On 28 June 2025, the ESSKA ESMA Focus Meeting brought together an international faculty of sports medicine experts at the ISOKINETIC Campus in Bologna, Italy. Centred on the theme "The Future of Sports Medicine: ACL and Beyond", the day featured engaging sessions on muscle and tendon injuries, surgical approaches to common knee injuries, return-to-play strategies after ACL injuries, and cutting-edge ACL injury prevention.

With contributions from leading clinicians across Europe and beyond, the event offered invaluable insights and a collaborative space for learning and connection. Our sincere thanks to all speakers, chairs, and attendees for making it a success.

We also extend a special thanks to Isokinetic team for excellent co- organisation and hosting of the meeting

We look forward to continuing the conversation—see you at the next one.

The History of EFOST

After the First World Congress of Sports Traumatology which was held in Palma de Mallorca in May 1992, Dr. Hans Paessler from Germany and Dr. Jean-Claude Imbert from France suggested the idea of founding a new organization in Europe dealing with Sports Traumatology, based on the association of different nations through north, east, south, west, or middle of Europe. This was a formation of an amalgam in sports trauma consisting of national sports trauma societies from the different European countries. This new group was planned to be a “Federation”, not an individual society with the purpose of coordinate and improve knowledge on sports related injuries. So, the creation of EFOST (European Federation of Orthopaedic National Association for Sport Traumatology) was completed in Munich by the initiatives of French and German National Societies (SFPTS and GOTS).

For the aim of promoting a “Federation" on sports traumatology as an independent specialty within Europe the founders contacted with National Sport Trauma Associations and 1st General Assembly of EFOST was held in Santa Margareta di Liguria, Genova (Italy) at the Hotel Miramare in September 1993 with the participation of Jean-Marie Baillon (Belgium), Jean-Claude Imbert (France), Wolfgang Pförringer, Hans H. Paessler (Germany), Pantelis Nikolaou, Georgis Priftis, Nikolaos Piscopakis (Greece), Filippo Rettagliata (Italy), Arthur Dziak (Poland), Jose M. Vilarrubias (Spain) and Mahmut Nedim Doral (Turkey) as delegates. A constitution for a European Federation of National Associations of Orthopaedic Sports Traumatology (EFOST) was accepted as a conclusion of this inaugural general assembly.

At the same time the European Union was founded in 1993 by the Treaty of Maastricht. This supplemented economic co-operation in the European Communities with a common foreign and security policy and co-operation in the areas of justice and home affairs.

The mission of EFOST was determined as bringing the Sport Traumatology chapter under the name of “Federation” together, spreading its concept throughout Europe and creating new ones in the Countries with no such organizations. Jean-Claude Imbert was elected as the first president of EFOST. Second general assembly was held at the second congress of the European Federation of National Association of Orthopaedics and Traumatology (EFORT) in 1995 in Munich and Giuliano Cerulli (1995-1997) was elected as the new president of EFOST by vote unanimously. At that time Dr. Huylebroek, Dr. Doral, Dr. Benazzo and Dr. Biosca were the pioneer of EFOST.

Fig : Presidents of EFOST and friends

Presidents of EFOST were Hans H. Paessler (1997-1999), Mahmut Nedim Doral (1999-2002), Paco Biosca (2002-2004), Franco Benazzo (2004-2007), José Huylebroek (2007-2010), Francois Kelberine (2010-2012), Nicola Maffulli (2012-2014) and Gernot Felmet (2014-2016).

MEETINGS and Education

The first Specialty Day Meeting at EFORT Congress in Munich, was followed by the other EFORT meetings in 1997 Barcelona, in 1999 Brussels and in 2001 Rhodes.

EFOST has than organized eight Congresses until 2015 :
• › Munich 2001, with GOTS, Congress President Dr. Hans H. Paessler,
• › Monaco 2003, Congress President Dr. Jean-Claude Imbert,
• › Madrid 2004, Congress Presidents Dr. Pedro Guillen & Dr. Paco Biosca,
• › Pavia 2006, Congress President Dr. Franco Benazzo,
• › Antalya 2008, Congress President Dr. Mahmut Nedim Doral
• › Brussels 2010, Congress President Dr. Jose Huylebroek
• › London 2012, Congress President Dr. Francois Kelberine & Dr. Roger Hackney (Combined with World Sports Trauma Congress)
› Torino 2015, Congress Presidents Dr. Gernot Felmet & Dr. Gian Luigi Canata

5th Meeting of the EFOST, Antalya, Turkey, November 2008

6th Meeting of the EFOST, Brussels, Belgium, November 2010

7th Meeting of the EFOST, London, UK, October 2012

8th EFOST Congress in Torino, Italy, November 2015

Fig Board and Team Session in the 8th EFOST Congress in Torino, Italy, November 2015

Fig EFOST Presidents_ J Huilebroek, N. Maffulli, hon. Member Werner Muller, G Felmet, GL Canata, F Kelberine, M Dorath

Guided by the European Spirit with friendship over the boarders and the enthusiasm to develop a European Education in Orthopaedic and Sports Traumatology on to a high level EFOST became visble. Behind this energy and activities were individuals and idealists with the idea of an EFOST Family as a European Friendship over the Boarders. Their tools where E-journal, fellowship programs and their education, improving national sports traumatology societies, later a modern internet presence with continuous E-Newsletter and many other current activities including the Biological Ligament and Joint Academy (BLJA) for training and education in conservative, rehabilitative and surgical techniques using a maximum of biological and individual resources.

