All right, guys, looks like we have some people trickling in here, so we'll go ahead and get going in the sake of time. Thank you for everybody for tuning in tonight. I'm Charles Kenyon, I'm the current Chief Fellow over the Emory Sports Medicine Fellowship Program in Atlanta. Welcome everybody here to the first day of Community Week. We have our sports medicine current fellows and future candidates community meeting tonight. Went with the title Major League Skills and Networking for Rising Sports Medicine Physiatrists. And when we're working to put this curriculum together and get some talks together, I was trying to think of a way that we could complement a lot of the material that's already out there, been addressed in previous years. And with the focus towards students, residents and early fellows to not only talk about some new skills, but also to augment and help people take their education and skill set kind of to the next level. So the night has been kind of structured with that in mind, we'll have three hours of content. First, looking at foundational ultrasound skills and curriculum development and musculoskeletal and neuromuscular conditions. The second hour, we'll be taking more of a look into biomechanical analysis and how you can take your physical exam to the next level and treating active individuals and athletes. And then the final hour, we'll do more of a traditional panel with some current sports medicine fellows from across the country, which I think will be a really great group. Moving into the first section here, the foundational ultrasound skills and curriculum development. We'll be starting out with Dr. Scott Klass, who is a Puman R graduate from the University of Miami. He then went on to do a sports medicine fellowship at Columbia and Cornell before heading over to Dartmouth as their newest attending physician in the sports medicine orthopedics practice out there. Dr. Klass has also worked and volunteered with the Physiatrist and Training Council, where he served on the Medical Education Committee before serving a term as the president and most recently as the past president and nominating committee chair. In the second part of this hour, we'll have Sarah Smith joining us from the Wake Forest Neuromuscular Medicine Fellowship. And I had the good fortune to work with Dr. Smith when we were both residents over at the University of Washington. And I was really interested for her to come out and give her perspective on ultrasound being more interested on the neuromuscular side. So we'll have a little bit of a different perspective there, which I think will really complement a lot of material people might be used to hearing in terms of foundations in musculoskeletal ultrasound and just getting a little bit of a different perspective of how you can apply ultrasound in different ways, both in neuromuscular conditions and looking at the peripheral nerves as well. So I appreciate both of you guys joining for the hour here, and we'll start with Dr. Klass. All right, well, thank you, Charlie. I'm just going to pull up a presentation here. All right, I think you all can see that. Let me know if you can't. And we'll get started. So yeah, Charlie asked me to come talk about how to start an ultrasound course and some tips and tricks in terms of, you know, trying to optimize your time in residency and get as much skills as you can, whether your program has a robust curriculum or not. I'm going to talk to you about what I did over at University of Miami and how we worked on that. Feel free to stop me if you want, and I apologize, I have a four-month-old around here. So if you start screaming, I'll try to try to get that under control. So just an overview. First, I'm just going to talk about the idea we had for the course, how we got our department approval to do the course, the logistics of actually making it work, and then my favorite part, which is talking a little bit in depth about the curriculum development and how to think about ultrasound and how to learn it and do it kind of in a systematic way. So first of all, I just got to give your thank yous. Dr. David Valdez was my partner making the course, and he put a lot of time and effort into helping me create what we did. And Dr. Tu, Dr. Irwin over at University of Miami gave us the ability to work and mentored us as we did along the way, and at Fellowship, Dr. Visco, Dr. Su, who were tremendous in helping me advance skills and learn more about how I think about ultrasound and bringing some of their perspective as well. And then, of course, Dr. Kenyon for having me here and being a colleague along the way. So the course idea first just came from my own difficulty learning ultrasound when I was a PGY2. We started out, we had a course, and I just got really confused with all these diagrams that had different legends. Look at this little triangle, this star, and I was like, what's going on? Like how do I get a handle on this? I'm just kind of, it was a little bit over the top for me. And that's what I found in a lot of the traditional books. And I was like, this is kind of, this is really hard. I don't really get it. And then when I did have a chance to practice on my own, I just lacked the confidence without having any attending that telling me that I was looking at the right thing. I was like, well, I think it's that, but I don't know, I'm not sure. And then the other kind of mentality of like, well, when you get in clinic, it's just like, just go do it. Just go scan that thing. And it was kind of hard for me to put that together without having some time to actually practice on my own ahead of time and learn the anatomy and all. Then I realized that the skills that I did learn whenever we would do our practice were kind of lost because I didn't have any routine and it was just kind of in for one session. And then when I would go out after that and try to recreate what I did, I just lost it because I didn't have any set thing that I was doing. And then just a plug for anybody who's going into fellowship, it's a great opportunity for you to practice your skills and you can actually apply some of these ideas to teach the residents in the program you go to. So first thing you have to do is get buy-in from your department. So there's a lot of challenges. We know as residents, we're very busy. You've got a lot of duties. You're getting paid by the hospital to do those duties. So taking time out for education isn't always the first priority. Some places don't have attendings that are well-trained in ultrasound. Some programs also think that it's too difficult to train and learn ultrasound and they think it's something that should be reserved for fellowship when in reality, I'll show you why, but I think it's a great opportunity to learn in a residency because it really complements a lot of our other skills that we have. Some programs have residents spread out among a lot of different clinical sites and they don't have any clinic where they can specifically practice. Always we worry about burnout and people doing too many things and adding ultrasound does add an extra thing to learn and it can be pretty comprehensive and take a lot of time. It also takes time away from the services that you're on. Another challenge is that people don't have the best educational materials, but like I was saying before, some of the traditional books are a little bit hard to really put into practice without having somebody there kind of leading you through it. And some places are already doing it one way and you have to try to think about how can we change this or make it better. So points that some of your programs may not consider is that when you look at the ACGME requirements for residency training, the residents have a residential experience in that they need to learn use of musculoskeletal ultrasound. So that's something you can go and talk to your program director about and just say, this is in the requirements, as well as also in the milestones. And you can see there in the milestones, one of the procedural skills is doing injections for tone, which Sarah's going to tell us a bit more about and using ultrasound for that. And then procedural skills, joint and soft tissue injections, including those under ultrasound. So you can say, listen, this is in my milestone that I need to learn these skills and we should put some more emphasis into this. I also think ultrasound is great because it helps us