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Running (more!) randomised controlled trials in sport and exercise medicine – Tips for clinical research

6 Aug, 17 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective  A BJSM blog series

By Dr Robert M Barker-Davies

Have you ever considered running a randomised control trial (RCT)? Or at least perhaps wondered why there aren’t more of them in sports medicine? RCTs along with systematic review and meta-analysis are the gold standard for evidence-based medicine. Just 3% of articles in the BJSM between 1991-1995 were RCTs, increasing to 7% from 1996-2000 compared to over 16% in the BMJ1. More recently across sports medicine literature, that figure has been reported as 6% by systematic review2.

Most readers will be familiar with how quickly autologous blood/platelet rich plasma injections rose to fame. Early on in the process of putting my PhD research proposal together, a PubMed search on this topic found 3 out of 62 papers to be RCTs. As the quality of the research improved, the justification for administering this treatment disappeared.

A challenge in sports medicine research is that most patients have a thirst for a winning new (medical) formula and they rarely want to be in the control group. Yet do we really adhere to the principle primum non nocere if we don’t have evidence for a new treatment? In the UK Military, we have a clear duty of care to our personnel that tips the balance away from the untried and untested.

The case of High Volume Injection

High Volume Image Guided Injection (HVIGI) has promise as an adjuvant therapy3. At Headley Court Rehabilitation Hospital, we appraised the evidence and decided to practice HVIGI within the framework of an RCT before rolling out its use more widely. With the support of the Higher Education Funding Council for England’s catalyst fund in collaboration with Loughborough University, the National Centre for Sport and Exercise Medicine and Defence Medical Services, I am now studying as a full time PhD student to run this project. This has meant taking 3 years out of SEM registrar training.

Running an RCT poses many challenges and requires a committed team. Processes such as blinding, randomisation, unblinding, safety reporting and data monitoring all require additional staff members outside of the traditional multidisciplinary team. Much of this relies on the good-natured professionalism of those involved.

Getting off to the right start is key to avoid later pitfalls and delays re-submitting applications for regulatory and ethical approval. Dr Ben Goldacre’s book, Bad Pharma, brings to life the all too common problems with clinical trials. The cornerstone of his text relates to publication bias and missing data both well illustrated by the case of TGN1412 in 2006. Six participants suffered multiple organ failure; all were possibly avoidable had the results of an unsuccessful trial 10 years earlier been made public4. A key recommendation here is that trials are registered. We have taken the additional step of publishing our High Volume injection protocol in a peer-reviewed journal5.

Once you have your funding, academic, institutional, ethical and regulatory approvals in place, comes the next challenge: recruitment. The excellent resources from the NIHR website highlight the danger of overestimating the ease with which you will recruit the study population6. Much of sports medicine is practiced away from a large institutional setting making this a constant challenge for the specialty. Pooling results in multi-centre trials is one way around this but presents organisational challenges.

Increasing engagement with research as part of SEM training perhaps offers us an opportunity here. Universal understanding makes collaboration easier. Good Clinical Practice (GCP) training is a short course covering the international governance standards for research. I would highly recommend Sports Medicine as a specialty engages with GCP’s language and processes to help bring the evidence we really need within our grasp.


Robert Barker-Davies is Sport and Exercise Medicine (SEM) and Rehabilitation Medicine Registrar and Clinical Research Fellow with the Academic Department of Military Rehabilitation and Loughborough University. He joined the RAF on a medical cadetship whilst at the University of Nottingham in 2004, attained MRCGP in 2012 and served in the Falkland Islands, RAF Waddington and RAF Scampton as a station GP. He represented the RAF, Coventry Godiva Harries and Wales U23s as a sprinter and hurdler. He holds UK Athletics qualifications in coaching and has sought to bring together his knowledge of the sport with his professional training and experience. He commenced dual specialist training in Sport and Exercise Medicine and Rehabilitation Medicine at DMRC Headley Court in 2014.

Farrah Jawad is a Sport and Exercise Medicine Registrar and co-ordinates the BJSM Trainee Perspective blog.


  1. Bleakley C, MacAuley D. The quality of research in sports journals. British journal of sports medicine 2002;36(2):124-5.
  2. Harris JD, Cvetanovich G, Erickson BJ, et al. Current status of evidence-based sports medicine. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2014;30(3):362-71. doi: 10.1016/j.arthro.2013.11.015
  3. Wheeler PC, Mahadevan D, Bhatt R, et al. A Comparison of Two Different High-Volume Image-Guided Injection Procedures for Patients With Chronic Noninsertional Achilles Tendinopathy: A Pragmatic Retrospective Cohort Study. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 2016 doi: 10.1053/j.jfas.2016.04.017
  4. Goldacre B. Bad Pharma. London, UK: Fourth Estate 2012.
  5. Barker-Davies RM, Nicol A, McCurdie I, et al. Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC musculoskeletal disorders 2017;18(1):204. doi: 10.1186/s12891-017-1564-7
  6. Research NIfH. Clinical Trials Guide for Trainees [accessed 26 May 2017.

Team Doctor reflections from the 2017 Fazza International Para Archery Championships

25 Feb, 17 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Ajai Seth and Chris Tomlinson

On January 25th 2017, para archers from all over the world gathered in Dubai, United Arab Emirates, for the 3rd Fazza International Para Archery Championships. I was fortunate enough to travel with the Great Britain (GB) team. I was previously unfamiliar with the sport, and I learnt a great deal serving as the team doctor.

Archery GB led the world at the Paralympic Games in Rio with 6 medals including 3 golds. Their next Paralympic cycle is already underway.  Seventeen of GB’s top para archers participated here in the first warm weather training and competition of the four-year cycle. This was also good preparation for the upcoming World Archery Para Championships in Beijing later in the year.