EFOST fellowship have been organized by Francois Kelberine and became to one of its most successful brands and very popular like for Dr. William Wind and Dr. Michael Rauh from USA who were the fellows of EFOST fellowship program in 2008 with intensive exchange of their experiences in Belgium with Dr. Huylebroek, Italy with Dr. Benazzo, France with Dr. Kelberine and Turkey with Dr. Doral at the 5th EFOST Meeting. The EFOST DJO Global Fellowship from USA to Europe (Oct. 2012) with Jonathan T. Bravman (Devison of Sportsmedicine and Shoulder Surgery, University of Colorado; Denver, CO) and Robert A. Magnussen (Ohio State University college of Medicine, Columbus, OH) and the EFOST Team Physician Travelling Fellowship with M.D., Ph.D. Pierre Rotzius from Stockholm, Sweden and M.D. Timo Rahnel from Tartu, Estonia Nov. 2015 highlighted the educational program. This fruitful US and European Fellowship for the Ambassadors of EFOST had been organized by Burt Klos.

Several Summer Courses in Kalamta and Marathon (Greece) in cooperation with ECOSEP (European College of Sports and Exercise Physicians) and ISMuLT (Italian Society of Muscles, Ligaments and Tendons) were held 2013 – 2015. EFOST impact is documented with presence in several European associations in the years 2015/16 as EFFORT, ECTES, the German VSOU Baden Baden and DKOU Berlin and the International Baltic Sports Medicine Conferences.

BOOKS and Journal

The M.L.T.J. Muscles, Ligaments and Tendons Journal, founded by Nicola Maffulli, enabled an independent scientific presentation and once again emphasised the important position of EFOST in this field.

A series of four EFOST Books about surgical techniques in orthopedic traumatology initialized by Francois Kelberine and Nicola Maffulli and others had been published 2015/16.

1. EFOST Surgical Techniques in Sports Medicine - Knee Surgery Vol.1: Soft Tissue. Henrique Jones, Tiburtius V S Klos, François Kelberine, Jamie S McConnell. Series Editor: François Kelberine, Nicola Maffulli. JP Medical Ltd. 2015. ISBN: 9781909836372

2. EFOST Surgical Techniques in Sports Medicine - Knee Surgery Vol.2: Bone and Cartilage. Tiburtius V S Klos, Henrique Jones, François Kelberine, Wasim Khan. Series Editor: François Kelberine, Nicola Maffulli. JP Medical Ltd. 2016. ISBN: 9781909836389

3. EFOST Surgical Techniques in Sports Medicine – Foot and AnKle Surgery. Gian Luigi Canata, Lee Parker. Series Editor: François Kelberine, Nicola Maffulli. JP Medical Ltd. 2016. ISBN: 9781909836341

4. EFOST Surgical Techniques in Sports Medicine – Elbow Surgery. François Kelberine, Wasim Khan. Series Editor: François Kelberine, Nicola Maffulli. JP Medical Ltd. 2016. ISBN: 9781909836391

From 2010 and the following years a new thinking in between Scientific Associations and a growing centralization of the medical industry to global players could be observed. Europe was changing and many things changed around and in EFOST over the following years.

The international and worldwide process of growing centralism also in Scientific Associations made a standing for a Federation out of the European National Associations in Orthopaedic and Sports Traumatology more and more difficulty. Therefore wise and intelligent solutions had to be found and devised. –

The last EFOST congress in Torino in November 2015 was celebrated with the motto “With Enthusiasm to New Horizons“. After this highlight and outlook for the future of the last President of EFOST Gernot Felmet, Germany and Vice President Gian Luigi Canata, Italy EFOST ended all activities after 23 years with the 4th of May 2016. EFOST supported to establish a new and modern platform and so became a part of ESMA which has been founded at the 6th of May 2016 in Barcelona. ESMA is the European Sports Medicine Associates, a section of ESSKA. –

Fig : EFOST friends: Henrique Jones, Gian Luigi Canata, Grzegorz Adamczyk, Gernot Felmet at the 21st ESSKA meeting in Milan, May 2024

Today, ESMA, as the mental successor to EFOST, is still driven by the sporting spirit and the European idea of the founding fathers, which is now becoming increasingly globalized.

June 2024 Gernot Felmet, MD

Sport and Exercise Medicine (SEM) is an independent medical specialty in the United Kingdom. There are currently specialists in SEM on the General Medical Council’s Specialist Register. There are two ways that doctors can be registered. We will consider both the direct route and for a medical student who wishes to progress directly to become a Consultant in Sports and Exercise Medicine or a doctor who has not completed GMC approved training posts but has gained equivalent knowledge, skills and experience and wishes to gain a place on the register.

In the United Kingdom undergraduate training is typically a 5–6-year course at medical school or University. During this period students commonly have an elective placement of one to two months in a medical area of their choosing and those interested will choose to undertake this in SEM either in a UK centre or overseas including time at either a sports club or an academic centre. Additionally, students may choose to study an intercalated undergraduate degree in SEM for an additional year.

After graduation doctors complete two years of Foundation Training in medical subspecialties before being registered on the General Medical Register and then going onto further training. To be eligible to apply for Higher Specialist Training in SEM, junior doctors must complete core training in Internal Medicine Stage 1, Acute Care Common Stem or General Practice. During this time, they would take postgraduate examinations to achieve Membership of the Royal College of General Practitioners, Membership of the Royal College of Physicians or Membership of the Royal College of Emergency Medicine. This minimum two-year training is required for application for SEM Specialty Training.

During this time period it would be expected that potential SEM trainees gain experience in SEM through relevant work experience within the NHS and sport. For example, by working on exercise medicine promotion and quality improvement projects, shadowing musculoskeletal medicine services and volunteering to provide medical care within sport. This could be either sports teams or sports events. It would be unusual to be paid for this activity and it would normally involve weekend activity. It is important to note that during the post foundation training doctors would be expected to work at weekends or for on-call periods which actually is full-time work at the weekend or overnight during the week.

Applicants may also choose to undertake a Master’s of Science postgraduate degree at the same time. This could be a full-time one-year programme or parttime over two years. Some of the most popular courses are organised by University College London or Queen Mary University of London. The MSc courses also involve a dissertation project which may progress to a publication or presentation.