learn anatomy. And I really learned how to picture the body in three dimensions by having to learn ultrasound. For me now, now that I'm coming into a job, I realized that ultrasound is a very marketable skill. I've joined the orthopedic practice where they hired me literally to be the guy who does ultrasound and bring that skill to the department. So it really is a job relatable skill that I think is important these days and can get you where you need to go. Then last thing is program recruitment. So everybody that is coming out of medical school has seen or heard about ultrasound. And a lot of times that's a tool you can use to your program to tell them, hey, this is going to help us bring in really good residents if we have a nice program and that may help get you started on your ultrasound program. So how we did it in order to get buy-in from our program, we basically had a established course already, but I felt that it was not the most efficient way to do it. And I felt like that it could be improved. So we made a proposal and we came up with just one scan. So I think we started out with the shoulder and we were like, this is how we think about the shoulder and this is our notes and what we have. And then we made a proposal to the person who was running the course and we deemed it a QI project. So we tried to use a way to teach them like, hey, we're just trying to do this to see if we can make an improvement. We'll do some research, we'll see pre and post tests and see if it works. And if it didn't, you don't have to use it. But if it did, great. So I think that was a very non-threatening way to bring it up to a department faculty Then in logistics, you have to think about time. If you want to run it over one year, two years, how do you want to divide sessions weekly, monthly, semi-annually, and how much time will you need and how much time do you have for actually doing that type of education? We often have really packed curriculum. Some programs are heavy and inpatient or heavy in neuro and they may not be thinking so much about ultrasound or musculoskeletal medicine. But I think it does have a lot of crossover. So that's just something you have to think about. With all these things, I'm going to give you some information about how I did it, but really it takes the creativity of you to sit down and think about like what's the schedule like and what's the actual things that we have here. So location is important. You need to have available rooms. And then you should also think about if you want to use a clinic, like after hours or before hours, or if you need like a large shared space and you'd rather do it in a big hall together. So that's some things to consider. Then how many machines do you have and how many do you need? Something that is important as well is making sure that machines are going to look at what you want. So if you're going to look at small nerves and you're going to try to learn some really detailed anatomy, you need machines that have the capability for high frequency. If you've got old machines that are just kind of left over from wherever department they came from, they may not have the capability to really learn what you're looking for. So something to consider. And then of course, you need to know how many residents you have, how many ultrasound faculty you have that are willing to help you with the course. What scanning resources like books or other innovative things that your program might have. Any instructor's availability, so when can they do it, when can't they do it? Covering any services. So if you're going to take any time out from your actual responsibilities as a resident, who's going to cover that? Any models that are going to be used, so are you going to have other residents do it or are you going to hire people? And then supplies. Of course, it's pretty low key, but gel towels and gowns are the most important things. You can always use paper towels if you don't have real towels. And then so how we did it. So basically our course ran from 4 to 7 p.m. one time per month. The attendings covered our services from 4 to 5 p.m. So kind of one of the part that was a little bit challenging is that after 5 p.m., if you hadn't finished your notes, let's say you're an inpatient resident, you hadn't finished your notes for the day, you would still have to do those after the course, which could end at 7 p.m. So that was one thing I thought about with our program. That was a little bit challenging for residents. And then we started out our course with a 30-minute to one-hour lecture, and then we followed that with a two-hour live scan, and we had an 11-month schedule. We started out with an introduction where you just taught the basic skills of ultrasound. Then we did upper extremities, so we went shoulder, elbow, and wrist. Then we reviewed that. Then we went hip, knee, ankle. We reviewed the lower extremity. Then one more month, we did a full review where you could come in and just kind of practice everything. And we finished off with an OSCE that was graded. So where we did it in terms of location, we did it in our clinics after hours. We had a nice clinic where we had a few rooms we could use, and we had to go and talk to the staff that runs the rooms, the people who clean the rooms, and make sure that they knew we were going to be there and that we weren't in their way and that we were able to have those kind of rooms reserved, so something to consider. We also had two available ultrasounds, but you can really contact reps for any ultrasound machine that you like or that you may have. I know the reps specifically up in my area right now for GE, and I was talking to them about starting a course at Dartmouth, and they were happy to – they're like, oh, I've got three machines in my house, and they were happy to come bring them over once a month. It's great for them because they get their brand recognition out to the residents, and they say, okay, these people may buy our machine if they like it afterwards. At the same time, it's good for you because it allows you to have smaller groups, unless your program happens to have a ton of ultrasound machines. We had 22 residents, so we had four to five residents per group. We tried to keep it a ratio of four residents per one instructor in each group, so we had four instructors. That included myself, my co-resident David, and Dr. Tu and Dr. Irwin were our staff faculty. We tried to balance the groups out so that there were PGY2s with PGY4s, so some people who had a little bit of experience and others who didn't. At NYP, we did it more in a year base, so we had all the twos together, and then the material was geared towards that PGY level, so there's really different ways to do this. You kind of have to see what works best for you, but for us, it worked pretty good having the fours, being able to teach the threes and the twos and kind of vice versa. We also tried to balance out those with interest in ultrasound, so some of our musculoskeletal or sports medicine-focused residents were more experienced with ultrasound than some of the others because they'd done electives and things like that, and then the residents just scanned each other as volunteers. All right, so curriculum development, so first, you should identify your learning philosophy and then identify what resources to use, if it's books, videos, lectures, think about the structure. We wanted to be the teachers because we felt that it was best to learn the material ourselves if we actually have to teach it, so that's why we took on that role, but you may not want to teach. You may feel that you're better as a facilitator and have faculty teaching, so that's really an option there, what you want to do. Then do you want to have pre-session, in-session, do you want to do lectures? You've got to think as well, how are you going to make the residents accountable because often we do these courses, but we don't actually hold anybody accountable, and then, like I said, the information goes in. The next time you go to practice, you've lost it all. How are we going to reinforce it, and then, how are we going to put everything together? So we'll go through that, so when you talk about learning philosophy, there's an acronym people use called VARC, which are the different types of learning, so visual, auditory, rewriting, kinesthetic, so the ideal program is one where you can use multiple different senses to get the material