All you need to know: Cortisone.

In orthopedic offices cortisone shots are offered to patients every day. What exactly is a cortisone shot and who needs it? What are the risks and benefits? 

Let’s start at the beginning.  Cortisone is the name used to describe a group of steroid medications we inject into the body. In orthopedics a cortisone shot is given into your knee, shoulder, finger etc… basically any joint space or area. Other names you may hear are methylprednisolone (Depo-Medrol), Triamcinolone (Kenalog) and betamethasone (Celestone). 

I describe these injections to my patients as strong anti-inflammatory medications that are injected into (as one example) your knee.  They work similar to anti-inflammatory medicines you take by mouth (like Advil or ibuprofen) by decreasing inflammation.  However, the mechanism of how it works is different. Also, since we are directly injecting them into the area sometimes they are more effective. 

What does the cortisone actually do? I want to make this super clear- a cortisone injection does one thing only- decrease pain. Cortisone does not fix the injury, repair the joint it is injected into, grow back cartilage or any other magic. Just pain relief. 

How is the shot usually given? Most often cortisone is mixed with a standard numbing medication and injected using a syringe and needle. The numbing medication helps short-term with the pain (just like going to the dentist and getting numb before they pull a tooth) and it also helps distribute the cortisone evenly. My standard recipe is 40 mg of Kenalog and 4 mL of 1% lidocaine in the knee.  Another doctor’s recipes may differ based on their preferences and experience. 

When are cortisone shots needed? That is a difficult question without knowing the specifics of your injury or problem.  That said, the most common thing injected with cortisone are the things that cause us pain. Makes sense, right?  But also keep in mind all things that cause pain do not get a cortisone shot.  One very common use for cortisone is in the treatment of osteoarthritis. Osteoarthritis is the degenerative breakdown of cartilage (a whole topic we will discuss another day) but simply put it is wear and tear on a joint surface.   When someone has pain from osteoarthritis cortisone is often the first go-to for relief. Cortisone also can help with pain associated with meniscal tears, labral tears, bursitis, and several other conditions. Be mindful that there are certain areas of the body, such as tendons, ligaments or soft tissues spaces that either should not have cortisone injected at all or it is at best questionable to do so. 

Who needs one? That is a great discussion for you to have with your doctor!  I would ask the following: What are the goals of the injection? How can I optimize the pain relief to make it better long term?  What are the risks, side effects or alternatives? Remember although very well tolerated any medication we give isn’t a free pass and has risks and side effects. You need to know these ahead of time.  

Here are some of the ways I answer the above. First, how to optimize the pain relief?  I optimize the pain relief after giving a cortisone shot by focusing on the overall function of the body.  If you have a shoulder problem, I want your shoulder to be functioning as close to a normal shoulder as possible.  This is often hard to do! Your shoulder moves differently when you have pain.  Without guidance it is nearly impossible to fix.  Also, with a shoulder problem you are limited in your ability to use that arm normally which can affect other body parts.  This is called compensation.  It can include how you hold your arm, the alignment of your neck or back, and even how you move the other arm. We need to break this cycle for your pain to go away for good!  Cortisone can help with the pain but if the movement pattern is not improved it isn’t a long-term solution. Why? Your body has gotten accustomed to moving the injured way.  If you get cortisone and are having less pain, this is a great time to try to optimize the shoulder movement to keep the pain away. I often recommend physical therapy for this.  Also please note- physical therapy can be fantastic even without a cortisone shot. 

Next, what are the risks? Every medication has risk. I always remind patients every needle stick has a risk of bleeding and infection. The skin is your safety barrier and sticking a hole in it means breaking that barrier.  When sticking a needle into the skin there are structures below the surface.  Depending on where the needle is headed (more for certain injections than others) we need to be aware of blood vessels to avoid bleeding.  These are both very small risks but depending on the person getting the injection.  Another important risk I always discuss applies to patients with diabetes.  We know cortisone injections can transiently increase blood sugar for about two weeks after the injection.  If you are a well-controlled diabetic you can likely still have the injection, but your physician should have you monitor your sugars closely and report any issues. Unfortunately, if your sugars are out of control before the injection it may not be safe to proceed.

