All right, thank you all for coming. I hope this is a great opportunity for good conversation and dialogue, so please feel free to ask questions. I want this to be the majority of what our session is about. But this is the Running the Runners Clinic, a how-to expert panel discussion. My name's Sarah Reiser, I'm from the University of Virginia Runners Clinic, and I'm very excited to have these four running medicine greats who are going to talk about their experiences and how they develop their own running medicine practices, how they might be different, how they might be the same, and some tips for you as either a trainee who potentially wants to learn more about running medicine or someone who's already in practice and wants to potentially develop a clinic. A little bit about me before we get started with our panelist introductions. I have had the fortune of being able to train with a number of nationally-renowned running medicine specialists, so University of Florida with Dr. Vincent, University of Virginia with Dr. Wilder here, Stanford with Dr. Fredrickson, and then I've worked a good bit with Dr. Tenforty, and then I just gave a presentation with Dr. Cianca. So I've been very excited to be able to be engaged with all of them and learn from them as well. To get kicked off here, I'm gonna have each person introduce themselves, and I do have a slide with a little background information. We're gonna start with Dr. John Cianca. Hi, everyone. I am in Houston. I have a solo practice now. I started out with Baylor College of Medicine and then became an independent, but I still have adjunct appointments at UT and Baylor. I got my start in running medicine really with Bob. We were both interested when we were residents, and then we evolved from there and came into our little clique after a while, and we were the running fellow guys, which was an unusual thing back then. But I evolved my practice over years, and predominantly with taking on the Houston Marathon as a medical director. So it's a little different than having a running clinic, but it was a lot of exposure to runners. So I did that for 23 years, and alongside that, I developed my own practice where I evaluated runners and worked with PTs and runners and had various types of ad hoc clinics that I saw runners at over the years. So done it a long time, somewhat at high level, but also predominantly amateur level. Great. So next is Dr. Michael Fredrickson. Great. Well, welcome, everybody. Glad you're still here on a Saturday morning. So more, a little background of how I got into this? Yeah. Yeah, okay. Yeah, so I was a collegiate runner, not like Dr. 1040. I was like an average D3 runner, but it was something people knew I had an interest in. And so when I was finishing fellowship, there was an opportunity, they were changing things around at Stanford, and they asked me to stay on and be a team physician. And one of the teams they wanted me to take care of was track and field, given my background. So in a way, I kind of fell into that. That was pretty fortunate. But it also timed when we had a new track coach coming in, Ving Winana, who's now at Virginia. And Ving was a powerhouse, and he built Stanford into this, we were winning national championships every year, and that brought a lot of things to Stanford. So before you know it, we were hosting the national championships there. They asked me to be the medical director. Then the Nike farm team decided to move to Palo Alto. They're now in Oregon. And so we had, at times, we had almost 100 runners on that team. At one point, we had 36 make the Olympic trials. So that was something I volunteered to do, but it definitely was a great opportunity. And that led to involvement with USA Track and Field, and becoming a national team physician with them. So, you know, you never know where things are gonna head, but one opportunity can often lead to another opportunity. Dr. Addington, 40. Hi, everyone. So, you know, my exposure to running medicine really was as a student athlete. I was fortunate to be recruited to run in Stanford, and had a team physician named Michael Fredrickson. So, you know, when I was kind of looking at my journey, there was a question about, you know, what I wanted to do when I grow up, and I'm still not sure the answer to that, but decided I wanted to go into medicine and was interested in sports medicine. And I remember the head trainer, Don Chu, being like, oh, so you want to be a physiatrist? And I was like, what the heck is that? And he was like, well, you know, Mike Fredrickson, he's a physiatrist. And I was like, yeah, you know, I want to do what Mike Fredrickson does. So, you know, that's really what led me down my pathway. And, you know, I think with the sport, getting injured, I ended up meeting my wife through that, and had my experiences and frustrations around being an injured runner. But then also having the perspective of trying to navigate the medical system, and having, you know, sometimes not so positive experiences, but really learning what sports medicine could look like, having great mentorship from Dr. Fredrickson, and then allowing that to kind of build into the practice that I have at Spaulding, where I direct the National Running Center. Dr. Robert Wilder. Yeah, hi, Bob Wilder. I'm the Chair of Physical Medicine at the University of Virginia, where I also direct the Runners Clinic at UVA. And as John and Mike have already mentioned, many years ago, the three of us were graduating from residency, and going into our fellowships, and focusing on sports medicine, and physiatry was just getting started at the time. And here we were with interest specifically in treating runners. So the whole concept of running medicine gets born, and it was neat to have two of my young colleagues at the time be as supportive as they were to help kind of support this whole idea that we had, that yeah, there's a need for a specialized area of sports medicine for runners, and encourage developing that. My first practice was in Dallas at the Tom Landry Center, and a lot of opportunities come to you when you have a seven-story building developed to sports medicine, and developing the Runners Clinic there was an important part of that. And then six years later, I get this phone call from Charlottesville, and the University of Virginia, which was my med school alma mater, saying, hey, we've got an opportunity, would you come back and join the faculty? So we looked at this wonderful practice that I had built, and this wonderful home we had built in Dallas, and we pitched it all to start all over again in Charlottesville. And as I came to Charlottesville, it was very clear to me that sports medicine was very heavily controlled by orthopedic surgery. So I focused on a community that I knew from my med school days, and that was the runners. And just started patient by patient, building a practice, largely treating folks that I used to train with. But over the years, it developed into being the true majority of my practice, and now the Runners Clinic's grown to where we have four physician faculty, and a network of consultants and therapists, and it's a really neat part of the practice that we get to do every day. So the next thing I'd like you all to touch on, which you let us off a little bit there, is what your running medicine clinics look like, and what kind of programming you might have, what types of resources you have, and think are important for runners. You want me to start? So my clinic has changed over the years. When I first started, and at that time I was full-time faculty, it was in conjunction with a venture that my chairman had the great courage to start, which was to go to an outpatient setting, which was, at that point, unheard of for a physician not to be hospital-based. And so we partnered with a PT company, and started this PT MD clinic for musculoskeletal care, and I, as I mentioned earlier, started focusing on runners, and I had a physical therapist with me who was also quite adept, and really taught me much of what I know. And so that's how we got started first, and then subsequently to that, there's lots of ownership changes. I left Baylor as full-time faculty, and started my own practice, which was a cash practice, so that changed the dynamic quite a bit. And, you know, the volume went down a bit, but I also matured in my own skills, and I came to be sort of the when nobody else could fix it guy, and so I'd see a lot of complicated running cases, and at that point I was fully involved with the Houston Marathon too, so my clinic was both in my office, and at Memorial Park, where a lot of the runners congregated during marathon training season, and I would have a clinic right there under a big pine tree with my