Editor-in-ChiefDr Peter N. SperrynMB, FRCP, FACSM, DPhysMed

Editor EmeritusDr Henry Evans Robson

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EditorsSurgery: Mr Paul G.StableforthMB, FRCS (Bristol, UK)Science: Dr Ron MaughanPhD (Aberdeen, UK)Physiotherapy: Mr Julius SimBA, MSc, MCSP(Coventry, UK)

Statistical ConsultantsMr F.M. Holliday, MA, DLC, FSS(Loughborough, UK)Mr Simon Day, BSc (London, UK)

Regional Corresponding EditorsBelgium: Prof. M. Ostyn,MD (Leuven).

Brazil: Prof. Eduardo H. DeRose,MD (Porto Allegre).

Bulgaria: Dr Virginia Michaelova,MD (Sofia).

Caribbean: Dr Paul Wright,LMSSA (Kingston, Jamaica).

Cote D'Ivoire: Prof. Constant Roux,MD (Abidjan).

France: Dr Pierre Berteau,MD (Rouen).

Groupement Latine:Dr Francisque Commandre,MD (Nice).

Editorial BoardDr David A. Cowan,

BPharm, PhD, MRPharmS (London, UK)Dr Wendy N. Dodds,

BSc, MRCP (Bradford, UK)Dr Adrianne Hardman,PhD (Loughborough, UK)

Mr Basil Helal,MCh(Orth), FRCS (London, UK)

Dr G.P.H. Hermans,MD, PhD, (Hilversum, Netherlands)

Prof. Ludovit Komadel,MD (Bratislava, Czechoslovakia)

Prof. W.P. Morgan,EdD, (Madison, Wisconsin, USA)

Prof. Tim D. Noakes,MD, FACSM (Cape Town, South Africa)

Hong Kong: Dr K.M. Chan,FRCS (Hong Kong).

Hungary: Dr Robert Frenkl,MD (Budapest).

India: Dr D.P. Tripathi,MB, BS, MCCP (Patna).

Indonesia: Dr Hario Tilarso,MD (Jakarta).

Malaysia: Dr Ronnie Yeo,MB (Kuala Lumpur).

Maroc: Dr Naima Amrani,MD (Rabat).

Prof. Qu Mian-Yu,MD (Beijing, China)

Dr Allan J. Ryan,MD (Edina, Minnesota, USA)

Prof. Roy J. Shephard,MD, PhD (Toronto, Canada)

Prof. Harry Thomason,MSc, PhD (Loughborough, UK)

Prof. K. Tittel,MD (Leipzig, DDR)

Dr Dan S. Tunstall Pedoe,MA, DPhil, FRCP (London, UK)

Prof. Clyde Williams,PhD (Loughborough, UK)

Dr William F. Webb,MB, BS (Sydney, Australia)

New Zealand: Dr Chris Milne,MB, ChB, DipSportsMed (Hamilton).

Pakistan: Dr Nishat Mallick,FPMR, FACSM (Karachi).

Spain: Dr J. J. Gonzalez Iturri,MD (Pamplona).

Thailand: DrCharoentasn Chintanaseri,MD (Bangkok).

Uganda: Dr James Sekajugo,MB, Dip.SportsMed. (Kampala).

USSR: Dr Sergei Mironov,MD (Moscow).

Publishing Director: Charles FryManaging Editor: Sarah Graham-Campbell

Advertisement Information: Displayadvertisement space is offered within theBritish Journal of Sports Medicine with acomprehensive range of advertisementoptions available. Loose and bound-ininserts are also invited. For furtherinformation please contact Mark Butler atMTB Advertising 11 Harts Gardens,Guildford, Surrey GU2 6QA, UKTel: 0483-578507, Fax: 0483-572678.

The British Journal of Sports Medicine ispublished quarterly by Butterworth-Heinemann Limited on behalf of the BritishAssociation of Sport and Medicine,Editorial Office, Butterworth-Heinemann,59/60 Grosvenor Street, London W1X 9DA,UK. Tel: 071-493 5841 x395,Fax: 071-499 3384, Telex: 27278.Reprints, Butterworth-Heinemann, LinacreHouse, Jordan Hill, Oxford OX2 6DP, UKTel: 0865-310366, Fax: 0865-311270,Telex: 83111 BHPOXFG.Registered office: Butterworth & CoLimited, 88 Kingsway, London WC2 6AB,UK

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Annual Subscription to the British Journalof Sports Medicine (4 issues):UK and Europe £77.00.North America and rest of world £84.00.

