MSK Matters Dr. Ali Rendely and Guests

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

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

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

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

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

Additional resources:
1. Acute ankle sprain in athletes: Clinical aspects and algorithmic approach
Halabchi, F., & Hassabi, M. (2020). Acute ankle sprain in athletes: Clinical aspects and algorithmic approach. World journal of orthopedics, 11(12), 534.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745493/
 2. Lisfranc injuries
Welck, M. J., Zinchenko, R., & Rudge, B. (2015). Lisfranc injuries. Injury, 46(4), 536-541.
https://pubmed.ncbi.nlm.nih.gov/25543185/
 3. Turf Toe: anatomy, diagnosis, and treatment
McCormick, J. J., & Anderson, R. B. (2010). Turf toe: anatomy, diagnosis, and treatment. Sports Health, 2(6), 487-494.
https://journals.sagepub.com/doi/pdf/10.1177/1941738110386681
 4. Anterior calcaneal process fracture (on differential for lateral ankle injuries)
https://radiopaedia.org/articles/anterior-calcaneal-process-fracture-1
 5. Sports Medicine Review – Foot Review
http://sportmedschool.com/sports-medicine-review-foot-review/

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

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

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

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

Additional Resources:

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

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

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

https://longcovid.physio

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Additional Resources:

Sleep and athletic performance

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

Sleep in elite athletes and nutritional interventions to enhance sleep

Physiology, sleep stages

Welcome to Season 3!  Three new residents will be co-hosting this season alongside Dr. Ali Rendely.
PGY1: Dr. Chris Wavell
PGY4: Dr. Melissa Weidman
PGY4: Dr. Natalie Daly
 Episode one focuses on nutrition and physical activity through the decades.
How do patients optimize nutrition and physical activity as they age? 
It’s hard to “out nutrition” inactivity, but exercise is the forgiver of many sins!  
The recommended dietary allowance (RDA) is 0.8 g protein per kg of body weight per day. For older adults, that may not be enough and 1-1.2g/kg/day may be more optimal, to a max of 1.6g/kg/day. This max dose may be less for those that are less active and those with kidney disease.

All movement is good and more is better, in addition to dietary protein. 
A dietary history should include what they eat, how much, and when they are eating. This should include screening for Vitamin D intake, calcium intake and protein intake. 

Protein assists as a bone builder and can be helpful in minimizing morbidity and mortality associated with fractures. High energy density proteins help build and maintain muscle mass i.e. yogurt, eggs.
Anabolic resistance is analogous to insulin resistance, but relating to protein and muscle mass. The key active amino acid is leucine. This can be obtained from whey protein supplements and whole foods.
Prevention (re: bone loss, muscle loss) is key. Patients should build up a reserve and prevent decline instead of trying to reverse it once it’s started.
 Recovery: 3 R’s: rehydration, refuel, repair!
Additional Resources: 
https://blogs.bmj.com/bjsm/2021/09/26/physical-activity-in-young-adulthood-pays-dividends-decades-later/
Nutritional Supplements in Support of Resistance Exercise to Counter Age-Related Sarcopenia
Skeletal muscle protein metabolism in the elderly: Interventions to counteract the 'anabolic resistance' of ageing
Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group
Does nutrition play a role in the prevention and management of sarcopenia?
Additional research from Dr. Stuart Phillip @mackinprof
Feedback, thoughts, questions? Tweet us @MSKMatters @alirendely

In this episode, we review all of the episodes from this season and highlight our favourite clinical pearls, while adding some new ones! 
A huge thank you to all of our guests for sharing their knowledge and time. 
To recap:
Low back pain with Dr. Stuart McGill
Diet and Sports Nutrition with Jennifer Sygo
Exercise is Medicine with Rob Bertelink
Sport Concussions with Drs. Alex Francella and Scott Shallow 
Lower extremity injuries with Dr. Tim Rindlisbacher 
Physical Activity and Pregnancy with Dr. Rebecca Titman and Jenni Diamond 
The Tokyo 2020 Olympic Games with Dr. Janet McMordie 


Thank you to everyone who has listened, downloaded and engaged with this podcast. We are so thankful to you, the listeners, for your support! 
To my co-hosts, Drs. Alex McDougall, Stephen Szeto and Nicholas Sequeira - thanks for all the time, effort and energy you put into making this season such a great success.
And to our irreplaceable editor, Enrica Ammaturo, the podcast would not run without you! 
Stay tuned for MSK Matters Season 3 - there will be new voices and new topics! Please tweet us @MSKMatters or @alirendely with topics you would like to learn more about, questions or feedback!
Thanks for listening!
Dr. Ali Rendely