How long does the pain relief last?  That is highly variable.  I tell my patients the medication effect lasts a few months. That is how long the medication itself is altering the insides of joint.  However, if you do more (refer back to the above about PT and shoulder pain), then it may last much longer.   Another possible and important ‘risk’ to be clear on is sometimes cortisone does not provide any pain relief at all. 

What if I need to get several cortisone injections to maintain pain relief? This again is variable but could be a concern.  Let’s revisit the knee example for osteoarthritis.  You as my patient have had one the injection every few years and otherwise have done well!  You are able maintain your exercise program, stay at a healthy weight and are maintaining cardiovascular fitness… to me, this is great! Those benefits clearly outweigh the occasional injection.  However, if you notice that you are having repeat injections and the time between them is getting shorter to maintain pain control this may not be the best solution any longer.  There is some data that suggests repeated cortisone injections may advance breakdown of the tissue faster than normal.  So, we must proceed with caution.  

Overall injections of cortisone are safe and well-tolerated in many and can be extremely helpful in alleviating pain. If you have questions about cortisone or whether you are a candidate for one it may be time for an educated discussion with your orthopedic physician.

Ski Season.

The cold winter air on your face, fresh powder under your feet, stillness of the wilderness… Whether you tackle the slope on skis or a snowboard nothing quite compares to the feeling of that first run of the day. But as with all sports, injuries can ruin what started as the perfect alpine morning.  Read on to learn about the most common issues snow seekers face and what can be done to stay as safe as possible. 

Common Injuries

For winter sports enthusiasts of the skiing type, the most prevalent injury is in the knee.  With the feet and ankles locked in a hard sided ski boot, the force is directed to the knees means when you fall on the slope.  This force can cause a variety of knee issues, one of the most feared is the ACL Tear (which I wrote about in depth here… LINK), but you can also injure other areas including ligaments such as the MCL or LCL, the menisci, or even the bones (femur/tibia) as they join at the knee.  

For snowboarders, knee injuries can also occur. However, given the orientation of the board on the slope and the single-sled positioning (feet both fixed to the same board), the most common area injured is the wrist. When a snowboarder starts to fall, they instinctively reach for the ground causing injuries ranging from minor sprains to fractures of the wrist bones. 

For all alpine lovers, injuries to the shoulder can also occur.  During a fall you can easily land on your shoulder or outstretched arm causing injuries to the tendons, muscles, or ligamentous structures in and around the shoulder. Shoulders can stretch out of place (subluxate), dislocate, or break with this mechanism. 

Other areas of the body are also prone to injury from a fall on the slope including the hips, spine, and chest wall. 

The most traumatic snow sport related injuries are those to the head or neck. For experienced and novice skiers alike, barreling down a slippery slope can be hazardous. Conditions that make this worse are crowded areas and other obstacles like trees or rocks.  Hitting another person or a tree can have devastating consequences as can your head on the hard packed snow.  Injuries can range in severity from concussion  to bleeding or fractures to severe traumatic brain or spinal cord injuries.

How to stay safe

Staying safe on the slopes makes for a much better day then ending a run with an injury.  

My recommendations: 

1- know your limits and the trail maps

2- train before you ski

3- save the alcohol for the après

4- wear a helmet, always

1. Know your limits

Staying safe on the slopes requires a level of understanding of what you are getting yourself into as well as a knowledge your ability. If you are a beginner or novice, look at the trail map ahead of time and stick with the runs appropriate for your skill level. You are not competing for a spot on the Olympic team… Even if you are more advanced, remember to avoid putting yourself in a position where you feel out of control.  The number one reason I see patients in the office with an injury is getting themselves into an uncomfortable position.  If you end up in this scenario, it is best to stop and ask for help. Ski patrol is always available to keep you safe.  They would much rather help you down the slope than find you injured. 

Another great tip is to take a lesson. No matter how advanced of a skier you are, lessons can be extremely helpful! During my last ski trip, I took a lesson, and it was worth every penny. The instructor was a true gem, helping me (more novice) and my husband (more intermediate) at the same time by challenging each one of our levels safely.  He was so great that when he ran into us the next day while skiing with his daughter, he skied with us for a bit for follow up tips.  These instructors live for skiing, know the terrain, and know how to teach you to be better. Everyone can learn!