Some Back issues prior to the currentvolume are available from: Dr Henry EvansRobson, 43 Westfield Lane, Rothley,Leicester LE7 7LH, UK

US mailing agents: Second class postagepaid at Rahway, NJ, USA. Postmaster:Send address corrections to British Journalof Sports Medicine, c/o Mercury AirfreightInternational Ltd, 2323 Randolph Avenue,Avenel, NJ 07001, USA, for further details.

Copyright: All rights reserved. No part ofthis publication may be reproduced, storedin a retrieval system or transmitted, in anyform or by any means (electronic,mechanical, photocopying, recording orotherwise) without the written permissionof the Publisher. Readers who requirecopies of papers published in this journalmay either purchase reprints or obtainpermission to copy from the publisher. Forreaders in the USA, permission to copy isgiven on the condition that the copier paythe stated per copy fee through theCopyright Clearance Center, Inc., 21Congress Street, Salem, MA 01970 forcopying beyond that permitted by Sections107 and 108 of the US Copyright Law. Feesappear in the code that appears at the footof the first page of each paper.

© 1992 British Association of Sport andMedicine.ISSN 0306-3674 CODEN: BJSMDZ

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BASM news

BASM Annual Congress, Windermere, 8-10November 1991

Friday found us assembling in dribsand drabs on the top of the LakeDistrict. The ever changing lightbrought out the best of the lateautumn colours, tempting many to thescenery, to visit Beatrix Potter's cot-tage or to try more vigorous pursuitson the Lake. Golf was abandonedwhen heavy rain left the coursewaterlogged but not before PeterThomas, having finally fulfilled hiscareer ambition by winning the trun-cated competition on the dry bits, feltfree to resign the secretaryship. DanTP kept disappearing to inspect his10k race circuit, even inducing somecouncil workmen to clear a drain andremove a water course. The teatimesession featured an outstanding pairof illustrated talks on MountaineeringMedicine, Charles Clarke, keeping ushanging by the finger-tips as hestrolled in off the fells on the dot oftime!

Friday's excellent dinner was fol-lowed by Fun House's grand illusions.Their twin act of escapology andillusion kept us on the edge of ourseats for a good hour and set the tonefor continuing conviviality in the firstconference we have had where thebars have actually been open till theparty has chosen to end! Admittedly,young spirits ran a little high but wewould like to think that the affinity ofyoung hands for professional samplesrepresented an inspired enthusiasmfor the immediate practice of sportsmedicine.

Saturday dawned fair for the run-ner's morning. The Finnish speakersMartti Kvist and Pekka Kannus gaveus detailed accounts of their bio-mechanical surveys of foot, ankle andAchilles injuries. As so often, theresimply wasn't enough time to developan intriguing turn of discussion, espe-cially on Achilles injections andsurgery, where it is becoming clear

that earlier reservations on inter-ference are being questioned. Themorning programme was alwaysgoing to be tight. Furtive supplingduring the knee session betrayed ourrunners' tension - the first time thatathletes had, in Pheidippides' lengthyexperience, warmed up just for thecoach-ride to the venue. What anexample to the idle!The bus filled on the dot of twelve

then chuntered round the narrowlanes, the travel-sick hanging from thewindows, adding their own colour tothe glorious Cumbrian tints. Then thecystitic rush and suddenly they wereon the line by the old Hawksheadschool. The Chairman's last tenseadmonition '. . and DO run like re-sponsible road users. .' and they wereoff. This galvanized the observers toshow their solidarity for half-an-hourfrom the warm safety of a comfy caffuntil Roger finished at a canter, timedhimself, entered his name and sum-moned them from their window over-looking the public convenience tomuster a blockboard and watch andcomplete the recording duties.