Applicants may also choose to undertake a Master’s of Science postgraduate degree at the same time. This could be a full-time one-year programme or a parttime over two years. Some of the most popular courses are organised by University College London or Queen Mary University of London. The MSc courses also involve a dissertation project which may progress to a publication or presentation.

All of the previous training is in preparation for application for a Specialty Registrar training position in Sport and Exercise Medicine. These positions are awarded through competitive application with the number of positions determined by NHS commissioning and educational bodies.

This training programme is of four years duration and includes experience in Sports and Exercise Medicine, General Practice, Public Health, Accident & Emergency and Specialist Medicine. During this time trainees have an annual work-based assessment and are expected to complete the Faculty of Sport and Exercise Medicine UK membership examination.

After the final ARCP trainees will be awarded a Certificate of Completion of Training and be allowed to apply for a place on the General Medical Council’s Specialist Register as a Specialist Sport and Exercise Medicine Consultant.

That was the easy route. Alternatively, Doctors can apply for a Certificate of Eligibility for Specialist Registration CESR Article 14 route to apply to gain entry to the Specialist Register. Here applicants have to submit evidence of relevant training and experience which is scrutinised using the same standards as trainees would have their training scrutinised. This is performed retrospectively and is very onerous. This can take many years to assemble all this evidence in addition to ongoing work.

It is not a requirement for Doctors who work in sport to be a Sport and Exercise Medicine Specialist. Many sports teams employ doctors who are qualified as General Practitioners. These skills are very applicable to the needs of elite sport participants for example the management of the covid pandemic, skin and urogenital issues. These doctors may either head the sports medicine or performance team within a sports club or have a role in it holding clinical sessions with the club for several sessions per week.

The term Team Physician course is used infrequently in the UK. A team physician would encompass the general medical responsibilities of signing medicals, day to day management including injury profiling injury prevention and linking with strength and conditioning. On match days pre-game duties, pitch side cover for injuries as well as post game assessments would all be involved. In the UK following injury it would be unusual for the doctor that performs the game day activity to also perform the reconstructive surgery discussed on many team physician courses. The vast majority of injured players from Premiership Rugby, Rugby Super League the Premier League in football and would be referred to elite surgeons in the private sector. For clubs this means that patients are seen promptly by surgeons with experience in managing players at that level together with the entourage that accompanies them. It also reduces doubt if the player suffers a complication of surgery.

To provide game day cover for teams in elite sport medical staff must have completed a pitch-side resuscitation course. This is a two-day practice course featuring continuous assessment, together with an end of course written and practical exam. The first course was Resuscitation and Emergency Management On-Field (REMO) in 2002 and subsequently courses have been developed in by the Home nations rugby unions, and the Advance Trauma and Medical Management in Football. Courses are accredited by the Faculty of Pre-Hospital Care at the Royal College of Surgeons of Edinburgh. The Scottish Rugby Union medical department under the leadership of Dr James Robson provides these courses free of participant charge to ensure there is no obstruction to teaching and knowledge for those providing care for rugby in Scotland.

Courses involve the management of cardiac arrest, head and spinal injury management and player extrication in addition to extremity injury management, recognition and management of concussion as well as medical emergencies. Emergency planning and travel with teams is also taught. Without a certificate of completion of one of these courses team medical staff cannot work in pitch side care. This means that when a catastrophic injury occurs providers work as a team together. There is no place for senior doctors in suits coming onto the pitch shouting at physios.

Additionally in some sports medical staff have to complete modules in Concussion management, antidoping and mental health management.

Once Specialists and other doctors working are registered with the General Medical Council, they are required to undertake an annual appraisal and to undertake revalidation every five years. Appraisals require a demonstration of continuous professional development and governance. In Sport and Exercise Medicine this is undertaken by the Faculty of Sport and Exercise Medicine thus maintaining the highest standards of practice and ongoing patient care.

The route to being a Specialist Consultant in Sport and Exercise Medicine in the United Kingdom is a long one and practice is a privilege.

For more information:

JRCPTB: Sport and Exercise Medicine Training Curriculum

FSEM (UK) Appraisal Services

FSEM (UK) Membership Examination in Sport and Exercise Medicine

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¹ Director Centre of Sports Traumatology, Koelliker Hospital, Turin, Italy. CUS Torino Team Physician.
² Director Institute of Sports Medicine, FMSI, Turin, Italy.
³ Team Physician Torino FC, Turin, Italy.

How to become a Sports Medicine Doctor in Italy

The Italian Federation of Sports Medicine was founded in 1929. Since then sports clubs in Italy must have a sports physician as part of the staff. The first University School of Specialization in Sports Medicine in the world was established in Milano in 1957. Even in Italy doctors specialized in Sports Medicine play two roles - typical of the medical profession - to intervene in case of accidents or emergencies during training and sport events, as well as to prevent the occurrence of problems during physical activity.

In Italy, Sports Medicine is a specialty by itself, but often can be a complementary one which accompanies, for example, Orthopaedics or Cardiology.

From an academic point of view, in Italy the course of study currently passes through the Degree in Medicine and Surgery. It is therefore necessary to obtain the single cycle master’s degree of Medicine and Surgery, provided by a large part of the Italian university faculties. This degree course with limited access requires an admission test and lasts six years. Upon the Law 27 dated 24.4.2020, students holding the assessment of suitability of the practical internship will automatically obtain the qualification to the medical profession.

However, to become a sports medicine doctor it is necessary to pursue university studies by enrolling in the Postgraduate School of Sport and Exercise Medicine (four years training), whose access is - once again - programmed. Eligible candidates are selected through an annual entry test based on qualifications and examination, provided that they are Members of the Italian Medical Association.

The School of Sport and Exercise Medicine provides future sport physicians with a wide knowledge of biomechanics and musculoskeletal system, biochemistry, genetics and nutrition, cardiology, as well as teaching methods and didactics of physical activities.

The academic course includes subjects specifically focused on sports medicine.

Along with the theoretical disciplines above, residents are also required to attend the respective clinical departments. Such activities may not be necessarily related to sport.

