Boxing in the Olympics


Rio de Janeiro - Robson Conceição derrotou na tarde deste domingo o cubano Lázaro Álvarez e vai a final do boxe categoria peso ligeiro. (Fernando Frazão/Agência Brasil)

The new look to Olympic Men’s Boxing  (photo: Fernando Frazão/Agência Brasil)

With summer holidays and work, I will be honest — I have not been watching too much of the Olympics on the television.  I have made a point to watch Michael Phelps’ last (possibly?) Olympic swim and Usain Bolt’s historic 100m gold medal performance.  I am a former track and field athlete myself, and so I also have witnessed Jamaica’s Elaine Thompson win the women’s 100m and South Africa’s Wade van Niekerk set the 400m world record.  I catch up on news in the newspaper when I wake up (for instance, the story of Anna Sofia Botha is possibly the most heartwarming of these Games).  But watching live TV?  Not so much.

Between the track events, I have caught some of the men’s boxing and I, like possibly many of you CJSM blog readers, have been struck by the absence of head protection.  Our world of sports medicine is big, and I’ll confess I had not been aware of the rules changes going into these Olympics regarding the non-use of this protective equipment for men’s boxing:  since the 1984 Los Angeles Olympics, mandatory headgear has been in place for boxers until now, in Rio.

There has been some controversy over this issue — both when it was introduced as a safety measure, and now in 2016 when it has been removed, also for stated safety reasons:  the incidence of concussions is expected to decline without the headgear in place.  The International Boxing Association (AIBA) made this rule change since the Beijing Olympics, and International Olympic Committee (IOC) spokesman Mark Adams is quoted as saying, “AIBA provided medical and technical data that showed the number of concussions is lower without headgear. They have done a lot of research in the last three years. The rule will go ahead for Rio.”

Some of that research has been published in our journal, including this cross-sectional observational study on the use of head guards in AIBA boxing tournaments.   The results of this study show that referees had to stop matches for head injuries more often when boxers were wearing head gear than when they weren’t.  At the end of the day, after integrating all the available current evidence, it was understood that the headgear was not sufficiently protective to prevent concussions (no surprise there: the holy grail of contact sports may be effective, ‘concussion proof’ head protection), and, instead, promoted more frequent hits to the head — a good example of ‘risk compensation’ in injury prevention.

The CJSM study, authored by a group including lead author Michael Loosemore and senior author Julian Bailes, has already generated a fair amount of debate on social media and commentary in the media, including the New York Times.  We have been receiving a fair number of ‘letters to the editor’ regarding the study since these Olympics have begun, and we will be publishing both the letters and the authors’ responses soon.  A robust debate looking at the evidence, and pointing toward where research must head to resolve this issue — that is a ‘contest’ that will extend beyond Rio and into Tokyo, site of the 2020 summer games.  Stay tuned to the blog and to CJSM to stay abreast of this issue.

Major League Baseball: the All-Star game and more


CitiField, Home of the New York Mets
and host to the 2013 MLB All-Star Game

Major League Baseball’s (MLB) All-Star game takes place tonight at CitiField, the home field of the New York Mets.  The All-Star game has a rich history and in the culture of MLB has always represented, at the very least, the mid-season pause where the collective baseball community could reflect on the game:  where it has been, and where it is going.

zack greinke at 2009 MLB all star game

Zack Greinke, pitching in the 2009 MLB All-Star game
(He will not play in the 2013 edition)





From the perspective of sports medicine, this baseball season has been a rich one already.  From Zack Greinke’s clavicle fracture and surgical repair, to Derek Jeter’s recovery from ankle surgery and quad strain, to the, er, inimitable ARod’s hip surgery and the ever growing issue of PEDs in MLB,  it’s been a very interesting spring and early summer.

In the spirit then of this mid-season pause, I wanted to sit back and review just a few baseball-related, clinical sports medicine issues before we all enjoy the game tonight. Read more of this post

Injury risks of artificial turf in soccer

Ever since Astroturf was first installed at the Houston Astrodome back in the 1960’s, there has been much controversy about the use of artifical grass playing surfaces used in a number of different sports. The main issues relate both to ‘playability’ and the way that the surface properties affect playing dynamics, and to the risk of injuries occuring on artificial surfaces.