Para sport and classification systems can leave even the brightest amongst us scratching our heads, and para archery is no exception. Any archer can apply to be classified at international level through their national governing body. Since 2014, para archery includes three competition divisions: recurve open, compound open and W1. These divisions allow athletes to use modified-specification recurve and compound bows. Only a thorough classification examination determines whether an athlete can compete in any category. However, there are basic differences between the three:

Recurve open: These athletes compete by standing, stool or wheelchair and have upper and/or lower body impairment. They must use a standard recurve bow which conforms to World Archery rules. Competition rules are the same for able bodied recurve competition, with a ranking round consisting of 72 arrows at a target 70 metres away.

Compound open: Similar to recurve open, compound open athletes must use a standard compound bow and vary in upper and lower body impairments. A 72 arrow ranking round is still in place but this time the target is set at 50 metres. Head to head matches are resolved using a 15 arrow shoot out.

W1: All W1 athletes compete in a wheelchair but may shoot with either recurve or compound bows with slightly modified rules. W1 recurve athletes may use mechanical release aids, but the peak draw weight is limited to 45lb. The use of peep sights or leveling bubbles is also limited.

Role of the Team Doctor

Looking after a Paralympic team has its own set of unique challenges. Part of the role as team doctor in preparation for the Fazza Championships was to ensure that the pre-travel medical screenings for all the athletes and staff were done. A team of para athletes will present with a wide variety of complex medical pathologies and potential emergencies such as autonomic dysreflexia and infections. Of particular importance is careful considering of each individual athlete’s care requirements. This may include changing and showering facilities, bathroom and lift access. Transport to and from airports, training and competition venues also needs to be carefully considered before the departure.

Back in the UK, the Paralympic Podium Programme is dedicated to supporting mature, highly skilled elite archers as they aim to win medals in major competitions, such as European and World Championships and The Paralympics. Para archery training facilities are based at The Archery High Performance Centre at Lilleshall. Once on the programme, athletes can access the new state of the art facilities and analysis equipment including:

  • A new outdoor archery range (70m) with a covered technical area.
  • A refurbished indoor range (70m) with high speed motion analysis cameras.
  • New support staff facilities and communications facilities.

The English Institute of Sport provides Sports Medicine and Sport Science support for the archers, and I am based here as part of my training scheme, learning the demands of a high class disability sport and support team.

To find out more about archery or para archery, please visit


Dr. Ajai Seth is a Sports and Exercise Medicine registrar and General Practitioner in the West Midlands. His sporting interests include racket sports, golf, football and expedition medicine. He is currently Birmingham City Football club academy doctor and works at the English Institute of Sport.

Dr. Chris Tomlinson is the Chief Medical Officer to British Gymnastics and Archery GB and a Senior Sports Physician at the English Institute of Sport.

Farrah Jawad is a registrar in Sport and Exercise Medicine in London and co-ordinates the BJSM Trainee Perspective blog.

School Games: great introduction to a multi-sport experience

24 Sep, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr Philippa Turner

If anyone is looking for an introduction to the multi-sport experience, look no further than the School Games! Previous medical team alumni (and athletes, of course) have gone on to World University Games, Commonwealth Games, Olympic and Paralympic Games success.

About the games

Developed and organised by the Youth Sport Trust, Sport England and the Department of Culture, Media and Sport, the School Games creates an inspirational and motivational setting. It provides elite young sports people with the opportunity to perform at the highest level. It also encourages more young people to take part in sport. Over 1,600 young athletes competed across three days this September at Loughborough University, England.

The Games currently includes twelve sports: Fencing, Rugby Sevens, Gymnastics, Hockey, Athletics, Cycling, Judo, Swimming, Table Tennis, Volleyball, Wheelchair Basketball and Wheelchair Tennis; disability athletes compete in seven sports: Athletics, Fencing, Swimming, Table Tennis, Cycling, Wheelchair Basketball and Wheelchair Tennis.

Organisers make the School Games as similar to the Olympics and Paralympics as possible. This includes an Opening and Closing Ceremony to participate in and enjoy, shared flats as accommodation, communal food halls, accreditation procedures, volunteer support staff, and a central medical clinic alongside pitch-side support.

SEM takeaways – ‘court-side’ lessons learned

This was my first experience of working at the School Games. It made me realise the massive logistical planning which goes into providing medical cover at such an event compared to a single one off fixture. A day of introduction and CPD was put on prior to the competitions’ start. This included sessions on safeguarding, anti-doping, dental injuries and venue familiarisation. It also allowed the medical team to get to know each other and practise moulages. This was a great opportunity to learn from both more experienced colleagues in a supervised setting, and other health professionals who work in a wide range of sporting environments.


I was placed at Volleyball with three physiotherapists, a paramedic and technician. I had no prior experience of covering Volleyball. It was quickly evident that the crowd was enthusiastic and loud! The competition was tight at the top of the tables in both the girls’ and boys’ groups. This made for some aggressive warm ups causing bloody noses, but also some great games to watch.

The main issues we saw included shoulder, knee and lower back pain. The athletes’ long levers with little muscle bulk to control movement patterns were clearly causing issues. Many of the boys were over 6’5” tall and did not fit on our examination plinths. Many also appeared to rely on K-Tape to get them through matches. So as a medical team, we tried to educate our patients as much as possible about activation and strengthening exercises they could perform in order to improve their performance both in the short and long term.

