Welcome, everyone, to this Member May session. I'm Mona Artani. I am staff here at AAP MNR. I just wanted to briefly go over two slides for housekeeping notes, just to share that the views expressed during the session are those of individual presenters and participants and don't necessarily reflect the positions of AAP MNR. We're committed to maintaining a respectful, inclusive, and safe environment in accordance with our Code of Conduct and anti-harassment policy, which is available on our website. All participants are expected to engage professionally and constructively tonight. This activity will be recorded and it will be made available on our online learning portal. An email will be sent with a link after. For best attendee experience, we usually ask people to mute their microphones, usually when there's a larger number of participants. With a smaller number, I encourage everyone to engage, talk, keep your cameras on so that everybody can see you, and mute and chat with each other. You can also use the raise your hand feature if you have a question, but this is a networking session, so make with it what you will. I'll pass it now over to Dr. Hampel, Chair of this Member Committee. Thank you so much, Mona. My name is Dr. Hampel. I'm a new attending in physiatry, and I started working a little bit over a year ago. I do a little bit of everything, but most of my practice mostly focuses on musculoskeletal sports and then electrodiagnostic medicine. I work at Advocate Christ Hospital in Oak Lawn, and then there's also a children's hospital associated with it, and I'm part of the Department of PM&R. I'm the Chair of this Member Community. This is my second year being Chair. Last year, we were able to get a talk together for managing pain in pediatric sports medicine. I thought it'd be nice to have a networking session because I think there's few of us interested compared to other topics. I think there's fewer of us interested in this topic or this community, and I thought it'd be nice for us to all meet each other and potentially collaborate or get some new ideas and just talk and hang out virtually. As I suspected, it's a small group, but I'm glad I have more people than myself to talk on here. If you're planning to come on here and just listen, I'm sorry if I'm calling you out, being a little bit picking your name. If you don't want me to pick on you, just send me a shoot me a message and say, hey, I just want to listen and I don't want to talk. Hopefully, you're willing to talk because it's a networking session. With my introduction, I would like to maybe Dr. Kathirthambi, if I say it right, Kathirthambi, if you want to introduce yourself next. I'm Rani Kathirthambi. I'm a pediatric physiatrist at Montefiore Medical Center, which is a part of Albert Einstein College of Medicine. Actually, my main interest, I see a lot of patients who are NICU graduates, preemies. I also see a lot of kids with cerebral palsy. I also work in the Department of Pediatrics in the Child Development Division of the Department of Pediatrics. I get to see a lot of kids with autism and speech and language impairment, developmental delay. That is one area of my interest. The others are neuromuscular care, spinal muscular atrophy, muscular dystrophy, myopathies. I'm also part of the neuromuscular clinic. The third area of interest is Fret syndrome. I'm the physiatrist in the Fret syndrome center. Those are actually my areas of interest. Not so much sports medicine because I don't see too many kids with any muscular skeletal sports related injuries. The orthopods see them and they actually send them for therapy. That is one area of my weakness, so to speak, because I don't see too many. That's what I think. Thanks for joining us. We're happy to have you. You said you moved to New York. Sorry, New York. How long have you been practicing for? For a long time. I'm one of the most senior physiatrists. Dr. Molnar was my mentor, who started the subspecialty of pediatric rehabilitation medicine. That's crazy. Wow. She was at Montefiore Albert Einstein College of Medicine. She was the chief resident. Then she stayed as an attendee. Then she became the chief of pediatric rehab. She was my program director and she was my mentor. She's the one who started the subspecialty of pediatric rehab. I had the best teacher to learn. I've been the program director for the fellowship programs. I am now just doing things that interest me, so to speak, because we have other younger attendings in the group. I should be responding, but I like what I'm doing. Actually, my cell phone number is still 718. I'm originally from the East Coast. New York City number. I haven't changed it. I'm now in Chicago. It's a competitive city, I guess, but there's some things that aren't here that New York has. I do miss it sometimes. It's a very small group of people. We know each other and it's very tightly knit group of people who have similar interests. I see Dr. Kravac is on as well. Sorry if I'm putting you on the spot. Feel free to unmute or take your video off if you're comfortable or if you're in a good place. I know you missed my introduction, but basically, this is informal. I'm a new attending, a younger attending that just started working. I do a little bit of everything at the Department of PM&R here in Illinois. I am mostly involved in musculoskeletal medicine. I do some sports medicine as well. Then, I do electrodiagnostic medicine, mostly for adults, but there are some peeds. I'm hoping to grow that at some point. Dr. Kravac, you want to go ahead and unmute and share your story and who you are and where you're from? All right. Thanks for having me. I'll apologize. I do not have too long because I have to get somewhere a little after this. I have a dog barking in the background. If you hear some dog like there, she's excited about the neighbor. I'm Brian Kravac. I am a PM&R physician at the University of Washington. I've been out there for a while. I practice all outpatient sports medicine. I work at the University of Washington, but I also spend time at Seattle Children's. I live in the world of a sports clinic where I basically see about 10 and over, where we manage fractures. We see all the fun things you learn about ACLs, low leg elbow, all that, just pick something, apophysitis, osteochondral defects. We do all the management of that. It's a multidisciplinary clinic, which is really nice because it gets us to coordinate with our orthopedic colleagues and then pediatrician colleagues. I'm not a pediatric trained as much as PM&R trained and sports fellowship trained at Mayo Clinic. Been bouncing around for a while now and provide early part of my career, provided sports coverage, things like high schools and stuff. Now, I get to unfortunately travel the world providing some sports medicine fun stuff there. Definitely have a lot of experience. Not as much as previous speaker in the worlds of Peds, but I'm here for a tiny bit. I know if you wanted to ask us some specific questions. By the way, thank you for the invite. Hopefully, we'll see you next week for our overhead athlete