Despite this controversy, artificial surfaces have been used in a wide range of different sports and in some famous venues. In American Football, for example, the New England Patriots and the New England Revolution share an artificial playing surface at the Gillette stadium, whilst most field hockey games these days are played on an artificial surface.

In the UK, I vividly remember the early artificial surfaces used in football back in the 1980’s, when many teams dreaded the trip to Queens Park Rangers, Luton Town, Oldham Athletic and Preston North End on account of their ‘plastic pitches.’ At the time, most of the pitches were derided by football fans due a combination of their poor playability and recurrent carpet-burn injuries sustained by the players and they lost favour quickly.

I was therefore somewhat surprised to read on the BBC sport website that there are moves afoot for a return to the use of artificial turf in the Football League, headed by Wycombe Wanderers and Accrington Stanley. My interest was all the more galvanised by the fact that Wycombe play in the same league as the team that I look after, Leyton Orient. From the Clubs’ point of view, the argument for installing an artificial playing surface centres on economics, with artificial pitches being much easier to maintain than grass. In addition, it is easy to host other events at stadia with an artificial surface such as pop concerts and other social events. There are independent advocates both for the use of artificial surfaces in soccer, and against their use.

As a team physician, my immediate thoughts turned to the risks of injury when playing on artificial playing surfaces. There is no doubt that there has been an evolution of the quality of playing surfaces over the years. Astroturf, developed back in the 1960’s, was known for it’s somewhat abrasive properties, and the risk of ‘carpet burn’ injuries was all-too-apparent to anyone who dared to perform a slide tackle or similar manouvre on the surface. These were not the only injuries of concern on early artificial surfaces, and there were plenty of papers in the literature that reported an increased risk of other injuries on artificial playing surfaces (see Ekstrand & Nigg, 1989 ; Girard et al, 2007 ; & Steele & Milburn, 1988).

However, the modern third and fourth generation pitches are very different in construction and often promoted as possessing the same properties and injury-risk profiles as grass. For example, Dragoo and Braun reported that the overall injury rate on the new surfaces is comparable to that seen on natural pitches.

Therefore, it was with interest that I read a new review article by Williams and colleagues published in Sports Medicine in November 2011 of football injuries on third and fourth generation artificial turfs compared with natural turf.

The authors performed a literature search using Cochrane Collaboration review methodology to evaluate injury characteristics and risk factors for injury on artificial turfs compared with natural grass turf over a range of ‘football’ codes including Rugby Union, Soccer and American Football. The outcome measure used to assess each included study was the incidence rate ratio for injuries on natural and artificial turf, calculated using natural turf as the reference.

The authors found an increased incidence of ankle injury playing on artificial turf in 8 cohorts, although injury risk for knee injuries was inconsistent. There seemed to be a trend towards less muscle injuries playing on artificial turf compared with natural turf. There was, however, no data on head injuries and concussion.They concluded that their included studies showed a trivial difference in injury rates between third and fourth generation artificial turf when compared with natural turf. Limitations of the study were accepted, including the need for longitudinal prospective cohort studies including an adequate number of teams, and controlling for confounding factors such as weather and gender etc, and I think that there were indeed a number of important limitations of the study such that it is perhaps difficult to draw conclusions based on the evidence we have.

For me, the jury’s still out on the issue of injury risk with the newer artificial playing surfaces, but the traditionalist in me still thinks that soccer was meant to be played on a natural surface. Even if the risk of injury is, in time, proved to be no greater on an artificial surface, having watched soccer played on 3rd generation pitches and having played on them myself, I can say that from my point of view it never really looks or feels the same.

What do our readers think?

Should we entertain an expansion of artificial playing surfaces? If so, should that be just within specific sports? How do you think that we should assess injury risk on these surfaces and do you think that the effects seen would be different in different sports?

CJSM would like to hear your thoughts.

