can be life threatening, and an associated acute compartment syndrome can be limb threatening. If rhabdomyolysis is suspected, then the investigations should include a CBC, CRP, creatinine, electrolytes, plus ECG (to look for peaked T waves as a sign of hyperkalaemia). Thomas and Ibels summarised the recommendations for management of rhabdomyolysis in the 1980s and it has not been improved upon. They advocate:

  • A- aggressive fluid replacement 4-11 litres in the first 24 hrs
  • B-resonium ion exchange resins to correct  significant hyperkalaemia. Dialysis may be required in some circumstances
  • C-compartment pressure testing if there is suspicion of acute compartment syndrome, and decompressive surgery when required.

Management of Haematuria in a Runner

For a first episode where history and physical examination do not suggest any of the differential diagnoses, the physician should manage the patient as a case of runners’ haematuria ie bladder wall abrasions. Apart from the basic investigations mentioned above, the athlete should rest from exercise until the haematuria clears, and then resume exercise. Some authorities advise the athlete to exercise with the bladder partly full, with the idea that this will reduce the contact between the trigone and the opposing bladder wall. Practically, this can be difficult to achieve! Athletes should also be advised to minimise NSAID use prior to races and long training runs, particularly in the heat. When there are recurrent episodes of exercise related haematuria, the patient should be referred to a renal physician or urologist. The referral route will be determined by the clinical picture  and local or regional availability of services. Cystoscopy may be required to identify the source of bleeding

In summary, Runners’ Haematuria is uncommon, but sports physicians need to know how to deal with it. In most cases, the cause is relatively benign, but be aware of the occasional serious cause, and refer those people for prompt further management.

Other Readings:
Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure. Aust N Z J Med 1985;15(5):623-628.

Mercieri A. Exercise-induced hematuria. Up to date Oct 14 2015, http://www.uptodate.com/contents/exercise-induced-hematuria?source=machineLearning&search=runners+haematuria&selectedTitle=1~150&sectionRank=1&anchor=H138038#H138038
Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B.. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-392.

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Dr Chris Milne is a Sports and Exercise Physician based in Hamilton New Zealand. He has particular interest in exercise related renal and GI issues. He has been Team Physician to several NZ Olympic Teams, and is Chair of the Medical Commission for Oceania National Olympic Committees.

Retrospective Part I: American Pioneers in Distance Running Research

20 Mar, 16 | by BJSM

By Phillip B. Sparling        
Many scientists worldwide have made lasting contributions to today’s scientific understanding of distance running. During the first half of the 20th century, a number of notable Americans paved the way. With insatiable curiosity and drive, early researchers used the best scientific tools available to unravel the physiology of endurance performance. They were scientific explorers of physical performance. Here are a few.

D.B. Dill & S. Robinson: From 1927-1947, acclaimed scientist David Bruce Dill (1891-1986) and colleagues at the Harvard Fatigue Lab studied champion runners as one of many approaches to investigate the physiology of performance and fatigue. Arguably their most famous subject was Clarence DeMar, 7-time winner of the Boston Marathon (1911, 1922-24, 1927-28, 1930). His participation in the lab’s experimental studies on exercise was instrumental in showing the enlarged heart of distance runners was the consequence of conditioning, not pathology (1, 2). In 1936 Dill and doctoral student Sid Robinson (1902-1982) assessed the work capacities of Glenn Cunningham and Don Lash, world record holders at 1-mile and 2-mile, respectively (3). Before joining Dill at Harvard, Robinson had competed in the 1500 meters in the 1928 Olympics and coached the Indiana University cross-country team to five straight Big Ten championships and three national championships. In 1939, he returned to Indiana University with an appointment in the department of physiology, where he created a nationally prominent research program in exercise and environmental physiology. Dill and Robinson posed basic and applied questions. What are the underlying biochemical changes and physiological mechanisms associated with distance running? And more broadly, how does physical training influence performance under different environmental conditions (in the heat or cold, at altitude)?

Sid_Robinson_HFL

Sid Robinson on treadmill with oxygen uptake and heart rate apparatus in Harvard Fatigue Laboratory, 1938.