2. Train before you go

If you were going to run a half marathon you wouldn’t just show up race day and expect to finish without problems.  Same goes for snow sports. Even if you are in great physical shape at baseline, some activity specific training can be beneficial.  Skiing and snowboarding are physically demanding sports. You need strong legs, great control of your upper and lower body, and stamina to survive the day.  I can’t count the number of patients who describe their injury as something like, “I was tired, out of control and crashed but can’t remember what actually happened.” Don’t be that person. 

3. Save the Après

Ah yes, the time-honored tradition of that first amazing post-ski après beverage at the lodge. It may be my favorite part of the ski day.  However, studies have shown that alcohol increases the risk of injury for both skiers and snowboarders. (As does any illicit/mind-altering substance use). Save the après festivities for after you are done skiing for the day. 

4. Wear a helmet, always

This one cannot be stressed enough. Head injury can be a devastating outcome of a crash on the slopes. No matter how well you ski, a fall can still happen. It is sort of like driving, even if you drive perfectly, someone else can hit you or cause you to crash. So, we were seatbelts, right? Wear a helmet every time you ski or snowboard. Protect your skull and brain and decrease your risk of tragic outcomes. 

If an injury occurs

Ski patrol is always available for injured skiers. They are all over the mountain and at the base, and most resorts employ trained medical staff. Some even have physicians available. Every ski town I have been to has a local urgent care as well with a team that is used to seeing slope related injuries. If you need follow up after a day on the slopes for a bone, muscle or joint problem seek out your local sports medicine orthopedist. It is always helpful to bring any images (Xray’s, MRI’s, etc…) that were taken on the slopes or after.

And of course, enjoy the snow!

Need to know: Ankle Sprain

The ankle sprain… One of the most common reasons patients see me in the office. Here is all the information you need to know if this happens to you.  It will be just like if you were visiting me in the office!

An ankle sprain occurs when your foot rolls in or out putting extra stress on the ligaments.  This causes the ligaments to stretch/tear, which is by definition an ankle sprain. If your ankle rolls where sole is facing in, it is called an inversion injury (most common). If your ankle rolls where with your sole facing out, it is an eversion injury. These injuries can happen during sports, basketball and volleyball are common, or in any setting when athletes can land awkwardly from any jump or step. Sometimes though for the unlucky patient the injury can occur during day-to-day activities, something as simple as stepping off a curb wrong at the grocery store.  I have seen all of the above (and more) in my office!

During the sprain, the ligaments are stretched/torn which causes pain and swelling. The great news is these ligaments are not typically the type we need to fix with surgery, and most people heal quickly without long-term problems.  However, more complex types of sprains do exist that take longer to heal or may need more intervention.  For example, a “high ankle” sprain results from a more forceful twist that injures the ligaments above the ankle between the lower leg bones in an area called the syndesmosis. With other high energy injuries, you can also injure ligaments lower down in the foot or even break the bones.  If you are a kid and still growing, your growth plates are weaker than the ligaments.  Because of this when you twist your ankle, the bones may be more likely to break than for a ligament to tear.  This is a commonly missed injury by non-orthopedic physicians, can take longer to heal, and needs a correct diagnosis to be treated properly.

 Today we focus on the essential adult ankle sprain, the inversion (sole of foot turning in) injury that tears ligaments mainly on the outside part of the ankle. The most common injured ligament is called the ATFL, or anterior talofibular ligament.  If you look at your right foot it is that approximately at the 2 o’clock position on the top of your foot about 1 cm from the ankle joint. 

The injury causes a tear/stretch of this ligament resulting in pain, swelling, and bruising. 

 Treatment is usually very straightforward. I recommend starting with ice for the first 24-48 hours with rest (doing as little as possible) and elevation (at or above the level of the heart) for swelling. You should only do light activities that do not increase pain. If you have a more significant injury and you cannot walk normally, sometimes I recommend using a brace or other support device like a medical grade boot short term.

The timeline for recovery is variable and depends on how bad the injury is and what your goals for return to activity are. If you have a small injury and are doing low impact movements (sitting/walking) a full recovery is quicker than if you have a larger injury and play sports that require cutting, jumping, or pivoting. 