fellow, or my other colleagues, Dr. Chorley and Dr. Devine, and we did that for 16 years, and then I left the marathon during the pandemic, and my practice got even more narrow as I went to a separate office where it's just me now. And so I still see runners, but it's in a very confined setting. I have a treadmill in my office, and I do whatever I need to do, but I don't have the same level of interaction with other medical professionals. But, you know, at this point I know what I need to do, and I know where my resources are outside of my clinic, so it's changed over time, and I think you could be open to doing your running clinic in any number of ways, and so it doesn't have to be a one thing only, and my practice is sort of an attestment to that. Keep it the same order. Doesn't matter. Yeah, so I love to treat runners, but I have to say it's not what I want to do full time, like they would drive me crazy, because runners are very obsessive, as I know, being one. With that said, you know, liking that I would like to treat all athletes, and that's the kind of practice I've built, I have advertised early on a runner's injury clinic, which was really just, you know, telling runners in the community you could come to me, and then we would evaluate them in the clinic with somebody who had expertise in that. But then it grew to something a little different, and we started a program called Run Safe. And so this was something we would do in the evening, and we would just do four runners at a time, and it was cash pay, so it was outside of our regular medical system, and we have four stations. So there's a gait station, and we put the markers on, and we do a 2D evaluation of their gait, and we video that, and then we slow it down, and we put markers on, and we show it to them. You know, ways in which maybe they could improve, right? Then there's a strength and flexibility station, which one of our physical therapists would always run. And then we have a foot and ankle station, and we had a really good orthotist in town who would run that, and he just retired, so we're kind of looking for a different way to do that. And then we have a nutrition station, we have a really good dietician who would run that. And so they spend about 15 minutes in each station, and then they get a nutrition lecture while the treatment team gets together, and we come up with a plan for each person, and then we bring them back in the room, and we show them the video, and we try and give them sort of an overall assessment from those four stations what they need to work on, and what's a good take-home program. And so that was a really good model. I have to say, it's not so much that it's gonna bring in a lot of money, and it's something you do in the evening, but it's a great way to get your name out there, it's a great way to offer that kind of comprehensive service to runners. It's really hard to do in the middle of the day in a busy clinic. Yeah, so my current practice is primarily seeing runners two days a week, and then doing research the other three days a week. When I came to Spalding nine years ago, there had been the establishment of the Spalding National Running Center, which was directed by Irene Davis, and was really a physical therapy-based approach for gait retraining, really with the philosophy of teaching people how to run with minimalist footwear with a forefoot strike. So when I came to Spalding nine years ago, I started out with a half-day clinic, a lot of crickets, maybe one or two people that would come in for a half-day, and could spend as much time as I needed with them, but started to build some trust, and I think that's a big part that you'll hear across speakers, is when you develop the trust of the injured runner, and they understand they're gonna get something different than, well, if it hurts to run, don't run. I mean, my rebuttal is if a soccer player hurts their knee, we don't tell them not to go back to playing soccer. We try to figure out what the multifactorial nature is of the injury, and the appropriate rehabilitation. So what's really kind of evolved over time is that I now direct the Spalding National Running Center. Our goal is to be kind of the go-to location in Boston, so we have six different centers where we have physical therapists who have been trained on doing an hour and a half gait assessment, as well as using an instrumented treadmill to determine load rates and other aspects of biomechanics. My clinic is really on evaluating the runner, and thinking in a holistic approach, and very similar to what you heard from Dr. Fredrickson with the Run Safe program, thinking about, is this someone with low energy availability who needs to meet with a sports dietitian, and we have a really good established sports dietitian, but there are a number of other aspects that go into sports medicine. It's not just acute and overuse injuries, it's sometimes working up fatigue, it's the middle-aged athlete that also starts to develop cardiovascular risk profiles, so having a relationship with sports cardiology. And where this is all heading is they've built a new clinic for me at Boston Landing in the New Bounce facility, and so the goal is to have like-minded, non-operative counterparts that are gonna be seeing the injured runner, and kind of thinking from a multifactorial nature of sports dietitian, sports cardiology, our gait retraining program, but then also trying to think of other interventions and strategies to take care of the injured runner, and that's where I've found Shockwave to be quite helpful, because the downtime with it is quite short. It is a cash-based service, so that also can sometimes be helpful for getting a new technology into the clinic if you can show that the economics are gonna be good. So it's really kind of a hybrid approach where I'll see people through typical insurance, aspects of the gait evaluation aren't covered, the instrumented treadmill, aspects of Shockwave and other different forms of orthobiologics may not be covered, but we can take a multidisciplinary approach and figure out how to safely get people back to running. So if anyone has questions, feel free to step up to the mic, and that'll pique my interest to come over and have you pose your questions. So any questions right now? I've got plenty more to ask, but if there's anything that's coming up for you guys. While you're coming up to the mic, so a couple patterns that I'm hearing is certainly a very multidisciplinary approach, and that folks really got into running medicine in a number of ways, sometimes just falling into your lap in some ways. Hi, my name's Zatar, I'm a fourth year medical student in Roslyn, Franklin, Chicago. I was really interested in hearing about this talk, I'm really interested in sneaker design, and so hearing about this talk, I was kind of interested in learning more if there's any applications of physiatry in, for example, consulting for a sneaker company and being involved in that sort of sneaker design aspect, or if any of you have heard about that before, if that's an opportunity available. So I'll jump in on this one. So our former chair, Casey Kerrigan, who came from Harvard to us many years ago, actually left opening up the door for me to become chair 15 years ago to start her own shoe company called Osh, and she models it after a minimalist type approach, but, and for years in our lab, we were partnering with some of the shoe companies to do testing, and I believe Adam's doing that as well, and so yes, definitely a role to be involved, and I think as physiatrists, we need to be aware of the developments and the options that are available to us so that we can apply them to our patients. Great, thank you very much. I'm happy to add a little bit to that too, as Dr. Wilder had mentioned. I don't think it's a coincidence that Mass General Brigham bought out the lease space on the first floor of the New Balance building, and there's a natural synergy there when you've taken care of their athletes and they have the trust of you, but then you also start to hear from the coach and the athletes what are their questions about the footwear design. So I think, you know, one thing Dr. Fredrickson hasn't brought up yet, and maybe he'll share a little later, is like a lot of some of the pioneering work in some of these injuries, like IT band syndrome. It was, you know, you just kept seeing it. And you're like, well, we should probably describe this. So honestly, one of the most impactful things I've published on, which I didn't think was really all that great, was describing five individuals that were wearing these carbon fiber plate shoes with a responsive foam, developing navicular bone stress injuries. And what's been really fun to see is trying to identify the appropriate partnership with industry. So that's still something we're fleshing out, but can we start to look at the footwear? Can we start to deconstruct the different aspects of the footwear and actually look at the running mechanics? So that's something we're exploring, is can we better understand, for example, in these carbon fiber plate shoes, how much of it is the plantar displacement of the tarsal navicular bone that is actually contributing to an increased risk for developing navicular bone stress injury. But even listening to some of the elite athletes in New Balance sharing stories of some of their teammates, you know, talking with other runners. And again, these were actually non-New Balance athletes, but across the use of these super shoes, developing meniscus root tears. I mean, that's crazy. 