Getting the best out of athletes: Load, Injuries and Determination

By Rory Heath (@roryjheath) and Xanni von Guionneau

The Arsenal SEMS Conference “Marginal Gains in Sports Medicine” provided deep insight into attaining and maintaining the highest level of sporting performance in professional athletes. As the elite athletic population becomes more homogenous, the value of “marginal gains” in achieving podium finishes and championship titles is more important than ever.

Below are our takeaway points focusing on Load, Injuries and Determination; we hope they provide a competitive edge to your practice!


  • One way to objectify ‘performance’ is to measure “load”; the stressors that affect a player’s physical and mental homeostasis. “Load” can be separated into “external”; the demands placed on an athlete through training and competition, or “internal” factors of psychological stress from the sport or other life events. (Halson, 2014)
  • “External” load is sport specific. Cyclists may calculate load by analysing power output for time duration, whilst Rugby players must factor in collisional, metabolic and mechanical load. E.g. Load = ((Duration X RPE ) +( X Number of collisions ))
  • Load is unique to the individual and their playing position – a tight head prop will experience larger mechanical and collisional loads than a scrumhalf, requiring individualised parameters
  • Monitoring “load” allows tailoring of future sessions and tapering/peaking approaches to match days
  • Be aware of OED and MEDs! The Optimum Effective Dose (OED) has its place in the preseason, building strength and speed. When load increases in-season, the Minimal Effective Dose (MED) is adequate to maintain or further training adaptations
  • “You can collect as much data as you want, but without conversations, data is meaningless” Nigel Jones
  • Success with metrics such as HRV require communication and understanding amongst the entire team, from medical staff to players
  • Understand the demands of your player to provide focused training and treatment – “Don’t put square pegs in round holes” Shad Forsythe


  • Although data is only a small part of the decision, “load” can predict injury risk – “The majority of our players have an injury – it is our job to help them decide whether this will stop them playing” Nigel Jones
  • The management aim for >90% player availability by optimising load management, recovery and player resilience
  • If an injury occurs, Dr Jones’ team will reflect on its aetiology.
  • Shad’s athletes focus on hip extension and thoracic mobility in their recovery work

Return to Play”

  • The injury doesn’t leave just a physical toll. Psychological effects (doubt, insecurity, fear) change the athletes view towards injury, subsequently effecting recovery and return to play
  • Returning to play comprises physical, psychological and contextual factors
  • Recovery is not a linear path and is not predictable!
  • A tailor made programme can address stressors and psychological barriers unique to the individual
  • Communication between all members of the medical team, the athlete and the family is needed to maintain steady progress
  • “Visualisation” of RTP is a useful tool to speed recovery
  • Pair a newly injured athlete with someone further down the road to recovery: positive mentoring potentiates a positive outlook


  • Although athletes may perform with injuries or in pain, they should not participate if there is a significant risk of further injury.
    • Imagine player recovery as a battery; a full battery of green bars shows adequate recovery, whilst a power level fading into a red zone implies poor recovery, accompanied by the risk of illness, injury and burnout. Effective recovery serves to recharge the battery and prevent the athlete going into the red
  • It is important to promote player understanding and ownership of their recovery. England Rugby use a “points based” system to incentivise recovery, providing players with quantifiable targets of positive actions
    • For example; a player is required to total 100 points in a day, selecting activities from broad headings of food, sleep, “headspace” and more specific methods such as cryotherapy or contrast hydrotherapies


  • Approach athletes through both a team and an individual approach. Shad’s approach at Arsenal for ‘Off pitch support’ is 80% team (Positive lifestyle changes, mobility maintenance and muscle activation sessions) and 20% individual (focused physiotherapy, individual dietary prescription)
  • Athletes can be “admired for talent but respected for work ethic” – Richard Moore
  • “I worried I hadn’t suffered enough” is a common thought of elite athletes pertaining their preparation for competition.
  • “Hunger” stems from early enjoyment and positive experiences of sport during childhood, with a subsequent feed-forward mechanism of further training to improve winning. On the contrary, “Hunger’ is brought by a fear of losing
  • Determination can be genetic, illustrated by the products of selective breeding of huskies. However, this genetic role is difficult to isolate in humans – “Performance in sport is highly multifactorial”Nigel Jones
  • There is no ‘cookie cutter’ approach to talent ID. Jamie and Andy Murray have very different character traits and personalities, yet both have succeeded in their sport
  • The first thing to look at in Talent ID is the parents – the environment shapes athletic potential.

We’d like to thank Arsenal SEMS for holding such an exciting and informative conference! See you there on March 21st next year!

You can find Dr Nigel Jones (@theboxingdoctor), Shad Forsythe (@ShadForsythe), Dr Clare Arden (@clare_ardern) and Mr Richard Moore (@RichardMoore73) on Twitter.

Interested to find out more? Check out related BJSM material:


J Windt, T J Gabbett, D Ferris, and K M Khan. 2016.Training load–injury paradox: is greater preseason participation associated with lower in-season injury risk in elite rugby league players? 

JL Cook, C Purdam. 2012. Compressive load a factor in the development of tendinopathy?



Rory Heath (@roryjheath) is a fourth year medical student at King’s College London with a keen interest in SEM and elite performance. He has played county rugby and rugby league for London and South and enjoys blogging. He is currently Secretary for the nationwide Undergraduate Sports and Exercise Medicine Society (USEMS), an Ambassador for Move.Eat.Treat and organises SEM-focused events in the London area. 

Xanni von Guionneau is a second year medical student at King’s College London. She has a background in multiple sports including rowing and swimming, currently representing the KCL Cycling and Triathlon teams! She has a growing interest in Sports Medicine, especially Orthopaedic injuries. 


Halson SL. Monitoring Training Load to Understand Fatigue in Athletes. Sports Medicine (Auckland, N.z). 2014;44(Suppl 2):139-147. doi:10.1007/s40279-014-0253-z.

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