Integrated Performance & Medicine in Elite Sport: A Perspective on Creating Competitive Advantage

Ben Bradley | Performance & Medicine Manager

The purpose of a Performance & Medicine department extends beyond delivering specialist services. In my view, its central contribution is to integrate expertise across disciplines so that athletes are better prepared to perform and teams are better positioned to achieve a competitive advantage.

Medical care, rehabilitation, physical preparation, nutrition, psychology and sport science each contribute valuable knowledge. However, their collective value depends on how effectively they inform a coherent programme of support, aligned with the demands of the sport and the objectives of coaching.

This article presents an evidence informed professional perspective on that process. Drawing on published research and applied frameworks, I consider how integrated practice can contribute to athlete health, availability, development and performance, and how departments might evaluate whether their work is making a meaningful difference.

Defining the department’s contribution

Performance & Medicine departments are often described through their constituent disciplines or the services they provide. Assessments, treatments, physical testing, monitoring, rehabilitation and conditioning are familiar examples.

These activities are necessary, but they do not provide a sufficient account of departmental effectiveness. Completing an assessment demonstrates that information has been collected. Delivering a programme demonstrates that an intervention has taken place. Neither establishes, in isolation, that the work addressed the right problem or improved the athlete’s preparation.

I would therefore distinguish between departmental activity and departmental contribution.

Activity describes what practitioners do. Contribution concerns what that work enables: a more appropriate training decision, an improvement in physical capacity, a better coordinated rehabilitation programme or a clearer understanding of an athlete’s needs.

The competitive value of a department lies in connecting the two.

This requires a shared objective that is more specific than “improving performance”. Staff need to understand which demands the athlete must meet, what currently limits their ability to meet them, and which actions deserve priority within the available time.

Integration as an organisational capability

Bringing specialists together creates the potential for integrated practice. Realising that potential requires deliberate coordination.

Dijkstra et al. (2014) described an Integrated Performance Health Management and Coaching model informed by UK Athletics’ preparation for the London Olympic and Paralympic Games. Their model connected health and coaching services around common performance objectives while preserving professional governance and appropriate autonomy. It offers a published example of how integration can be organised, rather than experimental evidence that a particular structure produces sporting success.

The principle I take from this is that integration should be understood as an organisational capability: the ability to combine relevant expertise and apply it effectively to a shared problem.

For example, an athlete demonstrating reduced training tolerance may require consideration of recent exposure, current symptoms, physical capacity, recovery, nutrition and psychological circumstances. An effective response depends on how these perspectives are interpreted together.

Without integration, each discipline may produce a reasonable recommendation that becomes less appropriate when combined with everything else the athlete is being asked to do.

The department must therefore consider the cumulative programme. Training time, recovery opportunities and athlete attention are finite. Prioritisation is a central part of the work.

Communication should improve decisions

Communication is frequently presented as a desirable feature of multidisciplinary practice. I would regard it as part of the mechanism through which the department delivers its work.

Relevant information must reach the appropriate person, be understood in context and influence action.

Ekstrand et al. (2019) examined medical staff perceptions of communication within 36 elite football clubs across 17 European countries. Poorer communication between medical teams and head coaches was associated with greater injury burden, a higher incidence of severe injuries and reduced player availability.

More recently, Ekstrand et al. (2025) reported an association between better communication between medical and performance staff and lower hamstring injury burden across 14 male professional football teams.

These studies do not establish that communication alone prevents injury. Staff perceptions, leadership, resources and other organisational characteristics may influence the relationships observed. Nevertheless, they provide empirical support for examining communication quality as part of departmental effectiveness.

In practical terms, I would expect communication to clarify:

• What has changed in the athlete’s status or circumstances.
• What that change means for preparation and participation.
• Which action is recommended and who is responsible.
• What uncertainty remains and when the decision will be reviewed.

A daily meeting can support this process, but attendance is a weak indicator of integration. The more useful question is whether the discussion produces a clearer and better coordinated plan.

Connecting availability with readiness to perform

Availability has competitive relevance because it influences who can train, develop and be selected.

