MSK Matters

Foot and ankle injuries can be overwhelming for new sports medicine learners due to the complex network of bones, muscles, tendons, ligaments and joints. Dividing the anatomy into the ankle joint, hindfoot, midfoot, and forefoot can be helpful. Learning the intricate anatomy is the first step in understanding what structures are located where, making it easier to narrow down the differential diagnosis. Foot and ankle injuries are common in the majority of sports, and learners need to become familiar with common and not to be missed pathologies.

In this episode, Dr. Fahim Merali, sports medicine specialist at the Dovigi Orthopaedic Sports Medicine Clinic at Mount Sinai Hospital in Toronto discusses ankle and foot injuries seen frequently in various sports.

Listen to learn how to provide an accurate on field assessment to determine appropriateness to return to the game, when to have a player sit out and undergo more urgent assessments, how to investigate and manage subacute and chronic foot and ankle injuries and appropriate rehab protocols for various foot and ankle conditions.

As always, understanding the mechanism of injury is a key component and mastering the anatomy is the only way to know what structures are present in the region of pain, which leads to the differential diagnosis. Remember to always palpate and image the contralateral side for comparison.

For learning anatomy, practice palpating structures on your own foot and ankle, use an anatomy colouring book and review resources such as radiopaedia or the Sports Medicine Review videos linked below.

Additional resources:

1. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach

Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745493/

 2. Lisfranc injuries

Welck, M. J., Zinchenko, R., & Rudge, B. (2015). Lisfranc injuries. Injury, 46(4), 536-541.

https://pubmed.ncbi.nlm.nih.gov/25543185/

 3. Turf Toe: anatomy, diagnosis, and treatment

McCormick, J. J., & Anderson, R. B. (2010). Turf toe: anatomy, diagnosis, and treatment. Sports Health, 2(6), 487-494.

https://journals.sagepub.com/doi/pdf/10.1177/1941738110386681

 4. Anterior calcaneal process fracture (on differential for lateral ankle injuries)

https://radiopaedia.org/articles/anterior-calcaneal-process-fracture-1

 5. Sports Medicine Review – Foot Review

http://sportmedschool.com/sports-medicine-review-foot-review/

Millions of individuals will have persistent symptoms following an acute COVID-19 infection requiring post COVID-19 rehabilitation. Common symptoms include fatigue, decreased activity tolerance, cognitive dysfunction (brain fog), shortness of breath, and pain. This leads to decreased ability to complete activities of daily living, return to work or school and affects quality of life.

There are many terms for post COVID-19 condition including long COVID (proposed by patients in May 2020) and post acute sequelae of COVID-19, also known as PASC. The World Health Organization created a clinical case definition in October 2021.

Ongoing research includes assessing risk factors to determine who might develop post COVID- 19 condition. Vaccinations reduce the risk of developing post COVID-19 condition to some degree, and reduces the duration of symptoms. However, even without risk factors, individuals can develop post COVID-19 condition. The primary preventative strategy remains minimizing risk of acquiring the initial infection.

In this episode, we discuss up to date evidence for post COVID-19 condition rehabilitation.
 
Guest: Dr. Simon Decary (https://twitter.com/simondecary)

Additional Resources:

World Health Organization Clinical management of COVID-19: Living guideline (including post COVID rehab)

CADTH Post COVID-19 Condition Treatment and Management Rapid Living Scoping Review

Scoping review of rehabilitation care models for post COVID-19 condition

https://longcovid.physio

What role does physical activity have in optimizing brain health and function?

There is strong evidence for exercise as a protective factor for dementia. This should include
reaching the Canadian Physical Activity / World Health Organization Guidelines including
strength training, balance exercises and aerobic activity.

Exercise induces neurogenesis, addresses cardiovascular risk factors, decreases depression
and anxiety and is associated with larger brain regions such as the hippocampus.

There is a brain health food guide that uses evidence from multiple diets. This is most similar to
the Mediterranean diet and should be implemented as early in life as possible.

Exercise can help increase cognitive reserve, delaying progression from mild cognitive
impairment to dementia. Always remember to match the exercise prescription to what the
patient enjoys!

Don’t forget to screen for sensory loss (hearing and vision) as part of dementia management.

Listen to this episode to learn how to optimize modifiable risk factors, including exercise, that
can outweigh non-modifiable risk factors related to dementia!

