Thanks so much for being with us. Yeah. Thanks for having me. Glad to talk and always, always good to talk about sports medicine. Um, yeah, so as to come in and talk about the field, um, it's one of the main things that we do as a physiatrist, obviously is musculoskeletal medicine. And so sports medicine is definitely a part of that. Um, so it kind of wanted to bring up, you know, what it is, and then you can decide, is it for you, but also other avenues of musculoskeletal medicine. If you so choose, no, right. These are my affiliations. Um, one of the team physicians for KU athletics, as well as for team USA swimming and, uh, disclosures, uh, nothing relevant to this. Um, it's more for my interventional spine. So today really want to go over kind of the field of sports medicine as a whole, uh, really describe the types of patients and injuries that you may treat if you choose to do this as a field, uh, looking at treatment options that we have, and then looking at different pathways to do sports medicine, um, as well as, uh, musculoskeletal medicine. And so again, there is a difference. I think we generically, a lot of times we'll have the two terms use synonymously, but they, they do vary quite a bit. So what sports medicine, um, any thoughts, anybody, does anybody know or had experience in sports medicine? You can either type it or you can, I'm fine. If you want to say something on your microphone, overall, it is a field that deals with patients who are involved with some type of sport, uh, optimizing performance is a good way to look at it. Um, keeping our athletes healthy so they can participate in sport recovery of injury prevention of injury. So it's kind of all of this, but one of the things that we look at though too, is like who is our sports medicine patient. So a lot of times we'll think of this. This is, you know, a typical Saturday morning, I think throughout the country, whether it's spring through the fall time period, um, talking about pediatric patients, this is definitely sports medicine. The part though, that makes us challenging for this age group is, um, immaturity in the sense of both physical and cognitive. Um, and I don't mean that in a derogatory way, but the physical sense is that, that organ systems are not fully matured tolerance to activities and, and, and changes in environment, whether that's a extreme heat, extreme cold are going to be a less tolerated than when you have older patients. Um, things to think about it also physiologically is, um, like bone structure, growth plates are wide open. Uh, there's a more flexibility to their skeletal structure, um, as well as even their soft tissue structures. So again, the likelihood of, uh, tearing and breaking things is going to be much less than some of your older patients, cognitively, which you may come into play when you're dealing with this age group though, is the, is the maturity level, um, you know, recognizing things to do and not to do, listening to direction, um, and then also having the understanding of when something may be injured versus hurt and keep playing through it. Next stage we get into is kind of that middle school through high school. Um, what would be differences here? Would you say in this patient group versus our young pediatric patients, greater volume of plate? Definitely, definitely, definitely more mature, understand the game better, understand rules and identify injuries. They're starting to get into that realm. Um, so this is, this is where we start getting to more traumatic injuries. To be honest, um, you're seeing, you're seeing a lot of these athletes start going through puberty. Uh, males in particular will start adding muscle mass to their bodies. Um, and so they're going to have more momentum and larger mass going. And so this is going to put them at higher risk for injury. Um, there are social pressures to play through injuries. Nobody wants to let their teammates down. And so we definitely see that a lot. Um, but understanding some of the changes that are going to occur, uh, throughout puberty. Again, typically your growth plates aren't going to be completely closed. Our female athletes are definitely going through more of a transformation. I would say skeletally than some of our male athletes as their pelvic, you know, their Q angle changes between their hips and the knees and their ankles. So that's going to cause changes in mechanical forces that are loaded through the pelvis, lower extremities, and even lower part of the spine. Um, and then also recognizing, um, possible nutritional deficits that may occur. Um, again, going back to social pressures that occur, you know, there's a lot, especially when we have aesthetic sports, uh, such as swimming, such as gymnastics, such as a dance and cheer teams. Um, these really have to worry about and wrestling and boxing actually to, um, where you have to worry about nutritional deficits because the body's trying to grow, uh, into adulthood. And so it takes a lot more calories. And then when you compound that with being an athlete and your caloric needs and nutritional needs are up anyways, um, a lot of times this is where we start seeing some shortcomings challenges to this group though also will be on because they are playing at a higher competitive level, they're moving a lot more, um, and you have prone to some of those overuse injuries and at the same time, they've been reliant on youth on protecting them. And so a lot of times stretch programs, warmup programs are not as good as they would be say at the collegiate level and up. Um, and so again, we're starting to try to do more training on preventative, uh, measures, whether that's a good solid warmup, making sure you stretch, you know, taking these avenues to prevent injuries from moving forward. Um, and then in some cases like ACL prevention, where we're doing a lot of lower extremity strengthening exercises, uh, really to help try to decrease risk as much as possible. Next level we'll get into is, is college athletics. What do you think are some of the big challenges here now? I