in, and then there's another acronym I like called PACE, where you prime, you kind of give the material prior or ahead of the session, then acquire, that's the time when you're learning, challenge is testing it, and then enforce is retention, so it's just kind of the same stuff we talked about, and in my research, looking at the different things that actually help us learn the most, the things that have been proven are those principles you can see on the right side, six of them, so one is spaced practice, doing things 48 hours after we learn it the first time. Another one is interleaving, and that's a philosophy where you combine multiple topics at once, retrieval practice, which is testing, elaboration, where you're asking questions and then you get answers, and you ask further questions, and then you get answers to those, and you try to get to more detail, giving concrete examples, so trying to show things in very basic ways that are concrete, dual coding, so again, that's talking back to the VARC, so just combining words, visuals, different things together, I also like to think of our education as like a Google map, where you're hyper-focused in on some really nice detail, and then you kind of zoom out to see where am I, and you zoom back in and zoom out, so I think that's constantly my thought in the education, is having the set places where you can look in detail and then kind of move back and get your bearings as to where am I in this map of the body when I'm ultrasounding, then thinking about patient education as well, so how can we use ultrasound to educate, and we want to try to make sure that we can explain it on a seventh grade level so everyone can understand it at that level as well, and then of course, we always have Dr. Hubris, where we kind of think we know a lot of stuff, so we wind up kind of thinking that we know all the anatomy, but sometimes you have to really step back to the very basics and learn our anatomy, and of course, getting hands-on, so let's go through some of this stuff, and these are just some resources you can see, some good reference books, the AMSSM and AAPMNR have teamed up with some great videos to learn, and essentially what we did was we created a book from those videos, and we tried to make the book as basic as possible so everybody could understand it, so for our teaching, we just talked about the residents and faculty started out initially, and eventually, all the residents were learning with the faculty just supervising, so we were kind of teaching and the faculty was more at a higher level, just making sure that everything was correct if we had a question, for example, and of course, you learn best by teaching, so the way we learn the material was starting at our end of our PGY3 into PGY4 year, but basically, the key is you're not going to be able to learn everything before you teach the course, so you just have to stay like at least one session ahead, so you know the stuff before that, so we watch all the AMSSM, AAPMNR videos, we took notes, we did screenshots, and then one night per week, we stayed for several hours with my friend David, and we just practiced scans, and we tried to recreate them as simple as possible, we created home bases, and then just kind of quick to follow routines, so like easy routine, so it was like, okay, you start here, you move in this direction, you see this, you move in this direction, you see this, and if you get lost, you can go back to that home base, and then at the end, I tried to make quick routines so that you didn't have to go through the entire notes again, you could just go through like a one-page summary of it, and then we used mental imagery, so we would quiz each other over and over, I would be like, okay, what's your next move from home base, where do you go here in the elbow or in the shoulder, and we just kind of talked it through time and time, and that really helped me to kind of get it down, so pre-session for our sessions, we used our guidebook that we made, our set of notes from the AAPMNR AMSSM videos, and then we did our simple text, as we mentioned, we used the home bases, we took the images, both anatomic, so like cartoon pictures, and then also the ultrasound pictures, and we tried to label them instead of those confusing labels with more concrete labels, I'll show you guys examples of this in a second, we then realized it's going to be challenging for the PGY-4s to learn the same as the 2s, so we created a checklist of the more basic structures for every resident to learn, and then the more advanced structures, which would be on a PGY-4 or somebody going into sports medicine level, we created a series of quick routines to review it quickly, and then we edited the book back and forth, we printed four color copies, put them in some protected sleeves, and we made kind of a binder or a book essentially of upper and lower extremity, and then we wound up getting the department to pay for it after we showed them the product that we had created, and we then left the books as our legacy to Miami, which was really rewarding for the both of us to kind of have something that we could give back to our residency. So in the session, our materials were short PowerPoints with the anatomic review, then I used animations to try and show the probe placement, and then of course you always have pros and cons of live versus PowerPoint, so you could also just do it live and scan in front of everybody, but sometimes that depends on space, it's hard for everybody to see one machine, you do get better engagement when you're scanning live than rather than just doing a PowerPoint, but you can't really see the basic anatomy, which I think sometimes we take for granted that we all know, but I think people forget that or sometimes miss a detail that you don't really understand without seeing the cartoon picture if you just look at the machine, and the pro of using the PowerPoint is that it's easy to do, and the con being it's hard to get engagement. So here's an example of what we did in terms of our PowerPoint, so this is a picture of looking at the hip joint, so on the left you can see I have this picture of the hip joint, this blue box is representing where the probe would be for scanning, this is the joint capsule, the femoral neck joint recess, all these things with stars are the things that you need to know that are on that specific area, and this is our kind of home base for where we're looking at that, and then we have on the right, you know, the ultrasound anatomy, so we go through that, and then I have animation, so as I press the button you can see that this probe is turning, so this is the orientation you should have when you're looking at this, and then you're sliding down to this area where you're looking right into the hip joint, so that was taking us basically from our position at the AIS, and then down to the down to the hip joint there to look at, to look at the hip, and just another example, then we would move let's say from the hip, and we were going to look at the labrum, we would then slide back up to the labrum, and once again we try to have pictures showing it very basically in different anatomic cartoons, as well as the ultrasound, so you could course correlate what, what, what corresponded to what, so this area right here being corresponding to right here in the 2D anatomy of ultrasounds, so here's a picture of the cover of the book, and me and David, we just had tried to have fun with it, you know, so we're having a good time, we used the book and checklist, so our residents during the session were able to go step by step on their own, and go page by page through through the scan, they had those pictures right in front of them while they were scanning, and it helped them to learn it on their own too by having to learn it themselves, and this is an example of our checklist, so on the right you can see this is a knee checklist for quite an extensive lift, on the left side is our more basic for the PGY-2 level. Here's an example of the hip here. This is an example of, hold on, sorry, my screen. Okay, so this is just another, another example of what the book would actually look like on the, on the knee. So we first started out by explaining the position you'd be in, then our home base, which is starting at the quadriceps musculature, and we just kind of went through it, like palpate the quadriceps tendon, place the ultrasound in short axis, and