30-year-old female runners, three different ones, all developing meniscus root tears while wearing super shoes. And if we really look a little more at what's going on with the sepal chase, we had a couple of women that had some pretty significant ligamentous injuries. So I think there's an opportunity for us to explore and to be seen as leaders in this field where we can really actually partner with industry in a responsible way to try to answer these questions. But I think that's the other piece, too, to kind of take away from this is just being intellectually curious about what's coming in, having standardized questionnaires, starting to phenotype the injuries you're seeing, and then you might actually be able to describe them. And that's honestly a model I learned from working with Mike Fredrickson. So I carry that forward. Yeah, I just wanted to take your question, maybe build a little bit on one of the last questions for those who were in the injured runner session, which what do you do when your athlete or your team is sponsored and they don't find a shoe that works within that brand? So this happened to us with Nike multiple times because that's who sponsors Stanford. So you're left with a couple options. One is the athletes get a new shoe and they tape over the logo and try and hide it. The other, which we did do on several occasions, is we actually fly the athlete up to the Nike lab, and I would go with them sometimes, and work with their biomechanists to redesign the shoe in a way that would work for the athlete. So in terms of shoe design, I think it's important to understand that to the degree that you can because sometimes you really do need to help the athlete work through that. We also had another athlete who was a professional mountain racer, was number one ranked in the US, and was sponsored by Hoka. I don't know if I should be saying these companies, but she was developing a number of injuries from that. She had a really bad tailless stress fracture and just said she couldn't run it anymore. So again, that was another situation where we had to talk to them how to modify the shoe so she could still be sponsored. So as a physician, if you're doing this kind of work, you may be put in those situations where you need to work with the company to help them redesign the shoe so it works for your athletes. So I think there's a lot of troubleshooting that happens with things like shoes, but as Dr. Sianca mentioned too, I mean, oftentimes we're the folks that people have seen, already seen one, two, three other people, and then they're coming to you hoping that you might be able to help them, and I think developing rapport is really important because you will become that person they come to. To put a little plug in for physiatry, I think PM&R is excellent for that position with the musculoskeletal training and functional training to be able to help provide that care. Hi, my name is Matt Allen. I'm a medical student at UC San Diego. So a lot of the purpose of these clinics, it seems like, is to help athletes who are runners who have injuries be able to keep doing their craft. But is there any role for these sorts of clinics in helping people who aren't running because they have XYZ physical limitation or whatever thing that has stopped them from doing that start doing it? Well, just real quick, and then I'll pass it on, but the idea of our Run Safe Clinic was actually geared towards that, was for people who were injury-free and wanting to prevent injury. So that was our goal. Well, what about people who aren't runners that would be injured, but maybe don't have to talk about where we're at? We would get a lot of people like that. They were thinking of training for a marathon, but they don't want to get injured. They're really worried about that. And so they just want to kind of make sure everything's okay. Is there something they should be aware of? Because it is brand new. So that kind of clinic setup that I talked about, the Run Safe, can be very helpful even for that type of person who's just starting. So is the question that they want to run a better idea for them to run? Yeah, that's a good question. I guess like lifestyle intervention clinics. Okay, right, okay. If they're not resistant, is there a role for these clinics to help them stay active? Well, certainly as a physiatrist, you're gonna try to get people to be active. Multiple ways to do that. But to address where Dr. Fredrickson's coming from, there was sort of the reverse approach. It was like, oh, yeah, you can run a marathon because you want to. I don't hold that view. I never have. Marathoning is arguably the hardest endeavor to train for. There's an issue of time and exposure. And then there's the race itself, right? So this whole idea that, yeah, just go train for a marathon, you'll be good. I never bought into that. But that was the way it was presented back in, I don't know, the 90s, 2000s, whatever, a long time ago. And I started this clinic at this program that was called Houston Fit, the notion being that anybody can run a marathon. So I kind of keep my mouth closed, but I didn't believe that. And so I was dealing with people who were diving in too deep, too fast. And that's the reverse strategy, right? You're trying to pull them back and say, why don't you do it a little bit differently? So the point being that the counseling aspect of that is important, as is common to what we do as a specialty anyway, right? We're constantly working with people, trying to get them oriented to a new situation. They've lost their leg, they don't have use of one side of their body, they wanna do something new. So one of our jobs, if not our primary job, is to educate them as to how to do this in a reasonable way so that they don't get hurt, or more importantly, are able to stay with it, right? I've even given some interdepartmental talks where I'm trying to talk about kind of the generalizability of running, right? I mean, we still have a kinetic chain that we're evaluating and people are still walking and mobile and moving, and you can use a lot of these similar tools with treating any of the patients that you're seeing. I think certainly having conversations about is it smart to start running and then training for a marathon is not just shin splints you could get, but you could have a catastrophic injury. I mean, it's not without risk, and so being able to educate on that piece. I do a fair amount of preventative training, which is helpful as you start getting more rapport with your community. I say preventative appointments. So people come in and they just wanna know about iron and vitamin D and nutrition, and I don't wanna get injured, and are these the right shoes? And I've had very long conversations with folks like that that come in, and that's the ideal, right? The preventative care. So I certainly think there's a lot of generalizability, and I would imagine the majority of you don't see only runners, right? We still see some general population or people who have stopped running, people who develop arthritis, or there's a variety of patient populations that we all see despite us being in runners clinic and having that particular specialty. One of the things that I did early on, I don't know, years back, it's still popular, but it was really popular probably 20 years ago where the team in training through the Leukemia and Lymphoma Society, so basically everybody wants to do a marathon. Their pitch was that we'll take you, you've never even run before maybe, we'll get you to a marathon in like, what, three months? So what I, and I mean, it was, my clinics were filling up with these people, right? So in a way it was good, right? It was filling my practice, but then I offered to start doing like injury prevention clinics, and I would go out and talk to them at the beginning of the season. And it got to the point where then the coaches basically learned