and the swimmer. I live in the swimming world, as you know, but I'd happy to answer any questions because I've spent a couple of decades working in the land of sports medicine and seeing kids since my fellowship. Thank you. Yeah. Well, definitely want to ask you questions on here before you go. Just so you know, he's also giving a talk on the overhead athlete community, member community. Is that in a few days, I think? A few days, right? Next Thursday. Not this Thursday, but the 29th, I think it is. Got it. Got it. Yeah. I encourage you all to show up. Yeah. And you're a Team USA swimming. You provide coverage for Team USA. You're the head team. Yeah. I'm a national team physician. So I've been traveling with them. Actually, apropos to this crew. So I've been traveling with the national team since 2009. And one of the reasons they asked me to go was my first international trip, which by the way, was to Stockholm and Berlin, which was totally awesome, was it was the first time they were letting junior athletes go to World Cup events. So they wanted someone who was familiar with adolescent medicine, the likes of, for those, you know, swimming people like Missy Franklin, Lilly King. Some of these kids, these were the earlier people now who are some of the top stars. And they wanted someone who could take care of these adolescents individuals. So I was the one and I was given a small medical staff to take care of because I was comfortable with the adolescent athletes. That was a big, big sell. And I've managed to, I kind of covered everything there is, practically everything in swimming, but also made it to like the first ever junior open water championship. And then they had a junior pen pack. So there was a lot of opportunity as you build your resume and get comfortable covering different events, especially from that adolescent standpoint, you know, you could leverage that skill well. And they liked the nice balance because you have to learn basic family med, like primary care kind of things to deal with and how to deal with the acute, but they also liked the musculoskeletal aspect of it, that kind of, that we're not just a surgeon to take care of people, but that we can kind of quickly work through the musculoskeletal stuff. So that's, I think one of the assets I would encourage all of you to kind of build on as you go, as you move forward and to learn a little bit about that primary stuff, especially if you're board certified, right? Like just simple things, colds, you know, GI stuff, skin, basic skin stuff. And then when something goes wrong, you know, our asset as PM&R people are to leverage how we manage team, which is something you've learned how to do throughout your residency career. And, and you're going to have to manage a team and how to manage the nuances. If someone is stressed out, right, this is right. Where's my going to happen? Well, this is called the team meeting in our world, right? When you're, you're trying to discharge someone. So there's a lot of corollaries that you can build on as you move forward. And, and if you think of it that way, it's not as scary as when you start, but so, you know, this is a good example of where, where that, our skillset came in nicely. Okay, nice. Thanks for the introduction. We might circle back to you because you have a lot to offer here, especially for this group, since I I'm not sure I have a very, I'm just beginning. So I'm a young attending, so not much experience. And so, and then I think we have some learners on here. Is this, I don't know what your title is, Jill Milan. Yeah. Hi. Hi. Yeah. So, so I just kind of flew in here. So I am on the very far ancient spectrum. So my pediatric rehab medicine board certificate is number 32. So I've been in practice a long time. And I was double boarded in practice, peds and adults until toward the end of my career, I am retired, but I'm still involved in research. And I'm involved in the Paralympics in the snow sports. So, and I live in northern Wisconsin. So that's kind of my thing. Yeah, I've kind of seen everything develop from the beginning. So I did my PM&R training at the University of Minnesota, and then peds at Gillette. And then I've been in private practice, basically, a group practice with orthopedic surgeons and, and then more lately with neurology, doing pede stuff. So, so I can talk a little bit about I'm being a medical provider for events. And then I'm also a classifier for, for snow sports. So, but, but how I got into it was not smooth. I stumbled around and totally sort of like stumbled into things that I'm happy with. So I don't know if I have any, any good stuff. But I'm, I'm always interested in, in learning more too, and being involved with other people who are interested in the same things I'm interested in. Thank you. Yeah, we might want to ask you more about how you stumbled into your current, your roles. After we introduce, I want to introduce one more person. Student Dr. Tomi Oke, is that how you say it? You want to introduce yourself? Yeah, that was actually perfect to be fair. So, yeah. So, hi, everyone. I am Tomi. That's my name. I'm a first year heading to my second year. I'm a med student over at Howard University over in Washington, D.C. Very interested in physiatry, physical rehab. So I'm involved with our PM&R interest group, and I'm currently serving on the board for that. And I'm hopefully trying to apply to the local DMV physiatry eboard for the whole DMV, coordinating with other students interested in physiatry, like at Georgetown, and other medical schools around there too. And I'm just really interested to hear from everyone. I think for myself, like, I'm very committed right now that I want to go down towards PM&R. I know things change over the course of four years for many students, but I think for myself, this is where I feel like I'm really being led to. And it's kind of also how I envision just practicing medicine in the first place, just being so involved with like that restoration aspect. And that's something that I really want to personally pursue as I go down my journey in medicine. Awesome. Yeah, it is the best specialty. I'm biased, but welcome. We're excited to have you. And as you discover which way your path is going to go, it's good that you're exploring as well and have a lot of people talk to. So with that, I think that's everybody on here. I wanted to maybe ask whoever wanted to talk about how you got interested in pediatric sports medicine. Was that something you kind of came to or you were directed yourself there or did it kind of come onto your lap? And then you're like, oh, this is kind of nice and stick with it. Or you didn't like it, but you're stuck with it. So how did you guys get into pediatric sports medicine for those of you who practice it? And for those of you who don't practice it, what makes you interested in it? I'm happy to start us off since I don't have much time with that. So I did my residency at Tufts and did our pediatric rotation there. And actually, that was more traditional pediatric rotation. The musculoskeletal related things was around