I also became more aware that, when working with young athletes, their overall wellbeing is paramount. We were not there simply to treat an injury or illness. When the competition started the pressure from coaches, parents and the athletes themselves was also a critical thing to manage. This was further intensified by the fact that this was many of the athletes’ first time away from home, and/or their first experience with a team of professional medical support.

A great opportunity


Philippa Turner, Phillip Harris, Jude Coe, and Leanne Simoncelli

I thoroughly enjoyed getting to know and learning from the medical team.  Working at the School Games lets you see first-hand young athletes gaining invaluable multi-sport experience. They performed at their best even if the results didn’t go their way. I would certainly encourage any doctor or physiotherapist who is interested in Sport and Exercise Medicine to look out for the job adverts on the UK Sport website early next year and do their homework before the interviews! You never know – you might look after the next Max Whitlock, Ellie Simmonds or Adam Peaty!

For more information about the 2016 School Games you can visit

Dr Philippa Turner, ST5 in the East Midlands Deanery. She works as the match day doctor for Aston Villa Ladies Football Team, Team Physician to England Cricket Disability Squads and the Women’s Performance Programme. She is also the Trainee Representative on the SEM Speciality Advisory Committee (SAC).

Dr Farrah Jawad is a registrar in London and co-ordinates the BJSM Trainee Perspective blog.



Wimbledon! A day in the life of an All England Club SEM Physician – BJSM trainee perspective blog

13 Jul, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr. Ajai Seth

Sports and Exercise Medicine Trainee, MBBS, BSc, MSc, MRCS, MRCGP, MFSEM

Wimbledon 2016 image 2As a life-long avid tennis fan, I was thrilled at the opportunity to spend some time with the medical team at The Championships, Wimbledon. Wimbledon is the oldest, perhaps most prestigious tennis tournament in the world. Held at the All England Lawn Tennis Club (AELTC) since 1877 and currently the only Grand Slam tennis tournament to be played on grass.


Wimbledon is a mass spectator event. Up to 39,000 people can be in the grounds at once. St John’s Ambulance provides medical cover for the crowd and most non-player staff members. For player medical care, the The All England Lawn Tennis & Croquet Club Limited (AELTC) employs a medical team for the duration of the Championships. The medical team at the All England club consists of 3 sports medicine physicians, 1 radiology consultant and a general practitioner who works with the AELTC full time (the Club doctor). In addition to this, there is a strikingly large number of other personnel employed by a variety of tennis organisations. For example, LTA, ATP, WTA and the AELTC. They may include physiotherapy, strength and conditioning, podiatry and massage therapy. Furthermore, top players may have their own entourage of coaching and fitness teams. All this adds up to an extremely busy working environment!

As you may expect, the medical team at Wimbledon hold a wide range of responsibilities. The Wimbledon qualifying event takes place the preceding week at the Bank of England sports ground in Roehampton. A whole host of other housekeeping tasks are associated with this event including: communications, dealings with the press, anti-doping and ensuring adequate medical staffing and equipment.

Pre-competition screenings

A change was made to the tennis calendar in 2015, pushing back The Championships by one week. This allows players more recovery time and transition after The French Open, the second grand slam of the year. Players therefore have an opportunity to use The All England Training club facilities prior to the tournament as well as during. These facilities include the use of 2 separate gyms, 22 practice courts, physiotherapy, massage services and 3 hydrotherapy baths, all at different temperatures. There is also offers a pre-competition opportunity for players to present injuries and seek advice from the medical staff. A sports physician may encounter: flares of chronic musculoskeletal injury, acute musculoskeletal injury and management medical conditions.  The majority of injuries presenting at Wimbledon are pre-existing or recurrent.1 Muscle and ligament injuries are the predominant type of acute injury in professional grass court tennis, with ligament and articular surface injuries being less common.1 Often, the player’s coach/team will attend the consultation and adjustments can be made to their training schedule. Occasionally players will want advice on whether they are fit to play or need to be rested.

Comprehensive AELTC player care

The vast majority of players rely on the medical expertise and diagnostic skills provided at tournaments as much of their year is spent abroad on tour. Therefore when they know good medical services are available, players may seek medical help for more chronic injuries. At the AELTC, they are able to get onsite ultrasound assessment by a sports physician with and offsite MRI assessment, interpreted by an experienced MSK radiologist. All members of the medical team have a vast experience of tennis medicine and years of medical experience at the Championships.

Wimbledon 2016 selfie

Wimbledon 2016 selfie with Professor Mark Batt, Medical Officer at Wimbledon

On the ground at Wimbledon

Perhaps one of the biggest challenges at the AELTC is navigation. Anyone who has been lucky enough to visit Wimbledon as a spectator, will have an appreciation for the complexity of the site layout, which includes 41 courts and a multitude of shops, restaurants and bars. Behind closed doors, there is a vast array of corridors, staircases, walkways and underground connections between the buildings. In order to provide effective medical and emergency treatment for players, it is vital that the medical team are aware of how to respond quickly and efficiently to incidents across the whole site with some courts being relatively difficult to access. It is also important to know how best to evacuate an injured athlete. This may not be as simple as it seems with many obstacles to negotiate. For higher profile matches with more media presence, it is not unusual for the doctor to be courtside, for example Finals Day.

Spending time at the AELTC with the medical team provided fascinating insight into what is involved in supporting athletes in perhaps the highest profile tennis tournament in the world. I would like to thank Professor Mark Batt and Dr. Ian McCurdie for this opportunity.


  1. Tennis injury data from The Championships, Wimbledon, from 2003 to 2012. I McCurdie, S Smith, P H Bell and M E Batt. Br J Sports Med January 11, 2016


Ajai Seth is a Sport and Exercise medicine Registrar and General Practitioner in the West Midlands Deanery. His sporting interests include racket sports, football, athletics and expedition medicine. He is currently Birmingham City Academy and GB para-archery doctor.

