Dear Colleague,

If you are reading this, it is highly likely that we share something in common: a fascination with human movement and physiology, and a particular interest in how they are expressed within the context of high-performance sport. As professionals in the sports sciences – whether you are a strength and conditioning coach, physiotherapist, rehabilitation specialist, or engaged in any related discipline – our primary motivation is to help athletes achieve their sporting goals. We invest our time and energy in continuous professional development to offer the very best to our athletes, seeking to optimise performance, prevent injuries and facilitate recovery. These are, without a doubt, noble intentions.

But what if we were to tell you that, despite this commitment and knowledge, some of our interventions – even the most well-intentioned and correctly applied – could have unintended or even detrimental consequences for athletes? This is where a concept comes into play that, although fundamental in medical practice, seldom resonates with the same force on the pitch, in the gym, or in the physiotherapy clinic: iatrogenesis. Let us delve deeper into this term.

The word iatrogenesis is derived from the Greek iatros (physician or healer) and -genia or -genesis (to create, to beget, to produce, or to originate). Literally, it means “physician-induced” or “originating from the healer”. It is interpreted as a harmful state or condition caused by the intervention of a healthcare professional. Although the term "iatrogenesis" was first used, as far as is known, in 1924 by Eugen Bleuler, an awareness of the potential harm of healthcare actions dates back to earlier times. From what we have been able to read, the Mesopotamian Code of Hammurabi (circa 1760 B.C.) already reflected mechanisms of societal defence against medical errors, and the celebrated Hippocratic aphorism Primum non nocere (“First, do no harm”) has underscored this concern since antiquity. It is a concern that endures to this day.

In the present day, iatrogenesis is understood as an undesirable and unintended harm to health, caused by a legitimate and validated professional act, intended to cure or improve a condition. It is a detrimental change in the state of the patient, brought about by the professional, which is unintentional and, on occasion, unconscious.

Perhaps upon reading these lines, the idea of professional malpractice comes to mind, but it is crucial to distinguish it from iatrogenesis. Whereas malpractice implies harm caused by a mistaken action, improper use of a technique, lack of skill, or ignorance , iatrogenesis is a negative consequence or effect of an action that is considered correct, appropriate, or indicated according to the knowledge of the time. The latter is more closely linked to bioethics and reflection on the limits and effects of our interventions, whilst malpractice has legal connotations. Iatrogenesis can exist without malpractice, and it is precisely in this domain that we wish to focus our reflection.

The objective of this first instalment is to open a space for dialogue and critical thinking about how this concept may manifest in our field: the sports sciences. Now that we have defined the term, let us proceed step by step.

Adapting the term to sport

Whilst iatrogenesis originates and is defined within the heart of medicine, its relevance extends to any profession that intervenes in the health and well-being of individuals. It is a term we rarely hear directly associated with our work, and perhaps for that reason, it is all the more necessary to explore. How does this translate to our daily work with athletes, whether in the gym, on the treatment table, during a rehabilitation session, or in the planning of sport-specific training?

We will focus particularly on those “complementary” or “adjuvant” interventions we carry out beyond the specific technical-tactical practice of the sport. We are referring to strength programmes, the design of “preventative or compensatory” exercises, manual therapies, postural or movement assessments, and technical instructions, among others.

Iatrogenesis in sport does not always manifest as a clear physical adverse effect (although it can), but may adopt more subtle forms:

• We could speak of clinical or physical iatrogenesis if a poorly designed exercise programme or an inappropriate manual therapy technique (even if theoretically “correct” for a condition, but not for that individual at that moment) causes pain, an injury, or a delay in recovery. This is true even if the consequences are not observed at the time of application.
• We could also highlight a potential social iatrogenesis, where the expert’s gaze tends to medicalise or problematise aspects of movement or physical condition that are simply variations of the norm. Does every athlete need to undergo the same battery of tests? Is it relevant to sporting performance to correct movement patterns identified as inadequate or inefficient? When does optimisation become an obsessive pursuit of a non-existent perfection?
• There is also cultural iatrogenesis in sport, where a dependency on certain techniques, technologies, or supplements is fostered, creating a culture in which the athlete feels they cannot perform or be healthy without them, thereby losing their autonomy. Consider the obsession with certain metrics or “bio-hacks” without a profound understanding of their actual utility. Do all athletes need to incorporate basic supplementation into their diet? If we give our athletes pre-competition caffeine, are we creating a dependency on this substance? What happens on the day the equipment is not available if our athletes associate a post-activation potentiation protocol using heavy loads with improved performance?
• And, perhaps one of the most prevalent and least acknowledged, is psychological iatrogenesis in sport. This occurs through the misuse of resources that act predominantly via a psychological pathway: the way we communicate an assessment finding, the labels we use (“unstable shoulder”, “degenerate tendon”, “weak core”), an excess of information, or contradictory information can all generate a fear of movement (kinesiophobia), anxiety, dependency, or a nocebo effect that negatively conditions the athlete's perception of their own body and capabilities.

Recognising these potential aspects is the first step towards a more reflective and, ultimately, more beneficial practice.

The common thread

To illustrate how these ideas can take shape in reality, allow us to introduce you to Alex. Alex is a 28-year-old amateur basketball player who is passionate about his sport. He plays twice a week and would like to improve his vertical jump whilst also preventing the mild, sporadic lower back pain he sometimes feels after more intense matches.

The objectives are clear. Alex, therefore, decides to seek advice from a strength and conditioning coach and a physiotherapist, both renowned for their achievements with high-performance athletes. After an initial consultation, the professional team proposes a comprehensive assessment: a standing postural analysis, an evaluation of the range of motion in key joints, isometric and dynamic strength tests for the lower limbs, and a battery of jump tests.