the program that I showed, and they were able to institute that. But I just mention that because it's a great way to get involved in the community, and to work with those people who are just starting, and to try and make sure they can do something like a marathon in a more reasonable way without getting injured, because we are seeing tons and tons of injuries. Could I hear how other folks have kind of integrated into the community, and developed that rapport with their community? So, a lot of ways. On the training front, I will say this. We're really fortunate in Charlottesville, our little, small world that it is, we've got a number of different training programs that we've been able to work with, and share education back and forth. But so many folks will start by enrolling in the Women's 4-Miler Training Program, which is our largest annual race for breast cancer. And they don't always start out by running it, they start out by walking it. And as the bug bites them, and a few years go by, then they join our 10-Miler Training Program, which is our big race in the spring. And they succeed with that, and they'll join the Half Marathon Training Program, and then the Marathon Training Program. To be able to just gradually progress people along has been a neat collaboration. But as far as being involved in the community, I mean, several options that you have. We cover a lot of races. We do the sports medicine coverage for a lot of the high school and college, cross-country and track invitationals, all of our community events. Some of them are very small community 5Ks, and we're really there just being a part of the community and providing that service. Some of these bigger races, obviously the services that we offer are pretty important. We do education on a number of different levels. We speak at a lot of high school cross-country camps, at the running shop, the training programs, which is another way of being active in the community. We hold our running medicine conference each year, which is geared towards physicians and trainers and therapists. Adam was our keynote speaker, and John and Mike have spoken at it over the years, and it's a way of building our community of healthcare providers throughout Central Virginia and beyond, and maintaining those relationships. So, a lot of ways that you can be involved with your community beyond just the day-to-day seeing folks in the clinic that we do. Hey, my name's Jack Kilgore. I'm a PGY-3 at Vanderbilt. My question is how often or what percentage of your practice involves ultrasound-guided procedures to treat a lot of these athletes with these issues that you're commonly seeing? Well, I'll tackle that first, because maybe you didn't see my previous presentation about 45 minutes ago, but I use ultrasound a lot to verify my history and physical, right? So, I'm doing diagnostic ultrasound. So, if there's a need, I don't put a needle in somebody without ultrasound almost never anymore, because it just makes the procedure safer, more accurate, and generally less obnoxious to the person. And they get to see it, too, and that's the other value I hadn't mentioned about ultrasound. It's a great tool to teach people what their body's doing, and that's sort of teaching sort of my thing. I like doing that, whether it's people in medicine or patients in front of me. So, I'll expand your question a bit. Ultrasound-guided procedures, absolutely, if you've got to do them, but ultrasound in general, simply because it's a great adjunct to what you do as an evaluating injury. I'll just jump on that and say, in contrast, I tell my patients, I dabble in ultrasound. I took one of the Mayo Clinic's very first courses in ultrasound. John was actually there 15 years ago, and I came back to thank my chair that I was gonna really look forward to incorporating that into my practice, and she said, oh, great, glad you had fun. By the way, I just turned in my 30-day notice, and I told the dean you should be chair. So, I got really busy, and so what do you do in that situation? You hire people that do ultrasound and are really good. So, we've got a couple of folks who are very talented in ultrasound, and one of them is at the podium. So, I do incorporate it into my practice, a little bit on my own, but largely by referring to Sarah and Dave Rivniak, who are on our faculty, to get that information for me, or to perform injections that I know are gonna be better done with ultrasound as opposed to blindly. So, it offers a really important addition to what we can offer, both diagnostically and therapeutically. I do a lot of ultrasound procedures in my practice. I don't do that many, actually, in the runners, but I use it more for diagnosis. So, for instance, Dr. Sianca mentioned this in his last talk, but I was always interested in, you know, I came out of the grading system years ago on using MRI for bone stress injuries, and I was wondering, you know, could we do the same thing with ultrasound? So, we did a study comparing ultrasound to MRI, and found it can be very helpful, you know, at point of care, at least as a screening tool. It gives you an idea of, you know, what's going on at the cortex, if there's fluid there. You're gonna miss things that you can see on MRI, but it's right there in the clinic. We have it in our training room. We have it in all our clinics, and outside for the community. So, that's just an example of a procedure, diagnostically, that you can use all the time. I was gonna say the same thing. I do a lot of injections. I don't do a lot of injections on runners. Certainly a handful, but. Yeah, I mean, you know, a word of caution with runners is, you know, they're looking for pain relief, and, you know, sometimes it can backfire. Kind of a memorable case in the past year is someone who's seen me for an additional opinion, who I think developed rapid progressive osteoarthritis of the hip after an intra-articular steroid injection, and was told, you know, go to physical therapy, follow up. Didn't follow up with the previous provider, ran a marathon, developed debilitating pain, and then had end-stage arthritis when they saw me. So, you have to remember, I mean, the reason runners will come to see you in clinic is they can't do something they love to do, and so it's really about understanding their goals, and it's also about, you know, really informing them of what the goals are around the different treatments you're doing. So, I agree with everyone. You're really not thinking about, like, how do I inject my way out of this problem for an injured runner? I like the orthobiologics in this population. I like Shockwave in this population, but that's always coupled with structured rehabilitation to ensure that we have a team-based approach to helping rehabilitate. Hi, I'm Jerry Miranda, faculty, maybe senior than the other questions. So, I have two questions, maybe for Dr. Fredrickson, the first one. The RunSafe, that's station-based logistics, and then you group together, and then you discuss. The patient, the runner, all of them at the same time hear the discussion of each other. Is that something that was helpful, or is it, how did it work? Yeah, so at the end, when we bring everybody back together, we found it really helpful if they hear the other person's story, too, because a lot of times, there's a lot of things that are not unique to them, and then they don't feel so bad when they hear, oh, well, this person has to work on the same thing. But we don't give it to them individually. We do it as a group, and we find that that just leads to more discussion, more acceptance of what's going on. They're not alone. Everybody in the room has some things. And I always say to the fellows who help out with this, don't start with something negative, right? So, start with something positive that they're doing, and then you can tell them things that they should work on. But yeah, we do it all together. That's the. And the second question is about when do you go to customizations of shoes, for example? You have this athlete, and you evaluate shoes, you evaluate their gait, you do the whole evaluation. Is this somebody that you made simple modification, not necessarily custom, and that person kept getting injured, same injuries or different injuries, and then when do you get to that customization? When does that high-level athlete goes to the company to get a custom-made shoe, pretty much? Yeah, I mean, the custom shoe is pretty rare, except for the professional athlete. I mean, occasionally, if somebody, for instance, we had one athlete who had, he actually transferred into Stanford, was supposed to be this incredible 800 meter runner. Within one week he develops IT band syndrome. Turns out he had almost 1.2 centimeter leg