Hägglund et al. (2013) followed 24 professional football teams over 11 seasons, comprising 155 seasons of team data. Lower injury burden and greater match availability were associated with better team performance, including league ranking and points per match.

The findings support the importance of athlete health within the wider performance system. They do not establish that departmental practice independently determines competitive results.

I would also argue that availability should be interpreted alongside readiness. An athlete can be selectable while remaining underprepared for some of the demands they are likely to encounter.

The Bern consensus statement distinguishes between return to participation, return to sport and return to performance (Ardern et al., 2016). This provides a useful conceptual basis for considering what lies beyond clearance to resume activity.

For departmental practice, the questions become more demanding: can the athlete tolerate the required exposure, execute the actions associated with their role, and sustain an effective contribution?

This perspective also guards against treating short term availability as the sole objective. Supporting competitive performance requires consideration of the athlete’s immediate contribution, longer term preparation and health.

Developing capacity that supports the sport

Physical preparation is a substantial part of the department’s contribution. Its objectives should be connected to the athlete’s sporting requirements.

Seitz et al. (2014), in a systematic review and meta analysis involving 15 studies and 510 participants, reported positive transfer between improvements in lower body strength, assessed using the back squat, and sprint performance.

This supports the relevance of strength development to a performance task. However, it does not mean that every increase in strength will produce a corresponding improvement in an individual athlete’s competitive contribution.

My position is that departments should make the intended relationship explicit. Which capacity is being developed? Why is it a priority for this athlete? How will progress be assessed? How does the intervention fit alongside sport practice?

Some benefits will be immediate and measurable. Others may concern longer term development or capacities whose contribution is difficult to isolate. In either case, the rationale should remain open to examination.

Integration with coaching is particularly important here. Physical programmes and sport practice should reflect an understanding of their combined demands, rather than develop independently and compete for the athlete’s capacity.

Monitoring should support interpretation and action

Monitoring can improve understanding of what an athlete has experienced and how they are responding. Its value depends on the decisions it informs.

The International Olympic Committee consensus statement on load and injury considered training, competition, psychological demands and travel within a broad account of athlete loading. It advocated consideration of both exposure and response, recognising variation between athletes (Soligard et al., 2016).

Saw et al. (2016), in a systematic review of 56 studies, found that subjective measures of wellbeing generally reflected training load changes with greater sensitivity and consistency than the objective measures examined. This supports the inclusion of information reported by athletes, while leaving room for appropriate physiological and performance assessments.

I would advocate interpreting monitoring information through three connected considerations:

Exposure: the work and demands experienced by the athlete.

Response: symptoms, perceived exertion, wellbeing and relevant physiological or performance changes.

Context: clinical history, individual circumstances and the requirements of forthcoming training or competition.

A change in a variable may justify a conversation, further assessment or a modification to the plan. It should not automatically produce the same response in every athlete.

It is also important to distinguish description from prediction. Bahr’s (2016) critical review explained why identifying an association between a screening measure and injury does not establish that the measure can accurately predict who will become injured.

Departments should therefore be precise about what their assessments can inform. Identifying a current deficit, monitoring adaptation and predicting a future event are different purposes.

Rehabilitation as integrated performance preparation

Rehabilitation is one of the clearest settings in which coordination across disciplines becomes essential.

Clinical recovery, physical reconditioning and sporting preparation must progress in relation to one another. The Bern consensus advocates collaborative decisions about returning to sport involving the athlete and relevant professionals (Ardern et al., 2016).

Taberner et al. (2019) offered an applied example through the control to chaos continuum. The framework connects progression in running exposure with increasing movement variability and perceptual and reactive demands, moving towards the unpredictable conditions of football. It is a practice based framework rather than a trial demonstrating superior outcomes.

The practical implication is that rehabilitation should address more than completion of physical workloads. The athlete must also prepare for the actions and decisions associated with their sporting role.

I would therefore advocate involving coaching perspectives before unrestricted team reintegration. Coaches can help define the sporting requirements, while medical and rehabilitation practitioners inform the conditions under which exposure should progress.