Meanwhile, the academic sessionsunrolled, covering Knees, Elbows andAquarobics, followed by the sustainedrigours of the Triathlon and Cycling.During the afternoon we hosted theassembled company of the North-West European Chapter of FIMS in itsannual meeting which proved mostrewarding politically and gave us allthe chance to restore good faith afterthe last World Congress and a ratherlong year of silence in FIMS affairs.

Saturday's formal dinner was dis-tinguished by the presence of ourguest of honour, Lord Whitelaw,lately Mrs Thatcher's deputy primeminister. A splendid dinner was fol-lowed by two of the best after-dinnerspeakers on our circuit. Ian Robert-son, Times correspondent and former

Scottish rugger international, excelledhimself with a stream of stories andmimicry in rich dialects which broughttears to many eyes. Then came ourown Harvey Standeven with his uni-que personalization of organizationalwit. Who would otherwise haveknown Peter Sperryn as 'Help TheAged's' Athlete of the Year?Sunday saw the rain back with a

vengeance. Sessions on Head andNeck Injuries and the Face, Teeth andJaws may have taxed the squeamish.The Back was esoteric in approachand the Short Papers continued toserve the important purpose of en-couraging research and its publication.Then it was time for the business ofthe Open Forum and the AGM, to bereported elsewhere. One last superblunch - spare a thought for thecommittee having to meet over thetable! - and off into the closing stormfor a rotten journey home.

This was a memorable AnnualMeeting and we really owe John Cleggand his regional committee an enor-mous vote of thanks for all their effortsfor what must have been great atten-tion to so many of the details whichmake all the difference between 'ameeting' and such a one as this!Pheidippides

News snip

The Society of Apothecaries haveannounced their intention to condensetheir examination for the Diploma inSports Medicine into one week for theconvenience of candidates. The examwill next be held on: Monday 1 June1992 (Written papers); and Thursday 4June 1992 (clinicals and orals).

4 Br J Sp Med 1992; 26(1)

I

Br J Sp Med 1992; 26(1)

From the journals

Sports medicine current awareness service

Prepared by Kathryn Walter and(LSMI) Library

Nancy Laurenson at the London Sports Medicine Institute

The following summaries are takenfrom a selection of recent journalsindexed in the LSMI database. A fulllisting is published monthly in SportsMedicine Bulletin.Copies of the complete articles areavailable (price 15 pence per sheetsubject to Copyright Law) from theLibrary, LSMI, c/o Medical College ofSt. Bartholomew's Hospital, Charter-house Square, London EC1M 6BQUK (Tel: 071-251 0583).

Anecdotal and experimental evidencesupporting the efficacy of psychologic-al performance enhancement techni-ques is reviewed by D. M. Onestak inThe effects of progressive relaxation,mental practice, and hypnosis onathletic performance Uournal of SportBehavior 1991; 14: 247-73). Of the threetechniques, mental practice has re-ceived the most empirical support. Itappears to be most effective in impro-ving athletic skills which have a largecognitive component, and is betterutilized by highly skilled athletes thanby novice performers. Progressive re-laxation procedures appear to be effec-tive in reducing anxiety levels andalleviating anxiety related symptoms.However, it is unclear whether thisreduction is associated with concom-itant improvements in athletic per-formance. Research investigating theeffects of hypnosis on physical andathletic performance has also pro-duced inconsistent results. Some stu-dies suggest that hypnotic procedurescan enhance muscle strength andendurance, while others observed noeffects of hypnosis.

Studies of the risk factors for sportsinjuries are needed in order to developsuccessful prevention strategies. As R.J. Lysens, W. de Weerdt and A.Nieuwboer discuss in a recent paper(Factors associated with injury prone-ness, Sports Medicine 1991; 12: 281-9),sports injuries are multirisk phenome-na with various risk factors interactingat a given time and consequently theirprevention is complex. Risk factors aregenerally divided into extrinsic factorswhich include training, participation,environment and equipment variables,

and intrinsic factors, which relate tomore individual characteristics andpsychological traits. Studies investi-gating the role of various attributes asrisk factors for acute and overuseinjuries are reviewed. Some psycholo-gical and psychosocial characteristicscan be attributed to persons suscep-tible to acute injuries while the over-use profile is mainly based on physicalcharacteristics. Intervention withprimary, secondary and tertiary pre-vention strategies is discussed.The causes of fatigue are of obvious