spasticity and stuff like that. But when I wound up going and doing my fellowship at Mayo Clinic, that's where I started really kind of deep diving into seeing those adolescents and those tweens coming to our clinic because that was just part of the sports fellowship and you provide care for that. So then when I eventually got recruited and took a job at Johns Hopkins, just really just jumpstart the PMR outpatient musculoskeletal, I had that experience. And I joined basically into an orthopedic practice and they were like, can you see these adolescents kids coming in? And I'm like, sure, no problem. And a lot of it was patellofemoral and a lot of the functional things we see. And they loved it because they were like, we need to offload this non-operative stuff to somebody. So I had this wonderful opportunity. And at the time, Dr. Barbara De La Tour, who's one of the legends, had just started the program. If you don't know that name, go look her up as well. She was the first ever female chair at Hopkins, I believe, when they hired her, which is kind of crazy because this was in the nineties. But she was a wonderful mentor to allow me to develop this. And she was like, hey, what do you need to do? What do you want to do? I'll set this up. So I had this great mentorship career and just ran forward into this of like, I'm going to see sports med. I set up my fellowship and I'm going to develop it through there. Eventually moved out to the University of Washington. And in the process of moving to the University of Washington, they were just starting to develop their pediatric sports medicine program in a more robust way. So they basically came to, I saw the opportunity to bring in PM&R and I hadn't seen as much fracture care at that standpoint. That wasn't something I'd managed. So that was one of the things I had to learn, but was very well coordinated because a lot of the pediatricians also didn't have that expertise as well. So we kind of grew together with that. And then that led me into basically where I am now with that. And a quick side note, Jill, do you know Kyle Nagel? Yes. All right. I work with Kyle Nagel. So when you, so I will, I will definitely. Dr. Nagel is a pediatrician who classifies in para sports and helps cover the winner team. So just a quick connection there. I'm sure he's going to be excited to hear that. I actually saw you there. So, so basically that's how I got into it. To me, it's fun, right? This is the group I see, whether, you know, their, their kids, they, in my population, they don't have a lot of complexity to them, which is nice. They're there for a specific thing. And then, you know, the goal is to try and, you know, continually to keep them active and exercising and work through their injuries and get back to what's important in their life. If we go all back to when we were teenagers and the role of sports. And so I spent a lot of time just kind of working on that. And, and to me, it's just super rewarding. It's one of the most fun clinics. We have our fellows come through it or sports fellows come true or residents come through. And we just have a lot of time. And I like to play music in the background. So you can always figure out where I'm sitting in the clinic. Cause there's something playing. You just got to figure out what my mood is that day. All right. Well, I'll stop there. Your ears lead you, right? Exactly. Thanks for that. It's interesting. Cause you said you did it kind of all started with a fellowship. Right. And it sounds like that's the more typical pathway for most people. But then Dr. Milan, obviously there wasn't a fellowship maybe around the time when, so it'd be interesting to hear what you, how you kind of got into it as well. So I I was always interested in sports medicine. I'm was an athlete myself way back at the beginning. I did played sports at the university of Minnesota two years before title nine and two years after. So that's, I could talk for hours on that transition. But so when I went to medical school, I was very interested in sports medicine. I was thinking the like orthopedic pathway, but during my medical school rotations, I did one summer after my first year with a family practice doctor. And we saw a runner who had shin splints or something like that. I don't remember. And she advised him to just quit running. And I was like, what? So, so I talked about him, how to, you know, modify and do all sorts of things, not stop running. And she's like, well, you should be a physiatrist. And that was the first time I had heard that term. So then the second year I did a rotation with neurology and you know, they were people with strokes and they were like, okay, you can go home now. Take this anticoagulant. And I'm like, they can't walk, they can't dress. How are they supposed to go home? And they're like, you should go into physiatry. So that was the second time I'd heard that I started looking into it. So that was kind of my introduction. And then my senior year in medical school, I was the president of the sports medicine club and we hosted a mini triathlon that was a fundraiser for a facility for kids with disabilities. And it was a beautiful day that we did the triathlon and we knew it was gonna be a beautiful day. So the people from this facility said, could we bring some of the kids out to watch this triathlon? And I was like, yeah, sure, that's great. And, still chokes me up, but somehow when it got to the run part, somebody just grabbed one of those kids in their wheelchairs and started pushing them for the run. And other people saw that and pretty soon all the kids were out on the course getting pushed with the wheelchairs. And they loved it, you know, they just absolutely loved it. And so they, so then when I went to present the check, I, instead of just mailing it, I went and I toured the facility and it was fantastic. They had Olympic pool, they, you know, got the kids involved in sports and I was like, okay, I wanna be a pediatric physiatrist because this seems to have everything. So I switched out of looking at orthopedics and doing that. So that was kind of my, I mean, again, total serendipity people were, you know, I was kind of doing what I thought and people were telling me, you know, giving me some guidance as to where to go. I would agree with Brian on Mayo's program. I did a rotation there as well and got really involved in sports. They were doing wrestlers and research on body fat percentages and guidelines for hydration and things like that for wrestlers. And that was kind of got me involved. And I've had friends that have gone through the sports medicine fellowship there. And they also have really good activities for kids with impairments and things like that. And I can't believe I'm blanking on his name, but there's one of the physiatrists there that's like really, really big on adapted sports. Anyway, so that's a really good program that also increased my interest. And then when I got out, I joined an orthopedic group and we were team physicians. It was in Des Moines and we were team physicians for Drake, which is a division one school. I