T H I R D E D I T I O N - E U R O 2 0 1 6 R E L E A S E

@UNDERGRADSEMS

page 5Dr Dean Chatterjee explains what life is like as a team doctor at Notts County Football Club and the responsibilities he has in the club.

page 12Dr David Eastwood provides a concise article on diagnosing hamstring injuries and the main principles of management and return to play.

page 21David Dunne highlights the importance of optimising nutrition in injury recovery and the key dietary element that can enhance recovery.

U S E M S E - M A G A Z I N E

FEATURED ARTICLES

Words that usually signal the beginning of a joke. In this context, however, it reflects the nationalities of the three editors for this quarter's football medicine themed edition. If you were a betting person, you'd have gotten long odds for predicting that (at the time of writing) the Welshman (Steff) would be the only one of us with a team left to support in the Euros.

The success of 'minnows' in Euro 2016 and the 2015/16 Premier League has once again reminded us of football's capacity to capture the imagination and inspire. Sports medicine has played a central role in these amazing stories, with Joe Ledley starring for Wales just over a month after a reported leg fracture. Additionally, how Leicester City managed to keep their key players fit and performing optimally for 38 games of the season is something which will be studied for years to come.

Football is a truly global game, and its potential to act as a catalyst for positive change and good health throughout the

world cannot be underestimated. It is very exciting that the opportunities in football medicine, and the research underpinning the specialty, is moving to reflect this. One of the most significant recent initiatives is FIFA's Diploma in Football Medicine, and we are delighted to have Dr Mark Fulcher and Prof Jiri Dvorak explain more about the Diploma in this edition.

We hope you enjoy reading this quarter's edition. As ever, your feedback is welcomed as we strive to grow the USEMS eMagazine to enhance the knowledge of students looking to explore a career in sports medicine.

Yours in Football,Sean Carmody (Ireland), Fadi Hassan (England), Steffan Griffin (Wales)

EDITORS’ NOTE

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"An Irishman, an Englishman, and a Welshman..."

Editors’ Note USEMS E-Magazine

FIFA Diploma USEMS E-Magazine

Over the past twenty years F-MARC has published more than 430 articles in peer reviewed journals. These have covered a diverse range of topics ranging from injury prevention, the use of football as a health intervention as well as the effects of playing football in a variety of environmental conditions. It is however important to recognise that many clinicians are not able to reliably access medical journals, or do not regularly review the scientific literature. As a result it can be difficult to disseminate this knowledge. In an effort to disseminate this knowledge, and to improve the care of players around the world, FIFA are developing the FIFA Diploma in Football Medicine. The diploma is offered free of charge, is 100% online and can be completed at the users own pace.

To illustrate the potential benefit from implementing some of the F-MARC research, considering the effects of a worldwide implementation of the ‘FIFA11+’ injury prevention program and the FIFA ‘11 steps for the prevention of sudden cardiac death’ projects are good examples. The last ‘big count’ showed that there are almost 300 million football players, in 207 countries around the world. F-MARC’s research has shown that on average each player sustains about two injuries per year. This means that there are more than 600 million football-related injuries worldwide every year. By applying the learning’s from F-MARC’s studies it should be possible to substantially reduce the risk of injury and to improve the treatment of those injuries that do occur. For example if we are able to implement the FIFA 11+ injury prevention program on a global scale we should be able to reduce the number of injuries by

between 30-50%. By treating the injuries that do occur more effectively, we should be able to substantially reduce the associated morbidity. In some situations, for example by managing sudden cardiac arrest more effectively, we may also be able to save lives. Spreading the message regarding the significance of ‘non-contact’ collapse, encouraging clinicians to perform pre-competition medical assessments and advocating for AED’s on sidelines should all help achieve this goal.

Medical schools offer little exposure to sports medicine and in many cases musculoskeletal medicine in general. The FIFA Diploma in Football Medicine is an ideal entry point for students who wish to learn more about sports medicine and the issues specific to football. While it is a comprehensive tool it may stimulate users to learn more and to pursue a career in sports medicine. It is also readily accessible and can be used to quickly answer clinical questions “on the fly”. The content of the diploma is designed primary for doctors and other allied health practitioners, who have little or no sports medicine knowledge or experience. There is however material which will appeal to anyone with an interest in sports medicine. Each module is written by a group of international experts in the relevant topic. The authours share written content, media content (like audio and video lectures) and provide links to journal articles and other resources. High profile players also share their experiences with injury and what they have learned during their recovery.

While the diploma is designed to be completed as a ‘whole’ it can be used in a variety of ways. For example one might want to learn specifically about a particular area and complete a single lesson or module only. By completing the FIFA Football Medicine Diploma you will be able to demonstrate your interest in Football Medicine and improve the standard of care you provide your patients.

At present there are a total of twenty modules online. A further twenty-two modules will be added over the next four months.

Dr Mark L Fulcher (@DrMarkFulcher)Sport and Exercise PhysicianEditor in Chief FIFA Football Medicine Diploma

FIFA DIPLOMA IN FOOTBALL MEDICINE

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“F-MARC is proud to offer another milestone project to translate research results and evidence to optimise the care of football players at all levels of the sport. It is an ideal resource for medical students and junior doctors as it requires no pre-existing sports medicine knowledge. It is free to complete and is ready accessible on any digital device. The goal of the diploma is to prevent some of the adverse effects of the game, such as injuries, sudden cardiac death and doping. We want to show too that the game can be used as a health-enhancing leisure activity, as proven by the Copenhagen Group under the lead of Prof. Peter Krustrup and Jens Bangsbo,”. We hope that you will register and join the more than 10,000 clinicians who are already using the site.

Prof. Jiří Dvořák, Chairman of F-MARC and FIFA Chief Medical Officer.

FIFA Diploma USEMS E-Magazine

Undergraduate PerspectivesInterested in Sports and Exercise Medicine? Three Things You Must Know!

CONFERENCE REVIEW USEMS E-Magazine

CONFERENCE REVIEWFMS: Return to play 2016

In a rare moment of free time at the Isokinetic “Football Medicine Strategies” Conference, an audience of thirty prospective SEM clinicians gathered to attend an exclusive Q&A with Dr Peter Brukner and Professor Karim Khan. We all know SEM can be a challenging career; as a student it can seem impossible to gather practical experience. Furthermore, competition to apply for training programmes is daunting, whilst job security is ever-changing. Luckily, Brukner and Khan discussed some of the key areas to ensure your success at staying in the game!