The biggest risk with an ankle sprain is repeat injury. Once the ligaments are injured, your ankle is more unstable and weaker.  You are more likely to sprain it again or injure it further if you have not fully regained all your strength, balance, and coordination lost with the initial injury.  Your body normally controls ankle stability (balance and strength) with proprioception. Proprioception is a protective sensation where your brain sends a signal to a joint and the joint responds with position updates.  Think of it like you brain asking your ankle, “Hey, how’s it going down there, which way are you pointing, how stable is that ground?” And your ankle responds, “I am okay, pointing straight ahead, ground stable no cause for concern.”  This happens constantly and nearly instantaneously with movement.  Consider this – don’t you always know where your ankle is without even having to think about it?  When you have an injury that feedback communication does not work as well.  The ankle’s response can be slowed and inaccurate.  This causes an increased risk of a second injury.

We can improve the ankle’s ability to communicate via proprioception, as well as its strength and our balance with physical therapy. A physical therapist can assess how the ankle is moving and what needs to happen to retrain it to be pain free and moving well. In my office I see people with the initial injury and then depending on the degree of injury will either send them straight to physical therapy or will send after a period of rest. It takes several weeks to get the ankle back to moving normally, but most often after doing so people do very well.  

One common question I get is why the swelling lasts so long after the injury, even if they are progressing well otherwise. This is usually not cause for concern. In addition to injuring the ankle ligaments the other soft tissues around the ankle were injured.  Because of this, swelling can persist for many months even after your ankle feels better.  Another common question is why the ankle feels stiff or not quite like the other ankle.  The stiffness is from the lack of movement in the early recovery and from scar tissue that forms during healing. The great news as that the stiffness dramatically with time and work with physical therapy. 

My goal with treating an ankle sprain is to get patients safely back to all the activities they love as soon as possible.  At my initial evaluation we make a plan for what one should expect in the next few days to week and schedule a follow up to assess progress.  Having two visits helps me understand your trajectory for healing – two data points helps me see the line of how quickly you are progressing much better than single point.  Once physical therapy is started, I continue to monitor progress and help determine when one can return to sport activities. 

A final word on return to sport.  I return most people cautiously.  As I mentioned, recurrent injuries happen.  I unfortunately see patients that have long term chronic ankle pain or instability due to having multiple sprains.  This is a harder problem to fix and may even require surgery.  Getting the physical therapy right from the first injury can help prevent this problem.  For those with recurrent sprains, optimizing a physical therapy program and integrating ankle rehab into your exercise will absolutely be helpful and may also prevent the above. 

Any questions about ankle sprains? Let me know!  Share this with anyone you know that may find this useful. 

The ACL Tear.

As we approach the end of football season, there is one injury that we have heard of several times throughout the year (and past years as well). The ACL tear.  Most sports fans have seen this listed on the injury report and heard the announcers talk about concerns for this when a player goes down on the field, but what is it? Why is it a big deal, how does it happen, and what is typically done about it?  

First, knowing a little anatomy of the knee is important. The ACL – or anterior cruciate ligament – is an important structure inside your knee joint.  We have 4 ligaments in and around that area, named for where they are located. Anterior (front) and posterior (back) cruciate ligaments, and medial (inside) and lateral (outside) collateral ligaments.  Today we focus on the ACL because it is usually the most ‘tragic’ when injured in sports. By tragic, I mean the one that is the most worrisome for an athlete because of the long treatment and recovery process that often alters one’s career short and long term. 

The ACL connects the bottom bone in the knee (tibia) to the top bone of the knee (femur) from front to back.  It plays a key role in stabilizing the knee. In medicine we would say it “resists anterior translation of the tibia on the femur.”  Stick with me here… this means in regular language that it stops the bottom bone of the knee from sliding forward in relation to the top bone during normal movement, aka inside the knee joint where it bends.  This bending is what allows us normal knee motion needed for walking, running, jumping, playing.  But we need something to help keep the bones attached to one another or else the knee may feel unstable (jelly-like) when we put stress on it.  [Think of the knee as a door hinge where the ACL is the pin that connects the two pieces of the “hinge”; without this the door can swing open and closed gently, but if it’s pushed too hard the hinge may not line up properly and may become damaged].  Not an ideal situation if one is interested in getting back to doing higher impact activities like playing football. 