notice the septation here between the layers, and then you'd move in different directions, and we just gave a very basic, short information on each one with, with the ultrasound anatomy, and then the regular anatomy. And here's just continuing that, then you move from that aspect, and you continue down, you look at the quadriceps fat pad, and such. So we just tried to give, again, this is another example of what our book looked like. Once, once we had the text, then we would have the ultrasound anatomy, and then right after that, the regular anatomy, all in front of them while they're scanning. And then at the end, we had the quick routine. This is an example of the quick routine. So for the shoulder, I have a one-page summary. This is how I would scan the shoulder. So starting at the home base, long head of the bicep tendon, you see the ascending branch of the anterior circumflex humeral artery, you then internally, externally rotate for subluxation, and then from the bicep tendon, you scan distally the pec major, and such and such through the scan, just one step after another. So eight steps in total for the anterior shoulder, five steps for the posterior shoulder, to try to make it very basic, so you could go back and review quickly. And then for accountability, that's an area where we can, we could have improved our, our, our course, but we reinforced informally, and then we did it in clinics while people were practicing. But I think a better system could have been having a buddy, where a senior and junior would be dedicated to certain times to scan together. And then another option, another thing I thought about was maybe like a photo submission, where they'd have to do per week, they'd get a prize or something, or you have to show us your best, you know, subscapular tendon or something like that. You can get creative with that as much as you want. Then to reinforce, we did an OSCE, where we had a case scenario, take to the wall. The attendings actually ran the OSCE, so David and I were part of the course, so we had to take it ourselves. But it took us, you had five minutes to identify the structures and image them that were on the list that you had to, to perform. And you had two rooms, one joint per room, you didn't know what the joints were going to be, you just had to basically know everything, and then come in and get it done. So that last month session where we review everything was a chance for people to kind of get themselves ready for the OSCE. And then putting it all together, those, those kind of concepts that we talked about earlier, the VARK and PACE. So we use those concepts by having people read ahead and watch the videos, so we had them watch the AMS videos, read ahead the notes that we would submit for our, from our book. Then during the thing, we would have our actual lecture, and then we would do our hands-on scan. At the end, we challenged them by doing the OSCE, and then we enforced by the quick summary, as I was talking about. And again, we use all those other concepts on the right by having people do space practice, learning multiple topics, all the stuff that we talked about. And that's the end. So I think at the end, we'll do some questions. I want to make sure Sarah has time for her presentation, but I have a four-month-old and my dog, so I just wanted to share a couple pictures of that with everybody. Awesome. Thanks, Scott. Like I said, we'll roll on to Dr. Smith and then kind of loop back and do some Q&A with both of the ultrasound presentations at the same time at the end of the hour. So again, we have Dr. Sarah Smith joining us from the Wake Forest Neuromuscular Medicine Program, sharing her perspectives on utility of ultrasound from a different perspective. So thanks for joining us, Sarah, and looking forward to the presentation. All right. Thanks, Charles, for the introduction. So I'm going to be talking about really just kind of an introduction to neuromuscular ultrasound. I've got no disclosures. So what are our objectives? So this is going to be a very basic introduction to neuromuscular ultrasound. My main objective really is to try and inspire physiatrists of any subspecialty, whether it's more neurorehab or more MSK, to think about incorporating neuromuscular ultrasound into practice. So we'll go through some more of the common uses, and then I'll make a case for how ultrasound can change not only the diagnosis but the patient outcomes at times, and I'll show you some specific examples as well. So just a little bit of background. Some of the earliest use of neuromuscular ultrasound was by Drs. Heckmat and Dubowitz, and Heckmat is a name that you're going to see a little bit later on, and they were both using it to study muscular dystrophy. So over time, resolution improved enough that we were actually able to look at the nerve structure a little bit more closely, and by the 1990s, it was pretty easy to visualize the median nerve in the carpal tunnel, just as one example. And then if you fast forward to today, there's now a couple decades' worth of literature to support its use in a whole bunch of different neuromuscular conditions. And actually, if you search neuromuscular ultrasound now on PubMed, you'll yield over 28,000 results. So why physiatrists? Why should we use neuromuscular ultrasound? Neurologists use it. In some places, rheumatologists use it. So I think that one of the most important reasons that physiatrists should be using ultrasound to assess neuromuscular structures is because we are uniquely trained to differentiate between neuromuscular and musculoskeletal pathology. I included this article off to the right, this screenshot. The Differential Diagnosis of the Painful Tingling Arm was a paper that I wrote with Dr. Chris McMullen and Dr. Stan Herring over at University of Washington. And I thought this was just such a perfect example of a chief complaint that's really best evaluated by a physiatrist and most comprehensively evaluated, because the differential is very broad, right? It can include anything from a rotator cuff tear to a brachial plexopathy. And both of these things can be evaluated with ultrasound. So mastering both MSK and neuromuscular ultrasound really gives physiatrists a diagnostic advantage over other specialists. And I won't talk that much about procedural applications today, but it's worth mentioning that neuromuscular ultrasound can be used for things like localization for Botox and EMG. Okay, so what are the benefits of using neuromuscular ultrasound? So first and foremost, there's no patient discomfort, which is great because a lot of the times in the electrodiagnostic lab, we're shocking people and sticking them with needles. So usually ultrasound is welcome, especially if you're doing it after those other studies. It is non-invasive, it's cost-effective, it's much cheaper than MRI, for example. We can use it to identify structural abnormalities, which we're going to talk a bit more about. And then we can even look at structures dynamically or when parts of the body are in motion. And then finally, it can provide some more precise localization than just electrodiagnostics. So axonal lesions in particular can be really hard to localize just with electrodiagnostics. And again, I'll give some more examples of this moving forward. So what conditions can ultrasound help us with? So probably most relevant for us in physiatry are the focal entrapments and traumatic neuropathies. So we get a lot of these referrals. And if you happen to be at a trauma center, like for me in residency, being at Harborview Medical Center, we saw a whole lot of rachial flexopathies and other traumatic neuropathies. We also see very specific changes in polyneuropathies, so both hereditary, like CMT1A, and then acquired, so CIDP, a multifocal motor neuropathy. We can use it to look at specific changes in muscle. So everything from Duchenne muscular dystrophy to dermatomyositis, these things both look distinct from each other on ultrasound. And then we can use it to look for fasciculations and diseases like motor neuron disease or ALS. So ultrasound is actually a lot more sensitive than EMG or just looking at the muscle itself with the naked eye. And then finally, we can look at the diaphragm when we're evaluating a patient with respiratory insufficiency. Okay, so let's talk about focal neuropathies. Focal neuropathies are the most common referral in the EMG lab. So especially carpal