Farrah Jawad is a sport and exercise medicine registrar in London and co-ordinates the BJSM Trainee Perspective blog.

Pedals, medals and splinters – working at the 2016 Track Cycling World Championships

31 Mar, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Clint Gomes

In March of this year I had the fortune to work at the 2016 Track Cycling World Championships in London. This was the first time that the annual event was held in the UK since the 2008 World Championships in Manchester. I was similarly lucky enough be track-side and witness Team GB winning 9 of the 18 gold medals on offer. Unsurprisingly I was extremely excited about the opportunity to work at this year’s competition but also prepared to be extremely busy!

The event took place at Lee Valley Velopark in London (nicknamed the ‘Pringle’ after a well-known potato-based snack). As an Olympic and World Championship standard track it measures 250m in length with banking of up to 45 degrees at each end. The five days of competition saw 390 riders from 42 countries take part in 10 events – namely the sprint, keirin, time trial, scratch race, Madison, points race, individual pursuit, team pursuit, team sprint and omnium. The latter is the track-cycling equivalent of the heptathlon and decathlon seen in athletics and comprises 6 events – a scratch race, individual pursuit, elimination race, time trial, flying lap and points race.

Track-medical team and approach

The track medical team primarily consisted of two doctors and two paramedic teams. Each morning we reviewed the days racing schedule and identified the events with a higher than average risk of collisions/accidents – generally those with multiple bunched riders and particularly those involving bunched sprints. On paper the Madison with its 32 riders completing 200 laps (50km) with 10 sprint laps, constant overtaking, undertaking and arm-sling changeovers is a recipe for disaster but thankfully wasn’t due to the immense skill of the riders! During these higher-risk races, a doctor was situated at the entry point to each straight (with paramedic back-up), ready to rapidly access the track in the event of an accident.

As with all pre-hospital care the most important consideration was for personal safety, especially since the riders can reach speeds in excess of 80kph during sprints and can therefore be passing the same point of the track again (and potentially an injured rider) within 10-15 seconds. Like elite athletes in many sports I discovered that the riders were extremely tough and would often be in the process of getting ‘back in the saddle’ in order to re-join the race as I arrived on scene. In cases where an athlete required further track-side assessment and the race had not yet finished, the race would often be neutralised (racing suspended) by the race officials until the athlete had been assisted or immobilised and transported from the scene.

Risk of crashes and typical injuries

Track burn

Track burn

Over the course of the event there were 10 crashes involving 19 riders, usually involving between 1 and 3 riders per crash. Crashes were evenly spread across the keirin, omnium elimination, points and Madison races. Only one rider required immediate treatment and immobilisation prior to hospital transfer. Seven other riders subsequently presented to the medical team after the race with the others most likely being seen and treated by their team’s own doctor. The majority of injuries seen were abrasions with two riders also being suspected of having sustained a fractured clavicle.

Abrasions of varying size and depth are the ‘bread and butter’ of track cycling injuries. They are often contaminated with splinters from the wooden track necessitating removal to prevent tattooing. This was carried out using lignocaine gel and a surgical scrub brush with an appropriate instrument to remove more deeply embedded splinters – unless particularly large and requiring surgical removal as was the case for a Malaysian sprint cyclist in 2011! Thankfully more severe injuries are very rare although a British cyclist did sustain pelvic and vertebral fractures in a sprint race earlier this year – illustrating the need for the track-side medical team to be appropriately trained and suitably experienced to deal with major trauma.

Ultimately the event lived up to my expectations and although tiring it was thoroughly enjoyable. I feel very privileged to have witnessed up-close some amazing displays of speed, endurance , bravery and tactical nous by the riders with the highlight being Mark Cavendish and Sir Bradley Wiggins teaming up to win the Madison in the most dramatic of fashions to repeat their success in the same event in 2008. Yet again Team GB managed to come out on top of the medal table with 5 golds and 9 medals in total. I for one will certainly be staying up and ‘tuning in’ to see how they get on in Rio later this year!

Clint Gomes is an ST6 SEM trainee in the North West currently based at the English Institute of Sport in Manchester. Prior to entering the programme he completed training in Emergency Medicine. He has a particular interest in the management of musculoskeletal injuries, physical activity promotion and sports event medical cover.

Farrah Jawad is an ST5 SEM trainee in London. She co-ordinates the BJSM Trainee Perspective blog.

Improving the clinical practice for athletes and military service people with Exercise Induced Leg Pain: my path from MD to PhD

9 Feb, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Dr. Dave Roscoe

I am a Sport and Exercise Medicine (SEM) and Rehabilitation Medicine trainee currently posted at the Defence Medical Rehabilitation Centre (DMRC), Headley Court. I am also a qualified GP and have recently had the privilege of completing a PhD in SEM under the supervision of the University of Surrey (UoS) Department of Biomedical Engineering. I focused on the diagnosis and management of Exercise Induced Leg Pain (EILP) and Chronic Exertional Compartment Syndrome (CECS).

Before transferring to the Army in 2014, I spent most of my career as a Royal Navy Commando Medical Officer working alongside the Royal Marines (RM). EILP, in all of its guises: shin pain, anterior knee pain, stress fractures, CECS and to a lesser extent Popliteal Artery Entrapment, is a well-documented problem blighting careers in military populations. As part of the medical team at the Commando Training Centre, home of the longest and most arduous initial infantry-training programme in the world, we saw a high volume of these overuse lower limb injuries on a daily basis. Consequently, this is a topic I have been interested in for many years. I wanted to improve the overall clinical service that can be offered to athletes and servicemen with EILP by trying to clarify the nature of the underlying pathology in CECS and identify the risk factors that might predispose to the condition. I wanted to investigate the effectiveness of the different treatment modalities and try to define, once and for all, the criteria by which a diagnosis of CECS should be made.