probably wouldn't have been able to do that on my own, but being with the orthopedic group, you know, that did that. And then the AAA team for the Chicago Cubs is in Des Moines. So, you know, we had that. And then Warner, Kurt Warner, and the beginnings of the arena league football, he played in Des Moines and I got to do his initial physical for that kind of stuff. So I knew him before he was famous. Anyway, just those kinds of things are like, they just happen. And I guess, you know, if you're interested in stuff and you volunteer and you kind of go down that path, hopefully things happen for you. And that same with the pair of snow sports. I was volunteering at a World Cup event, you know, and someone went, oh, you're a physiatrist. Have you ever thought about being a classifier? And I'm like, no, what do classifiers do? You know, I just totally ignorant. And just kind of, they led me down the path and got me involved in that, which has been just, you know, another really wonderful experience. So I can't say I had a plan. It's, you know, kind of serendipity, but, you know, maybe follow your heart. And if you're interested and get involved in things that you're interested in, you end up in the right place. Thank you. And maybe Dr. Kathariya Thambi, maybe you can talk about how more experience in the sports medicine aspect of things might help your practice more, since you said you were interested, but it was your weakness. Although you have so many strengths, so it's hard to believe your weakness, but anyway, carry on. No, that sports medicine is an area that I'm not very familiar with. We have a sports medicine fellowship and then the orthopods take care of the adolescents and the children with the sports injuries. So I really have not had much experience. So I thought I really should learn because that's an area that I have, I'm not very familiar with. So I just want to acquire some knowledge because I have been doing all the preemies and children with developmental delays and neuromuscular diseases. I thought this is an area that I should at least get familiar with. So that's my interest. Sorry, I had to stop quickly. All right, thank you for sharing that. Would you, if you were able to do more training in pediatrics, orthopedic issues, like in more sports medicine, would you, how would you incorporate that more in your practice? If you were going to do it all, do more? I, at the moment, I'm not sure because I really don't get too many patients referred to us, to Peds Rehab group. So it's usually the orthopedics takes care of them, but I think I really should get some more experience before I can decide how I want to incorporate that, yeah. Okay, thanks for sharing. I feel that I really don't have enough exposure, so. Thanks for sharing. I'll just, I guess, speak about myself since I'm kind of, I've been always interested in sports. I was an athlete too and always liked to help others. Actually, one of my trainers was a PhD exercise physiologist and I devoured every single book. And I was like, man, there's actually a science behind all of this. And so that's kind of what led me down this whole pathway and interest. And then when it came time to deciding my specialty, it was physical medicine rehab was awesome because I was like, well, I want to be an expert in the neuro and musculoskeletal system too, but I did like primary care issues as well. So I did take a lot of interest in my family medicine rotations, internal medicine rotations, and actually did apply to those specialties as well. Ended up going to PM&R and I've been here ever since, obviously. And so when I started working, I did not do, so I went straight out of residency and then I had a job and there were not many doctors doing MSK at the hospital. And so I was like, hey, I can help. And so I kind of started working, started small and then I've been doing okay. And so more people are referring to me and I've been able to help people with their musculoskeletal issues. But it's a challenge because in pediatric sports medicine world, most of those referrals go to ortho, especially for them. And so I don't get necessarily those referrals. However, I am very involved in this sports medicine world. So I volunteer a lot of events, sideline coverage, and I also run a nonprofit for children in youth sports. And so whenever somebody gets injured there, I let them know like, hey, I can help if you need me too. And so I've actually helped take care of some of these athletes. And a few complex MSK situations have been referred to me by other doctors, more like late teens. And so those have been interesting cases. But I'm still new to this whole thing. I'm still developing my interest and figuring out my pathway. But so that's why I'm on here as well. I'm here to learn from all of you, whoever, whatever we can get out of this short time that we have together. So, yeah. And so I guess that goes to my next question is, do you guys have any cool cases to share? And I know Dr. Kravac might have to go, but maybe I'll pick on you if you have time to share any cool case that you had recently that you would like to put on here. Sure, yeah. I gotta drop off in a couple of minutes. A cool case, well, there's lots of cool cases that wind up coming through in regards to that. One of them's a cool case. Actually, it's kind of a cool case. It's, we'll say it's sort of pediatric adolescent related because it did pertain to someone who was a college athlete but wasn't technically over 20 itself. But one of the things we learn about in PM&R, right, is concussion management, which I see a little bit of as well. But there's a great case we had where I was at actually a world event and somebody, one of our athletes dove in the pool and somebody who, when you're diving in the pool, sometimes there's a start lane. So it's a lane where you're supposed to only go one way. And somebody who had an experience didn't realize that and jumped in the lane while our athlete was moving into the area. And the person wound up hitting their head and having symptoms of a concussion. And at the time, they had basically about two days to get better because they were about to compete in their event. And the guidelines back then were pretty much like, you sit out, it's gonna take you a week to kind of get back, right? They were very specific. But really through a coordinated care program and assessment, we, in essence, sort of did an accelerated opportunity to take care of this athlete through the use of a massage therapist, physical therapist, and very creative ways of isolating out that athlete due to symptoms, but allowing them to return and be active throughout, which now, when you read about Leti and the sub-threshold type of exercising, right? Back then, that wasn't really necessarily something you would have done with that. And by keeping this athlete appropriately regulated and coordinated, we were actually able to accelerate this person through their symptoms. And they wound up getting a silver medal, where if you'd actually been very strict with the guidelines and didn't know what you were doing and