tunnel syndrome, ulnar neuropathy at the elbow. And of all the literature out there on ultrasound, the most evidence supports focal neuropathies. So media neuropathy at the wrist, ulnar neuropathy at the elbow, fibular neuropathy at the knee, tarsal tunnel syndrome, all of these have a pretty robust literature to support the use of ultrasound in helping with the diagnosis. And personally, carpal tunnel syndrome got a lot more exciting for me again when I started using ultrasound in conjunction with electrodiagnostics because it's not always just carpal tunnel. In fact, a lot of the times it's not just carpal tunnel. So there can be structural abnormalities. And so you can see things like a bi-fib median nerve. So there's two parts when there should be one or more normally there's one. There can be an artery there that is not present in most people. There can be kinesinovitis and rheumatologic conditions, ganglion cysts, tumors, and then abnormal tissue deposition near the carpal tunnel, like in amyloidosis. So all of these things give us a little bit more of an idea about what's causing the condition, which you can't do with just electrodiagnostics. Okay, so what does a normal nerve look like on ultrasound? So on this picture to the right, we can see in cross-section the median nerve in the forearm. So if you notice, there's what we call a honeycomb appearance. So you have the nerve outlined in yellow here. You can see that some spots are darker. Some spots are darker or more hypoechoic. And these are the nerve fascicles themselves. And then the lighter areas in between that are hyperechoic or lighter in color are the interfascicular perineum. So we really can get some detail on the structure of the nerve itself when we're looking on ultrasound. So contrast that with an abnormal nerve. So this is a study that I did a couple of weeks ago, I think. The patient had numbness and tingling, first three digits of the hand, really classic history for carpal tunnel syndrome. And this is a really classic ultrasound for carpal tunnel syndrome. So what we see here, so this is cross-section of the median nerve at the carpal tunnel. The median nerve is very enlarged. So the cross-sectional area here is 32 and normal is roughly 10. The exact normal values vary a little bit from lab to lab, but this is clearly three times the size of normal. And then we can also see that it's much darker in appearance or it's hypoechoic. And then it's a lot harder to discern the individual fascicles. And we kind of lose that normal architecture. And just by contrast, this is same nerve, same patient. Now we're looking in the forearm. Okay. So in the forearm, we can see that it's much smaller. It's 10. So it's less than a third of the size. We can now kind of see the individual fascicles again, these hyperechoic darker areas, kind of normal architecture. And so in this case, the lesion really clearly localizes to the carpal tunnel. So just looking at the difference again, you can see is pretty stark. And so that gives us a really good idea of exactly where the issue is. Other things that we can look at that I don't necessarily have an example of here, um, we can look at mobility of the nerve. So if we're assessing the nerve, um, in lab, what we'll have people do is slowly flex their fingers and then their wrist. And, uh, normally the median nerve in the carpal tunnel, it should move a little bit. It should move a little bit side to side. And when you completely flex the wrist, normally that nerve will dive underneath the tendons. And so what we see in carpal tunnel syndrome, uh, a lot of the times is that the mobility is really reduced. So sometimes it doesn't go anywhere at all. Um, and then we can also look at the vascularity. So we can throw the Doppler over the nerve itself. Um, and, um, first of all, that can help distinguish between a vessel in the nerve. If the nerve is looking very hypoechoic and it's a little bit hard to tell. Um, but if there is kind of hyper vascularity within the nerve, that can really give us a good idea about some things that we should be thinking about on our differential. Um, so, you know, if there's infection, um, some kind of rheumatologic disorder and, um, some kind of malignancy, we might see increased vascularity. Okay. And then here's an example of a very specific structural abnormality. Um, so in the previous example, there wasn't clearly any anatomic abnormality that was leading to nerve compression. Um, but in this example, there's this clear source of compression. So what we see this inner circle here, um, with the blue dots surrounding it, that's the median nerve. And then around it is a nerve sheath tumor or a neurofibroma. And in this case, that's what's compressing the nerve. Okay. And then this is, uh, this is a really great table that I, um, pulled from a paper recently. Uh, it kind of shows you the anatomic causes of vocal neuropathies found on ultrasound in, in kind of specific nerve injury. So carpal tunnel syndrome, ulnar neuropathy at the elbow, fibular nerve, tarsal tunnel syndrome, brachial plexus, you can, you can see pretty, um, commonly certain types of structural abnormalities. And then this table here on the right tells us how often we might see those things. And so I highlighted, um, ganglion cysts in carpal tunnel syndrome and, uh, instability. So subluxation or dislocation of the ulnar nerve in ulnar neuropathy at the elbow. I highlighted these two examples, just because those are things that you're going to see really commonly in the lab. So 25% of the time, um, you might find that there's a ganglion cyst in carpal tunnel syndrome and 25% of the time you might see the ulnar nerve dislocate when you look at things dynamically. Um, it's also great for other kind of less commonly, less common things that we look at in the lab. So tarsal tunnel syndrome, um, if you get a referral for tarsal tunnel syndrome, a lot of, uh, attendings might sigh just because, uh, it can be a little bit tricky to do those nerve conduction studies and, uh, maybe it's something that's a little bit over-diagnosed, but even just two weeks ago, um, we saw someone who did have true tarsal tunnel syndrome, uh, but they had a ganglion cyst and right. And so that's going to be one of the most common reasons that you would actually have tarsal tunnel syndrome. And then in things like, uh, neurologic amyotrophy or Parsonage Turner syndrome, you do see very specific findings. Uh, so you can see constriction and actually torsion of the nerves, which is really interesting to look at. Okay. So here is an example of, um, ulnar neuropathy at the elbow. So in this case, we're looking at the actual ulnar group itself. Uh, so the ulnar nerve, so the images on the top and the bottom are the same. Uh, the ulnar nerve is highlighted in yellow here in both short axis on the left, long axis on the right, both are within that retrocondylar groove. So this, the picture on the left, this structure that's way off to the left and very hypoechoic, that's the medial epicondyle. Um, so what we can see is that the ulnar nerve sitting to the right of it is very hypochoic. It's enlarged. Um, it provides a pretty good example of what an ulnar neuropathy within the retrocondylar groove can look like. Um, and then I don't have a video of this, but as I've kind of mentioned a little bit earlier, um, if I was seeing this patient in the lab and I was looking at their ulnar nerve on ultrasound, I would definitely have them flex and extend the elbow just to see what that nerve does. Does it stay in that position? Is it, um, is it sliding over the medial epicondyle? Because that gives us really a better idea about what might be causing their symptoms and it might actually influence the surgical decisions as well. Okay. Here's another example of ulnar neuropathy that localized to the elbow in nerve conduction studies, right? So this case, this case, let's just say that the nerve conduction studies looked exactly the same. The reason that I included both of these is because you can see that the exact localization with electrodiagnostics alone can be a little bit difficult. So this is ulnar neuropathy, um, at the cubital tunnel, which is just distal to the retrocondylar groove. Uh, so really it's a different entrapment site, but what we found on ultrasound here was that this was the location and actually it was really looking normal within the groove itself. Um, and so of course