Get Experience• Even the biggest and best careers start with humble

beginnings. Dr Peter Brukner started gathering experience as a volunteer for his Melbourne

University AFL team. This commitment of standing on rainy pitches in biting cold winds was rewarded by the position of Team Doctor for the Australian Universities AFL team on their international tour to Canada. •Get Qualified! Even as an undergraduate, a basic First Aid qualification could be the key to getting some pitchside experience. •When Brukner and Khan were training, vocational practical experience were

a necessity to become an SEM physician; nowadays, certified training programmes and structured academic courses (MSc., PhD etc.) allow easy access to develop your interest. Don’t let these courses just become three letters after your name; use them to show your determination by involving yourself with research projects, experience and skill development.

• If you are struggling to find practical experience, further your learning by hitting the books. Demonstrating interest in a sub-topic within SEM is attractive to clinics and sports teams and makes any further applications for experience stand out from the rest.

• Social media streams on Twitter, Facebook and Google+ can be a great tool to explore the SEM landscape; keep up to date with recent publications, follow conference snippets from @BJSMPlus and interact with the Undergraduate Sports and E x e r c i s e M e d i c i n e S o c i e t y @UndergradSEMS.

INTERESTED IN SEM? THREE THINGS YOU MUST KNOW

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“How do we get the job?” “How do we stand out?” “Where can we get experience from?”

CONFERENCE REVIEW USEMS E-Magazine

Work In A Team • Respect your elders (and experience).

Recognise that the medical team comprises multiple professions with unique strengths and weaknesses, working in a ‘horizontal model’.

• D e s p i t e d i f f e r i n g b a c k g r o u n d s a n d qualifications, many members of the team will have far more relevant experience than you. This “Horizontal model” of team organisation respects the value each component, removing an executive decision by incorporating an inclusive, multi-disciplinary approach to management.

• ‘Up-skill’ yourself! Use your exposure to different professions to share valuable skills. Teach your physiotherapist some medical management and receive skills in soft tissue work in return. You both develop as practitioners and can provide better and more efficient care to the patient.

• Know your own limits. When a patient presents with a problem, a clinician’s job is to identify this pain, specify further causes and manage appropriately. Even if you have ‘up-skilled’, often the best management is to refer to an appropr iate expert in the f ie ld; be i t physiotherapist, a nutritionist or a performance coach.

Be Valuable! • You’ve got to be good. If you’re not good, you

will fall by the wayside. • Exp lo re your in te res ts and embrace

opportunities to ‘up-skill’ with the aim of “differentiating” yourself. By enhancing your skill-set you provide unique value to teams and clinics; resulting in better employment prospects.

• “Networking” carries negative connotations of excessively goal-orientated shallow socialising. Instead, view gathering experience in SEM and

working as part of team as an essential process of self development. The organisations you contribute to and the friends you make will naturally take you to bigger and better things.

• Be patient; gathering experience may take time to get off the ground. However, once the initial inertia is overcome, opportunities will begin to gather at an increasing pace! Once the first structures are put into place, your network will grow itself and opportunities will arise.

Takeaway pointsI. Volunteer at your local/university sports club

to lay the foundations for your SEM career.II. Turn up, show interest and be friendly - the

interesting cases will come to you. III. Enhance your individual value within a multi-

disciplinary team by sharing your knowledge. IV. Get your network off the ground and watch it

grow - via experience, conferences & social media.

V. Develop your skill set to improve your patient care.

VI. Differentiate yourself by pursuing specialist interests.

VII. Start now!

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 cu r ren t l y Sec re ta r y f o r t he na t i onw ide Undergraduate Sports and Exercise Medicine S o c i e t y ( U S E M S ) , a n A m b a s s a d o r f o r Move.Eat.Treat and organises SEM-focused events in the London area.

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CONFERENCE REVIEW USEMS E-Magazine

LIFE AS A TEAM DOCTOR

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Life as a SEM doc USEMS E-Magazine

Dr Dean ChatterjeeNotts County Football Club team doctor

I would like to thank USEMS for giving me the opportunity to share my experiences of being match day doctor at a professional football club.

I have been undertaking duties as match day doctor for 2 years now and thoroughly enjoy every minute of it. It has taught me the importance and value of working in a team environment as well as gaining experience from physiotherapists, sports scientists and sports therapists a l l associated with the club. I canno t emphas ise enough the importance of working together to get the best out o f the

players and the best results for the team.

A typical match day starts early for myself. I get to the ground in the morning and do a check of the medical supplies and equipment and make sure everything is in place. I check the oxygen tanks are filled and the defibrillator is tested. I then meet up with the rest of the match day team. This includes the f i r s t t e a m physiotherapists, sports scientists, sport science interns and an osteopath.

At the club I work at we put a large degree of emphasis on continuing professional development

( C P D ) . We t a k e turns in teaching on a range of subjects from sports injuries, rehabilitation models a n d p i t c h s i d e e m e r g e n c y s c e n a r i o s . T h i s allows a discussion during and after each lecture and creates a learning environment where experiences and opinions of each individual are vital for enhancing the day.

A f t e r t h e C P D session and before the arrival of the p l a y e r s a r o u n d lunchtime I run a s e s s i o n o n Emergency Action protocol (EAP). This is v i ta l for each

match day and that t h e E A P t e a m individually knows their role at pitch side and after each game. We have an EAP board in our medical room. We go through the EAP for cardiac a r res t , gene ra l trauma and head i n j u r y . T h e paramedic for the match day is also invo lved in the EAP session. Each action protocol is m e t i c u l o u s l y r e h e a r s e d a n d

gone over so that everyone on the EAP team knows their role in depth. The EAP team involves the same people every match day so that there are no discrepancies in how the EAP runs at pitch side. This is vital for player safety and their wellbeing. We also practice and r e h e a r s e t h e extraction of a player from the pitch and have the same team l e a d e r f o r t h e e x t r a c t i o n t e a m every match day.

O n c e w e h a v e performed the EAP session the players start arriving and go

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USEMS E-MagazineLife as a SEM doc

through their various pre-match protocols which include massage and strappings. The first team physiotherapists and sports scientists look after the players while I discuss with them any minor complaints or worries they have prior to the game. Once the players are out for their warm up 1 hour before the match starts we invite the away team physiotherapist into our medical room. I then go through the EAP with the EAP team again and the away team physiotherapist, as I also cover the away team as they may not have a travelling doctor with them.