length discrepancy. All I did was correct that and his IT band went away. So that was putting something in the shoe. With the RunSafe program we do have an orthotist who can make a custom orthotic, but he never tried to push it. It was more like, let's try a few modifications. If it helps, let me know if you want something more custom. But it's so expensive we try not to push it too strongly. Try to tinker first. Jerry, one of the things that I've gravitated away from over the years is shoes being the primary source of the problem. I mean, that was kind of a mantra years ago. It's like, oh, I'm wearing the wrong shoe. Well, maybe. Really what you gotta think about is how that person functions and does the shoe help them or not? And I would start with, where's the mechanical problem? Can that be changed? Or do we have to do something with the shoe, as Michael was saying, that could make it more useful? So I used to do this thing at a running shoe store, help people get in the right shoe, which is still valuable. But it's not enough most times. You really have to get people's understanding of, one, what's their basic structure, alignment, function, along with that, those things. And then, does the shoe play a role in it? You know, a lot of runners still put an overemphasis on the shoe. Like, everybody wants to go to the latest shoe that's, you know, whatever, carbon fiber. You know, there's more to work on with the runner than the shoe. You know, and that's kind of where the focus, I think, is more appropriately spent. Now, getting runners to believe that, this is a different issue. I mean, you really have to help people understand what the issue is and accept the fact that you're injured, okay? You can't ignore that. You've got a problem. Why did you have that problem? And we have to go about correcting it. And then helping them with goal setting around that because too many people want to just get back out and running. They're like, it shouldn't take me any more than five minutes to get back to running. You've got to get them oriented to what are you doing, how can you do it better, and what's a more appropriate way to get to your goal? Yeah, I think it's worth recognizing footwear is just one of multiple factors that you need to be thinking about when you're evaluating a running-related injury. And again, I mean, I have the perspective from working with Dr. Fredrickson at Stanford. I also have the perspective from working with Irene Davis, which was pretty different, where it was the merits of not wearing footwear, the value of getting people out of foot orthotics and really focusing on foot strengthening. I really kind of fall in the middle. I think I prescribed custom orthosis a handful of times in nine years. Probably can count it on one hand. I usually will start the individual with a physical therapist that understands foot strengthening. And in terms of footwear, if you really look at the three randomized control trials that were in the military looking at people's foot posture and trying to match a shoe compared to just matching to a neutral shoe, there was no reduction in injury rate. I mean, you may have someone who has a more advanced or an underlying neurological condition which is affecting their foot architecture, and then they do need custom shoes or custom orthosis. But I think this is a challenge and this is a myth that we kind of have to dispel, as I think you're hearing from everyone, which is that, I mean, the reality is footwear industry is trying to sell a product, and that's what's being marketed to consumers, and there's nothing wrong with that. Just like my earlier comments on super shoes, there's nothing wrong with super shoes. It's just you have to understand how to use them appropriately, give your body adequate time to adapt, and try to mitigate the risk for injury if you're gonna use them from a performance standpoint. Who are your collaborators who help you take care of runners? And how did you find them? Well, I would say I was very fortunate. I came across a therapist who was just outstanding and was even more demanding and meticulous than I was. I mean, she was tough to work with from a runner's point of view, but she insisted that they do things correctly, which is important because you can't take shortcuts and expect to get to where you need to be and so she made them think and made them do things. So having a good physical therapist who works with the people to help them get the fundamentals into their body and then integrating those fundamentals is very, very important. As a diagnostician, I like to say or think that I was better at diagnosing than my colleagues because I put the time into thinking about it and understanding it beyond the point of complaint. So facilitating your own abilities, that's not really a partner, but it's allowing yourself to be better at what you're doing is helpful. Having somebody you can rely on to kind of take it from there and help implement it is a good step. And then probably a real shortfall is coaches outside of the clinic, right? Because you have to then translate this to training and that's not really something you can do in a medical practice. They have to get out of the physical therapy center at some point and then they've gotta integrate. So really, probably the weak link in this system is the community-based coach, personal trainer, whatever. You know, and a lot of people describe themselves as a running coach, but they're devising training programs. That's not all there is to coaching. Coaching is about teaching people how to do things in the performance area, not just give them a workout. And those people are hard to find. Certainly the physical therapists are very important and we have a number at our center that are great, but we also have a list that we can give folks that list therapists throughout our region that we know are gonna be delivering good care. We've got chiropractors that offer good services and I think it's important for us to know that not all therapy is the same. So making sure that you're on the same page with folks. We have a primary care physician in our clinic that provides some primary care sports medicine components and then a network of physicians that are quick to take on our folks when we need to, cardiologists and orthopedists and neurologists and others. So having that network's important. It goes into the coaches and then ultimately the athlete. I mean, you're collaborating with them in their care. So communication and education is just so important and those relationships get built over time, but you'll find that as you do that they're lasting. So it's important to really have good communication with these people that you're working with, the athlete, the coaches, and then the different levels of caregivers. Yeah, the one thing I would add to that, what's really helped us is you need to find a good massage therapist, not just any massage, but somebody who does really good deep tissue work, really understands the anatomy, and ideally somebody who has a lot of experience with runners. That has probably changed things more than anything for us. And where it started is, this goes back to IT Band Syndrome, when I first started taking care of the Stanford team, it was our number one injury, and we would have athletes out a whole year with it. And there was one athlete, one of our best runners, and it started in pre-season camp, and they were doing a lot of hills, it didn't seem like it came on, it was his first injury with it, but lo and behold, it lasted the whole season. We tried everything. And it got to the point, I said, I don't know what else to do, so I think you should see our surgeon. And he didn't like that idea. So he heard about this massage therapist from Ireland who was treating all the elite African runners, but he happened to be, this person was gonna be in Florida for a while treating some of them. So on his own, Stanford wouldn't pay for it, he flew to Florida, spent two weeks there, and every other day he had a treatment. And this is not like feel-good massage, this was like he had to do an ice bath before it because it was so painful just to get through the treatment. I had another woman go there, two-time Olympian, she said it was worse than childbirth. But he came back after the two weeks and his IT band was cured. So one of our massage therapists in town said, I better learn this technique. And he went and learned it, and then that athlete actually, even though he was like an anthropology major, decided to go into this for his practice. And the two of them formed a clinic. And I have to say, we use them a lot for our injuries, particularly for preventative or early on. If you can address some of these myofascial