If the ACL is torn the knee becomes unstable because the bottom bone can shift away from the top bone.  The cool thing the human body is that there are often redundant systems.  For the most part (although not always for every person) normal walking and low-impact day-to-day life can still be achieved without the ACL because the other ligaments and muscles around the knee can pick up the slack to provide stability.  This means even without an ACL, for daily life activities, many people move about fine.  The problem is with any sudden or shifty movements, such as cutting in sports or in high-impact jobs like law-enforcement or firefighting where folks are required to do movements that aren’t straight forward or backwards. These types of movements are more complex and require more stabilization, so without an ACL the knee can feel unstable and even give out.  For football and other sport athletes, one also would not get the control or explosive power she or he needs to play.   

An ACL tear most likely occurs when the leg is forced in a way that stretches the ligament too far.  Remember, the ACL blocks forward movement of the bottom part of the knee.  Consider a  a football player whose foot is planted to the ground when his knee gets pushed backwards, pushing the top bone away from the bottom bone. Pop!  The ACL is overstretched and gives way.  This is just one example, and there are of course other ways this happens.  Sometimes it involves a collision with another player (as described above) and sometimes it involves getting the leg in an awkward position when a person is running or jumping with the knee buckling inwards/backwards due to the force of the jump or a bad landing.  In this case, it is simply the lack of control and force of the jump landing or cut that causes the tear.  We tend to think of these “non-contact” tears occurring most frequently in young female athletes (maybe a teenage basketball player) that hasn’t developed full hip/knee control. 

The tearing of an ACL is an abrupt injury and not usually subtle.  Sometimes people hear a pop (but not always), feel a pop, have sudden onset of significant pain, and usually fall to the ground.  Most of the time the injured can’t walk easily (if at all) and don’t usually keep playing the game after.  The knee swells up from the inside due to the trauma (effusion).  I usually ask patients if it swelled up like a water balloon as an analogy.  A former mentor of mine taught me when I was learning about knee injuries that a young person running or cutting during sports with a sudden burst of pain with a pop in the knee and large swelling is an ACL injury until you prove otherwise.  This still rings true for my patients today.  #mentor

To diagnose the ACL tear we first talk about what happened when the injury occurred in great detail.  Then, we do an office examination of the knee, as well as the hips and lower legs.   Looking at the other nearby joints is important! Just because it seems that it might be an ACL tear it doesn’t always mean that is our answer.  We complete a few special maneuvers that help clue us in to what possible problem could be happening inside your knee. These maneuvers are helpful to distinguish other injuries that present in the office like an ACL tear.  This exam also helps us determine what next steps to take or if there is concern for other associated injuries (ACL tears often occur with other injures such as MCL tears, meniscus problems, and bone or cartilage injuries).

So you tore your ACL, what now?  Since it is such a crucial ligament for knee stability, most highly active people or athletes should discuss surgery to repair or reconstruct the ligament in the knee.  It does not grow back. It does not scar into place or heal. That said, it is important to note that older patients or people who are less involved in side-to-side/cutting sports or activities may not need surgery.  Be sure you have a discussion with your doctor about what the benefits of surgery are for you, the associated risks of the procedure, as well as the expected long term outcomes.  We practice medicine using the guide of high quality research, and if the studies show that you may do just as well without surgery, that may be the best way to treat your specific injury. Most important is to have these discussions with an orthopedic sports trained surgeon.  They will discuss options, the optimal timing to have surgery if it is thought to be best for you, and also very importantly your rehabilitation and expectations for recovery.  

Whether one has surgery or is treated without operation, he or she will need extensive physical therapy/rehab.  It takes many months for one to get back on the field!  One has to be patient.  For professional athletes that have dedicated athletic trainers and rehab specialists, these are season ending injuries. Often with great rehab, they can return in 6 months (at the earliest) though it can take 1 or more years to reach the prior level of sport.  But these are gifted individuals with many many resources.  For the average injury, it will be at least 1 year before one may feel 100%. And keep in mind, once a person has had an injury, and then had surgery, it is quite possible the knee will never feel 100%.  [Stay tuned for my article discussing preventing injuries like ACL tears.]