Already you can see how much is gone through each match day and the game has not even started yet!! Once the game starts I sit right behind the dugout along with the rest of the EAP team. It is vital to watch the players during the game and not always the match. In the current climate it is important to be aware of ‘off the ball drops’ with the potential for a cardiac arrest scenario. If a player does go down injured, the first team physio will run on and assess the situation. I will be standing pitch side at this point ready to run on if I am required. I always have my medical bag and defibrillator with me at all times. If I do go on then the extraction team is ready at pitch side with the stretcher or scoop in case we need to remove a player from the pitch.

Once the game is over, it is not necessarily the end of the day for me. I wait in the medical room to see if any players require any treatment for any minor injuries or knocks they may have picked up during the game. If any player has had a head injury and had been deemed fit and safe to play on by myself, I will thoroughly assess them again after the game with the rest of the EAP team according to the FA concussion protocols.

This is just a small description of what my job involves as match day doctor. I love and enjoy what I do and learn more and more every game. It is vital working as a team and it also means the players learn to trust us and know we are ready to look after them should anything happen on the

pitch. I would not be able to work as well or feel confident that the EAP was in place if it were not for the team around me. I encourage anyone who wants to be involved in sport and not just football to experience a match day at a club and see the hard work and dedication it involves.

Dr Dean ChatterjeeNotts County Football Club team doctorThe ECOSEP junior doctors committee (ECOSEP JDC) have a Twitter and Facebook page to raise awareness of research, courses, conferences and career pathways into SEM. These are regularly updated by committee members to provide the latest events and projects. On the Facebook page members are also encouraged to share their own ideas and post things that they find relevant to SEM.

ECOSEP news update Summer 2016:! 1.! Dr Malliaropoulos Nikos, General Secretary of ECOSEP, is happy to offer medical student electives in Thessaloniki at his sports medicine clinic they can contact him for more info at contact@sportsmed.gr! 2.! ECOSEP are co organising the 2016 podiatry sports medicine conference with reduced rates for undergrads-  http://www.scpod.org/conference/2016-podiatric-sports-medicine-conference/ 

Twitter: @ECOSEP_JDCFacebook: ECOSEP Junior Doctors

Website: http:/ /www.ecosep.eu/Junior-Doctors-Committee

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Infographic by: Rob Canfer

Football Medicine has never been in a better place. And I say this is both with the head and from the heart. As we watch the best of European football compete in France this summer, we need to look beyond the tricks and flicks on the field, and focus on the team behind the team. Not just the personalities that sit on the bench close to the coaching staff and substitutes, but the processes and player preparation techniques that are executed daily during the tournament af ter months of strategy, planning and dry runs. The days o f p layers be ing evacuated from the pitch piggy-backing the physiotherapist or an ex-player with a diploma and a “magic sponge” are gone forever. Now Football Medicine leads the development of Sports Medicine globally. It performance cycles and travel schedules are the most challenging of any sport, its players are some of the highest paid on the planet and the number of stakeholders involved (from managers to agen ts , to t v commentators to extended families back in the player’s homeland) is o f t e n m i n d b o g g l i n g a n d complexifying in the same vein. The future of Football Medicine is for sure bright, but there are challenges ahead.

Before considering the future we need to think about the past and present of Football Medicine.

The biggest single influencer on the development of Football Medicine has been Broadcast Revenues, led by the Premier League. The game is awash with funds, but not always blessed with the right sense or instinct to spend it wisely. Very often the administrators of the game are accused of too much money “going out of the game”.

Football Medicine though has benefited and been challenged in the same breath. In 1994 when FIFA established the F-MARC department (FIFA Medical Assessment and Research Cen t re ) th rough a collaboration of Professor Jiri Dvorak (then the team physician for the Swiss National Team at the World Cup in the USA) and a certain Roy Hodgson (who was coaching that same team and they exited early, so had time to discuss together), the size of the medical department at the top level club could be counted on o n e h a n d . T h e r a t i o o f physiotherapists to players was often 1:20, and the doctors were part-time and in most situations without any qualifications specific to the care of Footballers and their injuries. In the domestic leagues, the manager’s

nationality was most likely the same as the country of the team, and there would be 2-3 international players in the squad. Language skills were not seen as an important part of the job for the Football Medicine team. Opportunities also for continued professional development were scarce and infrequent, and little research was being published in this area.

Turn the clock forward 20 years, and we find ourselves in a different world. Yes the game has changed in his speed and demands, especially the n u m b e r o f e x p a n d e d c u p c o m p e t i t i o n s a n d i n c r e a s e d associated workload. But the most significant change has been in the size, dimension and sophistication of Football Medicine. This is both in respect to staff, facil it ies and collaboration. Now there are 50 FIFA Medical Centres of Excellence, monthly articles in the British Journal of Sports Medicine, and the largest Sports Medicine conference in the world (2000 delegates from 80 countries) is focused on Football Medicine strategies for player care and injury management. Football Medicine doctors are now front page news, as they defend their right to obey the ethical code of medicine

FOOTBALL MEDICINE HAS NEVER BEEN IN A BETTER PLACE

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Football medicine USEMS E-Magazine

Mike Davison - The Managing Director of Isokinetic London

and the laws passed by the game itself. Ratios of physiotherapists to players is now down to 1:5 in many clubs and staff often converse in French, Spanish and German.

Where does the discipline go next though ? The “Future of Football Medicine” is the title of our next conference at Barcelona’s Camp Nou in May 2017. It is not simply a title, it is a call to action to envision the next 10 years, campaign for a better future for players and practitioners, and decide upon real actions to see this vision reached. At the highest level for sure we will see an even greater level of investment, which in turn can only help give us the opportunity to enhance player care. We must though be careful not just to invest in fashionable technologies but in “know-how” and things that really make a difference. Alongside this there will be increased attention and scrutiny of medical practice and scientific advancement, especially as it is foreseeable that there will be live broadcast data for physical and physiological data such as heart rate, stress levels and effort expended. It is therefore in the themes of clinical governance and risk management, injury prevention and communication (internally and externally) that much of the focus needs to be.