T.K. Cureton, B. Balke & K.H. Cooper: From the 1940s through the 1950s, T.K. Cureton (1901-1992), who established the Physical Fitness Research Lab at the University of Illinois, profiled Olympians and world record holders including Roger Bannister (4). An excellent runner and swimmer himself, Cureton was one of the first to promote vigorous exercise to improve the health of ordinary Americans. At the time, only athletes and soldiers engaged in serious physical training. In the 1950s and early 1960s, Bruno Balke (1907-1999) conducted fitness research for the Air Force and developed the 15-min test (5). Kenneth H. Cooper, a former flight surgeon in-training under Balke, proposed the 12-minute run a few years later (6). These field studies were the first to correlate maximal oxygen uptake to distance run performance in samples with large variations in fitness. In 1964 Balke accepted a position as professor of physical education and physiology at the University of Wisconsin. Cooper published his book Aerobics in 1968 and established the Aerobics Center in Dallas in 1970. Most investigations from the 1930s through the 1960s focused on cardiac, respiratory, blood lactate, and oxygen uptake measurements.

J. Daniels. Jack Daniels’ background is akin to that of Sid Robinson from a generation before. A medalist in the modern pentathlon in both the 1956 and 1960 Olympics, he studied exercise physiology with two eminent researchers: Per-Olof Astrand (Sweden) and Bruno Balke (University of Wisconsin) who was his doctoral advisor. As his dissertation dealt with human performance at altitude, he became a key advisor to American distance runners preparing for the 1968 Olympics in Mexico City (7,350 feet above sea level) (7, 8). An accomplished scientist, he chose coaching over research as his main career path. His coaching is uniquely infused with science. He advised many of the world’s finest runners from Jim Ryun to Joan Benoit (Samuelson), along with coaching hundreds of modestly-talented runners. He was a highly successful coach of women and men at SUNY-Cortland. He also directed Nike’s exercise science lab in Eugene, Oregon (associated with Athletics West, an elite runners club) and the Center for High Altitude Training in Flagstaff, Arizona. Editor Amby Burfoot at Runner’s World described Daniels as the world’s best coach.

Jack_Daniels

Jack Daniels testing runner on the track at altitude in Colorado, 1967

D.L. Costill: In 1966, David Costill was hired to direct the Human Performance Lab at Ball State University (Muncie, Indiana). Over his 40 years there, he would conduct seminal physiological research on nearly every facet of distance running, test the world’s best runners – Derek Clayton (Australia), Alberto Salazar (USA), and Grete Waitz (Norway), to name a few – and become the pied piper for those fascinated with distance running (9). From across the USA and abroad, hundreds of runners, students, and scientists visited and studied with Costill. The overarching aim was to decipher what factors determine success in distance running, and how different types of training influence these variables. His initial papers identified lactate accumulation, glycogen depletion, fractional utilization of aerobic capacity, and temperature regulation as important variables (10-13). These findings had direct, practical impact on training and diet (e.g., threshold training, carbohydrate loading, fluid replacement). He was also among the first to perform muscle biopsies and fiber typing on distance runners (14), learning the techniques from Swedish scientist Bengt Saltin (1935-2014) and American physiologist Philip Gollnick (1935-1991) (15). Costill translated the concept of fast-twitch vs. slow-twitch muscle fibers to coaches and runners, helping them understand a genetic determinant of performance.

All devoted exercisers, these pioneering scientists were driven to learn more about the capacity of the human body. They conducted hands-on research in small labs with eager co-workers and students, often using themselves as test subjects. They laid the foundation. By 1970s, a new era in research on distance running began as new technologies and specializations within exercise science emerged. Part II of this retrospective will highlight two landmark multi-disciplinary projects.