mean, honestly, I'm sure they want to do PM and I'm like, I got a hot mic. Traumatic injuries. Yep. Anything else? Moving faster. These players are faster, stronger, definitely. How about issues with return to play? So this is where we start getting into more the business aspect of sports medicine, which as a physician, we need to, um, yep. that's where that business comes in is that, you know, when you're getting to this level and above, um, there's a lot of pressure, whether that's on themselves, from family, from teammates to keep performing, despite injuries, um, they usually have a vested interest now at this point, whether that's a fully funded athletic scholarship or they're being scouted. Um, so these are going to have financial ramifications if they get pulled and they're not playing. And so if you miss a game and a scout from a pro NBA team is there, you may have missed your opportunity to get drafted or recruited. And so again, there's these, these players are really feeling this pressure and then all the things that come into play about, you know, size, speed, strength, that's all coming into it. The one thing that is beneficial for it is now when we get to this level and we, and I've got that here at KU is we've got, we've kind of got a small army of people taking care of our athletes from nutritionists to athletic trainers, to therapists. And then, you know, myself and the other physicians, we're all there to try to make sure that the athletes are staying as healthy as possible and have trying to have their best interest, um, in mind. And so again, that's where we start coming into play as, um, the advocate for the patient because coaches want to keep players moving as much as possible, especially if they're a key or star player of the team. Um, they obviously want to keep that team in winning streak if they can. And so you're going to feel that pressure of what to do, um, at this point too, from a sports medicine physician standpoint, uh, you're going to get into the, uh, the aspects of media, uh, you know, a lot of times if there is an injury, people will be asking, you know, for quotes from, from news teams. Um, so again, these are areas where you're going to have to tread very delicately, uh, in most cases recommending to avoid talking to press at all, uh, that really is the coaches, the head coach's job. Um, now they ask you to make a comment about something that, you know, that's a different situation, but you know, you never necessarily want to be caught as a, as a physician, you know, with a sidebar comment from a reporter, you know, talking about an athlete's injury, uh, because that can seriously impact how other teams are preparing to play against them. And this will only continue to get worse, you know, as we move up. Um, so now we're at the college level, let's go one step further. Um, so this is, uh, this is where I really have a lot of fun at and fortunately able to do it. But when we get to this, uh, super elite level, uh, for sports, very specific sports, um, taking care of all these people, except the French French one. But I was at this games, um, for those winter Olympics. Um, this presents a whole new host of issues to deal with, um, because now there's a lot of personal pressure. Um, there are financial pressures that are involved, especially for those from American sports because we, you know, you're talking about endorsement deals and so they want to keep going. Um, but then even from other countries, there's a lot of political pressure for the athletes as well to perform as, as good as possible. Um, the other challenge too, is depending on when they're at in their cycle of training can really impact how much they're willing to share with the physician, the trainers, the therapist, because, uh, I will tell you when, when we plan for each games, we break it up into what we call quads. And so you're looking at a four year cycle going into it and you train with the intent of peaking at the, at the coming Olympic games. If you're under six months, it's very rare to have an athlete voluntarily admit they have an injury, um, because again, it's going to affect how their training goes and being able to be selected for the Olympic team to go forward and represent the United States. So again, a lot of pressures on these individuals, um, less of the contract negotiation issues and finances that we see sometimes at the college level, because, um, especially United States, it is an amateur sport, so they don't get paid for it. Um, you know, with the hopes that they get a medal, the, then they will look at potentially getting endorsements, but you know, these are not necessarily financially compensated athletes. Uh, they really are doing it for the love of the sport. But again, lots of challenges, lots of pressures on all of them. Um, and, and a lot of these sports too, there's repetitive motions that are again and again and again, um, you know, from, uh, Krauser here doing shot put, um, I took care of him when we were at training camp in San Diego and, you know, he's throwing all day long. I mean, that's what he does. He throws, he throws, he throws when he's not throwing, he's lifting weights. Um, you know, and so you have this repetitive motion on the same joints all the time. I mean, the trainers, uh, try to do their best to do some cross training to help prevent injury. But again, that's where you need to be very mindful of it. Next step that we go into is professional sports. Um, this is the fun sports, especially here in the United States, uh, where it's professional sports are mainstay of our culture. Um, very challenging at this level. Uh, used to work with the Kansas city Royals. Um, and you know, it has its own nuances because now you're talking about an athlete that stays in because they have a multimillion dollar contract or, you know, I have this picture being in Kansas, you know, we've got to go for Patrick homes, but you know, that's a half a billion dollar contract. There's an entire dynasty from a franchise it's reliant on, on a player. And so there's going to be immense