restrictions, it's really helpful. Like IT band now, if one of our athletes has it, boom, they're going over to the massage therapist right away. And we find if we can address that early on, most of them will get better without injections, things like that. Now the strengthening, which we did a study to show that runners were weak in their hip abductors, if you start that too early, it just makes them tighter. So first you have to work out all the myofascial restrictions, get them back to some running, and then the strengthening for more prevention. The strengthening will not cure the injury, per se. So I'll put a plug in here. Running medicine physicians are, they have a special amount of training and expertise, and physical therapists, same thing. So it can be tough finding a good physical therapist and doing your outreach and community, talking to people, asking your patients who they're seeing and if they were good and how they recovered with them. Ask your patients what kinds of physical therapy they're doing, their home exercises, have them demonstrate. So did they show you them how to actually do the exercises properly? But doing all those things, you can kind of figure out who might be good at what they do and understand runners from that standpoint. The other tip I was gonna throw in there too is when you're seeing someone who's been sent to you from elsewhere, try to go in there with a fresh set of eyes because if you're looking at it from a running medicine perspective, you may pick up on something that obviously this is what was going on, as opposed to kind of a more generic, maybe an acute injury or other type of diagnosis that doesn't quite match the picture. Sports dieticians I think are super important too, and again, not made the same. So you really have to test them out and figure out who knows what they're talking about, pick their brain, figure out how they're talking to their patients. They might even have a book, which can be helpful, because oftentimes that'll be their tidbits on how they provide their care. I have a sports dietician that I worked with with the Atlanta Track Club Elite Team, and fortunately some of the restrictions with dieticians across state lines aren't so stringent as they are with other specialties like medicine, and so you may be able to take those folks with you if you're changing states. She's never actually worked in the same state as me. But those are really special people, especially the person you can call up and be able to have a conversation about a patient and their care, because a lot of this is very ongoing care. This isn't, here's your plan, we'll see you next year if you have any issues. This is oftentimes something that you're following up on a pretty regular basis and tweaking the plan. And if you've got a therapist you can depend on to make those adjustments, and that's really great if you're not so confident in them, meeting with them more often can be helpful as well. I'm curious, so the triad, so male-female athlete triad has been around for a while. Relative energy deficiency in sports, getting more press recently. I'm curious how those types of conditions and the recognition, especially in runners and repetitive athletes, how that might have potentially changed your practice and things you might be doing differently, or? I'll take it first. I think that sometimes it's more subtly presented than others. It can be very apparent in elite-level runners as they kind of look at, right? Eat a sandwich, please. Do something to give yourself a little bit more energy. And we're talking beyond just disordered eating, too, and Michael and Adam can certainly be way more eloquent on it than I can. But you have to be aware of it being a thing with your runners. And again, outside of the elite-level, one, because that's mostly who you're gonna see, and two, it's more subtle in them. They may not be the obvious person to think about with that. So you kind of have to be able to get into it with them if you suspect that there's an issue. You know, you're having a lot of overuse injuries. You're not recovering well. What else is behind this? They may not bring it up. They may not realize it. They may wanna hide it. So, you know, be suspicious, I guess, is the best way, or certainly have your mind open enough to look into that, because it may be part of the problem, particularly if you're seeing them over and over again. Obviously, their training's an issue, but part of that is their recovery and their ability to sustain their training. Yeah, I mean, you gotta ask them. I mean, every athlete that comes into the office, we're gonna have some basic screening questions, and don't skirt around it. Just ask them, you know? Ask them if they've ever had patterns of restricted eating or, you know, excessive training and whatever it might be. And if you're starting to see a pattern of, you know, recurrent injuries to make you suspect it even more, you know, tell them, I'd like to do some more detailed screening to see if this is something that you're at risk for. There's no, you know... It does not need to be a stigma. It's a part of their condition that needs to be managed and treated. And that's what we're doing. We want to make people healthy, and we want to keep them active. And if that's going to be a component of what they're bringing in, we've got to identify it and treat it. Otherwise, we're doing a disservice. Yeah, I mean, I completely agree with that. I think, you know, what's important is, you know, to ensure that the athlete can open up and talk about this in an honest way. So I think the questionnaires, if you have the questions written in a way, like for example, age of menarche or secondary oligomenorrhea, amenorrhea, it's not necessarily stigmatizing if a woman has a menstrual period or not. So sometimes you can start with some of the basic questions and maybe not necessarily ask about, you know, have you had an eating disorder before? Because that might come across as not the easiest lead-in. So usually I'll start for, you know, the female athlete, you can look at the questionnaires and usually preface the comments, particularly if you're thinking about someone at risk for bone stress injury, you know, just saying, you know, there's a number of components. We're just trying to do a deep dive and be comprehensive. And, you know, sometimes you'll have questionnaires, like they have a special diet, or maybe they have celiac disease, or they have vitamin D deficiency, or they have iron deficiency. But, you know, getting into maybe the menstrual health, getting into, and then sometimes leading into that, like, hey, you know, is your weight stable? Have you, you know, ever had any concerns about your eating? And oftentimes athletes will open up about it. And also don't assume that the questionnaire will reflect their complete history. So you do need to ask, but sometimes those other questions can be good lead-ins. The science on whether it causes non-bone stress injury is still not completely settled. We actually looked at that in our Stanford cohort and assumed that, you know, a higher burden of triad would be associated with both bone and non-bone related injury. And it looks like it may not be, but at the same time, regardless of what you're recovering from, you know, the idea is you wanna be in an anabolic state. You wanna be recovering. And so that's really the way that I like to present it is it's more about identifying, you know, strategies around feeling, you know, well-energized and fueled and recovering as quickly as possible and being able to perform well, as opposed to, you know, concerns around, you know, the risk for injury, which, you know, might be appropriate in the acute phase, but the long-term phase, that's probably not gonna be the most motivating way for people to be afraid of getting injured again and focusing on their nutrition that way. And then getting back to the question on dietician, virtually everyone who has questions about their weight, and sometimes it's actually individuals that are doing weight loss. So you have to remember that some individuals who have history of eating disorder will actually develop obesity and vice versa. Individuals that are motivated to lose weight can develop eating disorders. So, you know, getting them partnered with a dietician, cracking the door open, being willing to help them with like getting connected with mental health providers if they're open to discussing it, but really it is a multidisciplinary team. And I like to say my dietician speak athlete, they're not gonna show the food pyramid, that would just be a waste of your time and co-pay. So, you know, we have to give you something that's gonna be helpful and is gonna speak to