Stay healthy-

What is a stress fracture? And when should I worry?

Given the state of the world, people are increasingly turning to outdoor recreation and exercise. More people than ever are out running! This is awesome. However, with this, comes the possibility of new injuries. Runners are some my favorite patients because as a runner myself, I see the motivation and time commitment as well as the joy that being a runner can provide. Unfortunately, when I am seeing patients in the office, usually, they are having pain or have had an injury. An injury that has presented more often recently due to people turning to the streets for exercise is something called a stress fracture.

A stress fracture is essentially breakdown of the bone that occurs from repeated small forces. When we run or do other high-impact activities (jumping, plyometrics, or other exercises when both feet are off the ground at once) our bones break down and then heal when we rest. This is a normal process that happens on the microscopic level and is the way the bone stays strong by regularly “remodeling” itself. When the balance between breakdown and healing becomes unequal, we can develop a stress fracture. This stress fracture is a weakness in a small area of the bone that does not have a chance to heal before the next round of impacts, an overuse injury.  

Other factors sometimes contribute to the development of the fracture.  Remember I said that they start by a disruption in the balance of breakdown and healing of the bone. For a person training for their first marathon it seems that an increase in the breakdown forces would be the cause.  Well, what about the other side?  What if the breakdown hasn’t changed, but the healing side can’t keep up?  This can also be a reason why stress fractures occur.  Why does this happen?  The reason we have slower healing can often be attributed to nutritional factors, hormonal factors, weakened bones from medications, or simply aging.

The main symptom of a stress fracture is pain usually described as an achy sensation deep in the area of the body that is affected.  What can be tricky is most people can continue to run but then experience this achy pain after the run or even at night. The lower extremities are where stress fractures usually develop.  This makes sense as are often due to the impact of running.  Common places are in the lower leg bone (the tibia) and the foot bones (metatarsals).  Occasionally, one can also develop stress fractures in the small bone on the side of the leg (fibula), in the upper large leg bone (femur), or in the hip socket or pelvis. How serious the stress fracture is depends on a few factors, and one of the most important is where it is located – that is, some locations are more high risk than others for bad problems!

When I see someone in my clinic that has a stress fracture, the story they tell usually goes a little something like this… they have increased their mileage, or they changed their running routine in some other way.  They may have started to train for a marathon having never done one before, or maybe they are just training harder to get to a faster race time. Maybe they are new to running… 

They usually report pain in a small area in one of the body parts we mentioned before.  

After we talk, I do a physical examination.  We get an x-ray that gives me a basic overview of the bone shapes, structures and the space between them. 

Sometimes we can see the stress fracture on the x-ray. If we do see it, we see a slight change in the contour of the edge of the bone that I like to refer as a “scaffold” (think scaffold on the side of a new building being built). This is what your body does in response to a stress fracture developing. It works overtime to build this scaffold to try to patch (heal) and protect the bone. If that scaffold continues to get abused by your activities (i.e. you kept running despite the pain), the body can’t keep up and the scaffold breaks down as well.  This shows up on the x-ray as a dark black line through your bone and is a more serious problem, the so-called “dreaded black line.”  This means that the stress fracture has progressed, is no longer microscopic and is a more serious problem.  In this instance, x-rays are great tools.  But keep in mind not seeing a stress fracture on an x-ray does not necessarily mean you do not have a stress fracture.  If only things were easy right!  So, what do we do if we highly suspect you have one and don’t see anything on the x-ray? Sometimes we need more information, and in this instance, we may do an MRI to evaluate the bone structures further. The MRI gives us more information because it not only shows us the bone but also can show swelling in the bone, the bone matrix in more detail, and any “black line” cracks are very apparent. Both imaging modalities can be helpful, and you don’t always need one or the other.  (We try to be thoughtful about ordering tests in medicine, so if things will not change the treatment, we just use the history and physical examination!)

To heal a stress fracture, we must first rest from the insult that was causing the problem.  Second, we must address what if anything in your body that caused a deficiency that the bones couldn’t keep up with. That is very important. If we just allow you to rest from running, and then you start back doing the exact same thing at the exact same speed and pace that you were before without addressing all the other factors, it is extremely likely that the stress fracture will recur. 

