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MSK Matters

Author: Dr. Ali Rendely and Guests

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



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 ( 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
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 includereaching the Canadian Physical Activity / World Health Organization Guidelines includingstrength training, balance exercises and aerobic activity.Exercise induces neurogenesis, addresses cardiovascular risk factors, decreases depressionand 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 tothe Mediterranean diet and should be implemented as early in life as possible.Exercise can help increase cognitive reserve, delaying progression from mild cognitiveimpairment to dementia. Always remember to match the exercise prescription to what thepatient 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, thatcan outweigh non-modifiable risk factors related to dementia!Guest: Dr. Nicole Anderson - Resources:The 2020 Lancet Commission on dementia, prevention, intervention, and carehttps://osteoporosis.caBrain Health Food GuideBJSM: Physical activity as a protective factor for dementia and Alzheimer’s disease



This episode deals with something we all do every day, sleep! Sleep is now seen as an active, restorative experience intended to optimize our functioning while awake, rather than a passive process. Sleep is closely tied with mood and pain, and plays animportant 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, weoften 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, itstarts with building a healthy and patterned night time sleep routine. We discuss ways torecognize sleep debt, means and by how much to repay it, as well as the effects of notdoing so.Sleep is crucial to overall performance, which hinges on four important domains:cognitive, physical, emotional, and social. Sleep deprivation also has different impactson performance, be it by altering our cognitive abilities, limiting endurance, reactiontime, 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 sleepjournals useful; are naps helpful, or harmful; should melatonin be prescribed; is thatmidnight snack keeping us awake or putting us to bed? Listen to learn how to optimizenightly sleep to improve performance and quality of life.Guest: Dr. Brandon Marcello – https://www.brandonmarcellophd.comAdditional Resources:Sleep and athletic performanceEffects of training and competition on sleep of elite athletes: a systematic review andmeta-analysisSleep in elite athletes and nutritional interventions to enhance sleepPhysiology, sleep stages
Welcome to Season 3!  Three new residents will be co-hosting this season alongside Dr. Ali Rendely.PGY1: Dr. Chris WavellPGY4: Dr. Melissa WeidmanPGY4: 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: Supplements in Support of Resistance Exercise to Counter Age-Related SarcopeniaSkeletal muscle protein metabolism in the elderly: Interventions to counteract the 'anabolic resistance' of ageingEvidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study GroupDoes nutrition play a role in the prevention and management of sarcopenia?Additional research from Dr. Stuart Phillip @mackinprofFeedback, 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 McGillDiet and Sports Nutrition with Jennifer SygoExercise is Medicine with Rob BertelinkSport Concussions with Drs. Alex Francella and Scott Shallow Lower extremity injuries with Dr. Tim Rindlisbacher Physical Activity and Pregnancy with Dr. Rebecca Titman and Jenni Diamond The Tokyo 2020 Olympic Games with Dr. Janet McMordie Thank you to everyone who has listened, downloaded and engaged with this podcast. We are so thankful to you, the listeners, for your support! To my co-hosts, Drs. Alex McDougall, Stephen Szeto and Nicholas Sequeira - thanks for all the time, effort and energy you put into making this season such a great success.And to our irreplaceable editor, Enrica Ammaturo, the podcast would not run without you! Stay tuned for MSK Matters Season 3 - there will be new voices and new topics! Please tweet us @MSKMatters or @alirendely with topics you would like to learn more about, questions or feedback!Thanks for listening!Dr. Ali Rendely 
The Tokyo Olympics mark the debut of new sports include karate, sport climbing and skateboarding, among others.In this episode, we discuss common injuries sports medicine physicians see when treating patients that participate in these sports.In sport climbing, upper extremity injures account for 80-90% of all injuries. Specifically, hand and finger injuries are exceptionally common. So common, that the injury has been named climber’s finger. In a distant second, shoulder injuries including rotator cuff strains, tears, impingement, SLAP injuries, and subacromial pain syndromes are seen in those learning to climb. In professional climbers, shoulder injuries are less common as they use their lower body strength to maneuver the climbing wall, instead of pulling from the upper extremities. For more information on climbing injuries:Rock Climbing InjuriesIncidence, Diagnosis, and Management of Injury in Sport... : Current Sports Medicine ReportPulley Injuries Explained – Part 2 – The Climbing DoctorFlexor Tendon Injuries - Hand Rotator cuff-related shoulder pain: does the type of exercise influence the outcomes? Protocol of a randomised controlled trialRotator cuff injury - Symptoms, diagnosis and treatmentSkateboarding has been a fun edition to the Olympics. With a relaxed atmosphere, punctuated by music and high-fives, these high flying athletes are injury prone. The best treatment is prevention –  new skateboarders to wear helmets, elbow