I first had to identify the most suitable host institution for this type of project so prior to commencing my PhD in 2012, I scoped several universities to establish which could provide the most relevant expertise and supervision. I decided on the UoS as it offered the perfect mix of research experience (UoS has one of the longest established biomechanics laboratories in the country), relevant ongoing research and quality of facilities with access to excellent academic supervision. I then had to successfully navigate the Defence Deanery Higher Degree Board, Ministry of Defence Ethics Committee and the UoS Higher Degree Panel. This required presenting a detailed background and rationale including assessments of potential clinical and financial benefits of both the work and myself. The whole application process took a year to complete after which I spent 3 years working in the gait laboratory at DMRC. I worked with a great team whilst learning a range of techniques including dynamic invasive intramuscular compartment pressure (IMCP) measurement, gait analysis with 3-dimensional kinematics, plantar pressure measurement and EMG as well as study design and statistical analysis. No mean feat for a mere GP!

All of these experiences informed my thesis, the abstract of which is below:

The Diagnosis and Management of Chronic Exertional Compartment Syndrome in the UK Military Population.


CECS presents as EILP in the lower limb is presumed to be a result of elevated IMCP although this has never been proven. Doubt exists regarding the validity of the diagnostic criteria for CECS, the role of IMCP and the outcomes from surgical management[1]. An alternative biomechanical condition, Anterior Biomechanical Overload Syndrome (ABOS)[2], was proposed to account for the symptoms of CECS and a programme of gait re-education (GRE) was introduced although no primary research has been carried out to investigate the predisposing biomechanical and anthropometric factors for CECS or ABOS.


Case-control studies investigated the anthropometric, biomechanical and IMCP differences between CECS cases and asymptomatic controls. A post-surgical study evaluated the role of IMCP and a longitudinal study investigated the effectiveness of GRE and the nature of resultant biomechanical changes.


Cases were significantly shorter than controls with specific biomechanical changes not akin to ABOS[3]. IMCP levels were significantly higher in cases than controls allowing for the extraction of diagnostic criteria for CECS[4]. Surgical responders had similar IMCP to controls but significantly lower than non-responders3. The biomechanical components of ABOS were not replicated. GRE made changes to gait but these did not correspond to those identified in the CECS case-control study3.


The intrinsic role of IMCP in CECS has been confirmed allowing for improved diagnostic criteria1. Use of these criteria should allow for improved patient selection for surgery and improved outcomes. Novel insights to the biomechanical and anthropometric differences are provided allowing for the proposal of a new pathophysiological model whereby extrinsic training conditions impact upon intrinsic risk factors leading to CECS. These studies do not support the existence of ABOS or the use of GRE in the management of CECS.

Having completed my thesis, I have had time to reflect. From the outset of the application process to getting completed works published4, a PhD is an endurance challenge like no other. At times, it can seem like a near impossible and ill-defined mountain to climb; along the way there are setbacks, false-summits and hidden crevasses to traverse. You must tread carefully and determinedly, breaking it down into smaller, more manageable questions but never lose sight of the overall goal. A PhD teaches skills in every professional domain not just the specific area of interest. Learning how to formulate and investigate research questions and critically interrogate evidence and data is as challenging as it is rewarding.

I have been very fortunate to lead research projects that have provided significantly improved and more accurate diagnostic criteria for CECS as well as delineating many previously unknown risk factors for the condition. We have analysed the different treatment options using the same criteria for success and used this to inform the commissioning of services. Our results have allowed us to be more certain in our selection of patients for intervention and to better identify those treatment modalities that offer a good chance of success. However, only time will show if this translates into a meaningful change in wider practices and clinical effect. Overall, I would recommend getting involved in research to all in SEM as I think there are a host of clinical domains that could benefit from well structured research and the casting of light into the dark places in order to further improve and standardise care for our athletes and populations.


David Roscoe is a Sport and Exercise Medicine (SEM) and Rehabilitation Medicine trainee currently posted at the Defence Medical Rehabilitation Centre (DMRC), Headley Court, Surrey.

Farrah Jawad is a Sport and Exercise Medicine registrar and co-ordinates the BJSM Trainee Perspective blog.


[1] Aweid et al., “Systematic Review and Recommendations for Intracompartmental Pressure Monitoring in Diagnosing Chronic Exertional Compartment Syndrome of the Leg.,” Clinical Journal of Sport Medicine : Official Journal of the Canadian Academy of Sport Medicine 22, no. 4 (July 2012): 356–70, doi:10.1097/JSM.0b013e3182580e1d.

[2] Andrew Franklyn-Miller et al., “Biomechanical Overload Syndrome: Defining a New Diagnosis,” British Journal of Sports Medicine 0, no. 2012 (September 14, 2012): 201209124, doi:10.1136/bjsports-2012-091241.

[3] Papers in submission.

[4] David Roscoe, Andrew J Roberts, and David Hulse, “Intramuscular Compartment Pressure Measurement in Chronic Exertional Compartment Syndrome: New and Improved Diagnostic Criteria.,” The American Journal of Sports Medicine 43, no. 2 (November 18, 2014): 392–98, doi:10.1177/0363546514555970.

Physical Inactivity and the Clinical Champions Programme

4 Jan, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Dr Dane Vishnubala @danevishnubala

Earlier this year, Public Health England (PHE) put out a job advert for GP Clinical Champions. The job involved educating clinicians on: (i) the benefits of physical activity in primary and secondary prevention of disease and (ii) the harms of inactivity.

