Hi, everyone. As you're coming in, I'm just going to go over some brief housekeeping notes. We are all super excited to have you here for this Member of May session on running medicine. The views expressed during this session are those of the individual presenters and participants. They do not necessarily reflect the positions of AAPM&R. AAPM&R is committed to maintaining a respectful, inclusive, and safe environment in accordance with our Code of Conduct and Anti-Harassment Policy available at aapm&r.org. All participants are expected to engage professionally and constructively. Of course, we want you to participate. This is going to be a really great discussion, and just be mindful of that when we're having these conversations. The activity is being recorded, so this session is being recorded, and it will be made available on the Academy's online learning portal. After this activity, an email is going to be sent with a link to bring you to the recording, and then you'll be able to do an evaluation. For this attending experience, please mute your microphone when you're not speaking. You can either use the raise your hand functionality if you have a question, or the chat feature if you have a question. My understanding is that we're going to have a really conducive conversation, so we'll look forward to that. We are going to be running on time today, so we'll look forward to these conversations going, and I will turn it over to Dr. Reiser. All right. Thank you, Anna, and thank you everyone who showed up tonight, especially us folks on the East Coast. This is pretty darn late for me. My name is Sarah Reiser. I work at the University of Virginia Runners Clinic, and I'm the chair of the Running Medicine member community. Today, I'm very excited to have an interactive session. So, everyone who's on, if you want to throw on your camera, feel free to speak up, raise your hand, throw things in the chat. I certainly want this to be a discussion, so you can throw your two cents in there, ask questions, and hopefully we can have a good time over this next hour. I am very excited to welcome Dr. Kate Mehevick-Edwards and Kelsey Pontius. Kate is a physical therapist, and Kelsey is a sports dietitian, and so a lot of what we're going to do today is really hone in on their side of the interdisciplinary team that cares for runners. So, to give a little bit of introduction, Kate is a physical therapist with running medicine expertise, and we were just chatting. She was telling me we have almost 20 years of running medicine expertise, so a lot of good anecdotal stuff, and so I hope we can delve into some of that today. She has a private practice, precision physical therapy, and she's adjunct faculty at Emory. Recently, she just got an innovative practice award, which is very exciting. So, a lot of really cool accomplishments, works with a lot of elite athletes, and we previously worked on an elite athlete team with the Atlanta Track Club and their elite development team. So, I had a really good time getting to know her through that process, and when I was in the Atlanta area, and of course, I have actually continued to work with her quite a lot since that transition. Kelsey Pontius is a sports dietitian and marathoner. She has a private practice, Meteor Nutrition, and recently published an e-book, the Meteor Marathon Method, that I refer a lot of my patients to. She excels at working with runners and endurance athletes from the sports dietitian standpoint, and I send tons of patients to her as well. I think it's really important to consider that physical therapists and sports dietitians are not all made the same, especially when it comes to runners and some of the intricacies that come with overuse injuries and relative energy deficiency. So, I love both of them and the counseling that they do, even above and beyond the PT and dietitian side of things, and I think it's really valuable for the interdisciplinary team. So, I've mentioned the word interdisciplinary a bunch here, and I think it's really important to distinguish it from multidisciplinary. So, multidisciplinary, we have multiple specialties working in parallel, all with patient, and that's great, but interdisciplinary means that we're working together and the providers are actually communicating and working together to provide a product that's even better than what you provide in parallel. So, I think it's really valuable for the providers to know how to talk to each other and engage and provide the best experience that we can for the athletes, which does take time, but really provides a superior product. A couple things I want to mention as well. So, I always talk about nutrition really being foundation for athletes, and we're going to talk about a couple of cases that are not just bone stress injuries and very clear reds, but other ways that nutrition may also be engaged in certain scenarios. I send a lot of perimenopausal patients, for example, to dietitians to have those conversations and answer questions that may be a little bit confusing and mixed. So, I think there are a lot of different reasons to send folks to dietitians, and I'd like to kind of elucidate a little bit of that today, especially from the running medicine side of things. With that being said, physical therapy also not made the same. Super important that we're asking folks what kind of physical therapy that they are doing and knowing what they should be doing if they're a runner and need runner-specific treatments. So, very excited to delve into this. Like I said, if you have questions, thoughts, feel free to throw things into the chat, raise your hand. I hope this can be some good, friendly conversation here. So, I've got a couple of cases here to help guide our conversation. So, I'm going to introduce the first case and then turn things over to Kate, and we're going to be on all first name basis here, so we can chat. So, the first case is a 17-year-old senior high school female cross country runner, and she presents to your practice, Kate, with groin pain. So, she has not seen a physician, and she shows up and says, hey, I got to get this better because regionals is coming up. So, my question for you is, how do you approach this case? What are some of the things that you're looking at? What might be some of the spidey senses that are coming up here and might send you in certain directions? Okay. Thanks, Sarah. Appreciate it, and thanks for that introduction as well. So, when somebody comes into my practice, it actually, we spend an hour, and a lot of that time is subjective evaluation, and it's probably 30 to 40 minutes of the treatment. I do end up treating people before they leave, but we have to get really down to the bottom of it because they typically have seen multiple people before they get to us. So, first things I'm starting to think of or ask questions about with a 17-year-old female cross country athlete with groin pain is, first, I want to know about her life and her training schedule. So, when I think of load, so a lot of times we think of just biomechanical load, and that is certainly something that we're thinking about, and I'll be teasing out when I'm looking at her gait analysis, and I'm looking at her functional movement patterns, but I'm also thinking about her mental load. What does it look like at school? So, is this a period of time where she's under a lot of stress? Maybe she is transitioning to college or applying to college. Maybe she has a big state meet coming up. Does she even like running at this particular point or not? What are the things that are happening in her life that might be adding to that load? Because some may say a lot of stress is stress, and mental, emotional, and physical load are all the same. Our body cannot differentiate between them. So, that's part of my foundational knowledge that I need to know. Secondly, we want to think, what could this possibly be? If it's in the groin, there are so many different areas that it could come from, as we all know. So, we have to start doing differential diagnosis in terms of, like, is this a stress or a bone stress injury? Is this a tendon injury? Is this something that's being referred to the area, perhaps from pelvic floor? Is this coming from the lumbar spine? Is this coming from the hip? So, we have to kind of tease out all of those things, and I'm going to be asking her specific questions about pain location and behavior to do that. And then, of course, there comes the nutrition questions as well. And so, while I'm not a sports dietician, and it's very likely this person will go see Kelsey or somebody else along those lines, I will be asking, what does your nutrition look like? Because I want to know if they're eating enough. I'm not going to guide them on their nutrition necessarily, but I want to know if they're eating enough and getting enough calories in so that we know whether or not they're in that low energy availability state and if that bone stress injury is going to become something higher on my list. Of course, I'm going to be talking to the coaches. So, in my practice, like we said, interdisciplinary, I'm