pressures from the team, from family, from the athlete himself on keeping playing as much as possible. But at the same time, um, trying to balance that with not overdoing it with an athlete, uh, cause sometimes you'll see burnout of athletes. A good example, going back to your high school athletes is a lot of times we'll see middle school to early high school baseball pitchers. Um, they get identified early. And so for their team, they're doing a lot of pitching, but they, they end up burning out their shoulder and their elbow because they're just doing it too much. And so once you get to this level, yes, the pressures are there, but at the same time, there's a lot of checks and balances that are going on because of the financial investment into, um, the athlete themselves. One of the things, uh, not necessary, but will make you a better sports medicine physician is also knowing sports that you're taking care of. Even if you don't play it, um, you definitely want to be able to identify how the structure of play for that particular sport is done and be able to identify how training regiments will be done. Um, so that you have an idea of what may cause injury by mechanism of action or the mechanism of the injury itself, um, you know, swimming, uh, tennis for I think volleyball all like big on overhead, what we classify as overhead sports injuries. But even those aspects here, there's variation of what's involved, um, uh, your high school pitcher or college pitcher, for example, um, high velocity torque that goes into the body, um, more rotational forces, uh, on the shoulder and elbow than probably any other sport going on. Um, but it's different as an overhead athlete compared to say swimming where you have on a regular training cycle, they may put in two to five kilometers of swimming a day. And so you have these overuse injuries that may not individual motion is not this high dynamic explosion of force, but the repetition is this there when you're swimming for hours on end. So again, you really want to have a basic understanding of some of the sports, whether you play the sport or not, you know, you don't have to have played every single sport to be a good sports medicine position, but you definitely want to have that understanding. You need to take time to go to practice sessions. You need to talk to athletes. Um, you know, the sideline coverage is kind of the, the glamorous part of it, but at the same time, most of the stuff that's done is done at the practice on the side of the field at practice sessions on the side of the court at practice sessions and in the training room in between. But again, you need to have a good idea of what the athlete is going through on their training regimen to understand how that injury came into play. Now we're getting into a different bracket, um, you know, as we age and, you know, as I keep getting closer to 50 myself, maybe I'll start identifying more in this group, but you have more of the senior recreational athletes. So again, these are athletes that aren't necessarily doing it for a team. They're not doing it for financial gains. They're doing it purely for recreation. What do you think are now some of the challenges here? Braxters. Yep. Weekend warriors. And that's a great example because we see that a lot. Any other thoughts from the group? Mobility issues. Yeah. And so now as we continue to age, um, a couple of things that change, one is the dynamic of the sport. Um, everybody, I think has heard the term of the weekend warrior. It genuinely is a real issue because you've gone from somebody who is training to play their sport most days of the week, like I'll tell you, Patrick Mahomes is probably practicing six days a week at this point, getting ready for the upcoming NFL season, um, and then the game time, typically at that level, gameplay is going to be easier than your practice sessions on the body. The opposite is true for the recreational athlete, where in a lot of cases, there is no practice playing the game is the, is the time that they do the sport. And so if they're not doing intermittent sessions throughout the week, the only time they're really stressed in their body, we may be, you know, a heavy pickleball game on a Saturday morning. And, and fortunately we see that a lot where since pickleball has gained more and more popularity across the country, I know I've seen definitely a lot more like Achilles tendon ruptures, um, because of issues with the change in flexibility. Um, the elasticity of our soft tissue structures changes as we age. And so if we're not actively stressing, um, joints, ligaments, tendons on a regular basis, and we don't stretch and maintain that mobility long-term, you know, that's where things will have that. Oh, I felt like somebody came behind me and kicked me in the back of my ankle, but nobody was there and then I couldn't walk anymore. It's very common to hear. Um, and then when I talk about, well, do you stretch what else you do? Like, well, no, I only play pickleball, you know, on Saturday morning, sometimes midweek, if I can make it. Um, but most people will have some type of job, um, that they're doing. And so they, that they're limited on what they can do because you're getting in this realm of people who still enjoy sports, but now they've got the responsibility of work. They've got the responsibility of life, maybe raising their own children, what bringing them to practice, but they still want to have fun. But if we're not taking care of the body, that's where we get into it. As we get into kind of these later stages, then we start getting into osteopenia osteoporosis, um, and definitely getting into more frailty. So as we're moving forward, this is kind of when we, uh, start getting to the tail end of our, our, uh, our, our cycle of the athlete. So anybody know what this is? Zumba maybe. Most of the time, this is yep. There it is. Silver sneakers. Um, and so you're looking at your, your geriatric patient group. Um, and the goal of this exercise now is again, less about sport. I mean, there's definitely a social aspect