managing teams, you would have just said, you're done, get out of here. Sorry, you're racing in 48 hours. So that's the one that quickly comes in because it's somewhat simple in some sense, but it's very complex because you have to take your understanding of team and physiatry and the athlete's needs and being comfortable caring with someone and knowing I wasn't sending them back to go play football, but to actually get them back in a graduated, safe way. And that person obtained their goal, right? Which was, I think, what we all kind of live for in the end. So I'll leave you with that. And I'm gonna do one last shameless plug. It's about one of the, a co-author and I, Alison Brooks, just recently published what is called The Youth Athlete. It's a, oh my God, I think it's like a 1,000-page textbook. Oh, really? That you can find, yeah. And it's very specific on the youth athlete. And so if you're looking to learn more and things that are specific for the athlete, I would encourage everyone to have it. It's a great fellow book. And it goes through everything from physiology to common musculoskeletal, primary care things, and then very sport-specific contributions in regards to managing diagnosis and return to play. And it's some of the top people in the country who take, many of which are a PM&R, by the way, who help take care of youth athletes. So if you, yeah, so if you just Google my name in the youth athlete text, you'll see it come up there. I found it. Awesome. Thanks for that recommendation. Yeah, if you wanted to share with that. I appreciate it. I will. I'll share it down with them. Yeah, and thank you for inviting me. Good luck. I'm sorry I couldn't say the whole thing here, but if anyone has any questions, please feel free to reach out. Yeah, thank you so much. We'll see you hopefully at your talk. Okay, take care. Bye. All right, take care. So does anyone else want to share any cool cases or cases that they got that they thought were cool, but obviously had to refer out or, or read about any cool cases and want to share? Well, I'm like trying to figure out what would be a case. Okay, there's so many, there's so many. There's so many different ways you could go. Yeah, I have lots of good stories. Yeah, I'll take a story. So I was thinking like more, relatively more recently. So when I was volunteering as a youth athlete, at a Nordic World Cup that was in Northern Wisconsin, I was, so prior to that, you know, I was doing adult and peds medicine. And so most of like amputees and stuff I saw were like diabetic adults. And you're basically, if you get them a prosthetic limb, they're maybe walking with a walker or something like that. And I knew that kids when they get a prosthetic device often are much quicker to learn. But most of the, where I practice, most of the kids were actually sent to Shriners in Minneapolis. So I didn't actually get to see them. But my story is that I was medical support at this event. And I was sitting in like a sunken living room, reading the actual physical newspaper, because that's what you did back then, and drinking a cup of coffee. And I look up and on the probably about eye level above the sunken living room, I saw high heels, high heels, prosthetic carbon legs above the knee, mini skirt, keep going up, and a woman with off the shoulder top, no assistive device, and drinking a cup of coffee. And it was my first meeting of Oksana Masters. You can look her up. She's won probably more Paralympic gold medals than anybody ever. And she was a Chernobyl baby. So she was born with bilateral limb amputations and problems with her fingers. And she was adopted from Ukraine to the US by a mom who said, you know, if you like sports, sure, we'll do sports. And never let her think that she was, you know, in any way unable to participate in things. And so she's a fantastic athlete. And I do use her example because when you talk with parents of kids with disabilities or impairments, they usually don't want the kids to participate in anything, even sometimes school, because they're like, oh, the kids will make fun of them. This will be embarrassing. They can't do anything. And, you know, showing examples, that's one of the things I think the Paralympics is great for, is showing people examples of ordinary people that have learned to be extraordinary and athletic, you know, and just because you have a disability doesn't mean you can't participate in sports. So not really a cool case per se, but. That's lovely. Thanks for sharing. Yeah. So I guess I'll do a traditional cool case, I guess, if there's a such thing. So, and I don't have many, so I will, it's not like I have a whole lot to choose from yet as a young physiatrist, but I have a, I had a kid sprain their ankle doing sports. And so they come into clinic and I see them and it's the mechanism. You always want to know the mechanism because the mechanism is, really gives you, I would say 70% of the diagnosis. And so if you see it, that's the whole point of sideline coverage. You see it and you can figure it out if you see it. But if you don't see it, then you kind of try to get the information from the athlete or the parent or whoever saw it, the coach. And so this, it was a very, very simple mechanism and the patient had no other medical history that would explain anything that I will tell you shortly what they complained about. But it was just like a simple ankle sprain should be something simple that they could rehab from within weeks, you know, doing PT. And, but the patient was unable to bear weight and was pain, he had, when I did my physical exam had pain higher up. And so then you're like, okay, if they have tenderness higher up, if there's a squeeze test you can do for potential for high ankle sprains. So, but the patient, he was hurting everywhere. And so I was like, okay. So then I'm like, I guess I have to get an x-ray, right? Cause he made the criteria for getting an x-ray and not just the x-ray of the ankle and foot, but of the, to look for anything more proximal. And so of course I get all this, you know, imaging on this kid, but it didn't make sense with the mechanism. Well, long story short, everything came back negative. I also ultrasounded him. You could see the ligament sprain on the ultrasound, some swelling there laterally, common ATFL, and then sent him to rehab, physical therapy to work on strengthening and all the good stuff that comes with ankle sprain. And he did PT, but then the therapist reached out to me and she was like, you know, he's not improving. And we were like, what? Why? And so then she said he's having, he has multiple joint pain that's kind of migrating and it's never, not really, it's kind of been there before, but it's more, it has worsened now after this ankle sprain and it's now sometimes the other ankle and it's just not making sense. And so of course I call him back into my office and I'm like, I mean, I'm trying to figure it out cause he's a little bit overweight. And so I'm thinking, okay, is it, and initially because he has no elevator in school, he was hopping up like two flights of stairs with one