As I was just finishing GP training and about to embark on Sport and Exercise Medicine training, the idea of teaching and talking about exercise and health sounded perfect. So I applied and got the role as a Clinical Champion.

The clinical champion network is definitely an interesting initiative and one worth sharing with you.

So lets start at the beginning- why is there a need for the physical activity champions network?

Inactivity in the UK

Inactivity is a major problem in the UK. The statistics do not paint a pretty picture. As well as GPs, this is a great opportunity for the SEM community to make a difference and show a different side to our specialty.

Key facts

* I have taken most of the statistics from the Every body Active, Every day document by PHE that is well worth a read.

1 clinical champion

45% of women are not active enough for good health


2 clinical champion

19% of men and 26% women are physically inactive.

We also know that as well as females, ethnic minorities and those who identify as lesbian, gay or transgender are all likely to be less active. As you can see inactivity is a major issue and we must look at ways of tackling this whilst ensuring we also involve these harder to reach subsections of the populations.

Graph in terms of risk to mortality:

3 clinical champion

How do we compare to other countries?

4 clinical champions

Poorly would be the answer! *Note the definition of inactivity in this study is different to the one used previously.


Here is the recent info graphic launched in England at the last PHE conference to get across the key messages of the UK CMOs’ guidelines. An infographic for children 5-18 years is currently under development.

5 clinical champion

The Clinical Champion Programme


We know from research that we as clinicians in all specialties can make a bigger impact. We have a lot of patient contacts and opportunities to change behaviour.

The aim of the Clinical Champion Programme is to educate clinicians around the following:

  • Physical activity and it’s benefits
  • Risks of inactivity
  • Current inactivity statistics.
  • Exercise physiology in primary and secondary prevention
  • Making every contact count
  • Motivational interviewing
  • Local provisions for physical activity

To do this PHE decided to recruit GPs in various areas with an interest in physical activity to deliver the education. GPs were selected after an interview process which including assessing their teaching and presentation skills.

Here is our promotional flyer:

 5 clinical champion


As part of the role, I attended a two day training session, which brought the Champions together for sessions on teaching skills and to review, discuss and practice the materials; it also provided the opportunity to gel as a cadre of professionals. In addition the Champions all attend a national PHE physical activity conference.

The physical activity champions

It was great to see the range of Clinicians in the GP Clinical champion team. As well as the Public Health England team, we have a range of GPs with considerable physical activity experience, some with an MSc in Sport and Exercise medicine, others dually trained in SEM and GP, and even RCGP Physical Activity leads. This range of people has led to some interesting discussions on our team forum and further in team education. I have learned a lot about the public health side of this problem since joining the initiative, as much from the other champions as well as the training.

Delivery Experience

The education has been tailored to be either 30min to 2-3 hours approximately. I have delivered to VTS groups, GP groups, hospital specialty and trainee groups and grand rounds amongst others so far. The variety of specialties and the length of time can be a challenge however PHE has presentation and lesson plans for different groups. There has been some travelling to do and I have delivered in Yorkshire, Lancashire region and even one in London. The general feedback from the physical activity champions is that the training has been well received and that we are providing education in an area not provided at medical school or usually further training unless you happen to be a sport and exercise medicine or public health trainee!

Top 5 tips for clinicians

  1. Understand the patient, their motivations and barriers- softer GP skills are definitely useful here.
  2. Motivational interviewing or elements of it can be helpful in behaviour change.
  3. Understand local provisions so that you can signpost appropriately for that individual.
  4. Remember that even if you don’t make a change today, you may cause a change later- don’t underestimate the impact we can have.
  5. MAKE EVERY CONTACT COUNT! Prevention is always better than finding a cure!

Further resources

  1. PHE- Clinical Champion Teaching session– Contact
  2. Motivational interviewing- BMJ
  3. BMJ Learning Modules.
  4. Intelligent health
  5. Motivate to Move:
  6. Exercise Works

Can you help?

Can you help us spread the message? If you feel any groups of clinicians, you are involved with would benefit from the session then…email us to get a free education session booked in and delivered by one of our Physical Activity Clinical Champions. Contact us at


Dr Dane Vishnubala MBBS PGCME MRCGP FHEA, is a Sport and Exercise Medicine Registrar in Yorkshire, GP and part time lecturer at Leeds Beckett University in Physical Activity and Health. He has a strong interest in exercise medicine and still actively works in the Exercise Referral industry as a BASES/REPs Level 4 Certified Exercise Professional.

Twitter: @danevishnubala


Farrah Jawad is an ST5 doctor in Sport and Exercise Medicine in London.  She co-ordinates the BJSM Trainee Perspective blog.

“”DEET me up, Scotty” Experiences at the Vth Commonwealth Youth Games, Samoa 2015

21 Sep, 15 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Farrah Jawad

I had the unique opportunity to take part as Team Doctor, alongside Dr Mike Loosemore, Consultant in Sport and Exercise Medicine, at the The Vth Commonwealth Youth Games took place from 5th – 11th September, 2015 in Apia, Samoa.  Samoa is a small country in the Pacific Islands with a population of around 187,000 – a little more than the population of Brighton.  The Games took place over two sporting complexes, the Tuanaimato and Apia Park Sports Complexes, which hosted aquatics, archery, athletics, boxing, lawn bowls, rugby sevens, squash, tennis and weightlifting. Team England arrived with a total of 60 athletes plus coaching and support staff.