to it that adds to the cognitive benefits, uh, long-term, uh, social interaction, uh, getting out and meeting other people in the community and getting less isolation, which tends to happen. Unfortunately in our geriatric patients, as they get out of the work environment, the kids have moved on and out of the house. And so it's them and a significant other. And, and a lot of times it's, you know, they've lost their loved one and so it is very isolating. But the goal of this now is more on maintaining physical function as much as possible. So again, now it changes entirely of what we're trying to do in the sense of sports medicine previously being optimizing, um, sports performance. And now we really are just optimizing overall function or your activities of daily living. And so that's maintaining muscle strength, um, trying to maintain a good ratio of lean body mass as much as possible and doing some resistance training, you know, especially for our, our, our females is they are going to be more prone to osteoporosis down the road, post-menopause than men do. And so again, adding some type of resistance. So the goals of what you're doing is changing. Um, but what that means though, for this, this group and where sports medicine comes into play is how do you, how you make recommendations for somebody who has blood pressure issues? Maybe they've got chronic kidney disease. It may be mild or some other comorbidity that really, you know, we see it all the time and as we're younger, we take advantage of it. But please consult your medical professional before starting this activity or, you know, make sure that you are healthy enough to go on this ride, if they go to an amusement park or something, I mean, this is where we may come in as sports medicine physician is making some of those recommendations on how we can participate in activities that we want to do from a recreational aspect, questions on that. We kind of went from young children to our geriatric population. So we made a big spread in a short amount of time. Hi, doctor. Um, I'm going to ask what are some exercises or what are some medical conditions that would make you stop a geriatric patient from participating in something like jazzercise? Um, not a lot from a jazzercise standpoint, it depends how much impact. So if they are very osteoporotic, you know, that's maybe where we want to look at getting DEXA scans, um, getting some labs, looking at their calcium levels and really treating osteoporosis. Cause you know, you run the risk of, of having skeletal fractures, even with some of the light impacts. Uh, the other part though, too, which is one of the other kind of focuses on silver sneakers program is mobility and balance. Um, and so if you're having somebody who has say severe peripheral neuropathy, um, they may not be a good candidate for something like this. And then maybe that's more of an aquatic, uh, kind of training program. So they've got the buoyancy of the water to help them. Um, but you know, it's, it's things that would put them at risk. Um, again, you know, making sure that their blood pressure is an overly too, or is not too high, or they don't have, um, poor ejection fraction. From their heart. Um, because again, we're trying to increase the stress on the body. It's mild, but it still can affect them. And so it depends on how fragile that patient is. Um, so again, that cardiopulmonary status balance issues. Uh, those will come into play depending on the sport, you know, it sometimes it's vision as well. Um, if you can't see what you're doing, you probably don't want to be playing pickleball. Um, but even from a silver sneaker standpoint, you know, if you're having a hard time, uh, seeing those around you, you know, you put yourself at risk of having a fall cause you trip over something. Um, but really anything. And again, that's what, that's what our job is, is to identify major risk factors that may cause them to have issues. Um, you know, some, it may be. You know, fluid overloads that they have, you know, even it, maybe they can tolerate the activity, but we have to be very mindful of how much fluid they're drinking, uh, post because if somebody has really bad renal issues, you know, they've, a lot of times they'll have limitations, how much fluid they should be drinking per day. Now, typically we don't see those patients doing a lot of activities, but sometimes they do. And as a physiatrist getting a little bit outside of the realm of sports medicine, but that's what we do as physiatrists anyways, we have to help develop a plan of recovery and rehabilitation for athletes with severe debilities. And so that's where we need to find that line of what is beneficial from an athletic and recreational aspect to when does it turn into, we're trying to rehabilitate a patient. Um, so again, that's the fine line benefit of a, of physiatry. Uh, cause that's what we do is our bread and butter, just sports medicine is a smaller niche of that group. So which of these, what do we see here? Both sports medicine issues. We've got, well, it looks like, uh, uh, rugby player probably has an acute injury here. What does anybody see? I'll give you a hint. It's a knee. Yeah. A lot of joint space narrowing right through here. Um, and so the reason I bring this up is, you know, a lot of times when we talk about sports medicine, we think of this, this is what we're thinking of. This is the person, the elite level athlete. Um, but the reality of it is, and so I, and that's why we kind of talk about it is in order to pay the bills, this is our bread and butter, the generative joints, um, kind of the recreational weekend warrior athlete and older, you know, these are the ones who probably have the most problems, uh, are younger athletes. They certainly have their issues, more traumatic injuries, but in the end, they're typically younger and healthier and bounce back. The patients that we hang on to for long periods of time, years, and really have those strong relationships with are the patients who have the degenerative joints, um, because they were trying