This should produce a shared understanding of the athlete’s objectives, current capabilities, remaining limitations and criteria for progression. Responsibilities must remain clear throughout.

Implementation is part of professional effectiveness

Knowing which interventions have supporting evidence is only one part of effective practice. Departments also need the ability to deliver them consistently.

Petersen et al. (2011) conducted a cluster randomised trial involving 50 Danish male professional and amateur football teams and 942 players. An additional Nordic hamstring exercise programme was associated with fewer acute hamstring injuries: 15 in the intervention group compared with 52 in the control group, with an adjusted rate ratio of 0.293.

Bahr et al. (2015) subsequently reported limited adoption in a survey of 50 professional teams. Across 150 seasons of club data, full completion of the programme was reported in 16 seasons, or 10.7%.

The studies involved different populations and designs, so they should not be treated as a direct comparison. Together, however, they illustrate the distinction between evidence of efficacy and implementation in practice.

My interpretation is that implementation capability deserves explicit attention within Performance & Medicine departments. Scheduling, athlete understanding, coach agreement, practitioner responsibility and continuity of delivery all affect whether a proposed programme becomes established practice.

An evidence informed intervention has limited opportunity to help if it is rarely completed. Understanding and addressing the barriers to delivery is therefore part of the department’s performance contribution.

A proposed approach to integrated delivery

I would organise departmental practice around a repeatable process linking the performance problem to action and review.

The following framework is an approach I advocate. It is not a validated assessment tool.

The connection between stages is critical. An accurate assessment may have little practical effect if it does not influence planning. A carefully reasoned plan may achieve little if delivery is inconsistent. An intervention may continue unnecessarily if outcomes are never reviewed.

Consider, as a hypothetical example, an athlete struggling to maintain repeated high intensity efforts. The process should establish the nature of the limitation before assuming that more conditioning is required. Relevant health, exposure and preparation information can then inform an agreed intervention and a suitable method of evaluation.

The aim is a disciplined process that improves the quality of the next decision.

Evaluating whether the department is contributing

A department should be able to explain how its work is contributing and how that judgement has been reached.

I would distinguish between resources, processes and outcomes. Resources describe the staff, facilities and systems available. Processes concern how work is coordinated and delivered. Outcomes concern changes in athlete health, preparation and performance.

Evaluation should draw on all three, with particular attention to the relationship between what was intended, what was delivered and what followed.

Relevant areas might include injury and illness burden, availability, progress towards individual physical objectives, rehabilitation progression, intervention completion, and athlete and coach experience.

These measures require context. Changes in competition exposure, squad composition, previous injury or coaching requirements may influence outcomes independently of departmental practice.

For that reason, I would seek converging evidence of contribution rather than assign success or failure to a single measure. Favourable results should not prevent scrutiny of weak processes, and an adverse outcome should not automatically invalidate an otherwise appropriate decision.

The purpose of departmental evaluation is to improve practice while providing an honest account of what the department can reasonably influence.

Professional accountability within a shared objective

Integration requires shared purpose alongside clear professional boundaries.

Dijkstra et al. (2014) incorporated governance and appropriate autonomy within their integrated model. This is a necessary part of coordinated practice.

In my view, departments should make responsibilities, decision authority and escalation routes explicit. Staff must be able to raise concerns and challenge assumptions within their scope of practice.

Athletes should also understand the rationale for their programme and have meaningful opportunities to contribute. Their experience, preferences and confidence are relevant to the support they receive.

The pursuit of competitive advantage must operate within professional obligations and athlete welfare. These responsibilities define the conditions under which effective performance support should be delivered.

What the evidence can and cannot tell us

The literature discussed supports the relevance of communication, availability, physical development, monitoring, rehabilitation and implementation. It does not establish that a particular departmental structure guarantees competitive success.

Much of the organisational evidence comes from observational research in male professional football. Its application to women’s sport, youth development, individual sports or environments with different resources requires consideration.

Similarly, practice based frameworks can offer useful ways of organising work without having demonstrated comparative effectiveness.