Clinical governance and risk management seem to be from another type of industry, like construction. Through agreed new standards on minimum qualifications, safety equipment and protocols, insurances and reporting, the end should be always be performance related in both the athletic and behavioural aspects.

Sitting alongside this is the underpinning of availability of players. Managers, Chief Executives and fans alike demand the opportunity to see the best players in the team pitted against the opposition. Prevention is much more ethical, sustainable and cost-effective than treatment and cure. The issue is how do we better prevent injuries, or more so, how to we avoid many of the injuries, especially the non-contact, that often blight the game ? We have to as a community face the facts that hamstring injuries lead to the highest number of games missed, and have done for 20 years. Despite all of the investment into space-age knowledge and facilities we have not made a dent. We have to find a way to individualise the injury

prevention interventions and improve our communication on the WHY of the exercises to both players and managers. Without improved compliance and quality of execution, we are wasting our time and resources.

It is though communication where Football Medicine needs to improve in order to make another step change in development and contr ibut ion. Communication is not what you say, it is what the other person hears or interprets. This can be clinician to clinician, from clinician to player, from clinician to manager or executive manager. Get it wrong or be untimely and it can impact injuries and team performance. UEFA’s injury study group this year identified communication as the 4th most significant risk factor for non-contact injuries amongst 33 Champions League clubs. The success of Leicester’s title run this year was fundamentally based upon excellent departmental and club wide communication.

I invite you therefore to come to Barcelona next May, to one of the homes of football, to help plot this future.

Mike DavisonThe managing director of Isokinetic London

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Football medicine USEMS E-Magazine

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Infographic USEMS E-Magazine

Hamstring injuries USEMS E-Magazine

HAMSTRING INJURIESDr David Eastwood

W i t h t h e E u r o p e a n Championships almost upon us, the speculation regarding injuries and the availability of top-class international players is rife.

Already, Northern Ireland’s Jamie Ward, Spain’s Diego Costa and England’s Phil Jagielka have sustained hamstring injuries close to t h i s s u m m e r ’ s m a j o r t o u r n a m e n t , t h e repercussions affecting some more than others.

Hamstring injuries are the single most common injury in football (1). In the recent 2014 FIFA World Cup, almost two-thirds of total injuries affected the lower extremity, with thigh strain (including the hamstring) being the most frequent diagnosis (2).

Anatomy and functionThe hamstring consists of s e m i t e n d i n o s u s , semimembranosus and the long and short heads of biceps femoris muscle bellies. The tibial branch of the sciatic nerve innervates most of these muscles.

The primary actions of hamstrings are hip extension and knee flexion. As a muscle group not particularly tested in the function of every day living, they are prone to injury. Strains arise as the musc le g roup r e s i s t s a p o t e n t eccentric load (3).

C u r r e n t l i t e r a t u r e proposes hamstring injuries involve at least t w o d i f f e r e n t mechanisms:1. H i g h s p e e d i n g

running2. S t r e t c h i n g t o

e x t r e m e j o i n t position (4)

B o t h o f t h e s e mechanisms can be i n f l i c t e d o n t h e football field. The mechanism aids the clinical history and can point to the site and extent of an i n j u r y. P r o x i m a l injuries with tendon involvement could mean a longer layoff time.Risk factorsT h e m o s t w e l l r e c o g n i s e d r i s k factors of hamstring injury are previous injury and age (5).

This highlights the i m p o r t a n c e o f a n effective rehabilitation programme after injury and the appropriate time for reintroduction to competitive sport. Re-injuries have been shown to cause longer absences from football (6).

Strength imbalance is a l s o a w e l l -d o c u m e n t e d r i s k factor. Concentric and eccentric assessments of the hamstring can identify players at risk. This is one of many reasons why muscle strengthening is core to football training.

HAMSTRING INJURIES

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Hamstring injuries USEMS E-Magazine

Diagnosis and return to playClinical assessment is essential in the evaluation of hamstring injury.

Bruising and swelling are commonly found on inspection, with weakened knee flexion on examination. Increased flexibility when compared to the contralateral side can also be found (3).

MRI and ultrasound can often assist in diagnosis and prognosis. Shorter time to return to play is associated with normal appearance on MRI (7). Hamstring injuries are graded radiologically using Peetron’s grading scale (1 to 3) (8).

A study I undertook whilst on a clinical placement at Sunderland FC compared MRI vs clinical diagnosis in predicting return to play. My results showed that there was not a significant difference between the two methods. Most injuries (18/27) were given the same MRI and clinical grading. MRI grading however, appeared to underestimate injuries. Injuries assessed as low grade in fact led to more days injured than predicted (9).

ManagementProfessional players are usually managed with a short rest period. The underpinning principles of soft tissue recovery – PRICE (protection, rest, ice, compression and elevation) are utilised to enhance the recovery process.

Mobilisation is then gradually reintroduced. Enough time (sometimes up to a week) must be given for rest, however longer time without exercise will adversely affect fitness. Progressive stretching and lengthening helps to recondition the injured muscle. This can start with isometric (joint angle and muscle length remain the same) and progress to isotonic exercise. Load can also be introduced, before moving onto football-specific exercise.

Surgery is reserved for severe injuries often involving the tendon.

Implications in professional football

A strong relationship with the coaching staff is required to update them about progress in rehabilitation and the presence of risks such as re-injury.

Summary1)! Hamstring injuries are common in professional football.2)! Communication between the medical and coaching staff is essential with regard to lay off time and return to play.3)! MRI and Ultrasound can add value to diagnosis and prognosis, but clinical assessment is the mainstay.4) Management is multifactorial and should be

tailored uniquely to each player. Nonetheless, a rest period followed by training of gradually increasing intensity is the recipe to recovery.