interest to the athletic community. EricNewsholme and his co-workers haveapplied metabolic control logic tocurrent knowledge of amino acidmetabolism in order to suggest a novelcause of fatigue which is summarizedas follows - tryptophan is a precursorfor the brain neurotransmitter 5-hy-droxytryp-tamine (5-HT). Prolongedaerobic exercise should result in anincrease in the plasma concentrationratio of free typtophan:branched-chain amino acids. This in turn shouldresult in an increased concentration oftryptophan and thus of 5-HT in someareas of the brain. This might ensure ahigh rate of neuronal firing andincrease sensitivity to fatigue. (Physic-al and mental fatigue: do changes inplasma amino acids play a role?Biochemical Society Transactions 1991; 19:358-62. The hypothesis was tested in aStockholm marathon where groups ofrunners were given either a solutioncontaining branched-chain aminoacids or a placebo. The experimentalgroup showed a slight improvementin performance but this was onlysignificant for slower runners. Thereason for the lack of effect onperformance in the faster runners isnot known. The workers also foundpreliminary evidence that amino acidsupplementation results in lowerperceived mental effort and improvedpost-exercise mental performance.Newsholmes work is summarized inlay terms by Owen Anderson in Thefriendly face of fatigue (Peak Perform-ance October 1991; Issue 13:2-5).

Patterns of physical activity withinfamilies were investigated by PattyFreedson and Sherrie Evenson in

Familial aggregation in physical activ-ity (Research Quarterly for Exercise andSport 1991; 62: 384-9). Thirty childrenand their parents wore Caltrac acceler-ometers for three consecutive days. Atthe same time parents completed aCaltrac Activity Record (CAL REC) forthemselves and their child. UsingCaltrac, familial resemblance occurredin 67% (father and child) and 73%(mother and child) of the families.Using the CAL REC, familial aggrega-tion was present in 70% (father andchild) and 66% (mother and child) ofthe families. Thus children of activeand less active parents exhibited phy-sical activity patterns similar to theirparents. This could have importantimplications for lifestyle modificationprogrammes - physical activity amongchildren may be increased by promot-ing regular physical activity amongparents.A recent letter to Nature suggests

that male athletes should watch out -if the current rate of progression ofworld record performances in runningevents continues, women may soonoutrun them (B. J. Whipp and S. A.Ward Will women soon outrun men?Nature 1992; 355(6355): 25). Both sexesshow a linear improvement in runningvelocity over a range of distances,from 200m to the marathon. Howev-er, the rate at which women's per-formances are improving is muchgreater in all events studied. Extrapo-lation of the graphs predicts an in-tersection for the marathon in 1998,and other running events in the firsthalf of the next century. As theauthors admit, their methods are notwithout pitfalls, but the results pre-sent a provocative challenge not onlyto the athletes but also to the phy-siologists to explain this phenomenon.Meanwhile, a comparison of men andwomen triathletes indicates thatwomen are closing the gap on meneven in this gruelling event (E. Hol-lander and W. Pieter Comparison oftop ten results of men and womenironman triathletes from 1985-1989Journal of Human Movement Studies1990; 18: 201-11). A study of theinteraction between sex, ageclass andyear showed three main trends - men

Br J Sp Med 1992; 26(1) 5

were faster than women in all age-classes observed, there was an abso-lute decrease in performance with age,and the total time for both sexesimproved during the timespan stu-died.Orthopaedic injuries are quite com-

mon among children, but if treatedappropriately, permanent disability israre. Certain injuries, however - suchas supracondylar humerus fractures,meniscal tears, traumatic hip disloca-tions, and fractures of the distalfemoral growth plate are notorious forcomplications that lead to permanentdisabilities. (. F. Downing and J. A.Nicholas, Four complex joint injuries- avoiding long-term sequelae inchildren, Physician and Sportsmedicine1991; 19: 81-97). These orthopaedicinjuries often appear to heal unevent-fully, yet they can result in delayedproblems such as pain, deformity, orloss of function. Early identification ofthese injuries, followed by urgenttreatment, minimizes complications.The traditional somatotyping of

