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MSK Matters

Education Podcasts

A sport and exercise medicine podcast for Canadian medical residents and senior medical students




A sport and exercise medicine podcast for Canadian medical residents and senior medical students




Foot and Ankle Injuries

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. 2. Lisfranc injuries Welck, M. J., Zinchenko, R., & Rudge, B. (2015). Lisfranc injuries. Injury, 46(4), 536-541. 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. 4. Anterior calcaneal process fracture (on differential for lateral ankle injuries) 5. 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 ( 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


Physical Activity and Brain Health

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 - Innovation/People/Researchers/Scientists/Dr-Nicole-Anderson Additional Resources: The 2020 Lancet Commission on dementia, prevention, intervention, and care Brain Health Food Guide BJSM: Physical activity as a protective factor for dementia and Alzheimer’s disease



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 – 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


Nutrition and Physical Activity

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: 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


That’s a wrap on MSK Matters Season 2!

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 2020 Olympic Games

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


Physical Activity and Pregnancy

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. 2. 3. 4. 5.


Lower Extremity Injuries

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


Sport Concussions

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. 2. SCHOOLFirst: Enabling successful return-to-school for Canadian youth following a concussion 3. 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:


Exercise is Medicine

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 2. Physical Activity Prescription: a modifiable risk factor for the prevention and management of chronic disease 3. Practical Approaches to Prescribing Physical Activity 4. Fitness as a Clinical Vital Sign: 5. Advice on exercise from a Family Physician can help sedentary patient become active 6. Health e-Univeristy: Cardiac College & Diabetes College (available in multiple languages)


Diet and Sports Nutrition

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 IOC consensus statement: dietary supplements and the high performance athlete Position of the Academy of Nutrition and Dietetics, Dietitians of Canada and the American College of Sports Medicine: Nutrition and Athletic Performance American College of Sports Medicine, Medicine and Science in Sports and Exercise, Position Stand: Exercise and Fluid Replacement American College of Sports Medicine Full List of Position Stands Professor Louise Burke – Head of Sports Nutrition, Australian Institute of Sport, Canberra


Low Back Pain

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 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


Preview - MSK Matters Season 2

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!


MSK Matters Season One Synopsis and Highlights

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!


ACL Tear

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:


Lumbar Pain

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 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. 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. 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? Here is the latest Cochrane evidence from @CochraneBack


Medial Knee Pain- Is it OA or a medial meniscus tear?

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: OA management diagram 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!


Cervical Radiculopathy

This week our guest Dr. Steven Macaluso will be adressing shoulder pain. Dr. Macaluso is an associate professor with the Schulich School of Medicine and Dentistry at Western University in the Department of Physical Medicine & Rehabilitation and a consultant physiatrist on the Stroke and MSK Rehabilitation units. Dr. Macaluso is also the program director for the post graduate program in the Department of Physical Medicine and Rehabilitation. He offers some great expertise you don't want to miss! Check out:


Elbow Pain in Baseball Players

This episode we are joined by Ryan Crotin to discuss elbow pain. Ryan is the Director of Performance Integration with the Los Angeles Angels of Major League Baseball, a certified strength and conditioning specialist, and a registered strength and conditioning coach. He also has his Interdisciplinary PhD in Biomechanics and Exercise Physiology. Ryan offers some great info on elbow injuries specific to baseball.