Training also includes compulsory activities that allow residents to mature professional experiences in the field and to learn the necessary skills. An end-of-term examination is required.

Sport Physicians are required to improve and refresh their knowledge through the continuous medical education (CME) like all other medical-health professions in Italy.

Academic specialty is the only way to be officially recognized as a Sports Medicine Doctor in Italy. Medical Doctors , e.g. Orthopaedists or Cardiologists, who are complementarily specialized in Sports Medicine, are allowed to have a full sports medicine practice, although they usually prefer to mainly practice their specific professional activity.

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How to become a Team Physician in Italy

Becoming a Team Physician (TP) is only one of the options after graduating in Sport and Exercise Medicine, along with the cardiological or functional evaluation branch.

In Italy, every sports federation sets the standard for which each club must provide the figure of the Team Physician (TP), although a distinction should be made between professional and amateur level. In fact, the TP of a non-professional Sports Club is not required to have a specific title, so that even doctors with different specialisations may cover this role. At a professional level, the TP must be registered in the National Sport Medical Federation. Even for non-competitive activities a medical certification is requested.

According to the provisions of the Italian Sport Medical Federation (FMSI), doctors not specialized in Sports Medicine will be able to enrol in basic Sports Medicine training courses offered within the FMSI Regional Committees, to become adjoin members.

The TP is appointed by the Board of Directors of the club/federation and has often a great affinity with a specific sport, especially when having practiced it as an athlete.

The tasks mainly include:

• monitoring the health status of each athlete and planning participation in the periodical medical-physiological assessments of the team. Periodic certificates of physical fitness for competitive sports are mandatory in Italy and released by sports medicine doctors.
• supervising, in close collaboration with the President of the Sports Society, the observance of the laws of the State and the Region on compliance with federal health regulations.
• providing the athletes involved in rallies and/or competitions with health and preventive information on medical issues and anti-doping.
• cooperating with all the medical/ technical members of the club/association/federation.

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¹ Sports Medicine Physician | Member of the Portuguese College of Sports Medicine Sports Medicine physician at Futebol Clube do Porto I Portuguese Volleyball Federation | Physician at Oporto Sports Medicine Center
² Orthopaedic Surgeon and Sports Medicine Physician | Member of the Portuguese College of Sports Medicine I ESSKA-ESMA Past Chairman I SPAT Past Chairman I UEFA Medical Committee Past Vice Chairman I Past Team Physician of the Portuguese Football Team

How to become a Sports Medicine Doctor in Portugal
by Diogo Dias

I. Introduction

Sports Medicine is the medical specialty that intersects medical and sports sciences, with the main focus on promoting physical activity and performing the medical follow-up of the active population. In Portugal it is a medical specialty that has been recognized by the Portuguese Doctors College of Medical Specialties since 1980. Recently, there was a fundamental change in the approach and revision status concerning sports medicine specialists in Portugal including the designation in order to become Sports and Exercise Medicine specialty. The Sports Medicine specialty programme was developed in 2013 and based on this, the medical residents should fulfil a programmed curriculum and be approved with a final exam to become specialists. Before this revised methodology, the title of specialist was attributed by the Sports Medicine College of Physicians to the sports doctors with relevant sports CV, attended a recognized post graduate programme in Sports Medicine, complemented with recognized experience working with top-level athletes after approval in written and oral examinations supervised by a nominated jury of the Sports Medicine Doctors College.

II. Requirements to become a Sports Medicine Specialist

Since 2013, thirteen young doctors concluded the specialty-based training programme corresponding to 10% of the total number of Sports Medicine specialists in Portugal. This Sports Medicine specialty programme allows a better, and more embracing scientific preparation of the Sports Medicine specialists, as this new programme promotes a more homogenous and diverse vision of sports medicine and how to understand the various aspects of athlete’s support.

In this way, becoming a specialist is an effort to complete an adequate curriculum and, at the same time, to meet the European and International standards. After successfully completing medical school, young doctors attend a mandatory supervised one-year residence in general medicine with the designation of general practice residency. After this, they can choose the speciality residency programme according to the former exam classification and their own choice of a medical or surgical speciality.

The actual residency programme in sports medicine in Portugal touches different areas of clinical practice and has a total duration of 48 months and is regularly updated.

During the first year, they then attend the so called “General Sports Medicine” period. This is usually performed in one Sports Medicine Centre, and represents the first contact with athletes and the specialty in a multidisciplinary context.

The second year includes a nine months rotation in sports cardiology and three months in pneumology. This is an important clinical period, to understand disability, restrictions, and contraindications for sports participation.

In the third year, they have six months rotation of orthopaedics, three months of rehabilitation and three months of sports physiology: This focuses on sports trauma, aetiology of sports injuries, understating fatigue, recovery and return to sports. The resident should be prepared to identify the injury mechanism, promote a diagnosis, schedule the adequate treatment, and RTS criteria.

In the fourth year, they have three months of clinical pathology, six months in a Sports Medicine department of an elite club or federation, with an optional three more months in sports trauma, imageology, nutrition, or another area of resident´s interest.

During the residency period, it is expected that they attend post-graduate course in sports medicine, developing scientific work, scientific publications and specific training in emergency advanced trauma and life support. The final evaluation of the resident after completed his (her) residency, is a final exam that contemplates curriculum evaluation, clinical case discussions, and theoretical evaluation, by a pre-nominated evaluation jury, normally composed of three sports medicine specialist nominated by the Portuguese Sports Medicine Doctors College.

An alternative way to become a Sports Medicine Specialist

Despite regular access to the speciality as described above, there is still an alternative way for other Portuguese, or foreign doctors who are specialists in other fields of medical specialities, to become candidates of Sports Medicine speciality. They can apply to a special examination approved by the Portuguese Doctors College if they have completed three years of department rotations included in the specialist´s residency programme, have at least six years of sports clinical experience, and demonstrate a motivational interest in Sports Medicine including scientific studies and post-graduate course in areas specifically relating to Sports Medicine. After analysis of the CV is completed and recognition that the candidate meets the requirements of the regular examination by a Sports Medicine Doctors College, they must complete a written and oral evaluation in order to obtain the specialist title of Sport Medicine doctor.