with your nerve conduction studies, you can use some more sensitive techniques. So you can do things like ulnar inching. Um, this is a bit more time consuming. It's not quite as accurate and honestly it's a lot less fun. Okay. Let's talk about peripheral nerve trauma. Um, so one of the best uses of nerve ultrasound, uh, at least in my opinion is in the setting of trauma. Um, so there was a study that was done in 2013, uh, which showed that using ultrasound changed the treatment for patients about 60% of the time. So it was a relatively small study with only 98 patients, but the results certainly are significant. Um, there have since been other papers which have shown us similar things. Um, I like this paper a lot because it really goes through the very specific uses of ultrasound in the setting of trauma. So what we can do is look to see if we can find a more precise localization. We can look to see if the nerve is in continuity or if it's entirely severed. Um, we can look at structural etiologies, um, of compression. So maybe there's an aroma, scar tissue, surgical hardware. Um, all of these things are really helpful to know before you go to surgery. So for example, it's helpful to know prior to surgery, if you're going to need a nerve graph or whether you can just throw a single simple suture in it. And then, um, here's an example that I pulled from that 2013 paper. Um, they had a 55 year old man who had a left humerus fracture. He went to surgery, they put in a plate. Um, he recovered well from that, but then unfortunately got a bit weaker after surgery. So they sent him to EMG a couple months later. And what they found was that there was signs of denervation and pretty much all of the radial innervated muscles of the left arm. So, um, looking at the actual images here. So what we see here in the bottom right is, so this blue rectangle here is the surgical plate. Uh, you can see kind of the screws that are on here. There's four screws, this nerve here, this is the radial nerve. And then each of these cuts, um, is correlates with one of these images above. And so what you can see is you follow the course of the nerve is that by the time that you get to figure C, which is this figure on the upper right here, um, is that the nerve is in direct contact with that screw. So this kind of hyper echoic white band right here, um, uh, is, is the screw. And so I don't have all of the cross-sectional areas listed, but, uh, what they found was that there was focal enlargement just proximal to the screw. And so that provides pretty good evidence that that's likely the area of pathology. Um, in compressive neuropathies, the area of focal enlargement tends to be just proximal to the area of compression. So that is a really good example of, um, uh, an iatrogenic injury. Um, okay. So this, this is an image from an ultrasound I did a couple of weeks ago. Healthy man, he was in his forties. He had developed bilateral foot drop a couple of years earlier, um, which was really odd. He, you know, he, he didn't have diabetes. He had no family history to suggest that maybe he had something like charcot-marie-tooth. Um, and even a little bit more odd than that was that it was kind of intermittently getting worse. Um, you know, first it started as toe drop and then it was kind of like that for a while. And then maybe a year later, he really started having weakness with the entire ankle on the right. Um, and then the left and somewhat of a symmetric pattern. So, uh, we brought him into the lab, his nerve conduction studies showed that there was probably a demyelinating etiology. This is when we were looking at the legs. Um, so we're already starting to think a little bit about CIDP. We're putting that on our differential, um, and demyelinating neuropathies are great cases to study with ultrasound because nerve enlargement can be so striking in these cases. So after we did the nerve conduction studies in his legs, we threw the scanner on his arm. And I should point out that he had no upper extremity symptoms whatsoever, none. We just decided to do this because we know that the proximal upper extremity is really the highest yield location to identify focal nerve enlargement in CIDP. So starting at the wrist here, so this is again the wrist median nerve in the carpal tunnel, we can already see that it's enlarged, right? So it's 18, 10 is normal. That's already big. Let's look at it here in the forearm. So it's a little bit smaller. It's 14, still big for what it should be, but it's smaller than it was at the wrist. And then this is just proximal to the elbow. So above the elbow, the nerve is 31. So it's largest at this proximal location. So this tells us like, no, he doesn't have carpal tunnel syndrome. It's not just focally enlarged at the wrist and it's not an incidental finding. This is really nerve pathology that goes up and down the entire arm. And then when we looked at the ulnar nerve, we saw essentially the same thing. So seeing enlargement of multiple nerves, especially at proximal sites provides really good supportive evidence for demyelinating conditions like CIDP. And I mentioned already, but he was completely asymptomatic in the upper extremities. So this was a really interesting thing to find that I wasn't necessarily expecting, although my attending was. Okay. So this is an awesome graphic from Preston and Shapiro. It basically shows us nerve enlargement in various degrees and distributions in different polyneuropathies. So mild nerve enlargement is nerve enlargement, not greater than twice normal average size. Regional nerve enlargement refers to nerve enlargement at one portion of the nerve, but not others. And then diffuse nerve enlargement refers to both the proximal and distal aspects of the nerve. So you have these conditions kind of listed throughout, which kind of show you what you might find when you're scanning the nerve, but just briefly. So CMT1A, this is kind of the prototypic polyneuropathy that shows really diffusely enlarged nerves. So this pretty much looks abnormal all over the place. And I have to say, this is something that's really useful when you're evaluating a child. So CMT1A is autosomal dominant. So parents come in, maybe dad has CMT1A genetically confirmed. We don't really need to do genetic testing for that child, but can we throw an ultrasound on real quick and prove our diagnosis? Yes, absolutely. And they'll probably be a lot happier about that than getting stuck. And then in different kind of polyneuropathy, so like an inherited polyneuropathy like CIDP, an inflammatory polyneuropathy, the nerve enlargement is more regional. And so that kind of checks out with the case that I just shared with you. It was really big at the wrist, smaller in the forearm, really big up in the arm, proximal to the elbow. And then ALS and then axonal neuropathies, generally the nerves are normal size. So if you're looking at like a diabetic polyneuropathy, for example, sometimes there can be a little bit of enlargement beyond normal values, but it's not going to be as striking as you would see in a demyelinating condition. Okay, so let's switch gears just a little bit and talk about muscle. These images are of my biceps. So on the left, we can see the image in short axis. And so you can appreciate the starry night appearance, starry sky appearance. So basically, it's kind of similar to the nerve. So you have darker hypoechoic kind of dots. And these are the actual muscle fibers themselves. And then these lighter structures in between are fascial structures. So they're kind of separating the individual nerve fibers and parts of the muscle. And then on the right, this is looking in long axis, and we can see that kind of penny or feather-like appearance. Okay, and so back to Dr. Heckmat, who I mentioned in the beginning was one of the first people to use neuromuscular ultrasound in the setting of muscular dystrophy. So he created this grading scale that's used to denote the severity of muscle atrophy. So it's on one to four. So on this scale here, we're looking at rectus femoris in each of these images. And so number one is normal. So normal muscle structure and echogenicity. The femur below is really apparent. Grade two, you can still see the muscle gray scale, but you know, it's kind of, it's not quite as, the distinction between, you know, the muscle fibers and the surrounding fascia is not as obvious, not as obvious here. In three, markedly