Dr David Eastwood1) R D Hawkins, M A Hulse, C Wilkinson, A Hodson, M Gibson. The association football medical research programme: an audit of injuries in professional footballBr J Sports Med 2001;35:43-472) A Junge and J Dvořák. Football injuries during the 2014 FIFA World Cup. Br J Sports Med 2015;49:599-602.3) E S Abebe, C T Moorman, W E Garrett. Proximal Hamstring Avulsion Injuries: Injury Mechanism, Diagnosis and Disease Course. Operative Techniques in Sports Medicine 2012, Vol.20 (1), p.2-7.4) C Askling, M Tengvar, T Saartok, A Thorstensson. Sports related hamstring strains—Two cases with different etiologies and injury sites. Scand J Med Sci Sports, 2000, (5) pp. 304–307.5) A M C Beijsterveldt, I G L Port, A J Vereijken, F J G Backx. Risk Factors for Hamstring Injuries in Male Soccer Players: A Systematic Review of Prospective Studies. Scandinavian Journal of Medicine & Science in Sports, 2013, Vol.23 (3), p.253-263.6) J Ekstrand, M Hägglund, M Waldén. Epidemiology of muscle injuries in professional football (soccer). Am J Sports Med 2011; 39:1226-1232.7) T O Clanton, K J Coupe. Hamstring strains in athletes: Diagnosis and treatment. J Am Acad Orthop Surg,1998, (4) pp. 237–248.8) P Peetrons. Ultrasound of muscles. Eur Radiol 2002; 12:35-43.9) D Eastwood. Hamstring injuries in a premier league football team. MRI vs. clinical diagnosis. Br J Sports Med 2014;48:21.

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PARALYMPIC YEAR

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I’ve been fortunate enough to work in disability sport since 2003, and for us medical staff involved in this area of sports medicine the Paralympic year is a busy (but exciting) one. P l a y e r s a r e o b v i o u s l y desperate to be a part of one of the biggest sporting events in the world, and as the staff responsible for their health, well-being, and performance it is clear that we have a big role to play in that process. My specific area of work is with Cerebral Palsy (CP) football, and I am currently the team physiotherapist with the GB CP squad and due to travel with the squad to Rio in September. One aspect of disability sport which separates i t f rom m a i n s t r e a m s p o r t i s classification, the process of ensuring eligibil ity of an athlete to participate in the sport. Those of you who will

have seen Johnny Knoxville try and cheat the system in the 2005 movie “The Ringer” [1] will be pleased to know that in the real world, classification is a robust and multi-stage process carried out by experienced medical professionals. Our BJSM podcast in 2014 [2] discusses classification in more depth, and one of the CP players gives their perspective on this process in this podcast. Bench testing, football drills, and observed play in competitive games are all

used to help determine which class the athlete is eligible to compete under. It is generally a stressful time for an athlete, but once selected the athlete can then focus on achieving their sporting goals and satisfying their coaches and the Performance Directors (who make the big decisions about player selection for an event such as the Paralympics). A real-world problem that occurs in the Paralympic year (in my opinion, more than in other years) is the desire of players to be fit and

The Paralympics USEMS E-Magazine

Osman Ahmed - Physiotherapist to the Great Britain Cerebral Palsy Football squad

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available for selection, and the implications that this can have on their injury reporting. For some players they might be unusually reluctant to disclose injuries for fear of this counting against them for selection purposes, whilst other players might seek more regular review/consultation than they would normally in order to guarantee that they are at their optimal condition. The importance of garnering trust with the squad that you are working with is c ruc ia l here , as t rus t and confidence between players and the medical staff negates any issues that may arise relating to this. When selecting a squad for an event such as the Paralympics there is initially a “long list” that gets whittled down to the final squad, and then from there are players who are on the back-up list in case anyone gets an injury after selection which rules them out of the tournament. The importance of those players on the back-up list staying fit is paramount; in both the 2008 and 2012 Paralympics, the GB CP squad have had to select players from this list due to injuries to players on the original list. Aside from injury, players may also be deselected from the squad due to loss of form or behavioural issues- something that the coaching staff are keen to reinforce to the players! For those of you looking to work in SEM, I can strongly recommend spending some time working in disability sport. Although it may be perceived to be less glamorous or “sexy” than other forms of elite sport medicine, the athletes you are working with will provide you with clinical reasoning challenges that will be far more complex (and in my opinion more interesting!) than working with mainstream athletes. Along with colleagues at the Football Association, we are trying to understand more about the complexities of disability football [3] and are conducting some

research projects to assist this process. Hopefully as the new generation of SEM clinicians, some of you reading this will be able to make successful clinical careers for yourselves in disability sport, and you will be able to facilitate tomorrow’s athletes to achieve their sporting goals and aspirations.

Osman Ahmed Physiotherapist to the Great Britain Cerebral Palsy Football squadTwitter: @osmanhahmed

References: 1. “The Ringer” (Accessed 20th May 2016). Available from:

https://en.wikipedia.org/wiki/The_Ringer_(2005_film) 2. BJSM Podcast- “Cerebral Palsy Football” (Accessed 20th

May 2016). Available from: http://www.podcastchart.com/podcasts/bjsm/episodes/cerebral-palsy-football

3. Ahmed OH, Hussain AW, Beasley I, Dvorak J, Weiler R. Enhancing performance and sport injury prevention in disability sport: moving forwards in the field of football. Br J Sports Med 2015;49(9):566-7.

The fragile athlete USEMS E-Magazine

THE FRAGILE ATHLETEProfessor Cathy Speed - Consultant in Rheumatology and Sports & Exercise Medicine“In a medical context, the term fragile athlete can be used to describe an athlete, of any age, who is more susceptible than normal to injury or illness. The term is also often used in the context of coaching, when the individual is considered to be psychologically vulnerable under pressure.”

In this lecture, I will discuss the adult fragile athlete in the context of musculoskeletal issues, defining fragility, e x p l o r i n g m e t h o d s o f detection and reviewing briefly some appropriate interventions.

Recognis ing f ragi l i ty in patients can be difficult, but all patients who present with an injury should be assessed for the possibility that the injury is a fragility injury: one that under the circumstances of the injury should not have happened. Whether a bone stress fracture, joint or soft tissue injury, it is important to question why the injury happened, should it have happened and could there be an undiagnosed underlying medical condit ion which caused it?

Fragile athletes include those who sustain a fragility injury, those who present with r e c u r r e n t o r m u l t i p l e sequential injuries, those who are slow to return to play, or who suffer so many illnesses that they have prolonged periods of time out of sport (due to their vulnerability when they try to return), those with mental illnesses or psychological issues and those with body weight e x t r e m e s , u n d e r l y i n g diseases or nutritional issues. Whether an athlete is fragile or not is influenced not only b y t h e i r p h y s i c a l , p h y s i o l o g i c a l a n d

psycho log i ca l make -up (intrinsic factors), but also their particular sport and the specific skills and techniques needed to excel, as well as t h e i r r e g u l a r c o a c h i n g environment.