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How to become a Team Physician in Portugal
by Henrique Jones

I. Introduction

A team physician is a medical doctor (MD) with a full license to practice medicine, a sports medicine specialty or a post graduate course in sports and exercise medicine. He, or she, should be able to manage on-field medical emergencies, be trained in basic life support, with knowledge of musculoskeletal injuries, medical conditions, and psychological issues affecting athletes. The role of the Team physician is to help the athletes maximize their performance levels, prevent injuries, treat health conditions affecting the athletes, control diet plans, exercise programmes and recovery strategies from exercise induced fatigue and rehabilitation. The team physician should be able to maintain a good relationship with coaches, sports physiologists, sports psychologists, Doping Agencies, directors and all the logistical staff of the clubs or Federations. Finally he, or she, should have a leadership role in the relationship with dieticians, physical therapists, strength and conditioning coaches, nurses, osteopaths, and other personnel that contributes to athlete healthcare.

II. Medical Qualifications to join a Team or Sports Federation in Portugal

Since the primary responsibility of the team physician is to provide optimal medical care for athletes, the team physician must possess certain qualifications and sports medicine competences. In Portugal, according to current law, , the sports practice should be monitored by an adequate structure of medical support to the athletes under the responsibility of a sports medicine specialist. The law reinforces that the referred structure is mandatory to Sport Teams that compete in professional competitions and the coordinator of Clinical Department in Clubs, Federations and National representations should be mandatory to be a Sports Medicine Specialist.

For the Sports Federations that includes top level athletes, it is absolutely mandatory to have a specialist with specific academic formation recognized by the Sports and Exercise Medicine College of Portuguese Doctors. Professional Teams and Federations, medical structures could include staff doctors with postgraduate sports medicine courses under supervision of the Sports Medicine specialist, according to the current law.

The Sports Medicine Specialist should have a work contract with the Team, Association or Federation that should be registered with the Portuguese Institute of Sports and Youth (IPDJ). This contract means that the doctor monitors the team on a day-to-day basis, including the team's training courses and matches. In most cases, the doctor is employed by the sports structure but he can also be self-employed, with a fee, which represents the majority of the situations. One important concern is insurance of Team Doctors practice. Although the specific insurance policies of the Club, Association or Federation recommends that Team Physicians have civil and professional liability insurance regarding the challenges of diagnosis, therapeutic decisions, recurrences and sports break time, concerning values of million euros athletes. The football Federation in Portugal incudes the Team Doctors Association (AMEF) who discuss several issues that the team doctor encounters during their activity and proposes changing measures that can benefits the doctors performance and players assistance.

III. The reality of Team Physicians activity in Portugal

In Portugal there are 587,812 federated athletes according with Statistics Portugal (updated in February 2022), consisting of 423,737 males 164,075 females. The number of Sports Medicine specialists is 142 with a relevant percentage of retired doctors. This means that it is almost impossible to have a specialist in each Sports Team, or Federation, although it is mandatory. The solution is, in the majority of cases, to have general practitioners or postgraduate doctors in sports medicine.

To this reality add the fact that several Sports Medicine Specialists work in National Centres of Sports Medicine, and Private Sports Medicine Centres in private hospitals, decreasing the number of available specialists for the Team Physician position.

Normally Team Physicians in a Club, or Sports Federation, is a senior specialist invited to do this job and become responsible for medical care and coordinate a team of younger doctors, physiotherapists, nurses, sports physiologists, among others.

In order to become a sports medicine specialist, the young fellows candidates should integrate into a Sport Club, or Federation, medical Team, for a period of at least six months, in order to have contact with regular athletes for evaluation, training and competition. After academic formation and successfully completing the final examination, they can, depending on his/her commitment, join the federation's teams, starting with cadet teams, then the junior teams and finally the senior teams. However it is not always like that and the invitation to senior and professional teams depends more on the friendship and influences from the Board of Directors or CEOs than experience, competence and qualifications of the doctors.

IV. How the sports physician can join Olympic projects and Training Centres in Portugal?

At the Olympic Project level, there is a medical commission of the Portuguese Olympic Committee chaired by a sports doctor chosen by the president of the Portuguese Olympic Committee, which invites sports medicine doctors from several Federations in order to support the medical assistance to the Olympic Athletes Project.

Regarding specific training centres, there are 14 High Performance Centres (CAR) in Portugal. Each centre represents an operative unity covering facilities, sports equipment and multi-disciplinary support, including sports medicine, in order to optimize the sports performance for high performance athletes from National Federations and Olympic Project. This support includes training methodologies, scientific research, medical support, psychology, physiotherapy, and nutrition, and more. The mission is detecting and empowering sports talents, internships, training evaluation, control and optimization, scientific research and results monitoring. CARs are classified as multisport or specific sport specialized. Normally the sports medicine support is performed by one or more invited sports medicine specialists who coordinate a group of professionals that support the athlete’s performance, injury prevention, rehabilitation and return to sports. These athletes are listed annually on a high-level list validated by the Sports Foundation, under ministry supervision and proposed by the technical director of each federation.

V. Final words and concerns about Team Physician practice in Portugal

1. Team Doctors Relationships and Duties

The Team Physician position is often seen as a privilege in the career of a Sports Medicine Doctor and represents the final ambition of young sports doctors. However, it still remains a challenge regarding competences, interpersonal relationships, decision capacity, permanent availability, human relations and psychological knowledge. Top level athletes are ambitious, self-motivated, with different and singular personalities, strong and fragile at the same time and mostly, easily influenced. Team Physicians need to be trusted and supported by their players in the first place which means rigorous decisions, open-minded discussion, and regular approaches with players, coaches and all technical and medical staff. Nowadays it is normal that the top athlete has their own trusted doctor and physiotherapist, and it is important that the Team Physician can discuss all possible problems that matters to the athletes in a serious, honest and transparent way. This is frequent between National Team Doctors and Club Team Doctors as well as between Federation Doctors and the athlete’s private doctors and, finally, between clubs doctors when a transfer between clubs happens. However, sharing information about an athlete can involve ethical, legal and professional secrecy that needs to be reviewed to protect doctors, athletes and clubs.