pads, wrist guards and knee pads. Common injuries include distal radius fractures from falling on an outstretched hand, lateral ankle sprains and mild traumatic brain injures (wear your helmets, kids!)For more information on skateboarding injuries:Common Skateboarding Injuries & Safety Tips Skateboard Injury Statistics (Updated 2020) - Safety First – Skateboarding SafetyDistal Radius Fractures - TraumaManaging head injury risks in competitive skateboarding: what do we know? Finally, martial arts spread across Japan in the early 20th century, and has been a candidate as an Olympic sport since the 1970s. Blending striking combat and rigorous discipline, the Tokyo games presented an opportunity to showcase it from its homeland. Using karate as an example, training fatigue can lead to technique errors and overuse injuries. It is important that physicians and therapists help guide athletes through an appropriate training protocol, including rest days. For more information on karate injuries:Martial Arts Injuries | Martial Arts Injury Prevention & Treatment Injury trends in sanctioned mixed martial arts competition: a 5-year review from 2002 to 2007 Epidemiology of injuries in Olympic-style karate competitions: systematic review and meta-anal
This episode is for all women of childbearing years and all of the healthcare practitioners who provide care to these patients!The new CSEP Physical Activity throughout Pregnancy Guidelines provide evidence around the benefits and safety of being active throughout pregnancy, for both mother and baby. Physical activity is now seen as a critical part of a healthy pregnancy. Following the guidelines can reduce the risk of pregnancy-related illnesses such as depression by at least 25%, and the risk of developing gestational diabetes, high blood pressure and preeclampsia by 40%. Providers should be educated on the absolute and relative contraindications for exercising during pregnancy to help guide patients safely.Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active in a variety of ways every day is encouraged. CSEP has created a Get Active Questionnaire for Pregnancy that providers can use to assist with safe exercise prescription.Pregnant patients should be treated for musculoskeletal pains the same way all other patients are treated. This includes assessing, working up and investigating patients appropriately. Treatments should include active rehabilitation with the mainstay of most MSK pains being treated with exercise. Women should be offered medications, as needed, always trying to use the lowest effective dose possible. First line treatment includes acetaminophen (4g/d max) and second line includes the use of opioids. MSK low back pain is very common! 20-30% will have pain that impacts quality of life and function. Pain education and a multi modal plan should be incorporated just as one would for the general population.Women often need to be “cleared” to return to exercise, and the 6 week mark is a classic timeline, but this is arbitrary. Waiting for clearance does not mean no movement for 6 weeks. Women should be reassured that early gentle activity is reasonable. This can include activities such as restorative yoga and walking.Share this episode widely with anyone who treats women of childbearing age.  It is our role to encourage women to be active, and as healthcare professionals, we need to work on minimizing barriers to exercise. This includes having conversations and discussions with patients that movement is necessary before, during and after pregnancy!Additional Resources: 1. 2. 5.
Lower extremity injuries occur in all sports and high profile athletes draw attention to such injuries. This episode delves into 3 of the most talked about lower extremity injuries in the last years. Using these athletes as a starting point, this episode discusses the differential diagnosis, assessment, work up and rehabilitation plans for lower body sports injuries. We start with the hip dislocation sustained by now NFL player Tua Tagovailoa. Posterior hip fracture dislocations are relatively rare in sports, but it is always important to think of the common and not to miss diagnoses when evaluating a player.  Once the diagnosis is made, treatment should surround improving function and minimizing or preventing future complications.Moving distally to the knee, NHL player Connor McDavid had one of the most talked about injuries in recent memory, complete with a documentary detailing his rehab and recovery. PCL injuries are also fairly uncommon when compared to ACL, MCL or meniscus injuries, yet, it is important to learn and understand the surgical vs non-surgical treatment options. Rehabilitation is often the mainstay of treatment for knee injuries, so having a good team of dedicated therapists and allied health practitioners to assist in the recovery is imperative. All trainees should spend time working in an allied health clinic to learn the intricacies and nuance of what rehabilitation entails. Finally, NBA superstar Kevin Durant sustained a calf strain followed by an Achilles tendon rupture suffered in the playoff finals. This case discusses the mechanism of injury and typical symptoms seen with Achilles injuries and other common ankle injures. As part of the rehabilitation plan, all sports medicine providers should be familiar with the Fowler Kennedy Achilles tendon rupture accelerated rehab protocol. MSK and Sports Medicine Resources for Learners:PMR Knowledge NowOrthobulletsRadiopediaMSK Medicine: Western University Physiatry Program Physical ExamsStanford Medicine MSK Physical ExamsBasic MSK Exams MSK Textbooks:Magee Orthopedic Physical AssessmentThe 5 Minutes Sports Medicine Consult
Sport Concussions