going to ask who the coaches are. I'm going to ask about what the training is like every single day from now and the last six weeks, because usually injuries start within the four to six weeks prior to people coming in, if not before that. I'm going to ask about running shoes. I'm going to ask about strength program. I'm going to ask about sleep. So, that's all within the first 30 to 45 minutes. And there's a lot of questions, and we're going to dive into each of those questions in a lot of depth. And because they're 17, they may or may not come in with a parent. If they're with a parent, I make sure that the athlete is actually answering the question. I've found now parents like to answer for the athletes more than they did five or 10 years ago. And so, I'm very clear that I want the answers coming from the athlete themselves. And if they don't understand exactly what I'm asking for, I'm going to change the question until they do understand. And then later, I'll ask input from the parent. And eventually, I'm hoping they won't be in the sessions or they'll be there and participate quietly. So, I think that was all that you asked me, right? Yeah. And I think, so, how about some of the nuances that you might be looking for in terms of how they might be answering questions that might be red flags? Yeah, sure. So, if they don't want to talk about nutrition, that's a serious red flag. If they've had multiple injuries in the past few years, that'll be a red flag. I will ask questions about menstrual cycle, for sure. I didn't mention that at first, but I always, with female athletes, I'm asking questions about menstrual cycle. One, I want to know, have they had their cycle yet? And if they have, is it consistent? I know that a cycle can stop after the first one briefly, but generally speaking, it still comes back fairly regularly. And if it doesn't, it could be a sign of low energy availability and a lot of other hormonal imbalances. So, we're asking, I'm definitely asking about that cycle. And I'm explaining why the entire time, so there's not so much awkwardness. It's really, what I really try to do is say, hey, I'm asking you this because I need to understand from a performance perspective and from an injury perspective, this information. Because if I don't say that, they kind of might flame up about it. So, those are things I'm thinking about. And then from a biomechanical standpoint, I'm looking at rotational stability because if it's an adductor, I'm looking at how the foot is hitting the ground. I'm looking at pronation control. I'm looking at distal tib-fib. I'm looking all the way up into what is the arm on the opposite side doing and how are they breathing? Because if they're holding their breath, then they're probably not getting enough ribcage mobility and they're probably not activating their deep core. And then that pelvic floor is not doing its job either. One of the referrals to that area is obturator internus, which is a pelvic floor muscle. And a lot of the times, obturator can show up in adductor or high proximal hamstring. And so, those are kind of the things that I'm doing a little bit more nuanced with. Awesome. So, I like to point out a lot of the things that Kate already ran through in terms of addressing menstrual cycles and pelvic floor piece and your differential and then also considering, hey, is this a stress fracture? I work with a number of physical therapists and the ones I work most closely with are the ones who they'll see a patient like this and they're calling me up and saying, hey, I got this patient in clinic. Can I get them in with you tomorrow? They're sitting right here with me. And I think that can be very valuable too to demonstrate that interdisciplinary care as well. So, say this patient ends up in the physician's office, gets an MRI. They're confirming there's femoral neck stress fracture. She does her six weeks of non-weight bearing. She's progressing back. Actually, she's doing six weeks of non-weight bearing. Kate, would you want to potentially see her during this timeframe? Yes, I would actually. So, when they're non-weight bearing, this is a crucial time. I'm actually seeing a lead athlete right now in this exact position becoming weight bearing. So, it's such a mental load and such a stressful time for these athletes. They need direction and they need a plan more than anything. Whether that's Sarah that's giving that plan, whether it's me that's giving that plan, it has to be somebody who's going to take charge and give them a plan. Otherwise, they're going to spin out of control. They're going to do things that you don't want them doing, which happens all the time, and then it's going to prolong the process. So, I want to see them for that aspect, but then I'm still trying to get them to maintain as much strength as they can so that they aren't set back even further when we do a traditional return to run program or when we start to add a little bit of body weight supported running or something like that. So, what we're doing is core stability, functional movement. Depending on where the fracture is, so like if it's a femoral neck, we're going to be very specific about what's happening at that actual hip, but we can do other things from like a core stability, upper body, arm swing perspective. Make sure that we're maintaining mobility from ankle dorsiflexion, things like that, that are really going to start to give them issues if we completely ignore it. Because I find that people actually become out worse on the other end if those things haven't been addressed during those six weeks. Because now they've lost ankle mobility, they've lost hip mobility, their lumbar spine doesn't move, they're stressed out to the max, they don't know what they're doing with their nutrition because they haven't had a guide from somebody, they often don't know like the next steps or what to ask. So, it's a really good time so they have a sounding board as well. And I'm definitely, definitely making sure that Sarah and Kelsey are in this and a sports psychologist. I'm almost always referring to a sports psychologist as well and we are talking regularly. So, one thing that I think is really interesting in the elite athlete realm is that we can do this and I think we can do this from a couple of reasons. One is the financial standpoint because we've got these folks on board and we have the rapport built. But the other thing too is I think a lot of physicians, if they don't have that connection with a physical therapist and trust the physical therapist with ephemeral neck stress fracture, I wouldn't let just anyone put their hands on them. I'd be concerned they were doing something that was risky and so in some ways it's almost protective to say, well, I don't want you seeing physical therapy at all because we could end up having a bad outcome. And so again, really valuable to have folks that you would trust because I would definitely let Kate lay hands on that patient and other folks that I felt like I could communicate very closely with. And I think there's so much value in being able to do that and of course our kind of conventional healthcare system is a little bit of a block from that perspective. So mental health, really big one. We don't have mental healthcare providers here today, but a really valuable piece of things. And I think that's probably, it's always very challenging to get my patients to go see nutrition, but it is really challenging to get them to see psychology and to have to pay all these different providers and understand why they're important. And so I also find it's very valuable for physical therapy, my dietician to understand those types of things as well, because they can still have some of that conversation. They're not doing formal counseling and CBT, but they can still address some of those things and acknowledge the challenges and kind of have an understanding of what's happening. So super important. And Sarah, I would like to say that I do see patients that have been told don't do anything. And I always wish that I had been able to speak to that physician beforehand. And it usually doesn't happen when it's a physician I know, but you're right. You have to be careful because a lot of times people don't know what not to do to protect the area. So I understand why that happens for sure. And I also tell them, you know, I'm not seeing them two or three times a week. I think that's also a really good point to make. I'm seeing them once a week or once every other week and guiding them and being a touch point. And I think I tell them because the resource that you just said, like in terms of money, I'll say, look, like you only need to see me maybe once every couple of weeks. Why don't use the money that you would have spent on nutrition or mental health so that you can get all of those pieces? So the next thing that I would potentially suggest is having folks see Kelsey. So getting it with a dietician while they are actively healing their injury, not waiting. And so I always pose it as, hey, there are things that we can be doing right now that can affect your ability