Read part two here: Distance Running Part II: Landmark Research Projects and Science-Based Books

***************

Phil Sparling is a professor emeritus of applied physiology at the Georgia Institute of Technology (Georgia Tech) in Atlanta, Georgia, USA. Decades ago he was a competitive distance runner and marathoner. He still runs several days a week. phil.sparling@gatech.edu

References      

(1) Dill DB, Talbott JH, Edwards HT. Studies in muscular activity. J Physiol 69: 267-305, 1930

(2) Dill DB. Marathoner DeMar: physiological studies. J Natl Cancer Inst 35: 185-191, 1965

(3) Robinson S, Edwards HT, Dill, DB. New records in human power. Sci 85: 409-410, 1937

(4) Cureton TK. Relationship of physical fitness to athletic performance and sports. JAMA 162: 1139-1149, 1956

(5) Balke B. A simple field test for the assessments of physical fitness. Report 63-6 of Civil Aeromedical Research Institute (pp 1-8), Federal Aviation Agency 1963

(6) Cooper KH. A means of assessing maximal oxygen intake: Correlation between field and treadmill testing. JAMA 203: 201-204, 1968

(7) Balke B, Nagle FJ, Daniels J. Altitude and maximum performance in work and sports activity. JAMA 194: 646-649, 1965

(8) Daniels J & Oldridge N.  The effects of alternate exposure to altitude and sea level on world-class middle-distance runners.  Med Sci Sports 2: 107-112, 1970

(9) Kolata G. David Costill: A Career Spent in Study of Training and Exercise, Lap by Grueling Lap. The New York Times. October 30, 2001 www.nytimes.com/2001/10/30/health/scientist-work-david-costill-career-spent-study-training-exercise-lap-grueling.html?pagewanted=all

(10) Costill DL. Metabolic responses during distance running. J Appl Physiol 28: 251-255, 1970

(11) Costill DL, Bowers R, Branam G et al. Muscle glycogen utilization during prolonged exercise on successive days. J Appl Physiol 31: 834-838, 1971

(12) Costill DL, Thomason H, Roberts E. Fractional utilization of the aerobic capacity during distance running. Med Sci Sports 5: 248-252, 1973

(13) Costill DL & Sparks KE. Rapid fluid replacement following thermal dehydration. J Appl Physiol 34: 299-303, 1973

(14) Costill DL, Daniels J, Evans W et al. Skeletal muscle enzymes and fiber composition in male and female track athletes. J Appl Physiol 40: 149-154, 1976

(15) Gollnick PD, Armstrong RB, Saubert CW et al. Enzyme activity and fiber composition in skeletal muscle of untrained and trained men. J Appl Physiol 33: 312-319, 1972

Running injuries and how to prevent them: BJSM article (by Irene S. Davis et al.) featured in the NY-Times

13 Feb, 16 | by BJSM

 

Running is a low barrier activity with ongoing popular appeal. Running injury prevention is therefore an (unfortunately) important related area of study, with practical – day to day- training implications for many individuals. Therefore it is no surprise that Irene S. Davis et al.’s BJSM publication Greater vertical impact loading in female runners with medically diagnosed injuries: a prospective investigation” sparked public interest. The authors’ work was recently featured, by author Gretchen Reynolds, in The New York Times:

Athlete running at sunset on beach

“…Running injuries are extremely common, with some statistics estimating that as many as 90 percent of runners miss training time every year due to injury.

But the underlying cause of many of these injuries remains in question. Past studies and popular opinion have blamed increased mileage, excess body weight, over-striding, modern running shoes, going barefoot, weak hips, diet, and rough pavement or trails. But most often, studies have found that the best indicator of a future injury is a past one, which, frankly, is not a helpful conclusion for runners hoping not to get hurt.

So for the new study, which was published in December in the British Journal of Sports Medicine, researchers at Harvard Medical School and other universities decided to look at running injuries, one of the more obvious but surprisingly understudied aspects of running, and to focus their attention, in part, on those rare long-time runners who have never been hurt.

Specifically, they set out to look at pounding, or impact loading, which means the amount of force that we create when we strike the ground. Pounding is, of course, inevitable during a run. But runners with similar body types and running styles can experience wildly different amounts of impact loading, and it hasn’t been clear to what extent these differences directly contribute to injuries…

During that time, more than 100 of the runners reported sustaining an injury that was serious enough to require medical attention. Another 40 or so reported minor injuries, while the rest remained uninjured.