2. Team Doctors Protection and Insurance Coverage

What are the legal risks a doctor may face and how can the risks be minimised and prevented? Team Doctors protection regarding consent, malpractice, confidentiality and disclosure (e.g. doping, social drug use, sexual health issues), data protection, doping rules liability (anti-doping rule violation because of an absent, or outdated TUE), medico-legal issues, means adequate Insurance coverage, which does not seem to be the current reality.

3. Team Doctor Contracts and Fees

Team Doctors must be paid properly in accordance with their duties and responsibilities. Contracts must be respected and competent qualifications should be the rule in Team Physician selection.

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¹ ESSKA-ESMA Board Member | ² ESSKA-ESMA Vice-Chairman | ³ ESSKA-ESMA Chairwoman

THE FACTS: FOOTBALL AS A PARADIGM

¹ Orthopaedic surgeon and sport physician | ESSKA-ESMA Chairwoman | President of the French National College of Sports Medicine
² Emergency and sport medicine | Federal physician of the French Modern Pentathlon Federation | Member of the medical commission of the French Judo Federation | Member of the medical commission of the French Olympic Committee

How to become a Sport Doctor in France
by Patricia Thoreux

Becoming a sport physician can be very different from one country to another, even in Europe. Sport Medicine can be a medical specialty on its own, be a “supra” specialty of your first one or be a second complementary specialty.

Those differences can be major from an academic point of view, especially when all of these trainings aim to the same points and objectives: athlete’s health, prevention of pathology besides performance and promotion of physical activity for any kind of prevention and treatment for chronic disease.

That is why the ESSKA-ESMA board has thought it would be interesting to have a monthly article in the ESSKA Times titled: “How to become a Sport Doctor and how to become a Team Physician” all over Europe and the world, to point out the best options to have an outstanding practice of Sport Medicine in Europe and to promote a European academic training.

In France, academic training to become a sport physician has changed frequently over the last 20 years.

The only common thing is that Sport Medicine in France is not a specialty by itself.

Before 2003, the only option to be trained and become a sport physician was to take an exam called “Capacité de Médecine du Sport”, nationally recognized but locally organised: you can sit for it only when you have finished your specialty and have your medical thesis. Training lasts one year with about 130 hours of teaching hours and a certain amount of half days of practical training (i.e 20 half days of clinics in sport trauma, six half days of physiological and/or cardiological activities, 3 half days of participation in supervision of competitions …). This option is what we call a “Formation Médicale Continue” (= Continuous medical training) which means that you do it to improve or maintain your knowledge in your own specialty or to add a new skill in your practice.

After 2003, a specific training during the residency to become “Sport Physician” appeared, in addition to your first specialty.

From 2003 to 2019, it was called “DESC de Médecine du Sport” (Complementary Specialized Training Diploma of Sport Medicine). It was made up of two years (the first during the residency and a second one after, like a fellowship) of Sport Medicine and was not accessible to all specialties (for example, Orthopaedic surgeons were not able to sit for this training). The number of positions was very restricted (one or two per university, for all specialties). Since 2019, “DESC Médecine du Sport” has been replaced by what is called the “FST de Médecine du Sport” (= Transversal Specialty Training of Sport Medicine).

To this date, there are two ways to become a Sport physician and be recognized as a Sport Physician (besides your first specialty) by the “National Medical Council”:

After medical school (six years training), all students in France sit for the “ECN” (National Classifying Exam) which ranks them from 1 to 9500. Depending on this ranking, they will be able to choose their specialty and the place where they will do their residency.

Besides this main training, you can:

1. Apply to a “one-year” specific training called FST “Formation de Spécialité Transversale” of Sport Medicine (= Transversal Specialty Training of Sport Medicine) during the residency.

Depending on the duration of the residency (depending on the specialty), this FST year is included in the residency for specialty in five or six years (as orthopaedic or cardiology) or is an additional year for specialty in three or four years (as general practitioner, emergency or rehabilitation).

This FST year is divided in two semesters as residents in qualified sport departments; during those two semesters, it is necessary to have been trained for both traumatology/osteoarticular aspects of sport medicine and on physiological aspects, medical problems, regulatory medical supervisions, doping rules…

This academic training is mainly practical, working in sports departments or rehabilitation departments for athletes and the students are trained on a daily basis (as all residents) by physicians and professors responsible of these departments.

The theoretical training is organised on a local basis but two national seminars are organised per year, involving all students all over France.

Every year, about 70 residents are chosen all over France to realize this FST “Sport Medicine”. The number of students allowed per year is decided by the “Ministry of Higher Education” and is allocated for each medical university all over France. The number is usually from one to three positions per university or city except in Paris where there are 11 positions per year.

The students are mainly residents in general practice and rehabilitation in about 90% of cases. The other most frequent specialties are rheumatology, orthopaedic surgery, cardiology and emergency.

2. Apply to the diploma called “Capacité de Médecine du Sport” which can be done only after the residency (cf supra).

The main difference is that when you receive this training, you are never totally involved in a sport department or in a national sport institute.

The acknowledgement is the same in term of “National Medical Council” but the practical training and the network you can develop is very different.

The number of positions per year all over France is approximately two to three times greater than the number of FST positions.

In addition to this training, all physicians (whether or not they are sport doctors) are able to apply to specific university training (attached to one university and with no national acknowledgment) in nutrition, exercise physiology, sports trauma, podology, doping, etc.