ankle. I'm thinking, okay, is it possible it's cause he's now using the other side of his body that now he's getting aches and pains somewhere else. And so, but long story short, it all came down to this syndrome called Amplified Musculoskeletal Syndrome, AMPS, which was an interesting diagnosis because before that it wasn't nothing that we would have noticed as doctors. I didn't, nothing kind of came up in conversation that would have made me think that he would have had this kind of syndrome after having an ankle, a simple ankle sprain. So that's my cold case. And that's a more interdisciplinary approach, including it's like a pediatric version of fibromyalgia. His was more localized to the legs. So that was an interesting case I had. I don't know if you have anything to share on that. Oh, I've seen, I've seen. Oh, you're muted. Dr. Milan, you're muted. There we go. Okay, so yeah, so I've seen quite a few and right when you started, I knew where you're gonna go with that because you can start getting a feel for that. And it's not as rare as you think and getting involved, getting them, you know, desensitization and movement of the joint, you know, above and below or whatever, it earlier is better. My question is sometimes I'll go back and look and often the kids that develop this will have issues in the past with like a lot of GI issues, tummy aches or coming into the doctor for, you know, school excuses. You know, that's not a hundred percent but it's probably pretty high if you go back. You know, I had the privilege of working in the multidisciplinary clinic where you can see all the records, all the family practice visits and the pediatrician visits and all those kinds of things. And so you'll go back and especially if they have that kind of history, I get suspicious of that very early, especially if, you know, your workup is negative. I don't neglect the workup because that's important in getting the parents on board to following through, but it allows me to go, okay, this is someone who every little thing is magnified. They just have a history of that. So that can be something if you have access to those records. Since you have seen probably more of these than I have, what have you, have you seen them get better? And I would say, I know we talked about the interdisciplinary approach, having psychology attack it and therapy attack it from their standpoint and then being involved in the parents as well and educating the child. But what have you seen as a, is there anything that could be more focused on than is in the books with success? I mean, the books are really pretty good compared to when I first started. But the key thing I think is to make a lot of contact. So I will see those kids frequently, like weekly. Oh, weekly? Yes, very frequent. Because part of it is they're just so anxious that people are missing something or, you know, and so if you see them regularly, you can address any concerns as they crop up. And you can also set a timeline. So I'll be like, oh, yeah, I've seen this before. This is how this is gonna go, you know? This is typically how this works. And then you also have to have really close contact with the therapist. It's great you had a therapist that called you and you can't force them to do anything. So you have to have them do it. So if you're gonna do range of motion, it has to be active range of motion or at the most active assisted. And then a lot of desensitization stuff with I do hot, cold baths or, you know, any of those kinds of things. But it's got, the kids gotta do it and they've gotta get the confidence that they can do it. So those are kind of the, I mean, a good workup, like it sounds like you did. Reassurance to the kid and the parents. Oh yeah, I know, I've seen this, I've heard this. Here's how this works. And then talking to the therapist and frequent follow-up. And I've, I mean, if you catch them early like you did, especially in kids, it's like 99% recovery on those. Okay. Really nice. That's good. That's awesome. That's reassuring. And then I had another case, I guess I'll share another one that again, these are ongoing. So I don't have a solution yet, but I actually had a couple of young adolescents, maybe I would say not young, they're in their 16, 17 year old range. So just, I guess, below the threshold of peds come in for persistent thigh or calf or buttock pain that started, one of them started after a trauma but didn't go away for two years. And the other one kind of just came on during her sports, but no like inciting incident. And then she had to stop the sport because of it. And then I would say those are the two main ones. And so workup was completely negative. Nobody knew what to do. Then they send them to me. So then I'm like, okay. And so I'm looking through everything. And of course the first thing I do when I'm thinking about this is okay, sometimes pain can be referred, right? So I checked the joint above and the joint below. Pain could be coming or problems could be coming from the back. So I look into the back. So back is always a big area of examination. I look at the joint above, the joint below. And so then I do our whole like thorough exam, right? And then make sure we've gotten all the imaging done. And then what's happening, what's often happening is it all comes out negative and it's not really a clear diagnosis. And so then I'm like, okay, I don't really know what this is. And I'm honest. I'm like, listen, we looked into everything and I really am not totally sure what this is, but we're gonna work together and try to figure this out. And if I have to refer you out, we'll refer you out kind of thing. And I'm still learning about who my referrals are, who I can trust, who can do a good job, who we can like, you know, what their areas of expertise are. But as I navigate that, I try to help the patient out. So I've often found something simple, like, and I know that a lot of therapists are doing this. So something simple, like even dry needling has been very helpful for these kind of cases. What's interesting is insurance has been giving us a little bit of a hard time covering dry needling recently. So then I have to either bill it as trigger point injections and then even then I have to put it over the verbiage in my note, in my physical exam, specifically what they want for a trigger point just to get it covered. And even then some insurances won't cover it. So it's kind of crazy how that's where we've gone. But anyway, I've noticed, I've gotten some great results from dry needling. And I guess I ultimately call it trigger points in myofascial pain syndrome. But yeah, have you guys seen cases like that or heard of that or read about anything like that? And any tips there? Sure, I'll weigh in. Okay. I mean, there's a lot of things going on there. So everyone wants a diagnosis, but I don't care what area of medicine you practice, there are times when you aren't going to have a diagnosis where medical doctors were not like omniscient, whatever. I tell parents, this is probably an old thing too. Has anyone ever seen Star Trek, the TV series? I have. So Star