MSK Matters – Details, episodes & analysis

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

Physical activity can help prevent and manage chronic diseases such as heart disease, depression and diabetes, but it is not a one size fits all measure. We need to tailor the intervention to the patient, as we would a drug. Check out Exercise is Medicine Canada’s prescription pad – a way to provide a personalized prescription to each of your patients and increase compliance.

Rob Bertelink, Cardiac Rehab Supervisor at the Toronto Rehabilitation Institute Rumsey Centre and registered Kinesiologist discusses the evidence behind cardiac rehab, at home exercise hacks, how to prescribe HIIT training safely and how to decide which patients need an exercise treadmill test.

Whether you review the Canadian Physical Activity Guidelines with your patient or the World Health Organization Guidelines on Physical Activity and Sedentary Behaviour, the key message is any amount of physical activity is better than none and more is better!

Remind patients that all physical activity counts, including work, sports, leisure, transport and activities of daily living!

To learn more, click on the resources discussed in this episode:

1.     Exercise is Medicine Canada Exercise Prescription Tools https://www.exerciseismedicine.org/canada/support_page.php/eimc-exercise-prescription-and-referral-tool/

2.     Physical Activity Prescription: a modifiable risk factor for the prevention and management of chronic disease https://bjsm.bmj.com/content/50/18/1109

3.     Practical Approaches to Prescribing Physical Activity https://pubmed.ncbi.nlm.nih.gov/26897182/

4.     Fitness as a Clinical Vital Sign: https://pubmed.ncbi.nlm.nih.gov/27881567/

5.     Advice on exercise from a Family Physician can help sedentary patient become active https://pubmed.ncbi.nlm.nih.gov/9713663/

6.     Health e-Univeristy: Cardiac College & Diabetes College (available in multiple languages) https://www.healtheuniversity.ca/EN/Pages/default.aspx

Jennifer Sygo is a dietitian, sports nutritionist, author, and speaker specializing in nutrition for prevention and performance.

Jen discusses how to help athletes optimize their diets to maximize their performance. She explains how to personalize dietary advice including how to counsel patients on dietary deficiencies, high risk diets and how to eat for sport performance. She gives a phenomenal overview of relative energy deficiency in sport (RED-S), a highly complex and nuanced topic. Finally, we delve into the various categories of supplements - supplements for deficiencies, supplements for health optimization and performance supplements.

For more information, please refer to the following resources discussed in this episode: 

IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 Update  https://bjsm.bmj.com/content/52/11/687.long

IOC consensus statement: dietary supplements and the high performance athlete https://bjsm.bmj.com/content/52/7/439.long

Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and the American College of Sports Medicine: Nutrition and Athletic Performance  https://jandonline.org/article/S2212-2672(15)01802-X/fulltext

American College of Sports Medicine, Medicine and Science in Sports and Exercise, Position Stand: Exercise and Fluid Replacement  http://journals.lww.com/acsm-msse/Fulltext/2007/02000/Exercise_and_Fluid_Replacement.22.aspx

American College of Sports Medicine Full List of Position Stands https://www.acsm.org/acsm-positions-policy/official-positions/ACSM-position-stands

Professor Louise Burke – Head of Sports Nutrition, Australian Institute of Sport, Canberra https://www.acu.edu.au/research/our-research-institutes/mary-mackillop-institute-for-health-research/our-people/louise-burke 

https://www.amazon.ca/Clinical-Sports-Nutrition-Louise-Burke/dp/0070277206

Low back pain is one of the most common clinical conditions seen in outpatient clinics by family physicians, physiatrists and allied health practitioners

It affects so many people and can be quite debilitating 

Dr. Stuart McGill is a world renowned back pain clinician and research, with over 30 years experience

In this episode he helps teach Dr. Alex McDougall, physiatry resident, how to approach patients with low back pain 

For more information on Dr. McGill and to learn more about his research and books please visit his website https://www.backfitpro.com 

Episode Pearls - 
-Back pain is complex and never nonspecific - help identify the cause of your patient’s back pain to create and guide a specific treatment plan. 

-Listen to your patient - each patient comes with their own triggers for their back pain and this can be the key to their recovery 

-Every patient needs a tailored physical exam to identify their specific pain generators 

-Understanding and using the psychology of pain is critical for the rehabilitation of back pain

-Empower your patients to take control of their pain, teach them how to implement spine hygiene techniques when completing everyday activities 

-Walking should not be underestimated! It is a very valuable tool for back pain rehab 

McGill's Big 3 Exercises:

1. Bird dog 

2. Side bridge 

3. McGill curl up 

Hi! I am Dr. Ali Rendely, a physical medicine and rehabilitation physician at UHN’s Toronto Rehab Institute

I am an MSK physiatrist doing both inpatient and outpatient work and have an outpatient sports medicine practice.