what your goals are. Yeah, I mean, I have a vested interest in this. I've actually just took on the position of president of the male and female athlete triad coalition. and it's only recently that we added males to that. We had two consensus papers that came out two years ago to define the condition as a real condition, so it's not just in females. I would urge you to go back to a 2014 consensus paper by the Female Athlete Triad Coalition. The first author was Mary Jane D'Souza, and as part of that, we described this, what's called cumulative risk assessment tool, and there's six questions, and most of those you've heard already, and we use this in our pre-participation physical, and then you can grade them, you know, age of menarche, BMI, history of amenorrhea, eating disorder, or just, you know, even energy deficiency, history of bone stress injury, and then DEXA, if you can get it, although even without the DEXA, it's helpful, and then different points you give them, and then based on those points, you could determine, at least at the competition level, do we clear them, do they have limited clearance, or no clearance, and then which of those, if they're in the moderate to high-risk category, they're all gonna see the dietician, and maybe even more than that, you know, maybe even a bone endocrinologist, so that's really helpful. We're coming out with a revised consensus statement this year, so keep an eye out for it with even a lot more information related to this, because it'll fool you, particularly in the males, you know, because you can't ask them, are you not having your periods, and some of the questions related to it, like is your libido low, or do you have morning erections, those are hard to ask, and they may not even want to be honest about that, so I look for subtle things, like is their performance decreasing, or the coach will say, you know what, he's just not responding to the workouts, and then you can't find anything else, start to look for, could be an underlying energy deficiency issue. So, you have a question? Hello, my name is Mary Rose Zavaro, I'm a fourth year medical student at Lake Erie College of Osteopathic Medicine. I recently did like a journal presentation, or journal article presentation on a study that was analyzing overuse injuries in first-time marathon runners, and the effects of strength training on that. In this study, they did like 10 minutes of hip abductor and core exercises, three times a week. I was curious about your guys', in that study, they showed no significant difference, but I was curious about your guys' experience with strengthening exercises, and their effects on like overuse injuries. Thank you. Okay, I'll keep going. Well, so you're defining the basic substrate of performance, right? You gotta have strength to even get to the start line. But then, maybe the reason that didn't show any significant results, is how are they integrating those exercises into the way they run, right? So what I'm getting at is, what are they doing when they're running? You can be strong and still run poorly. You could be strong and still have problems. Running is a dynamic thing. It's not just about a static exercise. Dynamic exercises are good, but they're still not running. So that's why I was getting to with the idea of a coach, right, you've gotta have somebody to help that runner translate the fundamentals, the core substrate of being capable to actually performing. And you just don't do that in my office. I mean, I can't do it in my office. I can talk about it, but you've gotta have somebody help them do it. And that's a hard thing to translate, right? You can't run and really think about your form very well. You might have a thought that you can go to, but it's really hard to change your gait while you're running. So, the point being that I think the study's reasonable, but it's not the whole story. And I think we look to 10 minutes three times a week. We're talking about a pretty minimal baseline type of activity there. And the other is what are we targeting here? So it's very different if we're targeting specific weaknesses that are identified than if we're just doing a general type program. So, as I'm counseling patients in the office, I mean, we do quite a bit of strength training, especially if we're identifying deficits that need to be improved. I mean, rarely are we sending people off with strength and development programs without a specific focus. Yeah. Just to build on what Dr. Cianca was saying. So, there was a really interesting study that looked at runners with patella femoral pain. And these were, they all had that increased femoral adduction and internal rotation, you know, where the knee kind of collapses when they do a single leg squat. So, they had them in physical therapy, and they normalized that. So, they were able to do perfect squats in physical therapy. Strength was great. Put them back to running, nothing changed. Nothing changed. And so, it goes to the point that you need to build that in to their mechanics. It's not enough to just do a pretty squat in the gym. You have to translate that into the running, and that's where the gait retraining is really important. We always say, and Adam will tell you this in our Run Safe Clinic, we say, you don't run to get fit, you get fit to run. And so, having that baseline before you start something like a running program, particularly if you're brand new to it, is really important. Yeah, just to piggyback off of that. I mean, I think we know that running is not, doesn't always produce athletes. I mean, you should be athletic to run, but you don't have to be athletic to run. So, there are a lot of muscle imbalances that we don't develop, and typically, it's weakness with the hip abductors, extensors, and the plantar flexors. So, the way that Irene put it, which I thought was really nice, is running's a series of single leg squats, hops, and landings without falling down. So, you can really learn a lot just watching someone in your clinic do a single leg squat. Can they even maintain single leg balance? You know, what's happening at the hip? How's that affecting the knee? But, yeah, I think what Dr. Fredrickson was speaking to is it was actually in healthy individuals, the Willie and Davis study, where these were males that had, you know, their single leg squats looked horrible. They did eight weeks of progressive strengthening. So, this actually would be very much in lines with the injury prevention study. 40% improvement in their hip abductor strength on average, improvement in their performance with single leg squat, but their mechanics look the exact same. So, again, yeah, when they ran. So, the integration of those movement patterns isn't always guaranteed by doing physical therapy alone, and that's really the value of doing gait retraining, but the other challenge is there's so many different aspects to strength imbalances. So, you know, I think we all talk about lumbopelvic core. People now are talking about foot core, and Dr. Fredrickson, I think, has been championing this for decades, but at the end of the day, you know, he'll recognize this just as everyone will, that, like, we have still not been able to develop an injury prevention program around strengthening. And so, that's really the holistic approach. Should people do strength training as runners? 100%. Should they focus on their nutrition? Yes. We haven't even talked about sleep. And let's face it, we're all type A, and we're all trying to get as much out of things, but you can have significant changes in bone metabolism with sleep deprivation. So, thinking about recovery, thinking, I mean, there's so many different aspects of this, the cycles of training and loading. So, that's what makes runners a little bit more challenging to treat, but that's also why, when you educate yourself and you can speak in that eloquent way, you're gonna get a lot of buy-in from runners. They're gonna be like, all right, this person cares, and they're actually trying to put together a strategy to get me better. And I think that's why that study, unfortunately, fell flat in their goals, but it doesn't mean we can't keep trying. Look, the other thing to consider is, injuries aren't gonna go away. You're gonna get injured. That's just the way it is. I mean, it's a nice edge that you train on, right? And you either stay on, you're not gonna stay on that edge all the time. You gotta train up to it, and then you gotta get off of it. You stay on that edge too long, you're gonna get injured. And runners sometimes think, well, I'm not supposed to be injured. Yeah, you're gonna get injured. And you gotta be able to recognize that and acknowledge it and deal with it. And too many times, practically all the