 

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How to become a Team Physician in France
by Alain Frey

I. Introduction

In France, after obtaining a sports medicine diploma, sports doctors have several possibilities if they want to practice sports medicine with high-level or professional athletes: by joining a sports federation, a training center for professional sports or a regional or national training centre following several sports.

Becoming a team doctor at any level is a gradual process while acquiring experience on the field. The doctor starts out alone in a local structure or joins a larger structure where there are already team doctors who will be able to supervise and accompany him in his training on the field.

The team doctor has to be available and therefore has to have a contract either full time or part time for specific weekly periods or only on a temporary basis for a few annual missions. In case of a contract with a club or a federation, he monitors the team on a day-to-day basis, if necessary, with the help of the sports medicine technical platform for annual check-ups, and monitors the team's training courses and matches.

In order to carry out these missions, it is mandatory to have a doctor's degree, be registered by the national medical council and have civil and professional liability insurance, although the structure employing them must also have its own insurance. Most of the time the doctor is employed by the structure but in some cases, he can be self-employed with a fee.

II. How the sports physician can join a sports federation in France?

Most of the time, the physician already practices this sport or has an affinity for it. He often starts by supervising competitions at a departmental level and then at a regional level before joining the pool of doctors supervising national competitions, all of which allow him to acquire experience on the field. He can then, depending on his commitment, join the federation's French teams, starting with the French cadet teams, then the junior teams and finally the senior teams.

The transmission is most often done by companionship in the field during the supervision of national competitions or the supervision of national training courses. The young practitioner learns to manage a high level athlete through contact with the senior doctor he works with. He then builds up his own experience as he goes along.

Once the sports doctor becomes the doctor of the senior French team, he supervises the team’s training sessions, the European and world championships and may sometimes go to the Olympic Games depending on the size of the delegation. He manages a medical staff that includes mostly sports physiotherapists and sometimes sports podiatrists.

Within the federation, there is a federal medical commission comprising the elected or appointed federal doctor, the team doctor(s), the doctor in charge of the regulatory medical following of athletes listed annually on a high-level list validated by the Ministry of Sport and proposed by the technical director of each federation.

At an even higher level, there is a medical commission of the French Olympic Committee chaired by a sports doctor chosen by the president of the French Olympic Committee and which brings together a certain number of federal doctors, representatives of learned societies of sports medicine as well as the medical unit of the Ministry of Sport. This medical commission deals with the two main aspects of sports medicine in France: the monitoring of the French teams and the development of sports health within each federation.

III. How the sports physician can join a training centre and then a professional sports team in France?

The evolution is somewhat identical to the previous one. The sports doctor joins a professional training centre and supervises young people, first at the junior level and then at the cadet level. Depending on his appetite and commitment, he can then join the French cadet or junior teams, depending on the age category of the athletes (for example, in football, there are U15, U16, U17, U18 and above teams up to U23).

The sports doctor can then gradually take over the management of a professional team such as in football, rugby, basketball, handball, volleyball or cycling for example. He often becomes a full-time doctor at the service of the team and has a whole paramedical team at his disposal, consisting mainly of sports physiotherapists, podiatrists and more if necessary. He is in direct contact with the technical staff and the performance unit.

The relationship is the same as with the French teams mentioned above. The small difference with the French teams of the other federations lies in the financial value of the players, which puts even more pressure on the medical staff, especially when the club has foreign players who can play in their national teams and who often wish to have the opinion of their sports doctor in their country of origin.

In these sports federations where there are professional clubs, there is also a French team which is often medically managed by a former professional team doctor in order to ensure his competence and seniority in managing high-level athletes. In this case, the doctor and his medical staff manage team meetings, friendly matches, official matches during the European Cup or the World Cup (in football as in rugby every 4 years).

In these federations with professional clubs, there is often an association of professional team doctors who meet at least once a year to discuss several issues that the team doctor encounters.

IV. How can the sports physician join a Regional Centre for Expertise and Sports Performance (CREPS) or the French national institute of sport, expertise and performance (INSEP)?

As with the federations' medical commissions, the sports physician can join a public establishment of so-called “Grand INSEP”. “Grand INSEP is a network of high-level training and education centres, currently 30 centres throughout France (INSEP, CREPS, National Schools, National Dance Center, etc.). It meets the requirements of high-level performance by supporting high-level athletes and their managers.

The CREPS are local public training establishments in the field of sport, training both athletes and trainers, and their main missions are to:

• ensure the training and preparation of top-level athletes and implement the dual project of top-level athletes, in conjunction with the sports federations
• organise initial or continuing vocational training in the fields of physical and sports activities or leadership
• within the framework of agreements with the Minister for Sport, ensure the operation of national resource centres
• host young talent detection courses, federal training courses for sports managers, technical meetings and general assemblies of the sports movement

The bridgehead of this network is the INSEP with a complete medical department with an integrated imaging department.

Each training centre has a medical service consisting of several doctors, dentists, physiotherapists, chiropodists, dieticians, nurses, clinical sports psychologists, …

Thus, the young sports doctor can join the medical team and learn his or her job in the field with top athletes of all ages in several disciplines. It is also a way to join a French cadet, junior and senior team, depending on the disciplines present at the CREPS or INSEP.

V. Conclusion

The sports doctor has a wide range of practice options and can therefore diversify his or her practice. He can also work in a sports medicine technical centre, either in a hospital or in a clinic, to provide annual check-ups and monitoring of athletes, whatever their level.

French law requires doctors to respect medical secrecy, which is highly regulated and can sometimes put the team doctor in a difficult position when it comes to sharing information about an athlete with the technical staff in order to optimize treatment in the event of injury.

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Available in "OPEN ACCESS" on the ESSKA Academy and available in English, French, Italian; Portuguese and Spanish. View all here!

It was a full house at the Inaugural ESSKA ESMA - IOC Team Physician Course welcoming over 100 international team physicians and physiotherapists and a top-class faculty. A huge thank you to everybody who took part and a special thank you to IOC for their great collaboration and to the Paris Olympic Games Team who delivered a fascinating overview of the road to 2024 Olympics.