Guest: Dr. Nicole Anderson - https://www.baycrest.org/Baycrest/Research-
Innovation/People/Researchers/Scientists/Dr-Nicole-Anderson

Additional Resources:
The 2020 Lancet Commission on dementia, prevention, intervention, and care
https://osteoporosis.ca
Brain Health Food Guide
BJSM: Physical activity as a protective factor for dementia and Alzheimer’s disease
https://endpjparalysis.org

This episode deals with something we all do every day, sleep!

Sleep is now seen as an active, restorative experience intended to optimize our functioning while awake, rather than a passive process. Sleep is closely tied with mood and pain, and plays an
important role in cognition, emotional regulation, injury, function, and chronic disease.

Sleep difficulties are incredibly prevalent and fatigue frequently accumulates over time –
the concept of sleep debt. Though generally 8 hours per night are recommended, we
often underestimate how much sleep we need and how much we are actually getting.

Sleep quality is as critical as quantity, and like the development of any good habit, it
starts with building a healthy and patterned night time sleep routine. We discuss ways to
recognize sleep debt, means and by how much to repay it, as well as the effects of not
doing so.

Sleep is crucial to overall performance, which hinges on four important domains:
cognitive, physical, emotional, and social. Sleep deprivation also has different impacts
on performance, be it by altering our cognitive abilities, limiting endurance, reaction
time, and accuracy, or by changing the body’s ability to metabolize fuel for activity.

Throughout the episode, we also debunk some common sleep myths – are sleep
journals useful; are naps helpful, or harmful; should melatonin be prescribed; is that
midnight snack keeping us awake or putting us to bed? Listen to learn how to optimize
nightly sleep to improve performance and quality of life.

Guest: Dr. Brandon Marcello – https://www.brandonmarcellophd.com

Additional Resources:

Sleep and athletic performance

Effects of training and competition on sleep of elite athletes: a systematic review and
meta-analysis

Sleep in elite athletes and nutritional interventions to enhance sleep

Physiology, sleep stages

Welcome to Season 3!  Three new residents will be co-hosting this season alongside Dr. Ali Rendely.

PGY1: Dr. Chris Wavell

PGY4: Dr. Melissa Weidman

PGY4: Dr. Natalie Daly

 Episode one focuses on nutrition and physical activity through the decades.

How do patients optimize nutrition and physical activity as they age? 
It’s hard to “out nutrition” inactivity, but exercise is the forgiver of many sins!  

The recommended dietary allowance (RDA) is 0.8 g protein per kg of body weight per day. For older adults, that may not be enough and 1-1.2g/kg/day may be more optimal, to a max of 1.6g/kg/day. This max dose may be less for those that are less active and those with kidney disease.

All movement is good and more is better, in addition to dietary protein. 

A dietary history should include what they eat, how much, and when they are eating. This should include screening for Vitamin D intake, calcium intake and protein intake. 

Protein assists as a bone builder and can be helpful in minimizing morbidity and mortality associated with fractures. High energy density proteins help build and maintain muscle mass i.e. yogurt, eggs.

Anabolic resistance is analogous to insulin resistance, but relating to protein and muscle mass. The key active amino acid is leucine. This can be obtained from whey protein supplements and whole foods.

Prevention (re: bone loss, muscle loss) is key. Patients should build up a reserve and prevent decline instead of trying to reverse it once it’s started.

 Recovery: 3 R’s: rehydration, refuel, repair!

Additional Resources: 

https://blogs.bmj.com/bjsm/2021/09/26/physical-activity-in-young-adulthood-pays-dividends-decades-later/

Nutritional Supplements in Support of Resistance Exercise to Counter Age-Related Sarcopenia

Skeletal muscle protein metabolism in the elderly: Interventions to counteract the 'anabolic resistance' of ageing

Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group

Does nutrition play a role in the prevention and management of sarcopenia?

Additional research from Dr. Stuart Phillip @mackinprof

Feedback, thoughts, questions? Tweet us @MSKMatters @alirendely

In this episode, we review all of the episodes from this season and highlight our favourite clinical pearls, while adding some new ones! 

A huge thank you to all of our guests for sharing their knowledge and time. 

To recap:

Low back pain with Dr. Stuart McGill

Diet and Sports Nutrition with Jennifer Sygo

Exercise is Medicine with Rob Bertelink

Sport Concussions with Drs. Alex Francella and Scott Shallow 

Lower extremity injuries with Dr. Tim Rindlisbacher 

Physical Activity and Pregnancy with Dr. Rebecca Titman and Jenni Diamond 

The Tokyo 2020 Olympic Games with Dr. Janet McMordie 

Thank you to everyone who has listened, downloaded and engaged with this podcast. We are so thankful to you, the listeners, for your support! 