to heal. Because, of course, everyone says, well, how do I make a bone heal faster? I'm like, well, you don't really make it heal faster, but can we optimize some of this? So I'm getting folks in with Kelsey or her business partner as quickly as we possibly can. Again, sometimes that's a phone call I think is really valuable. And sometimes I even offer to make that connection, which I think can help improve their likelihood that they will go see a dietician. So Kelsey, if you saw this patient in your clinic, where would you kind of start with things? Yes, much like Kate, we do our own version of an assessment, so a nutritional assessment. And so while the things that we're assessing, we're assessing their relationship with food. At 17, we're also assessing mom and dad's relationship with food? Is mom and dad doing any diet? Does mom and dad understand that they have far different nutrition needs as someone that is still developing, even at 17, if they're done growing in height, they're still developing, which places demands that takes calories to support. And so oftentimes, just like Kate brought up the menstrual cycle, I'm asking similar questions, asking about how regular it has been, where are they at in terms of their development also impacts their nutrition needs. And then I'm trying to figure out loosely what some of energy availability is. Most of the time, we do not have, they don't have a DEXA scan that would give us their lean body mass, which helps us more clearly define their energy availability. But I can still get, and this is all subjective information, but a diet recall of what's typical for them. And then also have them explain to me kind of how they were training before they got injured, because that can kind of tell me what their demands are. And then on top of like their basic demands and their training demands, and then how does that compare to the energy just in form of calories from food and beverages? And is there a mismatch there? Obviously, I'm doing estimations, especially if I don't know their lean body mass. A lot of times, it doesn't come to, oh, are they maybe plus or minus 50 calories or a hundred calories? A lot of times there's a glaring difference. And there are constants that are associated where, okay, this athlete is gonna start to have problems if their intake is under this amount. So the number that we all know can kind of point to low energy availability. I don't know that this means much to, but there are numbers like 30 calories per kilogram of fat-free mass. So if we have a DEXA scan, then we know they're fat-free mass. And around 45 calories per kilo of body weight, we kind of know, okay, this is gonna be more sustainable for them. And then you add their activity on top of that. And then there's a certain calorie standpoint if they were in the healing process that we would establish, because now their body needs restoration. So there's a few different ways that we're kind of attacking it depending on where they're at. I wanted to mention not just RET-US, but I'm also looking specifically, and this is newer literature we have since like last fall, what their carbohydrate availability is, because we know that low carbohydrate availability can have similar impacts as just low energy availability. So I'm looking at that. Dr. Kate and I have an athlete right now that she is like the picture perfect case and point of this where her calorie intake was fine, but her carbohydrate availability was poor. And she has really similar consequences in her body right now as RET-US. I'm also looking at the timing of nutrition. So we know that even within day, low energy availability, even if they catch up later. So what I mean by that is even if their calorie needs are 3000 calories per day, even if they get there, if they are operating and doing their training when their calorie supply isn't sufficient, then they can still have impacts. And this has actually been better studied in female athletes because there's been cases where female athletes have had hypothalamic amenorrhea, but they're still meeting their energy demands for the day. But that intake around the most active point of their day is low. So I'm kind of getting a feel of what that is like. Obviously they're injured at this point, but I'm asking questions about how their recovery was. Do they have any GI issues? Do I need to ping them back to another physician if they're having GI issues and they might be at risk of malabsorption? If we have access to labs, then I love to see micronutrient status. Sometimes I'll even take a peek at their thyroid. I would say, yeah, those are kind of the things that I'm looking at the most, but big emphasis on relationship with food and how they feel about fueling their body, definitely at 17. I'm curious about how social media is playing into their body image too. Lots of great points. I had to write a few things down here. So real quick, I have a few things that I wanna touch a little bit more on. I do have a question in the chat here. Kelsey, can you comment on a vegan diet for a 17-year-old runner? Any specific concerns? With vegan diets across the board, I'm really curious about what is the motivation behind being a vegan? Sometimes it really is a method of restriction. Not always though. Sometimes we love the environment for environmental reasons. So I like to dig in, like what is motivating us to be a vegan? And then in terms of 17, again, it's a big, big timing for development. And so just making sure that we're able to meet those demands. And then vegan diets are always gonna be lower in B12. B12 is really hard to get. So making sure that we're monitoring B12 labs. We are gonna need to supplement. There's just very little sources of B12. We're also assessing iron status in those athletes too. Those are the big ones that vegan diets can just be a little bit lower on. I actually feel really safe right now to recommending, actually Dr. Kate and I just talked about this, text exchange, I promise you guys, on creatine. Creatine is a little bit lower in vegan diets. Again, this is something that you're gonna find in supplemental form. Once we kind of got to where, okay, we're not skipping meals. High school athletes often skip meals because they wanna sleep as long as possible because sleep is also important and they're doing homework super late at night. So we're not skipping breakfast. We're eating every two to four hours, those kinds of things. Once we can kind of check those boxes is where I would kind of consider things that we're not getting in a vegan diet like creatine. B12, please supplement no matter what. But that's something that like, if you have a vegan all-star high school athlete, that would be the extra one or 2%. Yeah, great. And I do kind of the same thing as trying to figure out where they're coming from, the reasons behind it. And also, are they lactose intolerant? Is there something else that's going on? Kind of some education around bioavailability in certain products. And I try to really have an open mind. My first couple of visits, I'm trying to develop rapport. And the last thing I want is for them not to come back and see me. And so I usually try to kind of set these things up and then get them over to my specialty partners. And then as much as I can, really ensure that they come back and see me and we can delve into these things a little bit more. One way that I will sometimes, I always get the answer when I mention, let's get you a dietitian, kind of give the little spiel and they say, well, I eat really healthy. And I say, oh, I'm sure you do. But there's a lot of things that can be nitpicky things that can be different in your diet that could really change how you're getting your nutrition. So one of them is the within day energy. That's a really big one. And so I will oftentimes have that conversation, try to get them there that, again, this is also not a judgment on your diet. This is trying to get us back to a healthy place. So resting metabolic rate during injury, you touched on a little bit. And I was wondering if you'd mentioned that a little bit more. For a while, I was actually directing folks to one of your podcasts series where you mentioned this. And I thought it was really important because I think food restriction during this time when people are very stressed out and they may potentially be restricted from any physical activity besides little arm weights. How are you having that conversation with them about their nutrition during the lowest point in terms of activity level? Yeah, I always just try to explain that healing an injury takes energy. So it's an anabolic process where we're building up new cells that hopefully turns into healthy tissues and muscles. And so that takes raw materials and injuries that kind of take the most energy to heal. If someone has to have a surgery, that obviously is gonna place a lot of nutritional demands. Even I had this conversation, I had a college athlete that tore ACL and she's in the first three weeks, not doing much right now, but she's crutching around like crazy. And I'm like, that takes a lot of