As preparation, we had to consider both the medical and environmental risks we might encounter.  Samoa currently has an outbreak of Dengue fever, a mosquito-borne illness which can result in a range of symptoms from a flu-like illness to a severe haemorrhagic state.  As there is currently no vaccine available, the best way to prevent being bitten by the affected mosquito is to use insect repellent with DEET and wear long sleeves and trousers (the latter a challenge in the Samoan heat).  Chikungunya is a similar mosquito-borne illness that can result in flu-like symptoms and chronic joint pains.  Prevention is similar, by covering up where possible and using insect repellent with DEET.  We advised athletes and staff to each bring around 3 bottles of DEET with them.  We kept some spare bottles of DEET and sunscreen by the front door of the Team England accommodation to allow athletes to use these on their way out each day.

Another challenge was the heat. We advised Team Leaders and athletes to use sunscreen and seek shade where possible, and to keep well hydrated.

We took medical equipment with us to cover a variety of potential scenarios and took some medications from the UK as well as sourcing some from a local Samoan pharmacy. We advised Team Members to bring their own personal supply of any of their own usual medications, plus paracetamol, loperamide, antihistamines and a few others, in addition to their insect repellent with DEET and sunscreen.

On the ground in Samoa

The HQ staff and medical team arrived days before the Games commenced to prepare for the athletes’ arrival a few days later.  During that time, I went to all the venues to establish what medical facilities and personnel were available.  The Samoan doctors and nurses were friendly and accommodating and happy to show me the medical setup.  I also traveled to the local hospital to meet some A&E staff to see the facilities and what resources were available.

In an effort to give back to the local community that was so welcoming, Louise Bell, our Chef de Mission, organised a trip for the team to two local schools, Loto Taumafai and Aoga Fiamalamalama (schools for children and young people with special educational needs) to play games and demonstrate different sports. Team England donated some sport equipment, team kit and puzzles to the schools.

Overall it was a great experience for me to learn more about how a large multi-sport Games is run, consider the medical situations that may arise, and respond to them in the most effective manner possible.

The Vth Commonwealth Youth Games allowed our young athletes to go to the other side of the world and experience a multisport competition and culture in a country quite different to that of their home.

thank you samoa

Team England won a total of 12 gold, 16 silver and 16 bronze medals over the five days, finishing third place overall in the medals table – very well done, Team England!


Farrah Jawad is an ST5 doctor in Sport and Exercise Medicine in London.  She co-ordinates the BJSM Trainee Perspective blog.

Fit to Live? Genotype-positive Phenotype-negative Hypertrophic Cardiomyopathy

3 Jul, 15 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

By Dr Christopher Speers

At a recent Cardiac Conditions Clinic with Dr William Bradlow (Consultant Cardiologist) at the Queen Elizabeth Hospital Birmingham, we reviewed a number of patients with Hypertrophic Cardiomyopathy (HCM) and Dilated Cardiomyopathy (DCM).

genesThese consultations produced numerous patient-centered exercise-related discussions, but one case in particular raised a challenging and novel exercise medicine dilemma; genotype positive-phenotype negative HCM.

This is seen in patients who have a family history of HCM, and have tested positive for a genetic mutation attributed to causing HCM.  However, they have normal ECGs and echocardiograms with no evidence of cardiac hypertrophy or left ventricular outflow tract obstruction. Therefore they are diagnosed as having ‘genotype positive-phenotype negative HCM’.

Are genotype positive-phenotype negative individuals at increased risk of Sudden Cardiac Death?

We know that HCM is phenotypically heterogeneous; with the age of onset, severity of symptoms, and relative risk of Sudden Cardiac Death (SCD) showing inter-patient variability even within family members with the same genetic mutation (1, 2).

Some studies have shown that particular genotype sub-groups, for example mutations of Troponin TNNT2 correlate with a higher risk of SCD.  There is also evidence that some genotype positive-phenotype negative individuals have impaired relaxation of myocardium, altered energy metabolism, and phenotypic changes such as crypts. This inherently abnormal cardiac tissue may predispose to adverse events (2, 4).

However there are only a very small number of cases of SCD in genotype positive-phenotype negative individuals described in the literature, making deductions challenging (2, 3, 4).

At present the clinical implications of these pre-hypertrophy cardiac changes are not known, and the real risk of SCD is thought to be significantly lower than that in clinical HCM (2, 4).

So what exercise advice should we give?

The governing bodies are clear on competitive sport exemption in individuals with clinical HCM. However the genotype positive-phenotype negative sub-group poses both an ethical and practical dilemma; it is not known if individuals will develop left ventricular hypertrophy or when this may occur. Developing clinical HCM would increase the risk of SCD, becoming particularly dangerous if undiagnosed in those engaged in competitive sport. At present there is no agreed international consensus on management.

The 36th Bethesda Conference 2005 states; ‘Although the clinical significance and natural history of genotype positive-phenotype negative individuals remains unresolved, no compelling data are available at present with which to preclude these patients from competitive sports, particularly in the absence of cardiac symptoms or a family history of sudden death.’ (5)

However the European Society of Cardiology (ESC) 2006 position paper states; Based on the level of present knowledge, the decision for participation in competitive sport should be individualized. However, prudent recommendation suggests restriction of these individuals from participation in competitive sports, especially those with high cardiac demand (i.e. high dynamic, high static sports), and to recommend prudently amateur and leisure time sport activities.’ (6)

2014 ESC guidelines on HCM management have since relaxed this approach to some degree; ‘In definite mutation carriers who have no evidence of disease expression, sports activity may be allowed after taking into account the underlying mutation and the type of sport activity, and the results of regular and repeated cardiac examinations.’ (4)

It is clear that this subgroup of genotype positive-phenotype negative individuals need long-term regular follow-up with 12-lead ECG, echocardiogram, exercise stress testing and cardiac MRI, particularly if engaging in regular sporting activity. The adjunct of genetic profiling may aid with risk stratification in the future.