Predisposing intrinsic fragility fac tors inc lude: female g e n d e r, h y p e r m o b i l i t y, p ropr iocep t i ve de f i c i t s , deficiencies in movement, landing patterns and trunk control. Also, those who are too heavy for their sport or their injury, or too light, as well as those with a history of previous injuries or low back pain, those with nutritional deficiencies and/or diseases a n d t h o s e o n c e r t a i n m e d i c a t i o n s s u c h a s glucocorticoids.

Females are at much higher risk of fragil i ty injuries, ligament issues in particular (especially cruciate ligament d a m a g e ) d u e to a combination of factors that include proprioceptive impairment and deficits in landing pattern and trunk c o n t r o l . A l s o , t h e i r rehabilitation tends to be slower.

Hypermobile individuals are considered to be fragile, for some of the same reasons. But hypermobility is only the start of a diagnosis, as there a r e m a n y h y p e r m o b i l e a t h l e t e s w h o f u n c t i o n extremely well with stable h e a l t h . R e s e a r c h o n

hypermobile athletes and injury risk is scant, but a small study of footballers showed an injury risk of 22 injuries per 1000 hours played in hypermobile players, compared with 6 injuries per 1000 hours in non-hypermobile players. The risk of knee injuries was increased 5-6 fold, whereas no significant relationship with ankle i n j u r i e s w a s demonstrated (Pacey et al al, ajsm2010). Ankle restriction is far more l i ke l y t o make t he athlete vulnerable to injury. Issues related to low b o d y w e i g h t a r e a common cause of fragility. The female a t h l e t e t r i a d i s a complex sndrome of low body mass, reduced bone mass, menstrual d y s f u n c t i o n a n d p r o b l e m s w i t h reproductive function.

T h e e n e r g y i n t a k e threshold for negative effects is likely to vary between individuals, but it is considered that most athletes who have an energy intake ofless than 30 kilocalories per kg of fat-free mass per day, will fall into the more severe end of the spectrum. Changes are still likely in those who have energy intakes higher than this value if there is a deficit.

Subtle hypothalamic changes, a slowing of metabolism and broad hormonal dysfunction are considered very common. One result is poor bone and soft tissue health, including bone stress fractures, plus delayed healing. So if you see an athlete with bone or soft- tissue injuries which are slow to heal, do screen for

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The fragile athlete USEMS E-Magazine

eating habits to check the balance between calorific intake and exercise levels. This syndrome is not unique to females. Lightweight males can also be fragile, with reduced hormone levels and a slower return to sport. They are also susceptible. A l t h o u g h t h e a r c h e t y p a l f r a g i l e a t h l e t eis a lightweight female, it is worth noting that a very heavy athlete may also be fragile. Excessive body weight, in the form of adiposity or muscle, is a risk for fragility. Adiposity is pro-inflammatory, which drives the injury and slows tissue repair. The effects of increased mechanical load on, for example, a knee injury, may make an athlete fragile - but reducing weight may make them more vulnerable in their particular sport. The ideal body weight for someone presenting intra-articular injuries or lower patellar tendinopathy is often less than their usual weight, but this in turn may mean that they are too light to perform at a high level in their sport, in rugby for example.

So what is the best way to detect the fragile athlete and screen for fragility? A detailed history is necessary to identify the potentially fragile athlete, as is a physical examination to look for underlying intrinsic factors, patterns of injury or a slowness to heal or return to form. Some medical conditions can cause athletic fragility and impair soft tissue healing, so screening for conditions like vitamin D or iron deficiencies or hormone abnormalities is advisable.

In addition, consider the sport and the athlete’s training environment, as well as their support structures, both physical and social.

Different screening protocols suit different sports and there is much debate as to how sensitive or accurate these tests are. The Star Balance Excursion Test - one s i n g l e t e s t o f b a l a n c e a n d p r o p r i o c e p t i o n- has been shown to be a more sensitive predictor of injury than some other generic screening tools. It is also important to consider psychological screening for factors i n c l u d i n g a n x i e t y, f e a r, l a c k o f m o t i v a t i o n in rehabilitation and the absence of social support, which can all lead both to injury and to a slow return, just as fear of a recurrence can delay recovery.

The important thing is to use all of the information gleaned from a very thorough history, examination and screening tools to clarify the situation. Getting to know

your patient by seeing them regularly will enable you to judge when they are present ing wi th unexpected symptoms. If you suspect that an athlete is sustaining injuries too easily, but can’t pinpoint the reason, this is the time to refer the patient for a specialist opinion and further investigations. Similarly, those athletes who do not respond to s tandard treatments for their particular vulnerabilities should be referred.

One crucial factor which affects an athlete’s prognosis is their self-efficacy. Confidence, insight and engagement with the rehabilitation process will all positively influence the pace of recovery. Ensuring physical and psychological support and motivation is important. Resilience is a strong determining factor in outcome - both psychological resilience to cope with the stress and management of an injury and physical resilience to prevent a recurrence. Learning to cope with injury should be part of every young athlete’s training – there are huge demands placed on their bodies. Psychological and physical resilience training can both prevent fragile injuries and support fragile athletes.

Professor Cathy SpeedProfessor Speed specialises in the management of elite athletes and patients of all ages with arthritis and complex pain, bone and soft tissue conditions

Published by kind permission of The Fortius Clinic and The Football Medical Association

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Tissue damage, whether from surgery or injury, starts a 3 stage recovery process...1. INFLAMMATIONInjured tissues are deprived of their normal flow of oxygen and nutrient-rich blood. Pain, swelling, redness and heat are common.

Nutrition for the Inflammation StageInflammation is critical to the repair process. However, too much can cause additional damage. Below are some suggestions to optimise this stage of recovery...

Prioritise Anti Inflammatory FoodsAntioxidants in the fruits & vegetables may promote faster rates of recovery by reducing oxidative stress & inflammation, as well as supporting the immune system. Aim for 7-8 servings daily prioritising berries, cherries & green leafy vegetables. Additional dietary polyphenols & flavanoids can also have potent anti-inflammatory properties. Where possible try include pineapple (for bromelain), turmeric/curry powder (for curcumin), as well as dark chocolate & green tea. High quality unsaturated  & omega 3 rich dietary fats such as avocado, nuts/seeds, olive oil, flax & oily fish will provide energy for recovery & re-balance inflammation.

Keep Protein ConsistentDaily protein intake 2-2.5g/kg body mass is required to support muscle mass maintenance.