calories. And I'm like, aren't you tired? And she's like, yes, I'm so tired. And she's like, it's funny you should say that. My whoop told me I was burning a lot of calories. So yeah, both of those things, crutching around takes a lot of energy. It's very difficult if you've never had to be on crutches and then having a surgery, but even just healing soft tissue, especially bone injuries, places a really large metabolic demand on the body. And it can be even just to the BMR in total, it can increase your BMR by 40% an injury can, which is a lot. And those are calories that our whoops, our devices are not gonna be able to quantify for us. And so it's not calories that we can see. So I think a lot of times injured athletes in general have a hard time quantifying that and justifying replacing those calories so that their body can be supported. Honestly, I think it is a red flag sometimes when you have taken time off of your sport and your body doesn't change at all. I think that that sometimes can be a little bit telling and just reminding athletes that that shouldn't be the goal of your rehab process because once you get to a place where you can train consistently and your body's gonna normalize where it wants to be as a result of giving it the resources that it needs. So for some folks who have joined recently, we're talking about a 17-year-old senior high school female cross-country runner initially presented to Kate's practice for physical therapy with groin pain. Ultimately was diagnosed with a femoral neck stress fracture, made it a physician, made it to Kelsey. And if I now tell Kelsey that she has some labs, so her hemoglobin was 13, her ferritin was 25, vitamin D was 30, and then her free T3 was 2.8. My biggest question for you, Kelsey, is how do you have the conversation about ferritin? Yeah, so ferritin, I think in this specific case, it has such a large role in bone health. Obviously, ferritin is the storage of iron and iron is responsible for the delivery of oxygen around the body. And so when that is compromised, our bone health is gonna be compromised. There is a tight connection between bone turnover and iron status. For runners, it is a case of like everybody's different, but I still think everybody's different, but nobody's a special snowflake where the minimum values that we like to see is 40. That's what most of the literature supports. And so I'm really saying, okay, well, this might not be clinically normal and Dr. Reiser's are such gifts because she knows this and she knows clinically normal isn't normal for a growing runner. And so just saying, okay, this is really where we would want it. And it's not just a matter of trying to replace it via supplementation, because if we're not looking at the bigger picture, obviously now we have a bone stress injury, then we're missing the larger picture that can impact the future and risk of injuries in the future, risk of bone density in the future and so forth. And it's interesting how complicated that conversation has gotten, right? Like it used to be, oh, well, you know, eat more red meat. And that's just not the case. There's so much more complexity to a low ferritin. And I usually start that conversation and then have Kelsey continue that conversation. But I think it's really important. And again, a lot more telling than just simply iron stores in the body and getting enough iron through your diet. So let's transition back to Kate. So we've gotten through our non-weight-bearing period. We've gotten them in, fortunately, with both Kate and Kelsey. And now we're gonna start transitioning back to weight-bearing status. And so Kate, what would be your process through this? And, you know, interestingly, I think I do my best to try to get patients scheduled. If they're not gonna be seen, I give them the conversation about, hey, I'd love for you to be seen while you are non-weight-bearing, but if that's not possible because of insurance, I understand that. But I want you to go ahead and schedule for just after that six-week mark, because I wanna get you in as soon as possible. We don't wanna wait two months to, you know, for the PT waiting list to get you in once we've cleared you to start doing some weight-bearing. So if I can, I try to get them in right as soon as we start progressing with the weight-bearing status. Yep, so first I wanted to say something about the nutrition that I say to my patients a lot. A lot of times athletes don't know they're in low energy availability and neither do their patients, or I mean their parents, and they don't mean to be. And so they think they're doing everything right. So that's something I often tell my patients. Like, I don't want them to feel bad because there's this negative connotation around not eating enough for a lot of athletes or doing something wrong. I often say, look, you didn't know and that's okay, but let's correct it now. So I just wanted to say, like, that's something that comes up a lot and it usually breaks the barrier down to being able to refer to a dietician. If you say you didn't do anything wrong, you didn't know and that's okay, why don't we find out the information and do what's best for you individually? And that helps me refer. So I just wanted to, because sometimes it's so hard to refer you have to find ways to do it that makes sense. Yeah, good point with the unintentional under-fueling. Low energy availability and eating disorder is not, does not always coexist. And so I had a high school kiddo last week and he's six two and I'm like, makes sense. You know, his demands are just so large, like literally. So, and he has been so super receptive of everything. It's a true knowledge deficit. Yeah. And I always tell them when they're done with us, they should be a whole lot faster and they're going to have a longer career after us. So. For sure. Lucky them. But if we're going to come back to when the weight bearing piece comes. So first of all, the biggest thing is I want to make sure that they actually were released to do weight bearing because that conversation sometimes isn't clear if they haven't seen their physician. So I make sure to reach out to their physician and have that channel open so that I know that that's actually where we are. And because of that stress fracture or bone stress injury is in a critical area, I also want to know where, like where exactly it is. So I know about the kind of force I want to put through that area. And I want the, I want to talk with the physician about like, hey, what do you think in terms of this area? And I kind of run by some of my ideas in terms of like that progression to return to run. So that's a very collaborative process for me. But generally speaking, we'll start slowly, right? So you get them off the crutches slowly from two to one to none. And then we get them walking and we get them doing cross training. And as soon as, even in that, as soon as they can bear weight, I want them doing cycling so that they are getting some weight through that leg or that lower extremity, but it's in a safe way. So it's a little bit more, it's a little less difficult for them to get in trouble if they're doing it on a bike, for instance, but they're still getting that input. Then we're going to start talking about obviously functional exercises. First, just focusing on form and not a lot of weight. And then we're going to transition that to start loading that a little bit more, whether we're loading it with a little bit more weight or we're going down that process, but then also we'll work our way to plyometrics. And I have a whole return to run screen that I do, things that they need to be able to do in order to start the return to run process. And it depends on what the athlete has access to, if they have access to a body weight support system or they have access to like an Ultra-G or something like that, that typically speeds up the process for the actual return to run because we can take off some of that load and allow them to start getting the movements. So it's really, it's very individual. It's definitely matters what area of the body has the bone stress injury. And I really do like to collaborate with the physician on this. And again, I am still talking to the sports dietician like Kelsey to make sure that they're getting those nutritional needs in at the same time. And that's a conversation that we're having because obviously I want them to increase their caloric intake if they're in that kind of transition to more work. And in that transition phase, I also have the conversation of your nutritional needs are gonna be changing. If I could only get you to go to one session during that non-weight bearing phase, I really want you to go at some point as you're progressing back, ideally more than once as you're getting back to full loads and more competition season. So Kelsey, what would your conversation be if you were seeing them as they're starting to progress back into some running? Yeah, in those initial phases, while carb and fat intake isn't unimportant, there is an increased need for protein, which coincidentally makes us feel super full. And so I'm