References :

Ekstrand J, Nigg BM. 1989. Surface-related injuries in soccer. Sport Med 8(1):56-62

Girard O et al. 2007. Effects of playing surface on plantar pressures and potential injuries in tennis. Br. J. Sp. Med. 41(11):733-8

Steele JR & Milburn PD. 1988. Effect of different synthetic sport surfaces on ground reaction forces at landing in netball. J. Sport. Biomech. 4(2):130-45

Dragoo JL & Braun HJ. 2010. The effect of playing surface on injury rate :a review of the current literature. Sport Med. 40(11):981-990

Williams S, Hume PA & Kara S. 2011. A Review of Football Injuries on Third and Fourth Generation Artificial Turfs Compared with Natural Turf. Sports Med. 41(11):903-923

(Images of (1) modern artifical turf diagrammatic, (2) side view of artificial turf, and (3) Aspmyra, Norway taken from Wikimedia)


France, Le Tour, cycling injuries and cycle helmets

Welcome back following a short break in France, during which I spent a week in the Languedoc admiring the scenery and enjoying the French hospitality. Not everyone was as lucky as I was to be taking things easy, however, and Le Tour was in full swing during my time there, this being the 98th edition of the race since it was first held in 1903. The gruelling 21 stages run over 23 days covers a distance of 3430 km, and the race is a real test with a chequered and interesting history.

This year’s Tour was won by an Australian for the first time, Cadel Evans, who gained the lead on the penultimate day.

As usual, there were a number of casualties, mostly from crashes involving some high profile riders. These included Britain’s Bradley Wiggins who crashed out on stage 7 of Le Tour with a fractured clavicle during a pile-up which can be seen in this Guardian UK video footage . Others injured during the race included Andreas Klöden, Alexandre Vinokourov, Janez Brajcovic, Jurgen Van Den Broeck and Chris Horner who were all unable to continue the race due to their injuries.

Again this year, a large proportion of serious  injuries were caused by collisions with vehicles, including an incident with a car involved with TV coverage which resulted in injuries to Juan Antonia Flecha and Johnny Hoogerland and led to Christian Prudhomme, Tour organiser, to say ‘It’s a scandal.’ Hoogerland’s dramatic lacerations following his collision with barbed wire can be seen in this image. In addition, Nikki Sorensen was struck by a photographer on his motorbike.

For a useful review of injuries associated with cycling, see this 2001 article by Thompson and Rivara published in American Family Physician.

Those of us who are perhaps more used to keeping safe whilst cycling in the streets might be more interested in this article published earlier this year in Injury Prevention by Lusk and colleagues, based on regional data from Montreal, which highlights the differences in injury rates between cycling on cycle tracks compared with comparable reference streets. The study found that the relative risk of injury on cycle tracks was 0.72 (95% CI 0.60 to 0.85) compared with cycling in reference streets, suggesting that the risk of injury from cycling on tracks is less than cycling in the streets.

A key element of road cycle safety surely has to be legislation for the mandatory use of helmets which still hasn’t found it’s way here in the UK. This is perhaps regretful – especially following the introduction of the London Cycle Hire Scheme which merely advises riders to consider wearing a cycle helmet . The British Medical Association currently supports the introduction of legislation, but this is opposed by the Transport and Health Study Group. Whether or not the position on mandatory laws for cycle helmets in the UK will change in the future may well depend on reaction following  the recent publication of the ‘Health on the Move 2’ report .

Historically, Australia has taken the lead Internationally on compulsory cycle helmet laws which have been enforced there since 1990, with New Zealand following suit in 1994. Read more about issues related to cycle helmets in Australia and Internationally on this interesting Australian website.

A recent poll on the compulsory wearing of helmets by adult cyclists resulted in 68% of respondents (n=1439) voting no to the idea of mandatory wearing of helmets. The BMJ blog led to a lively debate on the topic. Despite the controversy, I for one will continue to wear my cycle helmet whilst cycling on the roads.

Do you think that there should be world-wide mandatory legislation for cycle helmet wear for road cyclists? CJSM would like to hear your thoughts on this – feel free to post your comments on the blog.

Vote on our quick poll on the issue on our website front page here.

(Pictures from mIKL194FV and AFP) 

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