Watch this space for the next edition in Milan 2024!

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The Covid pandemic has deeply influenced international scientific activity. Even the ESSKA Speciality Days scheduled for September 2021 in Warsaw was postponed to 2023 and replaced with ESSKA Sections Speciality September dedicated to their members. The ESSKA-ESMA virtual meeting was held on 21 September 2021 thanks to the great work of the ESSKA team.

The theme was ACL Injuries in Young Athletes. These lesions require dedicated care and ESSKA-ESMA is deeply committed to the study of the best preventive measures and optimal solutions for full functional recovery. The state of the art on this pathology was presented: Romain Seil, former ESSKA President, began the session by presenting the ESSKA pediatric ACl registry, an important initiative that will provide useful data for a better understanding of these lesions.

Stefano Della Villa presented the latest information on the dynamics of ligament injury whose knowledge is the best way to identify preventive actions. Core stability and motor skills are important.

Thomas Patt presented the actual best preventive measures and a short trailer of the ESMA video on ACL injury prevention in children which will be released at the ESSKA Congress 2022. It will be an extremely useful educational tool for schools and sports societies.

Werner Krutsch and ESSKA President Jacques Menetrey presented the latest news on ACL repair and reconstruction in children and adolescents: the surgical management of ACL lesions in the growing athlete requires specific anatomical and technical knowledge and experience.

Rehabilitation must be based on the progression of reparative biological processes and individualized: Angelina Lukaszenko presented the sequential steps necessary to favour a physiological healing and a safe return to sports.

The virtual format of the session obliged ESMA to select only four presentations for the free papers session, all of high scientific content (Note: All ESMA members will receive a pdf copy of all the ESMA submitted abstracts):

• A. Grassi, L. MacChiarola, J. Zambon, G. Lucidi, G. Dal Fabbro, F. Stefanelli, N. Pizza, S. Zaffagnini. Anterior Cruciate Ligament (ACL) Reconstruction and Lateral Plasty in High- Risk Young Adolescents: Failures, Functional Evaluation and the Role of Surgical Timing on Meniscal Preservation.
• L. MacChiarola, C. Mouton, J. Dor, C. Jacquet, R. Seil. Anterior tibial translation on Lateral weightbearing X-rays help to identify ACL deficiency and increases with time from first injury.
• C. Mouton, H. Moksnes, R. Seil, L. Engebretsen. Preliminary epidemiological data of the ESSKA Pediatric Anterior Cruciate Ligament Initiative.
• G.R. Harðarson, K. Briem, H.B. Sigurðsson. The effect of injury prevention program based on FIFA 11 on medial knee displacement in young athletes.

Despite the selected abstract having been all excellently presented and discussed, the ESMA Board could award only one as the best. Anterior Cruciate Ligament (ACL) Reconstruction and Lateral Plasty in High- Risk Young Adolescents: Failures, Functional Evaluation and the Role of Surgical Timing on Meniscal Preservation will be published in the Journal of Experimental Orthopaedics (JEO) without any charges.

If you missed the scientific meeting or would like to watch it again, the content will soon be available on the ESSKA Academy.

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Online Business Meeting

During the Business meeting at the end of the event, the ESMA Board highlighted the projects undertaken so far.

The following publications are almost ready and under publisher’s review:

• Epidemiology of Injuries in Sports, Eds GL Canata, H Jones.
• The Running Athlete, Eds GL Canata, H Jones, W Krutsch, P Thoreux, A Vascellari

The survey on Patellar tendinopathies is online and it is still possible to participate by clicking on the following link.

An ESSKA-ESMA Consensus Conference on Groin Pain, run by ESMA and the Hip Arthroscopy Committee, is in development to provide an update on clinical assessment, imaging, and post surgical treatment.

The ESMA Board has also conducted several webinars to favour the exchange of knowledge even in times with travelling difficulties. This included the SIAGASCOT Streaming Festival held on 19-20 March 2021 which hosted a combined SIAGASCOT – ESSKA-ESMA – ISAKOS session on Achilles Tendinopathies.

Further planned webinars are:

• ACL Beyond Surgical Techniques on 27 October 2021
• Pediatric ACL Conservative vs Surgical

A two-day Team Doctors Course in cooperation with the International Olympics Committee is being planned for the ESSKA Congress 2022 to improve and update the knowledge base of team physicians worldwide.

Also, a movie project for ACL injury prevention titled PREVENTION FOR ALL!, will be presented at the ESSKA Congress in Paris.

Gian Luigi Canata
ESSKA-ESMA Chairman

The next ESMA members' meeting will be an Online Meeting exclusive to ESMA members.

This meeting will focus on the topic "ACL injuries in young athletes" and will feature a 90-minute high level scientific programme followed by a members' meeting.

The scientific programme with feature presentations, four free paper sessions and the opportunity for discussion and exchanging of knowledge.

The topic will cover the ACL injuries in the young athlete, from prevention to return to sports,  giving ESMA members a full update on this important topic. The young athlete is different from the adult athlete. The ESSKA paediatric ACL registry is an important step for a better management of these injuries. Preventive measures are extremely important as well as information on the mechanism of injury. Participants to this ESMA online meeting will receive a detailed update on the surgical and non surgical management and on the specific rehabilitation modalities.

To view the preliminary programme for this meeting click below.

Would you like to join this meeting but are not an ESMA member? No problem, you can join ESMA today and still have time to register for the meeting!

Following the rescheduling of the ESSKA Speciality Days 2021 to November 2023, we are delighted to announce a series of four online Section Meetings organised exclusively for Section members.

A chance to get back together, enjoy some top-quality specialised science and hear the latest news from the Section leadership.

Each Section Speciality Meeting will focus on a specific topic and will feature a 90-minute high level scientific programme followed by a Members' meeting.

Save the date and keep an eye out for more information!

Not yet an ESSKA member or a Section Member? No problem - you can still join today!

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