More remarkably, in the minds of the researchers, 21 of the runners not only did not become injured during the two-year study but also had not had a prior injury. They remained long-term running-injury virgins, the athletic equivalent of unicorns…

…The never-injured runners, as a group, landed far more lightly than those who had been seriously hurt, the scientists found, even when the researchers controlled for running mileage, body weight and other variables.

That finding refutes the widely held belief that a runner cannot land lightly on her heels.

“One of the runners we studied, a woman who has run multiple marathons and never been hurt, had some of the lowest rates of loading that we’ve ever seen,” said Irene Davis, a Harvard professor who led the study. She pounded far less than many runners who land near the front of their feet, Dr. Davis said. “When you watched her run, it was like seeing an insect running across water. It was beautiful…”

Read the full NY-Times article HERE

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!

 

Can I tell you something? I’m doping…

16 Nov, 15 | by BJSM

By HP Dijkstra¹, N van Dyk², YO Schumacher¹

¹Sports Medicine Department, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.

²Rehabilitation Department, Aspetar Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar

runningfeet

Doping in sport, particularly in track and field, is a reality.[1] [2] The World Anti-Doping Agency (WADA) condemned a rife doping culture in Russian Athletics implicating athletes, coaches, doctors, managers, federations and even the Russian minister of sport. [1] The Council of the International Association of Athletics Federations (IAAF) reacted by provisionally suspending the All-Russia Athletic Federation (ARAF) as an IAAF member. IAAF President, Sebastian Coe commented: “This has been a shameful wake-up call and we are clear that cheating at any level will not be tolerated. To this end, the IAAF, WADA, the member federations and athletes need to look closely at ourselves, our cultures and our processes to identify where failures exist and be tough in our determination to fix them and rebuild trust in our sport.” [3] This was, however, not the only recent doping scandal in athletics.

The prevalence of blood doping ranged from 1-48% for subpopulation samples (country, endurance, non-endurance) of a blood-testing program by the IAAF. [4] In a study on Doping in Elite Sports Assessed by Randomized-Response Surveys, the prevalence of reported past-year doping was 29% at the 13th IAAF World Championships in Athletics in Daegu, South Korea and 45% at the 12th Quadrennial Pan-Arab Games in Doha, Qatar. [2] WADA published a list of 113 coaches, physicians and other support staff, guilty of violating anti-doping rules – athletes are not allowed to associate with any of these individuals. [5]

How easy is it then for athletes to beat the system? What help do they get from team medical staff?

WHAT ABOUT PATIENT CONFIDENTIALITY?

Consider this: you’re a team physiotherapist at an IAAF World Championships. While treating an athlete with Achilles pain he or she asks: “Can I tell you something? I’m doping… Please don’t tell anyone.” What do you do? Is this ‘patient confidential information’ or is it your ethical responsibility to report this?

This confession may be confidential in certain settings but in many countries (UK, Germany, Australia etc.) you are protected by the athlete’s contract and senior management, and must report this. Athletes who use performance enhancing substances do not generally involve their team physician, but carefully choose to operate outside organized structures. How can healthcare professionals protect themselves and athletes from getting involved or accused of doping?

HOW TO PROTECT ATHLETES AND YOURSELF

Healthcare professionals in sport should lead and implement change to protect athletes and themselves. Here are four elements promoting best practice:

  1. A comprehensive anti-doping education program warning athletes against taking supplements that might contain prohibited substances, and educating coaches and support staff (figure 1).
  2. An effective out of competition testing program based on athlete where-about registration. There is huge discrepancy in the operational efficiency of many National Anti-Doping Organisations (NADOs) especially in countries where doping is more prevalent. The recent WADA report on doping in Russian Athletics is a clear indication of this. [1]
  3. ‘Zero-tolerance’ athlete contracts. Many elite athletes in “non-professional” sports are funded by governmental programs, such as lottery funds or employed by the armed forces. These funded athletes sign a contract, relinquishing their right to medical confidentiality related to doping. All athletes competing at major events sign an athlete’s contract after team selection. These contracts underpin a zero-tolerance approach to illegal practices, including doping, and ‘patient confidentiality’ does not apply.
  4. A well-structured, professional and transparent coaching, training and medical support system.