to keep them as active as possible in order for them to get exercise and have the benefits from it, but also the recreational aspect. Um, but this will be a severe limiting factor if the pain is in control. So again, really wanted to emphasize, and this is one of the big areas where I try to talk to about anybody who's looking at sports medicine, sports medicine is not musculoskeletal medicine. Musculoskeletal medicine is a portion of it, and it's kind of the glamorous part of it. And the reason I'll tell you this is when we're working, especially at higher level athletes, even for myself, for the most part, I don't do any of the musculoskeletal care. Um, when I travel overseas with say USA swimming or any of the national teams, um, I typically am not taking care of musculoskeletal issues. They've got athletic trainers. They've got therapists that typically come with us. Um, I am dealing with upper respiratory infections, GI issues, sleep disturbances, um, uh, sometimes playing psychiatrist along with it, because if it's something really bad that pulls them from play, especially at high levels, it's typically something that's going to require an orthopedic surgeon. And so again, this is going to be a large component of being a sports medicine physician, going out and checking wet bulbs, checking humidity levels, what the temperature is. So you can give recommendations, setting up ice baths on the sideline of an activity. So if somebody goes down from a heat injury, you've got a way to treat them. Um, you know, the, again, it's, it's kind of the glamorous part of it, which is what we see from the musculoskeletal side. But again, you need to be comfortable doing the medicine part of it, um, just as much as the musculoskeletal, because all this plays into it, especially as your athlete is either more elite level, because the small nuances of having a decreased heart rate with a stronger ejection fraction, um, compared to the athlete next to it may mean that's the difference between a gold and a silver metal, that half second difference of touching the wall and on the swim meet. Um, that's where it comes into play. So it's really that optimization of overall health that gets into it. Now, certainly you could go into practice and do sports medicine fellowship and decide you want to do musculoskeletal medicine. And a lot of times there are plenty of, of peers that I have that do that and they work for either a private orthopedic group, and this is what they do. But if you're looking truly at sports medicine, being with a team, you're going to do a lot of medicine part of it. Um, that's just, that's the way it is. That's why it's called sports medicine. All right. The other big avenue that we as sports medicine physicians really take on is prevention. Um, this picture, if you don't recognize it. So this is a one we've taken to some athletes. We look at the rotational, uh, of the torso and how much they're turning. Um, we typically want to be somewhere around the 30 degree mark, because if not, what happens is they start over rotating their cervical spine to take a breath with every stroke, and then that leads to neck injuries that leads to increased fatigue, and then from a kinetic chain standpoint, everything below the neck then starts getting affected and decreases performance. Um, so again, understanding the sports and how to mitigate injury, but also how to improve performance. Again, a young athlete here, you know, these swimmers are probably in their early twenties. Um, you know, they're not going to develop real bad neck problems. It may strain some of the muscles, but they're not going to develop a cervical arthritis in a matter of a couple of seasons. But again, it's when we're talking about that performance, if they're very flat while they, while they swim. And now that we're going into the summer season, if you make it out to a pool and see somebody swimming, watch their shoulders, you know, a lot of times you'll see where you're, you're very recreational swimmer, or maybe somebody just getting into it, the, the back just looks like it's barely rotating versus when you have these elite level swimmers, you're seeing that shoulder really come out quite a bit. And so they don't have to turn their head as much to take that breath. Um, again, you know, this is just an example of it, but this is really what we need to make sure that we're doing, um, as well as identifying positions on a team that may be more prone to certain injuries, um, certainly you're running back on a football team and American football team would want to have as strong of lower extremities as possible in order to prevent the risk of ACL injury. Um, because we do know that even after an ACL repair, uh, there's a small percentage of athletes at the elite level that will continue on in their career long-term. So again, trying to prevent those injuries from occurring, um, is going to be probably more important than treating it after the fact. The other part is advocacy. Um, you know, and this can be an advocate for, for your athlete's safety. Um, you know, I I'd use this picture to kind of talking about anti-doping, um, in particular, you know, that's one of the things that I probably, I get asked the most about when traveling with teams. Um, especially the national teams is, can I take this supplement? Can I take this vitamin? Can I take this medication? Is that going to do anything? Because they don't know. They don't know how something will manifest itself once it's metabolized and down the stream, if they have to have a urine or blood draw taken, the last thing they want to do is win a gold at some event and then have it pulled from them a couple of months down the road, if they test hot for something. Um, you know, so it's a lot of my job too, is making sure that I stay up to date on world anti-doping regulations, um, knowing what drugs are allowed when they're allowed, um, like for example, you can do, you could do an intraarticular steroid injection or peritendin steroid injection, uh, to an athlete, but then there comes into depending