We also investigate why the stress fracture developed. This may mean you need an evaluation of your running gait and the strength and control of your lower extremity muscles. Sometimes all we need to do is discuss your specific training program and see how their progression and amount of running, volume of training, volume of cross-training, and rest all may have contributed to the injury (as a sports medicine physician my favorite part is to help you get back to running and sport ASAP!)  We also discuss nutrition, and whether finding a way to optimize this or other associated factors (think hormones, vitamins, blood tests, etc…) are needed as well. More on these topics another day.

If you have, questions about stress fractures let me know!

I miss sports…

April 30. 

The fiancé and I took a long run tonight around our neighborhood.  I have been trying to get into the swing of exercise during the pandemic. But if you read my last post (linked here!) it hasn’t always been easy.  So, when offered a leisurely paced (aka Morgan’s pace, not his pace) tonight after dinner, I took him up on the offer.  When we were about 1.5 miles out, we happened upon the local high school sports fields.  Immediately I felt the need to reach out my hand towards the gate.  There was a pit in the bottom of my stomach.  Seeing that football field I was struck with so many emotions.  I really miss sports. 

My job sometimes isn’t easy, and it often weighs on me.  As an emotive person the weight of everyone’s pains and injuries can build up. The expectations of seeing volumes of patients, doing paperwork, and managing a staff can weigh on my sensitive being.   And when you have games to cover on countless weekends and evenings it can start to feel like a chore.  But that day I felt such a strong longing to stand on the sidelines on a fall Saturday covering a football game.  I could feel the cool breeze in the air, hear the fans cheering in the stadium, and see our team playing on the field.  I long for the day we are able to play sports again.  But this longing is mixed with the fear I have for the safety of our athletes. COVID-19 has changed everything, including my perspective.   

May 3.

My fiancé and I have jumped on the bandwagon and are watching The Last Dance on ESPN (ESPN Story linked here).  The story for those that don’t know is about the Chicago Bulls in the era of the great Michael Jordan.  And you know what, I’ll say it again, I really miss sports. While watching I couldn’t help but think about why I feel so strongly about it.  I am not just a fan.  There is something more to the desire I feel.  

You’ve have heard the saying, “if you can’t be an athlete be an athletic supporter?” Well I think we as team docs are the ULTIMATE athlete supporter.  Let’s be honest again, I am not larger than life. I will never be.  But these athletes are.  And when they stand in victory we stand on the sidelines or in the very far background.  The feeling that we helped, even in a just small amount, contribute something towards whatever it was that allowed them to get there… WOW. Even if we didn’t directly contribute anything aside from being there in case, even when we are just there to watch it from behind the scenes while it is all happening…. Same feeling. Still Wow. 

The energy of being around sports is irreplaceable.  I don’t have a championship ring, but I know what it is like to watch that end being achieved. Maybe that is in part why we do our jobs;  it isn’t for the ring itself in our case but to be a part of something greater than ourselves, to help the best of the best achieve her or his best, to help those larger than life characters to be the gladiators of today. 

Team doctors are always there.  Winning seasons or losing ones. Pandemic or not.  There is no real credit and most of us don’t care. All we want to be there to help the best achieve greatness. We want the gladiators of our time to shine. We want those who are larger than life to make magic.   

Bottom line, I am honored to go behind the scenes and play my very small role in the greater world of sports.  It is absolutely my honor to have stood in every tunnel in which I have been placed. It is my honor to walk into a locker room and help an athlete in need.  

I often joke that it is like going behind the curtain of the Wizard of Oz at times. You know what is back there now, and some of the spectacle of it all changes.  But what an honor it is to know the greatest of the greats. 

Dang, I miss it. 

What is a Sports Medicine Doctor?

We are starting at the beginning again with this one but for good reason.  In talking with people both in the medical and outside, I realize that not everyone knows what a sports medicine doctor is or what we do.  To be honest, that is fair because it is actually fairly confusing. There are a few types of sports medicine doctors that exist, and to make it more confusing even doctors of the same type may practice in very different ways.  Lets get to it… 

First, all doctors go to college (undergraduate) and then medical school.  Near the end of medical school, we all choose a residency training program (aka the kind of doctor we want to be).  This would be choosing things like General Surgery, Family Medicine, Radiology, etc… you get the idea.  This is the first and main divide that divides the two types. 