The implications of this diagnosis and potential restriction from sporting activity are far reaching for the individual, having both negative psychological and physiological effects.

An individualised risk stratified exercise prescription with careful specialist follow-up must form the basis of current and future management. However further research is essential to enable us to understand the natural history of genotype-positive phenotype-negative HCM and the real risk of SCD in this sub-group.

What did we recommend?

In line with the ESC recommendations we worked with our patients, exploring the potential risks and current evidence, and together formulated an exercise prescription. We agreed upon maintaining a healthy level of fitness through regular exercise at an intensity level where one can still hold a conversation, with the stipulation of regular cardiology follow-up.


  • Ho CY. Genetics and clinical destiny: improving care in hypertrophic cardiomyopathy. Circulation. 2010; 122:2430Y40.
  • Sylvester, J. et al. The Dilemma of Genotype Positive-Phenotype Negative Hypertrophic Cardiomyopathy. Current Sports Medicine Reports. Volume 13 & Number 2 & March/April 2014.
  • Richard, P. et al. Advising a cardiac disease gene positive yet phenotype negative or borderline abnormal athlete: Is sporting disqualification really necessary? Br J Sports Med 2012;46(Suppl I):i59–i68.
  • 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. European Heart Journal. (2014) 35, 2733–2779.
  • 36th Bethesda Conference. Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology. Vol. 45, No. 8, 2005
  • Pelliccia A, et al. Recommendations for participation in competitive sport and leisure-time physical activity in individuals with cardiomyopathies, myocarditis and pericarditis. European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:876–885.

Dr Christopher Speers BSc(Hons) MBChB MRCP(UK) is a ST3 Sport and Exercise Trainee in the West Midlands Deanery. He works with Bristol Rugby, British Universities and Colleges Sport, and is an Amateur Boxing Association Medical Officer. 

Dr Farrah Jawad is an ST4 Sport and Exercise Trainee and co-ordinates the BJSM Trainee Perspective blog.

2015 Women’s Ice Hockey World Championships: An SEM trainee’s perspective

24 Jun, 15 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective – A BJSM blog series

As part of my Sport and Exercise Medicine training I attended the 2015 International Ice Hockey Federation Women’s World Championships, Division II A, held in Dumfries this April. This was my first experience both of travelling with a national team and working with a female winter sports squad. It certainly lived up to my expectations and more!

hockey1Women’s Ice hockey is an amateur sport in this country; our Great Britain squad ranged in playing experiences, providing me both with the biggest challenge and greatest opportunity to learn. A handful of players had moved abroad with their university studies to experience playing in Sweden and Canada, whilst the majority are based in the UK normally training and playing only once a week, for clubs with no to very basic medical support.

Strategy for Injury Prevention

The World Championships are a round robin tournament, formed of six teams including Great Britain, who won silver in 2014, Kazakhstan. They had been relegated from the division above while Croatia, South Korea, Poland and New Zealand, had been promoted from the division below. This format presented both a physical and mental test to the squad, and it was our aim as the medical team to ensure as many of the players remained fit to play across all five matches in seven days. In order to combat this we introduced ice baths post heavy practice sessions and matches from the outset of the tournament. For most this was a completely new concept and although we were not liked by the squad at first, within days the players recognized the benefits and by the end of the week I think we had converted them all!

“Off the ice” health challenges

Unfortunately, it was sickness off the ice which kept me most busy during the tournament. As many team doctors have experienced I’m sure, gastroenteritis can spread like wild fire! We faced the added challenge that squad members sharing hotel rooms, but we also shared the hotel with one of the other countries in the competition and the tournament officials.  So not only were squad members sharing bathroom facilities and changing rooms, they were also exposed in the self-service restaurant and transportation to and from the hotel. I highlighted basic hygiene techniques within the team meeting setting at the first sign of gastroenteritis affecting a player and was able to source multiple single isolation rooms at the hotel. Given that the tournament was being held in Scotland, I had sufficient access to a well-stocked medical bag in order to manage each patient’s symptoms appropriately.

Giving back to sport for women and girls

During one of the rest days, a ‘Learn To Play’ event had been organized where local school girls attended a one hour session full of basic ice hockey skills stations. Members of the Great Britain squad instructed the girls as they went around the stations. It was clearly a successful event with the children leaving full of memories and the players feeling good having given something back to both the local community and sport itself.

Success and lessons learned

The squad were successful in winning a silver medal at the championships. Their disappointment at the time, may serve to further fuel proactive  changes and development in the sport. I would encourage anyone working in the field of Sport and Exercise Medicine to get involved with winter sports, particularly women’s ice hockey: it is an exciting, high impact, highly skilled game where women’s participation is on the increase; there is the need and demand for medical team support within the club structure. It provides additional challenges to pitch-side care when the field of play is an ice rink – I managed not to be an additional casualty!

See related BJSM publications:

Injury rates, types, mechanisms and risk factors in female youth ice hockey

Seasonal variation in fitness in a women’s National League hockey squad

A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what?


Dr Philippa Turner, a Sport and Exercise Medicine Registrar in the East Midlands. I am currently working as the Aston Villa Women’s team Match Day Doctor, FA Super League Division 2. I’m a keen netball player, having previously played at the British University Games, and I am running the 2015 Virgin London Marathon for Asthma UK.

Dr Farrah Jawad is a ST4 doctor in Sport and Exercise Medicine and coordinates the BJSM Trainee Perspective blog.

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