just making sure that there's enough room in their diet when they are doing some of these higher demands, higher intensity type of exercise for carbohydrates. Carbohydrates does affect bone turnover too. And of course there's that concern that for another injury after a bone stress injury. Also, because calcium is an electrolyte, oftentimes people forget, we do some calcium intake around pre-exercise. there's actually some research that implementing calcium pre-exercise because they're gonna lose it in their sweat while they're exercising can be supportive and protective of bone as well. I'm assessing their calcium intake to begin with in the prior stage, but just making sure that they're getting enough of that, making sure I kind of discuss like types of how they should be building their plates. That's representative of how much they're training, I call them performance plates, that their performance plates mimics how much they're training and then how intensely they're training too. And then making sure that we're avoiding that within day deficit because now we're adding activity. If they also, oftentimes they also have a strength program or a PT program that we're fueling around that really well too, just to avoid any within day deficits and just larger, bigger deficits within the day and overall. I think that that's pretty much it. As soon as they like start is really making sure that their return to sport is well-fueled. Awesome, so I have one more question for this case for Kate. So as they're progressing back into their running program and they're comfortable running 15, 20 minutes at a time at least, you're thinking about, hey, we wanna take a look at their run gate. What are some of the procedures you might do around that and what might be the reason for that? Yeah, so I want to see, you can't, you don't know really how an athlete moves unless you watch them do their sport. And that's the bottom line. So like as a runner, we need to watch how they're moving because even though a single leg squat can show you what the knee is doing, what the foot is doing, what the hip is doing in terms of strength, it's really not giving you the full picture. You're still not really going to understand rotational stability. You're not really going to know what's happening in the arms or the trunk or how they're breathing. So it's really important to take that into consideration. And also the shoes, how are the shoes impacting the foot landing position? I mean, some people are in super shoes with the carbon plates, some people are not, some people are in spikes depending on what they're getting back into. So we do need to think about all of those things. So for a run gate analysis, there are a couple of different things and I did notice in the chat, someone asked about RunDNA, which is a system that a PT or some PTs developed, which is a 3D analysis run gate system. And so what I would say is that myself included, I've done 3D analysis for run gate. I've done that in a research setting and I have seen RunDNAs set up. And while it's great for research, it is not great clinically. A lot of the clinic owners that actually have bought this have actually stopped using it on a regular basis because it's not working in the clinic setting. So anyway, I'm going to do a 2D analysis with an iPad, which sounds crazy, but I've compared the results from that to this 3D. And in terms of what your recommendations are and what you're seeing, they don't really vary that much, which is crazy but true because I've actually taken all the printouts from these 3D analysis and compared it to what I wrote first and then put them together. So anyway, we're looking at how does the foot hit the ground? How are they absorbing force? Cause this is a load problem. We have to think about load. How is load being absorbed? What's happening at the foot? Are they starting to rotate and come down? Like what's happening at that mid stance phase? How are they, what kind of changes are occurring? Like are they getting enough hip extension or are they getting that from the back instead of the hip, which is what we need to do. But a lot of times people will extend from their back and then the rib cage will flare out and then their posture will completely change. And then they're not tapping into their diaphragm. They're not tapping into their deep core. They no longer have that stability. I'm looking at arm swing. Is it coming from, are they starting to swing their arms across their body or is it actually coming from the shoulder joint where it's supposed to be coming from? Are they compensating for a weakness on one side of their hips by leaning, doing a lateral lean and sticking their arms out? So all of these things matter and I probably didn't name them all, but I'm going, I'm starting from the foot and I'm working all the way up to the head. I mean, I'm even looking at head position because I'm thinking about how is the breath coming into the body? And we tend to follow where our head goes. So if we're following our head and we're leaning forward, then that's going to change trunk position, especially at the hips. So that's, those are all the things I'm thinking about or a lot of the things. I even think about sound. What does it sound like? Because a lot of times it's like, I'll close my eyes and I'll think about like, okay, what side feel sounds louder? And that's typically that side that's had an issue because they don't have the spring that they need. They don't know how to absorb and they don't know how to release energy as well. Awesome. Sometimes you say things and I'm like, did I get that from you or? Yes. That's funny. So a couple of things I want to point out here. We've already talked about pelvic floor a couple of times. I like to think that runners don't have to deal with spines, but they do. And I think one of the biggest things, downfalls that I had early on as I was looking at runners is you think about just legs. And the fact is that spine is super important and like she said, even all the way up to the head and the breath patterns are super important. I'm frequently writing into physical therapy scripts that I want them to go through diaphragmatic breathing. I tell the patient, I give them some education. I show them videos they can look at. So I really try to emphasize how important all those different pieces are and tell them all those boring things that seem really hard. Those are the things that are actually gonna be really valuable to you. So trying to kind of set the precedent that's, not all the things are gonna be big joint movements that are really fun, like heavy squats or something. So if you can remember that, so pelvic floor, breathing exercises, and the spine and the head are connected. You'll be well above the rest when treating runners. There's a great question in the chat. So Caitlin, thank you for your question. So asking about finding a good team. So how do you put together a multidisciplinary team? I think if we had that perfected, we'd have a lot more of them. But ultimately, so my anecdotal, my personal experience, I try to do a lot of networking. When they say someone did a really good job with them, that they got them on the treadmill and did a Rungate eval, I ask a lot of specific questions about the physical therapy treatments, the exercises, and same thing with the dietician. So getting out there and talking to people, getting the patient feedback, and just getting to know folks. Even just having a conversation about a patient you might share with someone and just see what sorts of things they offer you, I think would be very valuable. So just like when I talk to trainees and I give them an open-ended question so I can figure out where they are, I do the same thing for colleagues and potential collaborators. The thing that I also mentioned too is, dietician, there can be a very wide spectrum of education and there's a very wide spectrum of requirements in each state. So for example, Kelsey is located in Colorado and I'm in Virginia, and Virginia requirements are relatively low. So I am very fortunate that I get to continue working with Kelsey and send lots of patients to her, as well as some folks that I know back in Atlanta. And so we have folks who are boots on the ground here, and I love having that too. But it's also nice to have a few different folks. I always tell people they need to vibe with their provider. So if they meet someone and seem kind of down, I'm like, well, did you just not really get along with them? You didn't vibe, try to use terminology these days. Then I say, well, let's talk about someone else then, because I think it's really important that they do. Kelsey, this never happened with you, just so you know. How'd you know that was my first thought? Always important to have that conversation. And I mean, when I refer patients, I always try to fit personalities as much as I can. I'm not perfect at it, but trying to find people that are going to fit so that they will continue seeing that provider and develop good rapport. So yeah, the biggest thing I would say is networking and it's the politics