abnormal feet into flatfoot (pes planus)and high arched foot (pes cavus) doesnot take into account what the athleteis doing with his or her foot duringperformance. Additional informationis necessary to the static foot examina-tion when one categorizes the foot andpredicts its function under dynamicconditions. In The effects of bodyweight and foot-types of runnersupon the function of running shoes(H. Kinoshita, K. Ikuta and S. Okada,Journal of Human Movement Studies1990; 19: 151-70), the authors ex-amined individual body weight inrelation to the mechanism of shockattenuation characteristics of runningshoes with different midsole hardnessas well as the effect of extremefoot-type on the rear foot controlcapacity of the shoe. A force platformand 16-mm motion camera were usedfor data collection. There was nointeraction effect of body weight andshoe-type. Significant main effects ofbody weight and shoe type werefound in ground reaction force vari-ables. The heavier the runner, thegreater the reaction force generated.To compensate the stress of force,heavy runners used a relatively shor-ter step length. There was a significantinteraction effect between foot-typeand shoe-type, and main effects offoot-type and shoe-type invariables ofthe pronation time curve. The subtalarpronation for the high pronators large-ly increased when the soft shoe wasworn, while those for the normals andfor the low-pronators remained nearlythe same. Overall the results of thisstudy suggest that both body weightand foot-type are essential parameterswhen designing a running shoe.

In yet another review, The myth ofrunning limb varus (S. Tristant and R.L. Blake, Journal of the American Podia-tric Medical Association 1991; 81:325-27) the authors state the Foot Traksystem is the first system available togive biomechanical researchers theability to document the tibia-to-verticalangle with computerized digitation.This in turn has shown that runninglimb varus is not as important aconcept as previously discussed. Inaddition, functional orthotic devicesare more effective on primary cal-caneal motions and positions thanmotions and positions produced byextrinsic tibial, knee or hip factors.Thus, functional foot orthoses tend towork better in controlling varus dur-ing running that is produced by thecalcaneus, rather than the tibia.

Registration of heart rate (HR) anduse of intensity scales based on max-imal HR (HR max) values are widelyused to control or verify work orexercise intensity, especially by endur-ance athletes. Obviously the useful-ness of such intensity scale dependson HR values obtained from a reliableHR max test. However, there seems tobe no generally accepted method forassessing HR max. Many studiesreporting a measured HR max do notdescribe a specific HR max test proce-dure. Often the given HR max valuesoriginate from values obtained duringmaximal oxygen uptake tests(Vo2 max)- In Factors influencingassessment of maximal heart rate, (F.Ingjer, Scandinavian Journal of Medicineand Science in Sports 1991; 1: 134-40),the author determined the significanceof warm-up time, time and number ofruns, treadmill inclination and degreeof being rested, on the assessment ofHR max in 59 elite endurance trainedathletes. Following several differentprotocols, it was determined that twosubsequent 3-4 minute runs to ex-haustion gave the highest averagepeak HR values. Being rested beforethe start of the test, and a warm up of30 min (as compared to 10 min) wereboth decisive in reaching HR max. Ofmost significance, peak HR from fieldtests were significantly lower thanvalues obtained from lab tests. Meanpeak HR from VO2max measurementswere 5-6 beats min-1 lower thanvalues from the specially designed HRmax test already described.

There has been keen interest in 'stepaerobic' classes. This new exerciseregimen has been promoted for itscardiovascular fitness benefits withthe added benefit of decreased risk ofsustaining lower limb injuries. Histor-ically, exercise scientists used singlebench stepping as a means to deter-mine an individual's functional capac-ity. This new variety of bench step-

ping incorporates a variety of aerobicdance movements on and off singlebenches, 10.2-30.5cm high, per-formed to steady rhythmic music.Michelle Scharff Olson and othersinvestigated The cardiovascular andmetabolic effects of bench steppingexercise in females, (Medicine andScience in Sports and Exercise 1991; 23:1311-16). Four different bench heightswere used in a cross-over design.Oxygen uptake (Vo2) responses weresignificantly more pronounced indirect relationship to the bench height.Added hand weights of 0.91 kg eliciteda modest but statistically significantincrease in Vo2 compared with nohand weights. The authors concludethat aerobic bench stepping is anexercise modality that provides suffi-cient cardiorespiratory demand forenhancing aerobic fitness in females.A critical look at static stretching:

are we doing our patients harm? (D.R. Murphy, Chiropractic Sports Medicine1991; 5: 67-70) refutes most currentlyheld views on the status of staticstretching (SS). The author maintainsthat there is no rationale behind theuse of SS for any of the five primaryreasons for its use: (1) SS aids warmup; (2) SS aids cool-down; (3) SS helpsrelieve postexercise delayed onsetmuscle soreness; (4) SS helps enhanceathletic performance; (5) SS helpsprevent injury. His main argumentcentres around the fact that the de-trimental effects of SS are manifestedas two opposite situations - muscletightness and muscle hypoactivity or'looseness'. Muscle tightness resultsfrom the chronic stimulation of thestretch reflex over time. In this 'staticresponse', the muscle spindle re-sponds to the amplitude of lengthincrease. Thus, SS rather than reliev-ing muscle tightness appears to be aprimary cause of muscle tightness.Muscle hypoactivity, also causeddirectly by SS is said to be the morecommon sequela. It is based on thetheory of golgi tendon organ (GTO)stimulation following muscle leng-thening or stretch which is held for ashort period. The author states theGTOs do not necessarily fire to pro-duce muscle relaxation. Also, the GTOis not responsive to passive stretchbecause it is a tension receptor, not alength receptor. These and othertheories put forth by the authorwarrant further investigation. NormalRange of Motion (ROM) is consideredto be necessary for athletic perform-ance and injury prevention as well asthe strength associated with ROM.This normal ROM can be achievedand/or maintained by Dynamic ROMtraining which involves moving thejoints through their normal ROMusing the athletes own muscle action.

6 Br J Sp Med 1992; 26(1)

BASM Education Programme

BASM's current annual programme of Sports Medicine courses includes two introductory coursesfollowing the FIMS basic course outline and six advanced courses in physiology (cardiorespiratory),physiology (musculoskeletal), injury (head, neck, back and trunk), injury (lower limb), injury (upper limb),and advanced medicine of PE and sport.

Current Programme for 1992

Date Course Venue

January 10-12 Advanced Physiology: musculoskeletal

February 28-March 1

March 27-29

Advanced Medicine of Physical Exercise and Sport

Advanced Injury: Acute and Chronic Injuries to theUpper Limb

April 26-May 1

September 18-20

September 27-October 2

November 16-17

BASM Introductory Sports Medicine Course

Advanced Injury: Acute and Chronic Injuries to theLower Limb

BASM Introductory Sports Medicine Course

Joint Annual Weekend and Meeting

Br J Sp Med 1992; 26(1) 71

BOAMC

NSMI

RAFWroughton(Swindon)

Lilleshall

RAFWroughton(Swindon)

Lilleshall

Bruges,Belgium

Other Courses

Sports Medicine Course - 7-11 September 1992(Moray House in conjunction with Edinburgh Postgraduate Board)

To be held at Moray House Institute of Education, Cramond Campus, Cramond Road North, Edinburgh,EH4 6JD, UK, for doctors - suitable for Scottish Colleges examination, with limited places forphysiotherapists and coaches. Fee £240, PGEA approval for 10 sessions. Apply by 5 June 92.

Notes for Authors.

ScopeThe British Journal of Sports Medicine covers all aspectsof sports medicine and science - the management ofsports injuries; all clinical aspects of exercise, health andsport; exercise physiology and biophysical investigationof sports performance; sports psychology; physio-therapy and rehabilitation in sport; and medical and sci-entific support of the sports coach.

Types of paperOriginal papers (not normally over 3000 words, fulllength accounts of original research)Review articles (up to 4000 words, providing concise in-depth reviews of traditional and new areas in sportsmedicine)Case reports (up to 1000 words, describing clinical casehistories with a message).

RefereeingAll contributions are studies by referees whose namesare not normally disclosed to authors. On acceptance forpublication papers are subject to editorial amendment. Ifrejected, papers and illustrations will not be returned.Authors are solely responsible for the factual accuracy oftheir papers.