diminished gray scale, but we can still see a little bit of this bone echo here and again here. And then in four, very strongly increased gray scale, really hard to even know that this is a muscle at all that you're looking at. We don't see the bone at all. Nothing is bouncing back up off of the bone when we're looking at this image here. Okay. So here's a really great example of using ultrasound to look at selective muscle involvement. So you might be wondering why would we look at muscle? So this is a great case for that. It can be a really important clue in distinguishing certain myopathies. So in this case, this image on the left is, this is from a symptomatic patient. This image on the right is a normal patient. So on the left here, we have the ulna, which is the U here. This asterisk is the flexor digitorum profundus muscle or FDP. And then this arrow is pointing to the flexor carpe ulnaris. So what we can see is the FDP is really, really abnormal looking. So we've kind of lost all of that normal muscle echo texture, really hard to kind of see kind of those muscle fibers themselves. And so then if you kind of contrast this with the picture on the right, this is a normal patient. So FDP is really normal looking. And so you might be wondering, okay, well, why does this matter? And why is FDP more involved than FCU? And so this is a really common pattern in inclusion body myositis. And this patient did indeed have pretty specific weakness of the deep finger flexors. And so when you're using just your physical exam, it can be a little bit hard to kind of pick up these subtle differences. So this is a great case that's kind of showing why we would look at some muscle. Okay. So in conclusion, neuromuscular ultrasound is cost-effective, non-invasive diagnostic tool, provides important structural information and anatomic information. And at times it can even change the diagnosis management and patient outcome. So that's really it for me. I know that was a little bit of a whirlwind, but I hope it inspires some of you to at least pick up an ultrasound and look at some muscles and nerves. Awesome. Thank you, Sarah. That was really cool presentation. And I had a similar experience getting to fellowship and, you know, starting to do more nerve ultrasound and realizing, you know, how there's different algorithms out there and, you know, we're really just hitting the tip of the iceberg in terms of our understanding, you know, both for peripheral nerve and neuromuscular conditions. So just an invitation for anyone to drop any questions in the chat. Oh, here we got one from Rose. Is neuromuscular ultrasound, is it ever used as an alternate diagnostic tool instead of muscle biopsy or in conjunction with, and I guess you talked a little about EMG, but you obviously can throw EMG in that question as well. So muscle biopsy in general is not done quite as often as it used to be just because genetic testing can a lot of the times reveal a diagnosis. In the cases that are more acquired myopathies later in life where we're thinking about looking at a little piece of muscle with biopsy, neuromuscular ultrasound is helpful, not so much to replace the biopsy, but it actually helps us pick muscles for biopsy. And so when you're choosing a muscle for biopsy, you don't want to pick a muscle that's not involved in the disease process, right? Like an inclusion body myositis, FCU looked really normal. That's not the muscle we want to biopsy. On the flip side, we don't want to pick a muscle that's so incredibly atrophied that it doesn't look like anything at all when you look on the biopsy. It's just basically like fat and connective tissue. So we want to be able to see muscle that is affected but not kind of end stage and ultrasound can be really helpful for that. Awesome. Thanks. We've got a question for Dr. Klass with the current resolution available on portable ultrasound devices. Do you think this should ultimately be an ACGMA requirement to standardize education in ultrasound? Yes, I do. I mean, it is the milestone and the other requirements are already out there. So it is, but I think people are working on the standardization. I think there's a couple research papers already out there trying to figure it out. But I think the challenging part is like, at what level do you want people to get at within residency? So that's, I think, where they're going to probably put out a best practices and then it's going to be up to the programs, whether they adopt that or go above and beyond or not quite as far. And I thought there was one other question for me before that in the chat, which I'll just address really quick, if that's all right, Charlie. So it says, I'm curious how long it took the upper level residents to feel comfortable leading the teaching and attending transition to more of a supervisory role. So I may have misled when I expressed how we did, but basically as a PGY-4 resident, they were in the room and just kind of like helping out. But me and David and then our two attendings were in each of those rooms. There was four rooms. So one instructor in each room. So what I did was as a person would be, let's say on the knee, I would be like, okay, put your, you know, palpate here, put your transducer here. And if they move distally, okay, they'd be like, I'm having trouble finding this. And I'd say, okay, turn your transducer this way, do this, do this, do this, just like auditory instructions. And then, you know, we would have the book and we'd be kind of working back and forth that way. So they did kind of have me just leading them one step to the next step to the next step and then switching. But the upper level residents were definitely highly involved. They went through the course PGY-2, PGY-3, and PGY-4 years. So by the time they got to the fourth year, it was their third time hearing the material. And some of them that were interested, me and David would privately kind of show them one-on-one how to do the scan before like a couple of days beforehand so that they would be ready to kind of teach to other residents there. So I would say probably to their PGY-4 year was really the best term unless they were like really keen on ultrasound, then some got it in their third year. Thank you guys. So the common kind of thread between the two presentations and something I really wanted to be apparent for everybody is just the fact that, you know, ultrasound has utility beyond, you know, what many might think just as a physiatrist on the musculoskeletal side. You know, Scott, either talking with the younger residents or Sarah, now that you're kind of getting this different perspective in your fellowship training, any like parting thoughts or advice in terms of say you're talking to a second or third year resident who may not be interested in musculoskeletal, but just trying to how you would communicate to them the importance of learning this skill set no matter what they might be going into? I think at least on the neuromuscular side, honestly, now that I'm doing ultrasound with the majority of my electrodiagnostic studies, I kind of feel like there's no other way to do it. I mean, of course, a lot of people across the country are doing it without ultrasound, but it's incredible how much it adds. And I was talking to someone the other day and just, they were commenting as well, that it really kind of being able to look at these patients and be like, maybe they, you know, maybe abnormal biopsy, abnormal nerve conductions, abnormal EMG, and then also abnormal imaging really kind of brings the whole picture together and helps everyone kind of understand the pathology a little bit more. So I think it's, you know, it's such a useful tool. It's pretty quick once you know what you're doing. It's painless for the patients. I really would advocate for everyone to use it. So like every PAMNR resident should be using this eventually, right? When everyone kind of has access to the technology and everything, because that's certainly a limiting factors, the expense, and then just having the time in the lab to do it, of course. So I understand there are some barriers there, but just kind of in the longterm, that's just kind of what I think. Yeah, I can't agree more. I mean, now as an attending, I really, it's so critical to me, basically doing what I do all the time. And I use a lot of nerve ultrasound, just kind of like Sarah was saying as well. And one other, I mean, there's just