and getting to know the community and who has what to offer. Admittedly, it takes time. It takes quite a bit of time, but I think it's very valuable and worth it. All right, if anyone else has questions, feel free to throw them in the chat. I am going to transition our conversation to another case. So this is a 52-year-old male weekend warrior. He has this insidious onset of right knee pain, shows up in my clinic, gets some x-rays, and he's got knee osteoarthritis. So I'm going to skip the things that I would talk about in clinic and say, hey, he ends up agreeing to go to some physical therapy and shows up in Kate's office. Where would you start with things, Kate? Right, so the kind of questioning, line of questioning is very similar. Obviously, I'm not going to ask about menstrual cycle for a 52-year-old man, but the questioning about sleep and nutrition and stress and all of those things always happens for every athlete. But for this particular athlete, I want to make sure I'm having a lot of discussion around shoes, around what their schedule is, what their training schedule is, what types of workouts they're doing. How are they loading that knee? I want to see functionally, like are they somebody that's in a lot of knee valgus or a lot of knee varus? What's happening at the foot? Because we're thinking about, okay, with knee OA, if they're loading one particular side of the joint a little bit more than the other, how can we make adjustments so they can continue to run? Because ultimately, most runners don't want to give up running and have a knee replacement. So that's a conversation we're going to have to have. So I may end up putting some kind of wedge or some kind of orthotic in the shoe. I might get a shoe that has a different heel-to-toe ratio. I might get something that has a wider toe box. Like it depends, right? So it depends on what feels good because the most important things when it comes to shoes is how it feels. But when you have a case like this, when you're noticing how they're loading it and it's inconsistent across the joint, I'll try to make those recommendations early to make them more comfortable. So that's kind of where we would start. And then we would have the difficult conversation that says, okay, well, how much pain are you in exactly? And have you, and hopefully I've talked to the physician at this point already, but if I haven't talked to the physician already, I'll ask the patient, like, what other options were you given? Were you given any orthobiologics? Was that discussion brought up? Because a lot of times that can prolong their ability to run before considering like a knee, like a knee replacement or a partial knee replacement. So I'm really trying to understand what options they were given, what their knowledge base is around their options and how, and what their goals are from a life standpoint and their pain tolerance. And how does that weigh with what they wanna do from a running perspective? Because that is a very personal decision. If somebody has nine out of 10 pain, but they do not want a knee replacement because they wanna keep running, I'm with them. I'm doing, I'm like looking at their strength. I'm doing all the things. I'm clearly speaking to the physician and the dietician and probably a mental health professional, but I'm in it with them doing the best that I can to keep them supported. I had an NFL player that wanted to run so badly, but he had so much, so much knee barriers. Like it was painful for me to watch him run, but I really worked on a lot of hip extension, like more than I normally would have. We really worked through, you know, getting that anterior hip very loose as loose as we could. We worked on shoes, we worked on ankle dorsiflexion, trying to work above and below those knees to offload the knee as much as possible. And that's where I would start. And one of the things that I really like about what you said and I think this is part of where running medicine is kind of evolving, what it's evolving into, I think, in a lot of our healthcare, but really seeing patients where they are and giving them advice, you know. Maybe it's not the best idea that they continue to run on this, but if they're going to choose to, well, we can still help optimize their mechanics. We can still optimize their nutrition. What are all the things that we can do to minimize their risk of injury and give them all the education that we can, as opposed to saying, well, if you're gonna run, I can't help you. And so I think it's really valuable to have those types of conversations. And sometimes it's hard for me to continue to talk about running, but if they're gonna run, I wanna try to keep them as safe as possible. So I think that's very valuable and, you know, respecting what patients wanna do. It's their body. But if we can keep them active and keep their quality of life up, I think it's very valuable. So I would love for you to comment on your inserts, your orthotics commentary, and kind of maybe expand a little bit in what your general kind of approach to the idea of orthotics is. Yeah, so I'm not an orthotic person in general. I want to start with that. I'm leading with that. Typically, because I, you know, I see less people with OA and more people that are high performing at this point in my career. And so they don't really need it. So I can, in a lot of ways, I think of orthotics as a crutch. However, there is a whole subset of patients that it really benefits and they're not gonna do the things that they might do in terms of strength. They're just not gonna do it. So you might as well give them orthotics to support their goals, right? So I wanted to, I want to start there. So it's not my first thing that I would do, but if it can be helpful, I will. Or sometimes I'll use orthotics temporarily and get the over-the-counter orthotics that are less expensive and then wean them out of them. So that varies depending on the injury itself. But if we're talking about knee OA, I'm looking to, from the first day, I'm looking at functional movement. How are they squatting? Can they single leg squat? But I always look at bilateral first. Can they jump? How are they loading? Because you'll be surprised at how many people can't jump at this stage, even though running is jumping from one leg to another. It's just that lack of spring that's happening based on how, like as we're getting older, right? And so I'm looking at those things. In terms of the orthotics, if I see that someone is like going into a lot of pronation or if they're in a lot of supination, I'm probably going to start thinking about, okay, what shoe are they in and what shoe will give them a little bit support, more support to even it out. Like the whole idea is I want their foot in a more neutral position because it's the first part that touches the ground and transfers up. So that's really what I'm talking about is when I think of the foot, I think of it as you want equal weight in the four, like the four corners, or it's really three point if you think about the heel and the fifth mat and the great toe. So I'm thinking about that tripod, if you will, and that's what I want them to feel in their shoe and that relationship with the ground. Of course, I'm going to suggest strengthening of the foot and ankle mobility, like sub-tailor and tail accrual, but we'll see where we are and how much we can get them to do. So that's kind of where I'll go with the orthotics. Is that what you were asking? Yeah, okay. I'm sorry, you're going to lead off. I was just waiting for you to say it. That's scary. So I do have more questions for you, Kate, but I'm going to transition to Kelsey. So Kelsey, what would you offer to this patient? So I do want to give you a little caveat of BMI's 30. They are working with Kate and they express that, hey, what if I lost a little bit of weight? Would this be helpful? Yeah, I really try to not overthink the BMI thing. I think that really assessing, like if we have access to what body composition is kind of like, asking them if their body has changed. Recently, I think is sometimes a better question. And again, relating it back to what has the stress in their life been like? Because oftentimes when somebody just simply loses weight and has a more favorable BMI that puts them in a healthy category, it's interesting sometimes when their knee issue or whatever it is still persists. So I will, a lot of times, like the thing with being a weekend warrior too, I think there's a really big nuance between obviously their activity levels during the week and then how they're engaging in activity during the week. And so that's going to place a much different demand over the weekend. And so I like to make sure that like elements of recovery is accounted for during that time so that they're able to kind of manage that part of their activity a little bit better. And then make sure to like, their nutrition needs are gonna be so dramatically different. One of the things that I like to consider too with someone that maybe it is appropriate that they're able to have safe weight loss is making sure that we're implementing, I