Trek, they had tricorders. Dr. McCoy had a tricorder and he would run it down the person go, dee, dee, dee, dee, dee, dee, dee, dee, and it would tell him what was wrong. So I'd say to parents, I'd love to have one of those, but we don't have one. And so what we do is we do our best to work up anything big and bad. So I'm like, I reassure them, okay, you don't have a tumor in your back. You don't have some sort of odd arthritis that's affecting all your joints. I say, okay, all these bad things. And then I will ask them, is there something that you're worried about? And sometimes they'll be like, well, grandpa died of some weird thing. And if I can't with the testing I've done rule that out, I will actually do testing to rule out whatever the thing is that they're afraid of. So I'll make sure that they're convinced that, okay, I got something wrong. It hurts. I can't do these things, but it's not something that's gonna kill me or put me in a wheelchair. It's amazing the fears people come up with, even if they're like really smart in something non-medical, they'll still be afraid of medical things. So that's the first step. And then the second thing is while you're doing some of the therapy and stuff is do what we used to call relative rest. So maybe not participate in the sport, but start doing simple things and progress. So walking, jogging, swimming, biking, whatever they can do, start small. And I always tell them crazy small, like you used to run five miles, well now walk 200 meters or something like that. And then something that you know you can do without triggering whatever the pain is, and then just gradually build on that. And you can learn things from that too. So if they go, well, I've worked up, I'm now running, but once I hit three miles, I can't run any farther. It just, it's getting me and it's here. That can give you some information like compartment syndrome or whatever, but start having them do something, not just the physical therapy. So you're probably doing all that, but that's all I got. No, and I think you brought up like the anxiety component of it. It's kind of a big, big, big dog there, targeting that as well on this, as you speak to the patient and the family as probably very, probably like maybe 40% important, maybe even more, right? Right, well, and it's crazy because the better the athlete is, often the more anxiety they have, the performance anxiety and they're- They have more to lose. Yeah, exactly, exactly. So that anxiety gets, if they're like my body that's always been so great is doing this thing and no one knows what it is, that just really- It's crushing, right? Yeah, I mean, look at like Michael Phelps and all those people. They've all had that kind of anxiety that then goes, progresses into depression because they're used to performing at such a high level and if their body's not there, even on something that's not life-threatening, the anxiety just really kicks in. Yes, very good. That's awesome. Do you have any other- Anyone else have any cases or you have any cases you wanna share? All right, then I have another question. So where do you think we're heading as physiatrists providing care for the pediatric sports medicine population? And I think Dr. Kathirathambi brought up that she doesn't cement much of that because ortho kind of just takes care of it. So do you think that's where we're heading in the future where if we're not interested or really gung-ho about it and really establish ourselves in that field or do a fellowship in sports medicine, do you think that this is where our future is going in terms of musculoskeletal pediatric issues from, I guess, an orthopedic standpoint? Well, I'm doing all the talking here, but. So, I mean, I did partner, my first 16 years of my career was in an orthopedic practice that had two pediatric orthopedic surgeons and did sports medicine for local staff. So I think the referrers, whether it's physical therapy or primary care, think orthopedics first. Yeah. Yeah. But I know orthopedics, at least most of the ones I've worked with, they wanna do surgery. So I think like Dr. Karabach said earlier, it's nice to partner with them and let them know that you can do the non-operative stuff or the stuff they don't like, like the cases you presented. Orthopedics I know would be like, they're like, no, don't make me see them. Yeah, right. So, you know, if you communicate and a willingness to do those things and say, well, I can take a lot of these that you think are not ones that you're interested in and just, you know, I was always in the office, so it was easy to walk over and talk to each other. But if you're not in the same office, you know, having some kind of communication that, you know, I'm interested in doing that, I think you'd get the referrals because unless orthopedic surgeons have changed a lot in the last five years, I think they're definitely willing to not see a lot of the non-surgical patients. I guess for Tomi and, you know, if, you know, he's obviously deciding what he wants to do, right? You're deciding which way you're gonna go. If he wanted to, it depends on what program he gets it to and whether he gets into PM&R, right? But let's say he gets into PM&R, but he's at a program where you don't get a lot of pediatric sports medicine or pediatric MSK issues. What would you recommend to a trainee to help kind of get that experience and if that's the direction they wanna go? And I can chip in too. Yeah. Yeah, carry on. I think one thing that's at least been really beneficial for me is just volunteering. So I think fortunately for me, I've been like really blessed to be in a place where, like being in DC, there's a lot of like different, diverse and different opportunities to actually be active with volunteering locally. So there's one group called Keen that I and some of my classmates, also interested in physiology, were volunteering at. Just working with students and other young kids with different musculoskeletal diseases and problems and just spending like the day with them, usually on the weekends, just with activities and other things like that. And I think it was really a great opportunity just to like kind of get that, because we're not necessarily treating them, obviously we're not licensed physicians, but just at least getting that exposure and seeing what it really is to like walk in their shoes and spend some close intimate time around them. So I think just seeking out volunteer opportunities is a great way to at least get that first introduction if there's not that much exposure at your clinic or wherever you're practicing. Oh, I agree, that was great, thanks. Yeah, that's what I was gonna say is the most number one thing. The other thing is if you have any elective rotations, do those with some sports medicine physicians. So I was at the University of Minnesota, so I did one rotation with the team physician for the Vikings and one rotation with the team physician for the Minnesota Twins. And then I actually went to Arizona and did a rotation with the Phoenix Suns. So, you know, doing, you can do that kind of thing too, depending