on what the sport is and then how close they are to competition. Then some of those options go away and that's the same with a lot of medications. And so neat being able to recognize, you know, when it's also available for an athlete to be treated in some way. Um, huge limitations on IB solutions, obviously. Um, and so again, it is identifying comorbidities that an athlete may have, even at the elite level, understanding the medications and treatments are going through, and a lot of times being able to submit to an organizing, um, organization. Uh, you've got release forms, um, and waivers so that a medication can be taken. Um, you know, there's a lot, and one of the things that we have to battle with a lot for swimming in particular is very common to have, um, a bronchitis that occurs because the amount of time they're swimming in chlorinated water, chlorine itself is very aggravating to respiratory tissues. So you've got several that are several athletes at high levels that develop asthma down the road. Um, and so they take inhalers. Well, officially inhalers are banned, um, as they can be performance enhancing. So we have to demonstrate medically why that, that the medication may be necessary and then even looking at when they can take it, you know, obviously we don't want them having an unfair advantage because it takes away, uh, the intent of the sport. And so again, being that advocate for the patient and the integrity of the sport is kind of what we do. Um, the other part though, too, is the education component. Um, you know, I kind of talked about it before, but when we look at especially our aesthetic sports, but, you know, being an advocate for overall good nutrition, a good lifestyle, a balance, um, you know, there's a lot of times we'll actually, we will bring board games and card games with us because from a psychological aspect, we don't want our athletes in the nights leading up to a competition, sitting in their room in silence, perseverating on something. So we try to get it. And we usually will have a team room and we'll try to get something going to take their mind off of it. It's always there. We understand that. But at the same time, there is that aspect where we have to advocate for their overall wellbeing, um, in order to make them a better athlete. And so a lot of times this will fall on you as a sports medicine physician on how involved you're gonna be, but the more involved you are, the more successful your team will be. So how do you get there? You know, that's kind of one of the big questions. I will say, let me see. There's a few specialties that go that route, family medicine, pediatrics, emergency medicine, and obviously we are biased here, physical medicine and rehab. The pros and cons to it. And so this will kind of depend on, you know, what you wanna do. I will say that your family medicine definitely has a leg up when it comes to the medicine component of it, because it's part of their foundational training. They do that for three years and then they go off to do a fellowship. The downside of that from a family medicine aspect is if you talk to a lot of family medicine residents and those going through training or have done training, they don't get a lot of musculoskeletal medicine. They definitely don't get very much if any neuromuscular medicine, which is what we do. And so that's where we definitely have a leg up on it. Pediatrics, they kind of encompass it all, but again, it's gonna be more medicine heavy and for a very specialized age group. So it's an option to go that route, but I've had to advise people looking into it that if you're looking at a pediatric to sports medicine route, you know, your athlete patient age that you treat will typically fall off probably about mid high school. A lot of pediatricians don't necessarily like to take care of even high schoolers that really have, in all intense purposes, hit full maturity on size and mass. And so a lot of times they'll start pushing them off to those who do adult medicine. But again, they're gonna be very limited in how much neuromuscular medicine and training they get. Emergency medicine, their biggest benefit if you went that route is they obviously have the most training when it comes to trauma. That's what they do. One of the areas I know they sometimes will struggle with though is a lot of the rehabilitation preventative measures because their foundational training is in response to a traumatic injury, but they do excel at that. And probably I would say some of the best when you're talking about sideline coverage on stabilizing somebody to get back to the yard. But when it comes to the long-term care of the athlete and keeping them in play, I will say that I truly believe that PM&R probably has the best way to get you ready for it. We have all the years of residency that we do neuromuscular medicine or neuromuscular skeletal medicine. And we do a lot of medicine throughout. And so again, we don't need to necessarily do, we're not necessarily running IVs, but that's fine because the ones that would need that typically aren't gonna be on the field or on the ice or in the pool if they're that sick that they need what we would call typically inpatient medications. And so what we do as physiatrists is really identify functional problems. Our training deals with nutrition, psychosocial and how we play into it. We work very well with a team environment. If you haven't done so yet and you end up doing a rotation with PM&R, you'll see that weekly your inpatient team will have a multidisciplinary team meeting where we bring everybody together from therapist to nutritionist to psychiatrist and psychologist and really work on the performance of that patient in rehabilitation. But that's pretty much the same thing you do when you're dealing with an athlete. Your sports medicine doc is not going to be doing the therapy. They may prescribe it, identify the injury and kind of what needs to be done. But you've got a lot of athletic trainers that are well-qualified. You've got a lot of physical therapists that have