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David Dunne (@Dunne_Nutrition)

Nutrition USEMS E-Magazine

NUTRITION FOR INJURY RECOVERY

Aim for 4-6 protein meals/snacks daily spaced evenly every ~3-4 hours. Each meal/snack should contain ~0.3-0.5g/kg body mass of protein. Prioritise rapidly digesting sources with a high leucine content.

Avoid/Limit Pro Inflammatory FoodsConsult your team physician before adopting aggressive use of NSAIDs. Remember a certain amount of inflammation is critical to the recovery process. Heavily processed foods may have a pro inflammatory effect, slowing down the recovery process & should be avoided. As should alcohol. Consumption may decrease muscle protein synthesis rates; decrease testosterone secretion & can increase muscle loss.

2. PROLIFERATIONDamaged tissues are removed as the inflammation begins to settle down and temporary new tissue (scar tissue) is built.

3. REMODELLINGThe scar tissue that forms after the injury will be degraded and replaced with stronger more

permanent connective tissue as your rehab progresses.Nutrition for Proliferation & Remodelling Heavily processed foods may have a pro inflammatory effect, slowing down the recovery process & should be avoided, as should alcohol. Consumption may decrease muscle protein synthesis rates, decrease testosterone secretion & can increase muscle loss.

3 T’s of Protein1. Type: prioritise high quality protein sources that

are rich in essential amino acids, in particular leucine. These amino acids are the building blocks or "raw materials" required for muscle maintenance, growth & repair, with leucine acting as the "trigger" to muscle protein synthesis.   Not only do amino acids play a vital role in muscle mass maintenance & remodelling but they are also key regulators of immune function & hormone production.

2. Timing: to ensure a consistent supply of amino acids to the remodelling muscle and maximal rates of muscle protein synthesis aim to achieve your daily protein target by consuming equal doses of protein at evenly spaced intervals (~ every 3 hours) throughout the day.

3. Total: aim to consume 2-2.5g of protein per kilogram of bodyweight (2-2.5g/kg) per day. This should be consumed in equal doses of 0.3-0.5g/kg at evenly spaced intervals throughout the day.   For example, an 80kg male athlete may require 160g-200g of protein per day to help optimise recovery and his levels of muscle mass. His protein meal target therefore is 24g-40g per meal. Intake should be adjusted with the help of a performance nutrition practitioner.

QUICK TIPS TO MAINTAIN MUSCLE MASSSupplementationOmega-3 Fatty Acids, Branch Chain Amino Acids (Including Leucine), Creatine, & HMB may help

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support maintenance of muscle protein synthesis rates during a period of injury. Try having a "Injury Smoothie" daily as a snack, ideally post rehab/physio.Energy IntakeDuring reduced levels of energy expenditure during recovery from injury it can be challenging to achieve optimal macronutrient intakes. Prioritise protein intak and adjust both carbohydrate & fat type, timing & total according to training/rehab schedule & load.

StimulusAttention should be given to providing a resistance training stimulus to the uninjured muscle groups. Electrical stimulus (compex, etc) offers an alternative means to stimulate muscle protein synthesis & attenuate muscle loss during the recovery from injury.

AlcoholAlcohol can increase the severity of an injury & outcome of recovery. It should be avoided during as much as possible recovery from injury.Consumption decreases muscle protein synthesis rates, decreases testosterone secretion & can increase muscle loss.

REFERENCES1. Holt, M., et al. (2009). Fruit and vegetable consumption and its relation to markers of inflammation and oxidative stress in adolescents.2. Gonzalez, R., et, al. (2011). Effects of Flavonoids and other Polyphenols on Inflammation.3. Calder, P. (2001). Polyunsaturated Fatty Acids, Inflammation, and Immunity.4. Simopoulos, A. (2002). Omega-3 fatty acids in inflammation and autoimmune diseases.5. Calder, P. (2006). n�3 Polyunsaturated fatty acids, inflammation, and inflammatory diseases.6. Close, G., et al. (2016). New Strategies in Sport Nutrition to IncreaseExercise Performance.7. Wall, B., et al. (2015). Strategies to maintain skeletal muscle mass in the injured athlete: nutritional considerations and exercise mimetics.

8. Galland, L. (2010). Diet and inflammation. 9. Kelley, K., et al. (2007). Protein Hormones and Immunity.10. Phillips S. & Van Loon L. (2011). Dietary protein for athletes: from requirements to optimum adaptation.

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T h e p r e - c o m p e t i t i o n m e d i c a l a s s e s s m e n t (PCMA) involves a detailed exploration of the player’s g e n e r a l a n d musculoskeletal health. It is typically undertaken by t h e c l u b d o c t o r a n d p h y s i o t h e r a p i s t a n d i n v o l v e s a t h o r o u g h medical history, ‘top to toe’ examination of all bodily systems, musculoskeletal

examination and further investigations as required. I t p rov ides impor tan t baseline information about the athlete’s physical and mental wellbeing and is des igned to h igh l igh t potential problems that might arise from the high d e m a n d s o f f o o t b a l l training and match play. This includes detection of factors that may impair a

p layer ’s ab i l i t y to compete, such as existing injury risk factors or evidence of an overuse injury, as well as identifying m o r e s i g n i f i c a n t perhaps undetected h e a l t h p r o b l e m s i n c l u d i n g c a r d i a c pathology(1). It is helpful to consider the PCMA as broadly consisting of three elements, namely a general history and e x a m i n a t i o n , c a r d i o v a s c u l a r a s s e s s m e n t a n d o r t h o p a e d i c assessment. The g e n e r a l h i s t o r y

focuses on current and past medical complaints including specific enquiry into asthma, epilepsy, concussion or loss of consciousness, allergy, infectious diseases and mental health problems. A detailed medication and systems review w i t h f u r t h e r i n t e r r o g a t i o n o f positive responses also forms part of the general history.