time, they don't wanna deal with it. I don't wanna change anything. I just wanna run and not have to do anything differently. Wrong. Everybody gets injured. I've had all the injuries. You gotta deal with them. And that's part of the philosophy, or the psychology of dealing with a runner. You gotta make them understand that you're gonna get injured, you're gonna have to deal with it, you're gonna have to come back. It's not, you know, you can't go through your whole running existence not getting injured. I like that you brought that up, Dr. Cianca. I talk about that, the wisdom of having been injured. And sometimes it's gonna be five different injuries before they finally realize they need to do something different. And then sometimes it's that first injury where they're like, all right, I'm gonna take a step back and I'm gonna think about doing this differently. But that wisdom, it takes time. Sometimes people never get there. That's fairly rare because at the end of the day, these are very motivated people. But that's a very, very common issue that we face in our injured runners is a focus that oftentimes is on just one element as opposed to being willing to take a step back and do things differently. And I actually use that as one of my motivators to my patients. I'll say to them, that's one of the beauties of our sport. We get to figure out how far can I push the envelope before the wheels come off. But now let's step back and let's look at this together and decide how we're gonna be able to get you safely to go beyond that. And most folks look at that and say, yeah, I like taking on that challenge of getting better. Yeah, so going back to that article. So even though the results were negative, it doesn't mean runners shouldn't do strength training or core training. We put together a program for USA track and field runners years ago on a core stabilization program. It was pretty extensive, six different levels. And we've incorporated that with the Stanford runners. And so they're doing a good half hour of core work about three times a week now on dry land. We also get them in the weight room as well. So strength's important, we just haven't had the studies to prove it can prevent injury. But you know when somebody gets injured, that's what we're gonna have them do. So kind of makes sense, why don't we have them do that before they get injured as well. May not prevent it, but it might lessen the chance. So I'm gonna wrap things up here. We can take your question afterwards. But I'm gonna pose one more question to everyone. So I think we've got a number of trainees here who might be interested in doing running medicine and we need to train our younger generations. Do you have any tips in terms of the person who might want to learn more about running medicine? Any articles, any training programs? I hear there's a really good course at UVA. So there's a lot of different resources and I think as a chair of a department, I would say as you're looking at going into residency programs, there's a lot of residency programs that have stronger musculoskeletal sports medicine programs, not necessarily running specific, but certainly concepts that are similar. And then a number that have been developing running medicine specific programs. So targeting those is certainly gonna be helpful. There's a wonderful textbook out there called The Textbook of Running Medicine. That's just a neat resource and you know I think and taking advantages at the different meetings here at our academy and the different society meetings where you can network and learn about what's new and all of us have been, you know, seeing running medicine evolve over the past 30 years and we're all learning, we're all learning each day just by being, I say I don't go through a single season where I don't see something differently that I have to ask questions about and maybe alter how I look at things and prescribe things. So immersing yourself in the craft is gonna help develop your skills. There's a few things that you kind of have to do. Being a physiatrist is a really good starting point because you're getting that training throughout your residency and how to look at function, right, and we use that word a lot, that's what it's about, right? You've gotta know what movement looks like, you've gotta know how to change movement, how to change function. So as a physiatrist, you're really getting a head start on this and then topically or specifically, if you will, learning the quirks of runners and running and what's involved in it, those are more specific, you'll pick those up a variety of ways, exposure to it, right, just seeing it and learning how to think. Thinking's always a good thing. You need to really engage your mind and try to figure things out, right? Don't go just to the symptoms. What is causing the symptoms? Be willing to explore beyond the location of the injury. So you can do that any number of ways. Yes, you can take courses, you can read books, you can read articles, all fine, but that's all fine-tuning the basics of thinking and having exposure to things. I would just finish that up by saying when we started doing this years ago, there was no programs, there were no courses. We just kind of went, picked it up in different ways. I mean, I learned a lot by going to different physical therapy courses, I'd go to podiatry courses to learn more about the foot and ankle, you name it. Even myofascial courses, I mean, anything I can get my hands on that might be related. And then you kind of put it all together. So it may not be in one place, you just have to look in different areas and kind of put it together, but eventually it'll come together. Yeah, I agree. I mean, I'm probably the youngest person at the table, but you've got three pioneers here who have really pushed the field of running medicine forward and I've definitely benefited from that. But I mean, we're a great community in physiatry. I think you learn a lot, though, from all the patients you take care of because a lot of these running injuries, they're either acute or overuse injuries, but there's also the mental health piece to these athletes. And we deal with this across healthcare. So just take care of your patients and try to be intellectually curious about what's causing their impairments and focusing on their impairments. I think, again, physical therapists can really make or break your ability to take care of the injured runner. And half the time when I'm talking to runners, I think I sound more like a physical therapist than an MD, and I'll say that. I'll say, look, I'm talking more about your impairments. And I think that's more what you're focused on when you have a runner in front of you and being able to acknowledge what they want to be able to accomplish and focus on their goals. You're gonna be successful. Yeah, just two real quick comments. One, and I meant to bring this up earlier, you don't have to be fast and you don't have to even have a running background to be a really effective physician in running medicine. You need to have an interest in the sport and a passion for helping runners. And that includes patience and understanding and empathy and a desire to keep up on the newest things. And dovetailing on what John said about we as physiatrists being ideal to care for runners. When I was a PGY2 resident, I had the opportunity to run the slides for a physician who was lecturing at our Baylor Review course named Stan Herring. And of course, Stan was a much younger physician at that time in 1989. And I asked him after his talk, I said, Stan, I'm interested in getting into sports medicine. How do I do it? What are the tips? And his comment to me was, you become the best physiatrist that you can become. He said, everything you learn as a physiatrist, the functional approach to your patients will benefit you. So he said, immerse yourself in spinal cord injury, immerse yourself in brain injury medicine, areas that I didn't think I really had an interest in at the time. But boy, what a great recommendation that was because those very foundations have been what's carried me into what I do today. So I wanna thank you all for coming to this session and I wanna give a heartfelt thank you to all of you. If you are not ingrained in the running medicine community, you might not realize it, but this is a historical moment to see these four running medicine grades up here collapse, but this is true. I was taking pictures. So thank you all for coming and I appreciate you taking the time to talk with us. Thank you.

Running Medicine

Runners Clinic

Sarah Reiser

John Cianca

Michael Fredrickson

Adam Tenforty

Robert Wilder

Multidisciplinary Approach

Injury Prevention

Community Engagement

Innovative Techniques