on what kind of sports or level you're interested in. And what about for someone like Dr. Karthirathambi who isn't attending, but wants to get more exposure? Besides volunteering, is there any other recommendations other than attending conferences and maybe courses, volunteering, networking, and then obviously getting the word out once you get comfortable, you know, taking care of those kinds of cases? Any other tips there? Those are the ones I can think of. Yeah, I did. I took the American College of Sports Medicine team physicians course. That's a really good course. It's a really good course. Yeah, it was 20 years ago, probably still is, or 30 years ago, and it still is. And then being a member of some societies that you can, you know, go to. So that gives you some credentials, like if you're trying to work with orthopedics or volunteer that you know something about the different sports medicine issues. Yeah, and I think the main two are the AMSSM and the ACSM are the top two here, but there's also other avenues as well. But I think those are the main two that at least I know of. So getting involved there. And anything else? Any other, I think we have about seven minutes left. Any final thoughts or anything else anyone wanted to talk about? Just had a quick question. I guess with a lot of the talk, like especially with like the cases and like dealing with like the different injuries that you're exposed to. Cause I guess you go over some of like, I guess when dealing with patients with like chronic or like lifelong injuries and managing their care as they transition, I guess, from childhood to like adolescence, et cetera. Yeah, so I think the important part is as having that follow-up is important. So as they're transitioning a stage, an age stage, I guess having that follow-up is very important. And I know pediatricians don't necessarily stick with a patient after 18 to 22 range. And then pediatric physiatrist, I think it's dependent on the doctor. Correct me if I'm wrong. And so making that transition, being there for them during those transitions, I think is very helpful and not having a hard line of when you're gonna cut off care and refer them to somebody else maybe, especially if they're going through a tough time. Otherwise we're going through a rehabbing something like, but like you said, if it's a chronic issue, when do you do that transition of care? I don't know. That's a good question. I have patients who are, some patients who are 26, 27 years old and I still keep them because especially the kids with neuromuscular diseases and kids with muscular dystrophies and cerebral palsy. And we have, I've been seeing them from the time they were in the NICU and they usually the parents, they don't want to transition to adult rehab. So I sometimes keep them for a little longer, but, and they can continue to come back. So even when they are seeing an adult physician, they will call and say, could you please do this? Could you please, can I please come and see you just one time? So we end up saying, okay. So I have some patients who are 26 years old CP and I have a 27 year old muscular dysplasia patient. So we continue to see them. Yeah, there's no cutoff sometime. It's impossible. It's not easy to cut the cord. Yeah. Yeah, I never cut the cord. Wow. It's hard. Yeah, so. You grew up with them kind of, right? They grew up with you. Right, and so my practice the last 18 years was with, I was in with adults, PM&R, but they did not want to see adults with child onset disorders. So I just kept them because there really wasn't anywhere to go. So the pediatricians would move them on to internal medicine or med PEDS and ortho would move them on and neurology would move them on, but I was like constant. And then the hospital, they couldn't be on the PEDS floor anymore. They would go to the adult, but I'll tell you, I think pediatric training and knowledge about this is really helpful for the adult patients. So for example, I had one, he was in his forties and I hadn't seen him. I'd seen him like early in his twenties, but he had a hemipredic cerebral palsy. He had a girlfriend, he worked, he had all these things going on and he started having some hip problems. So he saw orthopedic surgeon and they looked and he had some arthritis. So they decided they would do a hip replacement. And so he came in to see me like two days before his hip replacement. And he was in a wheelchair because he couldn't walk. He'd lost function in the other leg. He'd lost function in his arms and he'd seen the orthopedic surgeon like just before me and then come down to see me. And I'm like, okay, this is not from your cerebral palsy and this is not from your hip arthritis. So I sent him emergently to get a cervical spinal X-ray and MRI. And he had a disc that was almost completely occluding his spinal space. And he underwent emergency surgery that night. So I think it was left up to the adult physicians. I'm disparaging them now. They may have just gone, oh, well, he's in a wheelchair because he has cerebral palsy. Not realizing that until the week before he was ambulatory and working for a furniture moving company. Yeah. So we have, unfortunately, this was such a fun meeting. I was afraid I was gonna be the only one on here talking to myself. So glad you guys joined us. We have to end and conclude. So Mona has jumped back on here. I just wanted to let you know that how, would you guys be interested in having a, I won't be able to make the annual meeting this year, but I could facilitate a meet and greet during the annual meeting if I have enough interest in doing so. What do you guys think? I don't have, my facility doesn't have money for sending us to meetings this year, so I won't be there either. Okay, well, maybe I'll put it together. Maybe I'll gauge interest online. But yeah, thank you guys so much for coming. And Mona, I'll pass it to you. Yeah, of course. So one thing I wanted to just mention also is that even if you're not able to make it in person in Salt Lake City, you can still do one of these again. Where you get together virtually. Yeah, it doesn't have to be in Member May. It could be outside of Member May. I'll forward you the link to it, Dr. Hemphill, and you can definitely request time, get together for an hour. And it doesn't have to be recorded. It can just be a casual conversation. It can be about anything really. It's available to get the communities together to talk about things that interest them. Yeah, I think that'd be great. I think I'm interested in getting that done. I think this is very helpful. And I think more people will grow, so. For sure. I'll pass it on to you. Yep. All right, thank you everybody. It was great talking. And nice meeting all of you. And thanks for sharing your experiences and your interests. And maybe I'll see you at the next one. Good night. Good night. Take care. Bye.

pediatric sports medicine

networking

collaboration

musculoskeletal sports

electrodiagnostic medicine

interdisciplinary collaboration

concussion management

pediatric to adult care transition

psychological health

physiatrists