ManuscriptsAuthors are urged to write as concisely as possible.Three copies should be submitted, typed on only oneside of the paper (quarto or A4) in double spacing with amargin of 30 mm at the top and bottom and on bothsides. Papers should be arranged in the following orderof presentation: title of paper; names of the authors;address of the place at which the work was carried out;an abstract of the paper (100-200 words in length; 4-6keywords; the text; acknowledgements (if any); refer-ences; tables; and abbreviated title for use as a runningheadline; captions to figures (on separate sheet ofpaper).

IllustrationsDrawings and graphs should be on heavy white paper/card or blue-lined coordinate paper using black ink.Label axes appropriately and clearly. Please use a selec-tion of the following symbols: +, x, ELI Of A, VI U,*,A, V. Photographs should be of fine quality, largeglossy prints suitable for reproduction and the topshould be indicated. Negatives, transparencies or x-rayfilms should not be supplied, any material shouldbe submitted in the form of photographic prints.Authors are asked where possible to draw diagrams toone of the following widths, including lettering,168 mm, 354 mm. During photographic reproduction,the diagrams are reduced to ½h their size. The maximumdepth at drawn size is 500 mm. Authors are asked to usethe minimum amount of descriptive matter on graphsand drawings but rather to refer to curves, points etc. bysymbols and place the descriptive matter in the caption.Three copies of each illustration are required and theseshould be numbered in a consecutive series of figuresusing Arabic numerals. Legends should be typed indouble spacing on a separate page but grouped together.Each figure should be identified on the back - figurenumber and name of the author. Figures which havebeen published elsewhere should be accompanied by aform of permission to reproduce, obtained from theoriginal publisher.

ReferencesThese should be indicated in the text by superscriptArabic numerals which run consecutively through thepaper. The references should be grouped in a section atthe end of the text in numerical order and should take theform: author's names and initials; title of article; abbre-viated journal title; year of publication; volume number;page numbers. If in doubt authors should always writethe journal title in full. References to a book should takethe form: authors' surname, followed by initials; title ofbook in single quotes; editors (if any); volume number/edition (if any); name of publishers; place of publication;year of publication and page number. Where a paper iscited more than once in the text, the same superiornumeral should be used on each occasion. e.g.21 Sperryn PN. Sport and Medicine. London: Butterworths, 1983.22 Ellitsgaard N and Warburg F. Movements causing ankle

fractures in parachuting. Br J Sports Med 1989; 23: 27-9.

TablesTables should be typed on separate sheets together witha suitable caption at the top of each table. Column head-ings should be kept as brief as possible, and indicateunits of measurement in parentheses. Tables should notduplicate information summarized in illustrations.FootnotesFootnotes should be used sparingly. They should be in-dicated by asterisks (*), daggers (t), and double daggers(t), in that order. In the manuscript, a footnote should beplaced at the bottom of the page on which it is referred toand separated from the main text by a horizontal lineabove the footnote. Footnotes to tables should be placedat the bottom of the table to which they refer.Drugs, Abbreviations and UnitsDrugs should be referred to by their approved, not pro-prietary, names, and the source of any new or experi-mental materials should be given. If abbreviations areused these should be given in full the first time they arementioned in the text. Scientific measurements shouldbe given in SI units, but blood pressure should continueto be expressed in mm Hg.ProofsAuthors are responsible for ensuring that all manu-scripts (whether original or revised) are accurately typedbefore final submission. Two sets of proofs will be sent tothe author before publication, one of which should bereturned promptly (by Express Air Mail if outside UK).The publishers reserve the right to charge for anychanges made at the proof stage (other than printerserrors) since the insertion or deletion of a single wordmay necessitate the resetting of whole paragraphs.SubmissionThree copies of the complete manuscript and illus-trations should be sent to Dr P.N. Sperryn, The Editor,British Journal of Sports Medicine, Butterworth-Heine-mann Ltd., 59/60 Grosvenor Street, London W1X 9DA,UK.All material submitted for publication is assumed to besubmitted exclusively to the British Journal of SportsMedicine. All authors must consent to publication. Theeditor retains the customary right to style and if neces-sary shorten material accepted for publication. Manu-scripts will be acknowledged on receipt. Authors shouldkeep one copy of their manuscript for reference. Authorsshould include their names and initials and not morethan one degree each.