Season 2 will sound a little bit different than season 1 as we add more voices including family medicine residents, physiatry residents and sports medicine fellows.

Each episode will continue to centre around a specific MSK topic. We will have a round table discussion with myself, a resident and a featured guest.

We have a wide range of experts lined up for season 2 including physicians, occupational therapists, physiotherapists, sports dieticians, sports psychologists and more!

We hope that this is an informative and useful tool to learn about MSK medicine.

It is important to us that you, the listeners, get the most out of this seasons so please let us know what topics you would like covered or if there are any guests you would like to hear from. 

Tweet us @MSKMatters @alirendely or send us a direct message with your thoughts and suggestions!

We look forward to connecting with you!

Dr. Jane Thornton imparts more wisdom for residents and then our incoming Season Two host, physiatrist Dr. Ali Rendely gives us her highlights from each of the preceding episodes.

Be sure to keep an eye out for Season Two!

This week's episode features guest expert Marc Rizzardo. Marc is a registered international sport physical therapist located in Burnaby, British Columbia. He has worked with Olympic athletes and was the Chief Therapist with the Canadian Medical Teams at the 2012 London Olympics, 2010 Vancouver Olympics and the 2007 Rio de Janeiro Pan Am Games. 

Also checkout these links:

https://www.slideshare.net/PedMenCoach/fifa-11-warmup-to-prevent-injuries

http://www.yrsa.ca/fifa-11.html

https://casem-acmse.org/resources/position-statements/

This week we are joined by Dr. Melissa Corso, a Sports Specialist Chiropractor and Certified Strength and Conditioning Coach.

Check out these resources:

Core Back Tool https://cep.health/clinical-products/low-back-pain/ 
The Centre for Effective Practice (CEP) has developed tools and education modules to help primary care physicians and nurse practitioners better manage patients who suffer from low back pain. This work builds from the Ministry of Health and Long-Term Care (MOHLTC) Low Back Pain Strategy, which began in 2012. The goal of this initiative was to reduce the number of unnecessary diagnostic tests, improve wait times, and enhance patient care. Feedback from primary care providers about the CORE Back Tool 2012 informed revisions to a 2016 update. Providers told us they wanted more information about the evidence, an expansion of the initial management options, more clearly integrated patient key messages, and improvements to the overall information flow to align with their decision-making processes.

https://www.isaec.org/ 
ISAEC (Ontario only) is an innovative, upstream, shared-care model of care in which patients receive rapid low back pain assessment, education and evidence-based self-management plans. 
Until ISAEC is fully rolled out to all primary care providers (PCPs), referral into the program is only available to patients whose family doctor or primary care nurse practitioner has enrolled in the program.  

https://oldiwh.iwh.on.ca/system/files/documents/pocket_evidence_summary_2009.pdf

The Cochrane Library @CochraneLibrary Acute low back pain is common, and causes pain and disability. Non-steroidal anti-inflammatory drugs #NSAIDs are often used in the treatment of acute #lowbackpain, but how effective and safe are they? https://buff.ly/3b6vwEX Here is the latest Cochrane evidence from  @CochraneBack
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013581/full

https://www.cochrane.org/CD008112/BACK_spinal-manipulative-therapy-for-chronic-low-back-pain


https://www.cochrane.org/CD005427/BACK_combined-chiropractic-interventions-for-low-back-pain 

This week we are joined by Dr. Roz Lougheed Simpson talking about medial knee pain. Dr. Lougheed Simpson is a sport and exercise medicine physician who practices at the Cleveland Clinic Canada. She is also a physician for the Ryerson University and Centennial College varsity athletes. Dr. Lougheed Simpson obtained her Doctor of Medicine and completed her residency in family medicine at the University of Toronto, where she was a co-chief resident at the Scarborough Health Network site. She completed her Fellowship in Sport and Exercise Medicine at the Fowler Kennedy Sport Medicine Clinic at Western University. You do not want to miss the excellent discussion!

Also check out these links:
Key link: https://www.bmj.com/content/357/bmj.j1982

OA management diagram

https://www.orthobullets.com/knee-and-sports/9019/meniscus

https://www.orthobullets.com/knee-and-sports/3005/meniscal-injury

https://bjsm.bmj.com/content/54/11/652

Check out our twitter @MSKMatters for a great visual of the OA Stepladder for what you can do as a Family MD for knee OA!