To my co-hosts, Drs. Alex McDougall, Stephen Szeto and Nicholas Sequeira - thanks for all the time, effort and energy you put into making this season such a great success.

And to our irreplaceable editor, Enrica Ammaturo, the podcast would not run without you! 

Stay tuned for MSK Matters Season 3 - there will be new voices and new topics! Please tweet us @MSKMatters or @alirendely with topics you would like to learn more about, questions or feedback!

Thanks for listening!

Dr. Ali Rendely 

The Tokyo Olympics mark the debut of new sports include karate, sport climbing and skateboarding, among others.

In this episode, we discuss common injuries sports medicine physicians see when treating patients that participate in these sports.

In sport climbing, upper extremity injures account for 80-90% of all injuries. Specifically, hand and finger injuries are exceptionally common. So common, that the injury has been named climber’s finger. In a distant second, shoulder injuries including rotator cuff strains, tears, impingement, SLAP injuries, and subacromial pain syndromes are seen in those learning to climb. In professional climbers, shoulder injuries are less common as they use their lower body strength to maneuver the climbing wall, instead of pulling from the upper extremities. 

For more information on climbing injuries:

Rock Climbing Injuries

Incidence, Diagnosis, and Management of Injury in Sport... : Current Sports Medicine Report

Pulley Injuries Explained – Part 2 – The Climbing Doctor

Flexor Tendon Injuries - Hand

Rotator cuff-related shoulder pain: does the type of exercise influence the outcomes? Protocol of a randomised controlled trial

Rotator cuff injury - Symptoms, diagnosis and treatment

Skateboarding has been a fun edition to the Olympics. With a relaxed atmosphere, punctuated by music and high-fives, these high flying athletes are injury prone. The best treatment is prevention –  new skateboarders to wear helmets, elbow pads, wrist guards and knee pads. 

Common injuries include distal radius fractures from falling on an outstretched hand, lateral ankle sprains and mild traumatic brain injures (wear your helmets, kids!)

For more information on skateboarding injuries:

Common Skateboarding Injuries & Safety Tips 

Skateboard Injury Statistics (Updated 2020) - Safety First – Skateboarding Safety

Distal Radius Fractures - Trauma

Managing head injury risks in competitive skateboarding: what do we know? 

Finally, martial arts spread across Japan in the early 20th century, and has been a candidate as an Olympic sport since the 1970s. Blending striking combat and rigorous discipline, the Tokyo games presented an opportunity to showcase it from its homeland. 

Using karate as an example, training fatigue can lead to technique errors and overuse injuries. It is important that physicians and therapists help guide athletes through an appropriate training protocol, including rest days. 

For more information on karate injuries:

Martial Arts Injuries | Martial Arts Injury Prevention & Treatment 

Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007 

Epidemiology of injuries in Olympic-style karate competitions: systematic review and meta-anal

This episode is for all women of childbearing years and all of the healthcare practitioners who provide care to these patients!

The new CSEP Physical Activity throughout Pregnancy Guidelines provide evidence around the benefits and safety of being active throughout pregnancy, for both mother and baby. Physical activity is now seen as a critical part of a healthy pregnancy. Following the guidelines can reduce the risk of pregnancy-related illnesses such as depression by at least 25%, and the risk of developing gestational diabetes, high blood pressure and preeclampsia by 40%. Providers should be educated on the absolute and relative contraindications for exercising during pregnancy to help guide patients safely.

Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active in a variety of ways every day is encouraged. CSEP has created a Get Active Questionnaire for Pregnancy that providers can use to assist with safe exercise prescription.

Pregnant patients should be treated for musculoskeletal pains the same way all other patients are treated. This includes assessing, working up and investigating patients appropriately. Treatments should include active rehabilitation with the mainstay of most MSK pains being treated with exercise. Women should be offered medications, as needed, always trying to use the lowest effective dose possible. First line treatment includes acetaminophen (4g/d max) and second line includes the use of opioids. MSK low back pain is very common! 20-30% will have pain that impacts quality of life and function. Pain education and a multi modal plan should be incorporated just as one would for the general population.

Women often need to be “cleared” to return to exercise, and the 6 week mark is a classic timeline, but this is arbitrary. Waiting for clearance does not mean no movement for 6 weeks. Women should be reassured that early gentle activity is reasonable. This can include activities such as restorative yoga and walking.

Share this episode widely with anyone who treats women of childbearing age.  It is our role to encourage women to be active, and as healthcare professionals, we need to work on minimizing barriers to exercise. This includes having conversations and discussions with patients that movement is necessary before, during and after pregnancy!