Sport Concussions


In this episode we review concussion, a large and nuanced topic. There are 200,000 concussions annually in Canada, making concussion knowledge required for coverage of all sports.To gain an understanding of sport related concussions refer to the consensus statement on concussion in sport (the 5th international conference on concussion in sport held in Berlin, October 2016)It is helpful to think of concussion management in 3 phases: acute, subacute and chronicIn the acute phase, a sideline evaluation must include screening for red flags. Review the CT Head Rules, C-Spine Rules and SCAT5 including what these tools assess, when to use them, and their common limitations. Always remember, when in doubt, sit them out!In the subacute phase, listen to your patient. Ask them about their most bothersome symptoms, track their progress and evaluate their symptom evolution with consistent criteria (ex. vestibular ocular motor screening assessment, neck exam, neurological exam, symptom questionnaires). Encourage early return to movement, emphasizing sub symptom threshold aerobic exercise as a safe and effective treatment for sport related concussions.Education and counselling are paramount for a good prognosis. Provide return to learn and return to play protocols with handouts. For example:1.     SCHOOLFirst: Enabling successful return-to-school for Canadian youth following a concussion3. of concussion patients will have persistent symptoms. It is important to fully understand the patient’s entire medical journey - track the their progression from the initial event to the current assessment. Ensure a multidisciplinary team is involved, if not already (PT/OT/VOR PT/SLP/Neuro-optometry/Psychology). And remember, counselling is essential! Concussion can have a large impact on a patient’s mental health and wellness. Ask about the patient’s social support network. Assess underlying mood or anxiety disorders that may have worsened from baseline since the concussion. If needed, consider pharmacotherapy or refer to a therapist or psychiatrist.Additional Resources:
Exercise is Medicine

Exercise is Medicine


Physical activity can help prevent and manage chronic diseases such as heart disease, depression and diabetes, but it is not a one size fits all measure. We need to tailor the intervention to the patient, as we would a drug. Check out Exercise is Medicine Canada’s prescription pad – a way to provide a personalized prescription to each of your patients and increase compliance.Rob Bertelink, Cardiac Rehab Supervisor at the Toronto Rehabilitation Institute Rumsey Centre and registered Kinesiologist discusses the evidence behind cardiac rehab, at home exercise hacks, how to prescribe HIIT training safely and how to decide which patients need an exercise treadmill test.Whether you review the Canadian Physical Activity Guidelines with your patient or the World Health Organization Guidelines on Physical Activity and Sedentary Behaviour, the key message is any amount of physical activity is better than none and more is better!Remind patients that all physical activity counts, including work, sports, leisure, transport and activities of daily living!To learn more, click on the resources discussed in this episode:1.     Exercise is Medicine Canada Exercise Prescription Tools     Physical Activity Prescription: a modifiable risk factor for the prevention and management of chronic disease     Practical Approaches to Prescribing Physical Activity     Fitness as a Clinical Vital Sign:     Advice on exercise from a Family Physician can help sedentary patient become active     Health e-Univeristy: Cardiac College & Diabetes College (available in multiple languages)
Jennifer Sygo is a dietitian, sports nutritionist, author, and speaker specializing in nutrition for prevention and performance.Jen discusses how to help athletes optimize their diets to maximize their performance. She explains how to personalize dietary advice including how to counsel patients on dietary deficiencies, high risk diets and how to eat for sport performance. She gives a phenomenal overview of relative energy deficiency in sport (RED-S), a highly complex and nuanced topic. Finally, we delve into the various categories of supplements - supplements for deficiencies, supplements for health optimization and performance supplements.For more information, please refer to the following resources discussed in this episode: IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 Update consensus statement: dietary supplements and the high performance athlete of the Academy of Nutrition and Dietetics, Dietitians of Canada and the American College of Sports Medicine: Nutrition and Athletic Performance College of Sports Medicine, Medicine and Science in Sports and Exercise, Position Stand: Exercise and Fluid Replacement College of Sports Medicine Full List of Position Stands Louise Burke – Head of Sports Nutrition, Australian Institute of Sport, Canberra
Low Back Pain