A d e t a i l e d cardiovascular history is an important aspect o f t h e c a r d i a c assessment, exploring exertional symptoms including chest pain, e x c e s s i v e b r e a t h l e s s n e s s , palpitations, dizziness or syncope. Enquiry is m a d e i n t o f a m i l y h i s t o r y o f h e a r t disease (particularly under 55 years of age), cardiac arrest, sudden deaths or u n e x p l a i n e d r o a d traffic collisions(2). Examination should include inspection for

THE PRE-COMPETITION MEDICAL ASSESSMENTS: A PRACTICAL VIEWPOINT

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Dr Craig Sheridan - GP and Academy Doctor for Ipswich Town FC

Nutrition USEMS E-Magazine

stigmata of Marfan syndrome and cardiac auscultation to assess for murmurs and added sounds. Bilateral resting blood pressures should be recorded with palpation of peripheral pulses for their character and delay, which might indicate stenosis or coarctation. History and examination alone are insufficient to identify those at risk of sudden cardiac death (SCD) and a 12 lead ECG is also necessary(2-5). Abnormal cardiovascular assessment would prompt referral to a sports cardiologist for further investigation. As cardiac screening is now routinely undertaken it is not uncommon to perform a PCMA on a player under surveillance with a known cardiac abnormality. This might be a structural anomaly discovered incidentally such as bicuspid aortic valve or mild aortic regurgitation or ECG changes requiring further assessment. Normal ECG variants in athletes, changes suspected to represent ‘athletes heart’ or subtle ECG abnormalities can pose a diagnostic challenge(3, 6). In each instance it is crucial that letters and results of investigations are reviewed. This firstly enables a more complete understanding of the players’ medical condition and secondly ensures that any proposed follow-up investigations have occurred and are not overdue. If any investigations are outstanding it may be necessary to arrange these before medically clearing the player for training or before the club can agree the transfer. This scenario of ‘overdue’ investigations is worth cons ider ing fur ther. Incomplete fo l low-up investigations may put the athlete at risk as they continue to train with potentially inadequate safeguards in place. The fact that football players regularly transfer between clubs creates the potential for fragmented medical care. Furthermore, the typical fail-safes of larger medical organisations with automated recall systems may not be present in football clubs. Medical care may also be shared

between the medical team at the players home club and their international team. It is possible that outstanding investigations only come to light during these hand over periods necessitating last minute fast-track appointments and tests to ensure the player can be medically cleared to play or train with their country. It is therefore essential to develop systems within the club setting to ensure timely follow-up occurs as well as involving the player in their own care. At Ipswich we have developed a database and traffic light system, which is maintained by the medical department to ensure follow-up takes place as planned, with adequate time to arrange any proposed investigations.The musculoskeletal history should explore not only current and past injuries but identify potential risk factors for future injury. Previous injury is an important predictor for re-injury with time also taken to consider the management and rehabilitation of any injuries sustained by the player. Time lost from training due to injury and number of matches played is also useful information. There are no short cuts to the musculoskeletal examination, which involves thorough systematic evaluation of the spine, upper and lower extremities. Deficiency or asymmetry in strength, range of movement, stability and coordination are assessed. This may identify existing pathology, risk factors for future injury or evidence of incomplete rehabilitation from prior injuries. It is also a valuable baseline assessment of a new player, enabling comparison of these parameters at a future date. Ultrasound can also be a useful adjunct bedside musculoskeletal investigation. Depending on the findings of the musculoskeletal examination further investigation such as MRI may be necessary. Arranging last minute imaging can present logistical challenges with potential pressures from transfer deadlines and expectations from the manager, player or their agent. Developing good working

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relationships with a few musculoskeletal radiologists helps to navigate through these challenges effectively(7).For those interested in exploring the subject of medical screening further I would recommend reading the 2 chapters listed below from the F-Marc football medicine manual, which can be downloaded in PDF format from the FIFA website ( h t t p : / / r e s o u r c e s . f i f a . c o m / m m / d o c u m e n t /foo tba l ldeve lopment /med ica l /02 /67 /46 /09 /footballemergencymedicinemanual2ndedition_2015_webversion_neutral.pdf).I would also encourage anyone who hasn’t already registered for the free FIFA Diploma in Football Medicine to do so and complete the PCMA module. Lastly I would recommend reading the papers listed in the references on ECG interpretation and cardiac screening by Jonathan Drezner, which also provide an excellent review of the most significant cardiac diseases associated with SCD in young athletes i n c l u d i n g h y p e r t r o p h i c c a r d i o m y o p a t h y, arrhythmogenic right ventricular cardiomyopathy and ion channelopathies(3, 4, 6, 8, 9).Recommended Reading:F-Marc Football Medicine Manual. 2nd Edition. Chapter 2.1 General Medical AssessmentF-Marc Football Medicine Manual. 2nd Edition. Chapter 2.3 Prevention of Sudden Cardiac DeathF-March Diploma in Football Medicine. Http://www.f-marc.com/footballdiploma/ . Module PCMA.

References:1.! Drezner JA. Is cardiovascular screening in athletes justified? Inconsistent messages from the American Heart Association. Br J Sports Med. 49. England2015. p. 1428-9.2.! Wilson MG, Basavarajaiah S, Whyte GP, Cox S, Loosemore M, Sharma S. Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. Br J Sports Med. 42. England2008. p. 207-11.

3.! Drezner JA, Ackerman MJ, Anderson J, Ashley E, Asplund CA, Baggish AL, et al. Electrocardiographic interpretation in athletes: the 'Seattle criteria'. Br J Sports Med. 47. England2013. p. 122-4.4.! Drezner JA, Ackerman MJ, Cannon BC, Corrado D, Heidbuchel H, Prutkin JM, et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease. Br J Sports Med. 47. England2013. p. 153-67.5.! Drezner JA, Ashley E, Baggish AL, Borjesson M, Corrado D, Owens DS, et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy. Br J Sports Med. 47. England2013. p. 137-52.6.! Drezner JA, Fischbach P, Froelicher V, Marek J, Pelliccia A, Prutkin JM, et al. Normal electrocardiographic findings: recognising physiological adaptations in athletes. Br J Sports Med. 47. England2013. p. 125-36.7.! McCurdie I. Imaging in sport and exercise medicine: "a sports physician's outlook and needs". Br J Radiol. 2012;85(1016):1198-200.8.! Exeter DJ, Elley CR, Fulcher ML, Lee AC, Drezner JA, Asif IM. Standardised criteria improve accuracy of ECG interpretation in competitive athletes: a randomised controlled trial. Br J Sports Med. 48. England: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.; 2014. p. 1167-71.9.! Drezner JA. Standardised criteria for ECG interpretation in athletes: a practical tool. Br J Sports Med. 46 Suppl 1. England2012. p. i6-8.

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