Extreme Sports have been defined as: “Sports (physical activity requiring specific skills) – that expose participants to the risk of serious injuries or death in the case of mismanaged execution”¹. However, risk alone does not adequately describe the wide variety of sports that can be considered ‘extreme’, with some overlap between ‘mainstream’ and ‘extreme’ sports. Extreme sports may be risky, but accidental death has also been recorded in ‘mainstream’ sports, such as boxing, horse racing, football, ice hockey, swimming, soccer and cricket. Whilst risk is undoubtedly a significant component of most extreme sports, the assessment and acceptance of risk is subjective - with perceived risk potentially more important than actual risk. 

Additionally, extreme sports differ from ‘mainstream’ sports in several other ways. It is often pursued by athletes who are more interested in exploring their own limitations than competing against someone else, and therefore many activities are solo or with small teams – all working towards a single, shared goal. The environment is usually a major component, with natural forces and weather contributing to the challenge. Many extreme athletes choose isolated natural environments for their activities, with traveling to and within these places requiring meticulous pre-expedition and contingency planning. Unexpected events happen, which heightens the thrill, but also requires appropriate preparation and training. High-tech sporting equipment is often necessary, requiring technical skills to operate and maintain in the field, ensuring optimal performance. Extreme athletes often spend years preparing for a single mission or expedition. 

Perhaps most importantly, many extreme athletes describe their motivation for pursuing these high-risk activities in far more positive terms than simple competition or thrill-seeking. Rather than being ‘crazy’ or having a ‘death-wish’, they seek what has been described as two of the ultimate human experiences: peak experience and a flow state - which can be described as ‘transcendence’. 

In this special edition of the journal, we are stepping over the boundaries of traditional sports medicine into the realm of extreme sports medicine - a branch of sports medicine which is still in its infancy. We have encouraged our stellar cast of exceptional medics and athletes to use their own experiences to introduce the topic to our readers, rather than focusing on academic evidence. This choice is deliberate, as it reflects the current state of extreme sports medicine, where the advice of legendary guides and superstar athletes are still considered more important than anything written in an academic book. Yet, we are on the brink of significant change, as the growth of many extreme sports outpaces that of traditional sports. Extreme sports medicine is becoming a speciality in its own right, with several universities now offering postgraduate courses and degrees in the topic. Additionally, good quality research is steadily growing.

In our first section, Mark Hannaford, one of the pioneers of extreme medicine (of which ‘extreme sports medicine’ is a subsection) guides us through the multidisciplinary approach required to take medicine outside the walls of hospitals and into low-resource environments as diverse as expeditions, disaster areas, humanitarian settings, hostile zones and even outer space. We also hear from an extreme sports medicine legend and athlete, Glenn Singleman, who discusses why wingsuit flying and BASE jumping may just be two of the most important things you could do for yourself and for everyone on the planet (we suggest you read it before you judge!).

In the second section, we are entertained by epic tales from a variety of extreme sports medics and athletes. Mark Sedon and a small team kite-skied 2000Km over the frozen Antarctic wilderness pulling pulks of almost 200Kg each, to climb one of the remotest mountains on Earth - with a James Bond-worthy name: Mt Spectre. Barry McKenna describes the enriching experience of being the expedition doctor for a group of disabled veterans as they kayaked the ‘Inland Passage’ from Washington to Alaska. Guy Cotter has climbed Mt Everest five times, completed the ‘Seven Summits’, climbed seven of the fourteen highest mountains in the World and skied to the South Pole. He discusses high-altitude medical issues and the requirements of the Everest expedition doctor role. Jeremy Windsor gives a very practical overview of how to provide medical care at one of the toughest mountain races in the World: the Dragon’s Back Race in Wales. And finally, Joe Rowles explains how extreme medics can provide support for reality TV programs, in this case, the toughest race on Earth: Eco Challenge in Fiji. 

The third section briefly touches on planning elements for expeditions and ultra-endurance races – with Peter Dzendrowskyj elaborating on lessons we can learn from some of the greatest explorers, Celeste Geertsema discussing the basics of expedition medical kit planning, and Chloe Lanthier showcasing her extensive and expert knowledge of training and preparation for mountain- and ultra-endurance racing.

One of the exciting characteristics of extreme sports medicine is that it does not have clearly defined boundaries. Therefore, in the fourth section, we explore the knowledge and experiences from other areas of medicine, which could be translated into extreme sports medicine practice. Peter Dzendrowskyj highlights the key elements required to achieve one of the most remarkable rescues in the modern era, sparking a Hollywood movie: the Thai cave rescue. Amelia Arundale explains how medics can use a multidisciplinary, sports-specific approach to design rehabilitation plans for athletes in disciplines that they may not initially be familiar with - breakdancing in this example. Mardi Steere beautifully demonstrates how advanced technology can be used to provide access to emergency medical care in one of the remotest areas on Earth - the Australian outback.

In the last section, we consider the final frontiers of human exploration: the deep sea, and space. Joe Dituri embodied the spirit of pioneering exploration when he spent 100 days under the ocean to understand the clinical implications of living in a hyperbaric and isolated environment. In addition to contributing to underwater and hyperbaric medicine, this knowledge also contributes to our understanding of what may be required when humankind reaches beyond low earth orbit, into deep space. We are extremely privileged to have as our final author in this extraordinary issue, James Polk, Chief Health and Medical Officer from NASA. He has taken the time to write this contribution, even whilst navigating the intricacies of how to bring the two astronauts, Sunita Williams and Barry Wilmore, back to Earth safely after their Boeing Starliner spacecraft experienced technical problems. He eloquently explains to our readers the current and future medical challenges of low earth orbit and long-duration space flight, and how these are tackled at NASA. 

Our interview with Andrew Murray brings us back to Earth – and Andrew seems to have seen most of it – whilst on a run. He discusses what it takes to run seven ultra-marathons on seven continents in less than seven days, to complete a 4300Km run from Scotland to the Sahara (it was for charity, not the weather) and how to bring that experience back to his patients. 

Finally, in a ‘Letter from the heart’, Peter Dzendrowskyj shares a very personal journey in the hope of helping cardiac surgery patients and their healthcare workers realise that it can be a life-changing experience - in a positive way, and that words really matter.

We hope that in this very special targeted topic, we ignite an interest in extreme sports medicine in our readers. Ultimately, humans love exploring and pushing the boundaries, and extreme sports medics will always be at the frontier – whether as the medic in Shackleton’s famous journey or the medical officer of the astronaut-athlete. In Mark Hannaford’s words: “where humanity goes, medicine must follow…”

Celeste Geertsema MD

Sports Medicine Physician in Aspetar

Peter Dzendrowskyj MD

Director of Anaesthesia in Aspetar

Liesel Geertsema MD

Sports Medicine Physician in Aspetar