We reported on the Integrated Performance Health Management and Coaching Model implemented by UK Athletics. [6] Athletes, coaches and support staff work together in an integrated and transparent model of shared decision-making and mutual accountability.

Medical Team: Medical support staff should undergo annual clinical appraisals. They provide evidence of regular peer reviewed clinical activities, patient log books, reflective continuing professional development (CPD) diaries and performance-feedback by colleagues and patients. UK medical staff, including Sport and Exercise Medicine (SEM) physicians is already subject to a robust peer review and annual appraisal system that informs General Medical Council (GMC) revalidation. [7] Although not impossible, it is difficult for a physician in such a program to engage in illegal practices without drawing suspicion.

Athletes: Athletes should live in the official team hotel or athlete’s village before and during major championships. These environments are not conducive to ‘easy doping’ – medical teams operate in designated ‘open medical spaces’ where peers observe and comment. Athletes and support staff, eat, train, rest and sleep (more often than not 2-4 in one room) in an environment where secret doping practices will be difficult. Athletes should be encouraged to embrace this type of organised team environment with appropriate performance measures (single rooms) to support individual medal-potential athletes.

doping

UK Athletics poster used at training venues before the London Olympic Games

SUMMARY

There is a systemic failure of certain countries to curb doping practices. Prudent federations, managers, coaches and medical staff would invest in robust systems of professional and ethical athlete coaching and support. National and international governing bodies should prioritize these systems, creating educational platforms and mandatory practices that hold individuals and teams accountable at all levels. This will not only serve to protect the vast majority of ethical athletes, coaches and support staff, but also safeguard sport from becoming a pharmacological spectacle. It is fundamentally about fairness and the integrity of true competition – “play true”!

****************************

Correspondence to:

H Paul Dijkstra MBChB, BSc (Hons) (Pharmacology), MPhil (Sports Medicine), FFSEM (UK); Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, PO Box 29222, Doha, Qatar; TEL: +974 4413 2000; e-mail: paul.dijkstra@aspetar.com

Contributions of each author:

Dijkstra HP: First author, substantial contribution to conception and design, coordination of authors, drafting and revising the manuscript and approval of the final version to be published

Van Dyk, Nicol: Contribution to drafting and revising the manuscript and approval of final version to be published

Schumacher YO: Contribution to drafting and revising the manuscript and approval of final version to be published

Competing Interest: All authors are prominent in sport and exercise medicine. Drs Dijkstra and Schumacher have practical experience as physicians working with athletes who have undergone drug testing. Dr Schumacher provides expert advice for various Anti-Doping Agencies including WADA. (See publications as well).

References

1          Wada commission wants Russia ban. BBC Sport. http://www.bbc.com/sport/0/athletics/34765444 (accessed 9 Nov2015).

2          Committee publishes “blocked” study on doping – News from Parliament – UK Parliament. http://www.parliament.uk/business/committees/committees-a-z/commons-select/culture-media-and-sport-committee/news-parliament-2015/chairs-statement-blood-doping-15-16/ (accessed 18 Sep2015).

3          IAAF provisionally suspends Russian Member Federation ARAF | iaaf.org. http://www.iaaf.org/news/press-release/iaaf-araf-suspended (accessed 14 Nov2015).

4          Sottas P-E, Robinson N, Fischetto G, et al. Prevalence of Blood Doping in Samples Collected from Elite Track and Field Athletes. Clin Chem 2011;57:762–9. doi:10.1373/clinchem.2010.156067

5          WADA Bans 114 Support Staff Banned For Doping Violations. http://www.swimmingworldmagazine.com/news/wada-publishes-list-of-banned-coaches-and-support-staff-for-doping-violations-italy-leads-tally-with-61/ (accessed 21 Sep2015).

6          Dijkstra HP, Pollock N, Chakraverty R, et al. Managing the health of the elite athlete: a new integrated performance health management and coaching model. Br J Sports Med 2014;48:523–31. doi:10.1136/bjsports-2013-093222

7          GMP Framework for appraisal and revalidation. http://www.gmc-uk.org/doctors/revalidation/revalidation_gmp_framework.asp (accessed 21 Sep2015).