Additional Resources: 

1. https://www.researchgate.net/publication/335928424_Returning_to_running_postnatal_-_guidelines_for_medical_health_and_fitness_professionals_managing_this_population 

2. https://www.pregnancyinfo.ca/

3. https://www.rosttherapy.com/rost-moves-mamas/

4. https://csepguidelines.ca/pregnancy/ 

5. https://bjsm.bmj.com/content/54/18/1114

Lower extremity injuries occur in all sports and high profile athletes draw attention to such injuries. This episode delves into 3 of the most talked about lower extremity injuries in the last years. Using these athletes as a starting point, this episode discusses the differential diagnosis, assessment, work up and rehabilitation plans for lower body sports injuries. 

We start with the hip dislocation sustained by now NFL player Tua Tagovailoa. Posterior hip fracture dislocations are relatively rare in sports, but it is always important to think of the common and not to miss diagnoses when evaluating a player.  Once the diagnosis is made, treatment should surround improving function and minimizing or preventing future complications.

Moving distally to the knee, NHL player Connor McDavid had one of the most talked about injuries in recent memory, complete with a documentary detailing his rehab and recovery. PCL injuries are also fairly uncommon when compared to ACL, MCL or meniscus injuries, yet, it is important to learn and understand the surgical vs non-surgical treatment options. Rehabilitation is often the mainstay of treatment for knee injuries, so having a good team of dedicated therapists and allied health practitioners to assist in the recovery is imperative. All trainees should spend time working in an allied health clinic to learn the intricacies and nuance of what rehabilitation entails. 

Finally, NBA superstar Kevin Durant sustained a calf strain followed by an Achilles tendon rupture suffered in the playoff finals. This case discusses the mechanism of injury and typical symptoms seen with Achilles injuries and other common ankle injures. As part of the rehabilitation plan, all sports medicine providers should be familiar with the Fowler Kennedy Achilles tendon rupture accelerated rehab protocol. 

MSK and Sports Medicine Resources for Learners:

PMR Knowledge Now

Orthobullets

Radiopedia

MSK Medicine: Western University Physiatry Program Physical Exams

Stanford Medicine MSK Physical Exams

Basic MSK Exams

 MSK Textbooks:

Magee Orthopedic Physical Assessment

The 5 Minutes Sports Medicine Consult

In this episode we review concussion, a large and nuanced topic. There are 200,000 concussions annually in Canada, making concussion knowledge required for coverage of all sports.

To gain an understanding of sport related concussions refer to the consensus statement on concussion in sport (the 5th international conference on concussion in sport held in Berlin, October 2016)

It is helpful to think of concussion management in 3 phases: acute, subacute and chronic

In the acute phase, a sideline evaluation must include screening for red flags. Review the CT Head Rules, C-Spine Rules and SCAT5 including what these tools assess, when to use them, and their common limitations. Always remember, when in doubt, sit them out!

In the subacute phase, listen to your patient. Ask them about their most bothersome symptoms, track their progress and evaluate their symptom evolution with consistent criteria (ex. vestibular ocular motor screening assessment, neck exam, neurological exam, symptom questionnaires). Encourage early return to movement, emphasizing sub symptom threshold aerobic exercise as a safe and effective treatment for sport related concussions.

Education and counselling are paramount for a good prognosis. Provide return to learn and return to play protocols with handouts. For example:

1.     http://www.fowlerkennedy.com/patient-resources/sport-concussion/

2.     SCHOOLFirst: Enabling successful return-to-school for Canadian youth following a concussion

3.     https://www.parachutecanada.org/en/professional-resource/concussion-collection/canadian-guideline-on-concussion-in-sport/

10% of concussion patients will have persistent symptoms. It is important to fully understand the patient’s entire medical journey - track the their progression from the initial event to the current assessment. Ensure a multidisciplinary team is involved, if not already (PT/OT/VOR PT/SLP/Neuro-optometry/Psychology). And remember, counselling is essential! 

Concussion can have a large impact on a patient’s mental health and wellness. Ask about the patient’s social support network. Assess underlying mood or anxiety disorders that may have worsened from baseline since the concussion. If needed, consider pharmacotherapy or refer to a therapist or psychiatrist.

Additional Resources:

https://cjsmblog.com/category/concussion-in-sport/

https://www.reframehealthlab.com/concussion-management/

https://abinetwork.ca/individuals-families/concussions/concussion-resources/

http://concussionsontario.org

http://obia.ca/concussion-resources/