PhDs in their area of expertise. And so they're doing that. And so it's a great way to develop leadership of a team in order to help that one patient, whether that be a stroke patient for rehabilitation as a whole, or when we're talking about that athlete, that elite level athlete. So multiple routes, obviously bias, but I think PM&R, I genuinely feel that PM&R is the best way to go when you're talking about sports medicine. We probably get the most interventional training throughout residency more than any other specialty. So again, I think it sets us up for success in helping out those athletes and entire teams. Oh, one thing I did want to go through though too is, is I want to touch, but I know it was more about sports medicine, but one of the things to consider because we are the only field that has it, but we also have interventional spine musculoskeletal medicine fellowships. The reason I bring that up is there's a lot of people traditionally in the past that have gone into sports medicine because they just want to do the musculoskeletal care. In the past, probably half decade or just more, there's been a lot more of interventional spine and MSK fellowships that have popped up that deal with musculoskeletal medicine. The benefits of it is they kind of take the, they kind of cherry pick what they want to do from a training aspect. And so it is the, we just want to do the MSK. That's what we want to take care of. If I have somebody who has relative energy deficiency syndrome, or female triad as it used to be called, they want to be able to say, I'm going to send you off to your primary care physician and work on nutrition versus I want to take care of your ankle sprain, your arthritis, your partial tendon tear, that kind of thing. And so if you want to do musculoskeletal medicine, there are different opportunities for you if you choose that route. You know, that's only going to be a question that you can answer yourself and how much you want to do for athlete and a team member. I will say, if you truly want to do sports medicine and be the physician for a team, sports medicine fellowships are probably the best route. If you want to be the specialist that does musculoskeletal medicine, you may want to consider doing an interventional spine and musculoskeletal fellowship because the other benefit they get is they spend the entire year doing musculoskeletal medicine, but they also do a lot of spine stuff versus your traditional sports medicine physicians typically wants to get to the spine, their hands off. And a little bit going a little bit deeper, and I'll get back on track, but is then compared to a pain fellowship or traditional pain fellowship, which is going to do primarily spine and then other causes to pain. But once they get out to peripheral joints, they tend to be very hands off and push them off to somebody else. So, you know, there's a couple of ways to deal with musculoskeletal issues down the road in your career. It'll be up to you to figure out what you want to do. In the end, I think PM&R is the way to go about it. I think we set us up for success as much as possible more than any other specialty moving forward. And that is a overview of sports medicine. There's entire textbooks that will take you a couple of months to read. And so you kind of got really just the top layer overview of everything. Any questions? Let's see. Yes, I do do some OMM, some osteopathic manipulation. For me as an osteopathic physician, I find it very useful for me because there are so many restrictions on medications and treatments you can do surrounding competition timeframe. And so this is where, you know, I do get to do a lot of musculoskeletal while we're at competition because you're not going to give them oral medications. You're definitely not going to inject anything. And so if we're trying to get something to work a little bit better, that's where I'll do some manipulation. Are there any differences in the management of athletes with physical impairments? Wholeheartedly, yes. And so that is an area where you really need to be not only a great sports medicine physician, but a great physiatrist, because that's going to come into play depending on the sport and the level of impairment, you know, what type of assistive devices that they use, are they a Paralympic skier? Well, they've got special tools that go into it and they're going to have their own set of injuries that come with it because the way you're loading the shoulder joints, if they're non-ambulatory, so definitely a difference. But in the end, it's about function. And that's why, you know, physiatry really is the best way to go because you can deal with it all. We're trained in orthotics, we're trained in assistive devices, we know how the body works. And so again, I think you'll have a better idea of how to treat that demographic. Which age group would you say is your largest? Probably the weekend warrior recreational athletes and older, to be honest. You know, when you look at say a high school football team, you know, during a season, you may have a couple of kids who have a real, like a serious injury, but other than that, it's some ankle sprains and pulled muscles and the athletic trainer can take care of it. But I would say from my practice that I see on a regular basis, it's primarily your 40 and up patients. Because as I stated before, they're probably not stretching enough and I'm probably following that myself where I think I'm younger than I am. And I try to do more than I should and that's where we get prone to injury. Question for you, Dr. Hall. Yeah. I, you know, at the end of last year, I was kind of following the NBA, updating their guidelines with physicians and it appeared they put some real restrictions on physiatrists. Do you know much about that and kind of what led to that decision? So that is, yes. So that's more of a political move because for the longest times, family medicine has been one of the few fields that could do sports medicine fellowships. It's only been, you know, in the past, you know, I say relatively recent