really do like a Mediterranean style diet. And the reason I like it in this event is because there are so many anti-inflammatory components to the Mediterranean diet. So you're not just saying, hey, because your BMI is this, that now you're on a diet. You're more coming at it with a conversation of, this is what you can add into your diet. This is what food's going to do for you to heal because there are these anti-inflammatory compounds. and right now your recovery is poor, you're having pain, there's probably a lot of inflammation going on. And we know that anti-inflammatory foods also do help support metabolism and that kind of thing too. So I always try to approach it that way. Again, I'm always, even if I don't think that they're in low energy availability, I'm always assessing how many calories they need versus how much they're taking in and getting them to a place where there's a good balance there too. After we kind of do all of that, there are some things that with a master's athlete, I think it's crazy that we consider master's athlete after 40. I'm like, my 40 year old friends I have to race are still so fast. No, thank you. But- 35, some of the categories are 35. Some of them are 35, so that's even worse. I can't handle that. But I mean, for clinical purposes, after 50, we really, and some of the research really does show for women like perimenopause, menopause, that kind of thing. And then men, 50, is making sure that we're doing additional things too. With anti-inflammatory foods, they tend to be more nutrient dense too. And so these are also foods that will help support collagen production. Obviously, as we get older, collagen production is going to slow down a little bit. And so making sure that we're getting those foods, seeing if supplementation is appropriate, that kind of thing, so yeah. So I'm going to, and I have more questions for you, Kelsey, too, but I'm gonna transition to some of our chat questions. John brought up a couple of great points. Would you like to come off microphone and mention your comments? Are you talking to me, Sarah? Yes. Well, hi, Kate, how are you? Hi, John. You know, with an arthritic knee, their knee's probably toast already. You know, how much worse are they going to make it by running? Now, their running form may suck. So that might be worth cleaning up and optimizing whatever you can in terms of their mechanics, what their surface is, how they're running, really, most importantly, how much they're running, and are they getting enough recovery after the runs? And then, you know, if they do end up having a knee replacement, there's no reason why they can't run. It's not maybe advisable. And if they choose to do things or run in a way that is going to be counterproductive, that's on them. But, you know, it's possible. They just need to modify their expectations. And, you know, John, I actually, that's a conversation I often have, is like, ultimately, it's up to you. That's what it comes down to. And I do have patients that have run on knee replacements or partial knee replacements. And again, it comes down to, we're working through consistency. How are they structuring their schedule so that they're not, you know, just running once a week at long distance? Maybe we're doing shorter distances multiple times a week, two or three times a week, and just changing that, making sure they're consistent, making sure they're strong enough. A lot of strength training around it in the biomechanics. But I think you're right. I don't think they have to necessarily stop running, but it is a conversation. And I do like them to have that conversation with their physician in terms of what could happen. Yeah, it's really a matter of them understanding what the parameters should be, what their limitations might be, what, you know, how well can that knee withstand constant pounding? And put them in the water, have them run in the water sometime. That'll, you know, allow them to do more when they do choose to run on land. You know, work around it, biking, you know, things like that. And one thought for Kelsey, who says master's athletes are slow? Oh, I didn't. Did I say slow? No. I didn't anybody over 40. No, I just was saying that a lot of my training partners, they like are technically masters. And I'm like, that's not fair that you're scooping up all that master's money. I'm way beyond that age anyway, so it doesn't even matter. So I've got a few more questions in the chat here. So this one may be geared a little bit towards Kate. I've been seeing a lot of runners who are in stability or motion control shoes, but don't really seem like they need it. They're recommended by a local shoe store. What are the downsides to using these shoes or orthotics if they seem to have good arches and no significant overpronation? Okay, so the shoe topic is a very, like this could be a whole hour. So I'm gonna really try to bring it down. The thing that we do need to educate our patients about shoes is that just because they're recommended to be, well, first in a certain shoe at a shoe store, we don't necessarily know why that recommendation was made. Was it because that shoe store person watched them run from here to the other side of the store? Did they only watch their feet on a camera or an iPad? Did they have in their mind that this injury equals this kind of shoe? So that would be where I started. The research that we have seen, so there are some conflicting things. The old kind of motion control shoes, which are not the same as the ones now. So every six months or sooner, the shoe technology changes. I actually go to a local shoe store and learn about it about every six months because it's so rapidly changing. So if it's a motion control shoe today, it's not what we typically think about as those really rigid motion control shoes that were like a year ago or five years ago. So that's what I would say first. A lot of times that category is even gone from the wall now. A lot of motion control shoes don't even exist. So the stability shoe that they have now is actually less stability than a stability shoe used to be. So all shoes have less stability. So there's that. And then on top of that, the most important thing when it comes to shoes is that they're comfortable, unless we're trying to make a little change because they have a leg length discrepancy or whatever it is. So as long as it's comfortable and they feel good in it, I will say that that's probably the shoe for them. I like them to have two kinds of shoes, two different shoes and trade them like every other run so that their body doesn't get used to one shoe and one movement pattern. I want them to have a little bit of variety. We've also seen across the research that there's less risk for injury if you have two different shoes versus one. So that's another education point that I like to make. And of course that might depend on finances, but if it does, then maybe the next shoe they buy is just different and we mix it up that way. So that's what I would say about the stability, the motion control shoes. Like in general, in the past, motion control shoes in the research caused more injuries. The other thing I would say is a lot of times people don't know they're not supposed to put orthotic over an insert. So I always make sure that they take the shoe insert out and then put the orthotic in. I can't tell you how many people don't know that you're supposed to do that because a lot of times that will cause injury because the shoe is no longer doing what it's meant to do. That's actually a really big thing or like how they put their orthotics in. And then I like John's comment. I think we can both relate to that as well. So if you'd like to. Yeah, when I grew up being a doctor, shoes were everything. It's like the shoes cured everything. And they really, they're just part of the equation and really the feet are more important. What the foot does, how the foot's set up to begin with, the motion that you can, well, it's easier to control motion than it is to create motion in a foot. So if your foot's made out of concrete, you're gonna need a cushioned shoe. That's just the way it is. If you've got a fairly flexible foot, you can induce some motion control which is probably more useful done intrinsically than it is done extrinsically using a shoe. And the other thing about shoes, which I'm sure you all agree with is how are they tied to the foot? If you can slip off your shoes without untying them, you might as well not even run with the shoes. So I see that all the time. I'm quietly screaming yes, because it's also like if athletes are triathletes in addition to just runners, a lot of times the shoelaces they'll use, it's like the bungee. There's all different names for them now. But like, and that actually can be a huge issue because it takes away any stability the shoe is giving them. And every time they land, the shoe is just kind of coming apart. So that's a whole nother thing is I'll look at the type of shoelaces. And there's like, I don't know how many ways to tie a shoe based on what's happening at the foot and how to support it. But