Low Back Pain


Low back pain is one of the most common clinical conditions seen in outpatient clinics by family physicians, physiatrists and allied health practitionersIt affects so many people and can be quite debilitating Dr. Stuart McGill is a world renowned back pain clinician and research, with over 30 years experienceIn this episode he helps teach Dr. Alex McDougall, physiatry resident, how to approach patients with low back pain For more information on Dr. McGill and to learn more about his research and books please visit his website Episode Pearls - -Back pain is complex and never nonspecific - help identify the cause of your patient’s back pain to create and guide a specific treatment plan. -Listen to your patient - each patient comes with their own triggers for their back pain and this can be the key to their recovery -Every patient needs a tailored physical exam to identify their specific pain generators -Understanding and using the psychology of pain is critical for the rehabilitation of back pain-Empower your patients to take control of their pain, teach them how to implement spine hygiene techniques when completing everyday activities -Walking should not be underestimated! It is a very valuable tool for back pain rehab McGill's Big 3 Exercises:1. Bird dog 2. Side bridge 3. McGill curl up Image Courtesy of Vox
Hi! I am Dr. Ali Rendely, a physical medicine and rehabilitation physician at UHN’s Toronto Rehab InstituteI am an MSK physiatrist doing both inpatient and outpatient work and have an outpatient sports medicine practice.Season 2 will sound a little bit different than season 1 as we add more voices including family medicine residents, physiatry residents and sports medicine fellows.Each episode will continue to centre around a specific MSK topic. We will have a round table discussion with myself, a resident and a featured guest.We have a wide range of experts lined up for season 2 including physicians, occupational therapists, physiotherapists, sports dieticians, sports psychologists and more!We hope that this is an informative and useful tool to learn about MSK medicine.It is important to us that you, the listeners, get the most out of this seasons so please let us know what topics you would like covered or if there are any guests you would like to hear from. Tweet us @MSKMatters @alirendely or send us a direct message with your thoughts and suggestions!We look forward to connecting with you!
Dr. Jane Thornton imparts more wisdom for residents and then our incoming Season Two host, physiatrist Dr. Ali Rendely gives us her highlights from each of the preceding episodes.Be sure to keep an eye out for Season Two!
Anterior Knee Pain

Anterior Knee Pain


This week we are joined by Dr. Jane Thornton as we diagnosis a simulated patient with anterior knee pain. Join Dr. Falconi as she tries to find the correct diagnosis. Dr. Thornton is a Clinician Scientist specializing in health innovation, medical education and is an advocate for sport and physical activity in the prevention and treatment of chronic diseases. Jane is a sport and exercise medicine doctor and has started many initiatives to promote physical activity.
This week our guest expert is Dr. Janice Harvey who is a Physician Advisor with The College of Family Physicians of Canada (CFPC) and is also an Assistant Clinical Professor at McMaster University Department of Family Medicine. Dr. Harvey is the Program Developer for MSK Education, a hands-on examination workshop on the shoulder, back, hip, knee and ankle. She offers some great insights and tools to use in shoulder exams with patients. Check out Dr. Carson's MSK videos here:
In this week's episode, our family medicine resident Dr. Falconi assesses a hockey player with groin pain. Our guest expert Brent Smith was an athletic therapist in the NHL for 20 years, including working with the Toronto Maple Leafs for 16 years.Extra Resources:,traditional%2C%20abdominal%20hernia%2C%20it%20is%20a%20different%20injury.
This week's episode deals with ankle sprains but our main message is to make sure to look at the patient as a whole, not just their immediate MSK concern. Dr. Cara Brown, a psychiatrist, is our guest and offers some important mental health tools.  Links mentioned in the episode:APPS:Mindshift appInsight timer appSmiling mind appCheck out these links:Exercise and depression toolkit is medicine Canada for Role Transition                                  Coping with Change / Role Transition                       Negatives/Challenges.                      Positives/Gains----------------------------------------------------------------------------------Old Role                                                       (before)-----------------------------------------------------------------------------------New Role(now)-----------------------------------------------------------------------------------
Welcome to episode 2 of MSK Matters!This episode Dr. Falconi assesses a simulated patient with Achilles tendonitis. Dr. Carson and guest expert Cathy Campbell discuss important topics not to be missed and offer physical exam pearls.Dr. Cathy Campbell served as the team physician for the Canadian Women's Soccer Team for 12 years. This team won the bronze medal at the London 2012 Olympics with a very inspiring performance. Dr. Campbell is the President Elect of the Canadian Academy of Sport and Exercise Medicine.
Welcome to the first episode of MSK Matters! This is a podcast aimed at helping Canadian Family Medicine residents and senior medical students, or those who would typically do an elective with a sport and exercise medicine physician. This episode Dr. Falconi assesses a simulated patient with medial tibial stress syndrome but she has no prior knowledge of the case going into the assessment. Dr. Carson and guest expert Steve Kopas discuss important topics not to be missed and offer physical exam pearls.Here is the link for Dr. Carson's knee and shoulder MSK Exam series on Youtube:
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