Figure 1: UK Athletics poster used at training venues before the London Olympic Games

Running Virtual Conference: all the hot topics and resource links in one blog!

7 Nov, 15 | by BJSM

A monthly round-up of podcasts and articles 

By Steffan Griffin (@lifestylemedic)

LONDON, UNITED KINGDOM - APRIL 26:  A runner dressed in a naked suit in the mass start during the Virgin Money London Marathon on April 26, 2015 in London, England. (Photo by Stephen Pond/Getty Images)

LONDON, UNITED KINGDOM – APRIL 26: A runner dressed in a naked suit in the mass start during the Virgin Money London Marathon on April 26, 2015 in London, England. (Photo by Stephen Pond/Getty Images)

In the penultimate virtual conference of 2015, the topic is one that becomes increasingly relevant at the turn of the year, likely featuring on a lot of people’s New Year’s resolutions – running. In the same format as its predecessors on the hamstring, shoulder, and tendons (among others) – here’s a list of BJSM resources so you’re clued up to treat any runners that come limping your way!

Running Injuries – an overview http://bit.ly/1P4Of6J

Don’t know where to start? This may be the best place, an overview of running injuries with Andy Franklyn-Miller, with secrets from 15 years of experience in treating runners and running injuries.

Running shoes and running injuries: mythbusting and a proposal for two new paradigms http://bit.ly/1KQZeJt 

A recent and hugely popular paper – mainly concerning whether or not running shoes (or sport shoes in general) influence the frequency of running injuries at all. Contains two new paradigms which are likely to stick around for the considerable future. A must read!

Biomechanical overload and lower limb injuries http://bit.ly/1KQZzeU

Sticking with one of the BJSM’s most popular podcast guests (Andy Franklyn-Miller), this podcast delves into the issue of chronic exertional compartment syndrome and the potential role of running re-education in managing the pathology. The podcast also touches on the historically hot topic of barefoot running.

Barefoot running: an evaluation of current hypothesis, future research and clinical applications http://bit.ly/1KQZLuN

The podcast leads nicely on to this fantastic review by the great team in Cape Town, looking into the factors driving the prescription of barefoot running, whilst also examining which of these factors may have merit, what the collected evidence suggests about the suitability of barefoot running for its purported uses and describe the necessary future research to confirm or refute the barefoot running hypotheses.

Keeping runners running – the secrets of running assessment and advice http://bit.ly/1P4OC18

Following on from Andy Franklyn-Miller’s podcast, this discussion with Andy Cornelius asks if we can assess running patients and guide them to improve their technique. Might gait education prove more effective than medication to treat symptoms?

Overuse injuries – what to consider http://bit.ly/1P4OG0S

Moving on slightly to an issue that most serious runners have to deal with at some stage – burnout. Although not quite specific to running, there are still some good nuggets to take home from this.

Patellofemoral pain – a masterclass http://bit.ly/1P4OHln

Likewise, not strictly unique to running is the issue of patellofemoral pain – but this chat with the world-renowned Kay Crossley is 100% worth a listen on the way to work – covering the best PFP treatments and evidence for them as well as new insights into knee pain after ACL reconstruction.

The foot core system: a new paradigm for understanding intrinsic foot muscle function http://bmj.co/1K3vbUB

The final resource on the list is another game-changing paper proposing a new paradigm, shifting the goalposts in regard to how we regard the intrinsic muscles of the foot. The authors draw the parallels between the small muscles of the trunk region that make up the lumbopelvic core and the intrinsic foot muscles, introducing the concept of the ‘foot core’, before then integrating the concept of the foot core into the assessment and treatment of the foot.

And that’s it! Hope you enjoyed trawling through the resources from some hugely influential names – please do let the BJSM know your thoughts/questions on twitter, Facebook and the Google+ SEM community, we are always open to suggestions for improvement!

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A peer review journal for health professionals and researchers in sport and exercise medicine. Visit site



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Latest from British Journal of Sports Medicine

Latest from British Journal of Sports Medicine