The decision.  Sort of like Lebron’s decision to go to Miami, only not nearly as televised… To be a sports medicine doctor you could decide to be trained in a field of general medicine first  (a residency in Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, Physical Medicine and Rehabilitation) OR you could decide to train in orthopedic surgery first.  This is the main divide – medicine or orthopedic surgery.  And hence really the main decision is:  do you want to be a surgeon?  This is how we divide the surgical sports medicine and non-surgical sports medicine doctors – how she or he trained in her or his residency.  

After residency of whichever variety, to do sports medicine you need further training.  We spend extra time after our first chunk of education studying a smaller area of medicine to specialize for our career.  These fellowships are separate for medicine and orthopedic surgeons, but sometimes (like the program where I trained) they parallel one another and have lots of shared/similar experiences. This process is like one that happens for all fields considered “subspecialized” as for a general surgery resident that decides he or she wants to be a vascular surgeon, or an internal medicine resident that wants to be a cardiologist… It is a way to focus further into specific area you choose. 

Back to us sports docs… Once you complete your sports medicine fellowship you take a test to be certified in sports medicine. For me, that was called the Certificate of Added Qualifications (CAQ). This officially makes you a sports medicine doctor.  After a minimum of 12 years of education after high school, now it’s time to get a job (finally). 

Orthopedic surgeons who become Sports Medicine-specialized work as surgeons. That makes sense, right?  They see patients with injuries of primarily the knee, shoulder, elbow, hip, and sometimes ankles.  They can do some treatment for other extremities like wrists too.  They often do surgery via arthroscopy (cameras used inside of joints) and repair/reconstruct ligaments/tendons, replace shoulders/knees, and sometimes fix simple broken bones.  Depending on their interests they might pick a body part to specifically focus in on; for example, one of my colleagues loves knees and now his practice is mostly focused on patients with knee problems.  

For primary care sports medicine doctors like me, the type of careers we have can be more confusing because our practice structure is more variable.  Basically this means even though we all have the same training, we end up working in different environments for our career.  Examples should help. Lets explore Doctors A, B, and C- all trained the same way as primary care sports medicine doctors to this point. Doctor A decided to continue to practice mainly their general medicine specialty. So although he or she is sports medicine trained they see patients of every complaint under the sun from colds, to high blood pressure to diabetes to knee pain.  You name it they have probably seen it.  Next we have Doctor B.  I like to think of Doctor B as a hybrid.  Doctor B works with other primary care doctors in a group setting and although they also probably see everything under the sun a patient might need, they also see the sport injuries for that group.  If you call to see your doctor and have knee pain for example, your doctor might see it or they might funnel it to the sports trained doctor that is a part of their team.  And finally, Doctor C.  Doctor C works within orthopedics along side our surgeon colleagues.  I am like Doctor C! We function in a similar way to our sports surgeon trained compadres and are part of the team that career for patient calling us for orthopedic concerns.  This of course is also not an exhaustive list and there are many other nuances about what we do.   We can be team doctors, we can take care of dancers and runners or prefer to primarily do procedures and injections, etc… etc… 

A great video can be found on the AMSSM website which I shared here. https://youtu.be/FExwzFWvpE4

My specific path went like this.  I spent 4 years in undergrad at the University of Evansville in Indiana. After that, I went on to medical school at Indiana University where I received my MD (Medical Doctor) degree.  After medical school I went to residency in Cleveland, Ohio to learn Internal Medicine (ie: general adult medicine) for 3 years. I could have stopped here- and the path I described above would’ve said the next step is going directly to fellowship.  But, after my internal medicine training I actually stayed on for a one year extra year of administrative work before heading off to fellowship.  This year was called a Chief Resident year and is something that you are selected to do by hospital leadership.  Back on the aforementioned path, my sports medicine fellowship was another 1 year program in Cleveland, Ohio.  These training programs are variable based off where you train and also your own background and career desires to add another layer of complexity.  My program did a great job of preparing me for my role now which is working in full orthopedics offices and as a team doctor at a large academic healthcare facility.  Pretty cool, right!

Best,