These limitations should shape the confidence of our claims. They also reinforce the importance of evaluating how published evidence applies within a particular environment.

My argument is that integration provides a defensible organising principle: it connects expertise to the athlete’s needs, the coach’s objectives and the practical demands of delivery.

Creating a competitive edge

A Performance & Medicine department contributes through specialist competence and the collective ability to apply it.

The competitive opportunity may arise from more appropriate preparation, clearer decisions, earlier recognition of problems or more consistent implementation. It may also arise from coordinating work so that athletes can complete the most important parts of their programme without unnecessary or conflicting demands.

The evidence supports components of this argument. The broader position remains a professional interpretation of how those components can be brought together.

I would therefore define an effective department as one that consistently translates relevant expertise into coordinated action, evaluates the consequences and adapts its practice.

Its ambition should be to improve the athlete’s opportunity to perform and, through that contribution, help the team establish a competitive edge.

The question I would keep returning to is: how has our combined work improved this athlete’s preparation, supported the coach’s decisions and strengthened the opportunity to perform?

References

• Ardern, C. L., et al. (2016). 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine, 50(14), 853–864. https://doi.org/10.1136/bjsports-2016-096278
• Bahr, R. (2016). Why screening tests to predict injury do not work—and probably never will…: a critical review. British Journal of Sports Medicine, 50(13), 776–780. https://doi.org/10.1136/bjsports-2016-096256
• Bahr, R., Thorborg, K., & Ekstrand, J. (2015). Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. British Journal of Sports Medicine, 49(22), 1466–1471. https://doi.org/10.1136/bjsports-2015-094826
• Dijkstra, H. P., Pollock, N., Chakraverty, R., & Alonso, J. M. (2014). Managing the health of the elite athlete: a new integrated performance health management and coaching model. British Journal of Sports Medicine, 48(7), 523–531. https://doi.org/10.1136/bjsports-2013-093222
• Ekstrand, J., Lundqvist, D., Davison, M., D’Hooghe, M., & Pensgaard, A. M. (2019). Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs. British Journal of Sports Medicine, 53(5), 304–308. https://doi.org/10.1136/bjsports-2018-099411
• Ekstrand, J., et al. (2025). Higher level of communication between the medical staff and the performance staff is associated with a lower hamstring injury burden: a substudy on 14 teams from the UEFA Elite Club Injury Study. BMJ Open Sport & Exercise Medicine, 11(1), e002182. https://doi.org/10.1136/bmjsem-2024-002182
• Hägglund, M., Waldén, M., Magnusson, H., Kristenson, K., Bengtsson, H., & Ekstrand, J. (2013). Injuries affect team performance negatively in professional football: an 11-year follow-up of the UEFA Champions League injury study. British Journal of Sports Medicine, 47(12), 738–742. https://doi.org/10.1136/bjsports-2013-092215
• Petersen, J., Thorborg, K., Nielsen, M. B., Budtz-Jørgensen, E., & Hölmich, P. (2011). Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomized controlled trial. American Journal of Sports Medicine, 39(11), 2296–2303. https://doi.org/10.1177/0363546511419277
• Saw, A. E., Main, L. C., & Gastin, P. B. (2016). Monitoring the athlete training response: subjective self-reported measures trump commonly used objective measures: a systematic review. British Journal of Sports Medicine, 50(5), 281–291. https://doi.org/10.1136/bjsports-2015-094758
• Seitz, L. B., Reyes, A., Tran, T. T., Saez de Villarreal, E., & Haff, G. G. (2014). Increases in lower-body strength transfer positively to sprint performance: a systematic review with meta-analysis. Sports Medicine, 44(12), 1693–1702. https://doi.org/10.1007/s40279-014-0227-1
• Soligard, T., et al. (2016). How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine, 50(17), 1030–1041. https://doi.org/10.1136/bjsports-2016-096581
• Taberner, M., Allen, T., & Cohen, D. D. (2019). Progressing rehabilitation after injury: consider the ‘control-chaos continuum’. British Journal of Sports Medicine, 53(18), 1132–1136. https://doi.org/10.1136/bjsports-2018-100157