time, but 10 to 20 years where physiatrists have really moved into sports medicine. And on a political stance, there is some, there's pushback from the national organizations is where some of that is coming from, to be honest. And so again, you know, their argument, which does have some merit, I will say, you know, when you're talking about the medicine portion of it, your family medicine, your primary care sports medicine trained people probably have a little bit better training on that. But at the same time, it's not necessarily justified because the athletes in the NBA are overall healthy. So that would be a more, that would be more of a realistic argument if you're saying, you know, physiatrists shouldn't take care of athletes 50 and over. You know, we have more medicine, we're family medicine. We understand this renal function, cardiopulmonary issues, we understand it better. But NBA athletes, that's primarily gonna be musculoskeletal. And so really there's not grounds on it. And I think they're gonna take some steps backwards, but, you know, I think it's one of those that politically has been set for the time being. And so you don't wanna step away from that. You don't wanna backpedal too much because it makes you look bad. So there's a lot of politics that go into that, which unfortunately is sports as a whole. So a lot more behind the scenes than it appears on face. Okay, that makes sense. Yeah. Regarding creating guidelines, return to play or preventative measures, thoughts on doing so with the most evidence-based practices. So again, this is gonna, all this will come into play on keeping up to date. You know, recommendations are always changing. If you're looking at sports medicine, you should probably join AMSSM. You know, we are constantly looking at what our current protocols are and try to update them with new science. It's gonna be your job as a team physician is to stay up to date on it. It's not as daunting as it seems because you'll be going to conferences regularly and you'll hear about it and you'll talk to your peers. And overall, sports medicine is a very friendly field because we all just love the sport. And so again, you'll get that a lot, but it is, if you try to ignore it, kind of just bury your head in the sand, it will pass you by and you'll become out of date. But again, that's all of medicine. When a sports medicine doc works in an orthopedics clinic, do they typically do the initial evaluations and refer to surgery if needed? Yeah, I would say that's very true. You know, there's a large part of it that when we work with our surgical counterparts, you know, they want us to see the non-surgical. And so a lot of times that's gonna entail that initial evaluation, doing initial treatments, whether it's medications, rehabilitation, injections, regenerative techniques, tendinopathy, or, you know, precutaneous tenotomies, those types of things, that's where we come into play. And once we exhaust all those options, that's when we end up turning it over to our surgical counterparts. But yeah, you'll typically be kind of where the rubber meets the road. I mean, unless they're getting referred there because they've got their femur sticking out of their leg, then obviously, you know, they need surgery right then. But yeah, you're typically gonna do a lot of the initial contact. Anything else? Dr. Elm, I had a question. Yeah. You know, when speaking to PM&R and applying for a sports medicine fellowship, would you say, is it more competitive for PM&R residents to do that compared to family medicine, or just because it seems there's a lot more family medicine accredited, like sports medicine fellowships than PM&R? Yes and no. And so some of it is gonna depend on the culture of the departments where you're applying to. They are supposed to be multidisciplinary. I don't know of any that officially are just family practice, but I've definitely have heard stories of ones that, which to a certain degree, I can't necessarily blame them. I mean, we all tend to look to our own specialty and, you know, in more favorable eyes. And so you might have a little bit more predisposition to choosing a family medicine resident to be one of your fellows. But I've only, I've heard random stories over the years and it's really not very common. I think ultimately, if you are the best applicant, you'll get the spot. Awesome, thank you. Any other last questions? How do I stay up to date on the comprehensive medical knowledge when a large part of the practice revolves around MSK? You gotta read. You've gotta read it. And in a lot of cases too, that's, I have to try to stay up to date on it, but that's also the point of once you are an attending physician of going to conferences so that, you know, you can have talks and have lectures given to you about what's up to date, you know, in certain areas. Yeah, you're not the only one that is worried about that. That's why conferences exist and that you'll always have that as opportunity. So as long as you're willing to go to a conference, you won't have to worry about necessarily staying up to date. All right, well, thanks for having me, everyone. Hopefully that was insightful. It gives you some ideas of, you know, routes to go from musculoskeletal management standpoint. And then, yeah, good luck on all your endeavors moving forward. Thanks so much, Dr. Alm, that was really great. I really appreciate you being here to talk with us today. Tomorrow, we're gonna have another small group discussion session and we will be covering a sports medicine case and a traumatic brain injury case. So that will be tomorrow's small group discussion and we will have some new group leaders so you'll get a chance to meet some additional residents and fellows that will be helping us out with that tomorrow. So I think that's it for today. Thanks everybody. I appreciate you being here and I will see you all again tomorrow afternoon.

sports medicine

musculoskeletal medicine

patient populations

injuries

performance optimization

athlete health

injury prevention

recovery

athlete advocacy