I might change and do the runner's loop. That's the most common to make sure that it's snug on the foot. And then of course, there's the whole, again, I'm gonna stop after this because we could go on forever. But like, there's also the whole Super Shoe Carbon Plate discussion, which again, is probably a whole nother hour, but. Which we don't have time for. Yeah, so moving on. Very good discussion piece though. So I have some more questions. So Michelle Bruner has a question and I think I need some clarification. So it says back stress fractures, wondering if high, I think high risk stress fractures that are sent to orthopedics. Can you clarify your question? Hi, sorry, I couldn't get my chat function to work. No worries. My camera's working. It says it is, but I don't see me. So no, I was just wondering, I missed the very beginning of the stress fracture, but I'm just wondering some of these high stress fractures, like the supralateral femoral neck or the anterior tibia, I generally send them to ortho. And I'm just wondering in general, are other people doing that? Or are you just making these people, non-weight bearing on crutches for six weeks? I just wanted to get an idea of what other people are doing. Great. So happy for other folks to chime in. The way I typically manage it is I give them a shot. So if this is the first time it's happened, we've caught it, we don't have another bunch of really big risk factors, which obviously we have some level of risk factor because they have a critical site stress injury. I will typically unload them and see if we can get this thing to heal. Now, if it's a really remarkable anterior tibial stress fracture, or if this is tension-sided for the femoral neck, yeah, I talk to ortho right away. Or if it's 50% or more on the compression side, I'm also talking to ortho. But if we're talking compression-sided, it's less than 50%. And thank you for bringing up that important detail. If it's less than 50%, especially if there's not a fracture line, which I actually infrequently have seen fracture lines with the femoral neck stress fractures I've seen, I will usually give it a shot to put them non-weight bearing. Now, if they've told me they're not gonna stop running and we need to start having conversations about surgery, we'll do that. But I think I've only sent one person to actually have their hip fixated. Very young person, unfortunately. But generally I'm able to manage these things with non-weight bearing. I just have to put a little bit of fear in them to make them understand how important it is. But I think it also depends on comfort level because I think there are surgeons who will manage these too. I'd love to empower folks to be comfortable managing these because there's so much that goes around it. It's not just the putting them non-weight bearing and seeing back in six weeks. I usually see folks a couple of times during that timeframe to have all these other conversations and make sure we're addressing nutrition and mental health and all those pieces. And so I think as non-operative sports providers, I think that we have a lot more kind of all-encompassing care that we can potentially provide. And I think it can be very advantageous. I've also sent folks to have a surgery and I say, I still wanna see you back in two weeks. So they can go get the surgery and their weight bearing status is being managed by the surgeon. But I see them back and I talk to them about diet and we talk about REDS and I'm monitoring menstrual cycles and we're addressing that non-operative side of things as well. So I definitely encourage you to keep seeing those patients even if you are sending them on to a surgeon to manage the bone piece of it. I don't know if anyone else wants to speak to that, what they're doing. That's a great question. So thanks for bringing that up. Femoral neck stress fractures are not all made the same for sure. Thank you. Yeah, absolutely. So Mr. Dan Herman. So he brought up, what about andropause in the sky? This is sort of a hot topic without a lot of great data but I imagine this is a topic that comes up probably not easy to handle but this is about difficult cases now. So I'm gonna maybe turn it over to Kelsey. Yeah, I oftentimes ask, with like female athletes, we get a report card depending on their stage of life. I've gotten more comfortable asking men about their libido and that kind of thing too because sometimes it can be indicative of nutritional status. Not just libido though, like their recovery because that can tell us more about their nutritional status as well and what hormones are doing. Have they noticed any, are they someone that is doing strength training? Have they noticed any changes there? And so, yeah, a lot of times that does kind of, we might not have, I might not have labs in front of me, right? Telling me things like hormone levels but that can kind of tell us a little bit subjectively if there's anything from my scope of practice that we might be able to do. Oftentimes again, like implementing anti-inflammatory foods and then there are some specific nutrients that play into specifically like testosterone production and that kind of thing. And then I think also like normalizing, hey, this is supposed to change, but are we at least in a place, if we have labs, this is much easier, that's normal for in this specific case, a 52 year old male. And we're running up real close to time here, but I was gonna add to that. I mean, I think the clinical picture is oftentimes super helpful. So they say, hey, my body's been changing or something just doesn't feel the same. How do we manage these sorts of things? And sometimes the labs have limited utility. Oftentimes I think just looking at how they're feeling and kind of managing them symptomatically, same thing for the perimenopausal piece of it as well. But putting these folks into the stress fracture picture, I see these all the time where folks have done very well with their negative energy balance for many years until suddenly they don't. And then we're having osteopenia, osteoporosis diagnoses and a lot of things that can happen around that timeframe that they've been working on for a long time and were able to manage and then suddenly they're not. So I've certainly found that to be common too. Even folks in their, especially men in their 30s, I've had a fair number of folks that that's the first time they start getting injured and kind of not able to keep up with their energy needs. But I think that's a very, very great point. And I would also say that I'm asking about their recovery and how do they feel? Like how long has that changed that it's taking them longer to recover? Or how do they feel in the gym after they do strength training? How did they feel like they're getting the same results? So those types of questions are really important. And I find that with specifically men, the recovery piece is really, really, really important and changing how often we're running and changing the intensity and the consistency and how many days, that type of thing. And just saying like, hey, okay, you still wanna run, you know, four days, that's fine. But why don't we add a little bit more recovery time or a little bit more mobility to that session than we would have before? So I find that those recovery phases get longer as we get older. Training load conversations, I was actually gonna ask that a ways back. I think that's another really important thing. And it can be very simple. I mean, simply by putting someone on non-consecutive days doing high impact activity, you know, some very basic, do you take a day off each week? Question I ask every runner that I talk to, because if you don't, start today. So there's a lot of high yield questions that you can ask and make a really big impact that you're not delving into all the details yet, but you're getting some of the big picture, I think can be very helpful. We're coming right up on that, if you're on the East Coast, 9.45 PM time. So I am gonna go ahead and wrap up here. We had a couple more questions that we didn't get to. I'm gonna take notes. And as I'm planning my National Grand Rounds for these next sessions, try to get some of these topics in here. We also need to get Dr. Edwards and Ms. Kelsey Pontius doing some talks too. So thank you all so much for coming out tonight. I hope you found this conversation valuable. Thank you for staying up late with us. If you're interested in the National Grand Rounds topics, I'm gonna make a post on our member community so that you can sign up if you're interested. I usually send those out via email. Generally have been monthly. I'm looking at doing them quarterly in this next year. So if you have topics that you wanna hear about, experts you wanna hear from, certainly let me know. I'm open to suggestion as I'm planning out this next year's talks. Thank you all so much for coming out. Hope you have a good night.

interdisciplinary care

running medicine

athletes

holistic care

femoral neck stress fracture

low energy availability

subjective evaluation

nutrition

knee osteoarthritis

biomechanics

sports medicine