so many avenues of using it, but I think as medicine is progressing, we're trying to get more ways in which we can actually show what we're doing. And so I think it's really important for patient outcomes, as well as them being able to see what we're doing and actually look at it and prove to them like, hey, here's normal, here's abnormal. You can see side by side. To our surgical colleagues, we can mark things, put a meplex over it. I mean, there's just so much that you can do to add to the care for people and help our colleagues. And once you kind of show them and they learn about it, it's going to be the standard. No one's going to want a landmark injection. No one's going to want to get stuck by needles if they don't have to, for example. So anyways, that's my two cents. Awesome. Thank you guys both for presenting tonight and really insightful presentations. Scott, sounds like you got somebody screwing for you in the background there. So thank you again for presenting. We'll let you guys go and look forward to catching up in the future. Let me see, get this slide advanced. So we'll move on to our second hour here. And we've titled that session, From the Lab to the Field, Sports-Specific Biomechanical Analysis for Early Learners and Fellows. We'll actually start out with Dr. Reiser speaking on running gait analysis and then transition to Dr. Bowers. These are both two of my amazing attendings here at Emory Sports Medicine and really great physiatrists. And every time I rotate with them, learn another thing about either throwing mechanics or running gait analysis. So I'm looking forward to the presentation. And in the sake of time, we'll transition over to Dr. Reiser if you're ready. All right. So it's fun to hear about the ultrasound. We're doing another talk on ultrasound tomorrow too. So I can't say enough good things about it from a musculoskeletal standpoint. This is one of my favorite topics is run gait analysis. Something I can talk about for a very long time. So it's always hard to boil it down to a few pointers, but hopefully I can give you something to work with and something that you guys can add to your repertoire as well. So I was lucky enough to work with a number of running medicine folks, ended up having some running medicine physicians at my medical school, which I didn't even know they were there. Didn't even know that was path I was going to go and was fortunate enough that they started off my career. So University of Florida, University of Virginia and Stanford, I got to work with running medicine specialists and see how everyone kind of integrated run gait analysis into their running medicine programs. So I'm going to talk a little bit about the utility of run gait analysis. When we talk about treating running related injuries, talk about how to conduct a clinical run gait analysis, just the basics, some of the basic elements of run gait, and then looking at some of the run gait characteristics that may be associated with increased injury risk. So what injuries do runners encounter? So effectively we're looking at overuse injuries in runners. Occasionally we have the runner who trips on the curb and has an acute ankle sprain or fracture, but usually we're looking at overuse injuries. And so of course we ended up looking at biomechanics a good bit with these types of injuries. So when you have a runner who comes in a clinic has, you know, you diagnose them, a bone stress injury, MRI that shows the injury, you have them rest. And then as soon as pain is gone, you send them right back off to running where they left off, right? The answer is no. There's a lot to look at underlying why bone stress injuries happen, why tenopathy happens. And if you don't fix the issue of why it happened in the first place, they're just bound to have it recur as soon as they go back to their normal antics. So how do we address overuse injuries? And of course, nutrition is a huge component. I spend a lot of my time talking about Red S with athletes and how we safely walk that line. I'm looking at sex hormones, bone health, micro, macronutrients, fueling patterns, something I can talk about for a very long time, but we won't discuss in depth today. Training loads and progressions is kind of a second pillar. So we need to make sure we look at that and then biomechanics. So we can't forget this piece either. There are some things that you can do in clinic. So you can look at different joint mobility. You can look at muscle balance. You can look at single leg squats, jumping. So a number of things that you can look at when someone is in the office, but until you see someone run, you don't know what they look like when they run. So this is my plug for doing Rungate evaluations. So jumping straight into it, if we talk about setup for Rungate, there are many elaborate ways to do it. There are also some very basic ways to do it. We need to have at least two views. So posterior and a lateral can suffice. I usually will also do a closeup of shoe view from the posterior view as well. So I can better see if there's what the pronation looks like and what the heel motion looks like throughout the Rungate cycle. Ideally, you want to be able to slow down to quarter speed. So I've used huddle technique and Dartfish are the two programs that are free that I typically use. And both of those have this capability. Ultimately, I usually end up really just kind of scrolling through and looking at specific views as opposed to really watching it in quarter speed. But you need to be able to slow it down in any case to be able to see what they look at each phase. And there are a lot of limitations. People say, well, I don't usually run on a treadmill. So what's this going to tell me? I'm usually running on trails or I'm running on asphalt that's on a grade or incline. I usually, what about how fatigued I am? So is my gate going to look different when I'm really fatigued? So a lot of different limitations that you may have. However, my argument is if a runner comes in, they're fresh, we get them on the treadmill, we're still going to have a general idea of what they look like when they move. I guess I may not know what they look like when they're at mile 10, but I do think that you can get a lot out of their movement simply by having to hop on the treadmill for a couple of minutes. Of course, you want to make sure they are not in pain. So I'll have athletes come to my clinic and they want to get a run gate evaluation because their knee hurts. But if their knee hurts so much that they're limping, what I'm going to tell them is you're limping. And we need to see you back when you're able to run without pain. So a few limitations with this, but we kind of take all this with a grain of salt. And I still think there's a lot you can gather from even 30 seconds of having someone run a treadmill. And I want to put in a plug, not to forget about shoes. If you can have an athlete bring in their shoes, they need to be something that's moderately worn. They can't be worn to pieces and it can't be brand new. But if you have a shoe, you can take a look at both of them. You can look for symmetries in their wear patterns. You can look for kind of the basic wear pattern. Usually we're going to expect them to be landing on their outer heel and then pushing through the midfoot. And if you see that pattern, then they have a pretty typical movement pattern through their foot. But if you see a lot more wear on the outside, maybe they're a big supinator, a lot more wear on the inside, maybe they're a big pronator. And also looking at symmetries from side to side, is there something unusual going on between the two sides? Because asymmetries are a big source of injury as well. So don't forget to look at the shoes. And then when we get someone on the treadmill, we're essentially going to be looking head to toe. So don't forget head, neck, thorax, arms, lumbar spine. These are areas that can get forgotten about. And oftentimes once folks are getting to me for a run gate, they're frustrated they haven't made progress. A lot of times we end up looking really at their thoracic spine or looking at their head posture, their forward neck posture, because their center of mass is gonna be dictated from where that heavy head is setting. So we've gotta make sure that we don't forget about that component. A runner who's running 26 miles, they have to hold up their arms for 26 miles. So having that postural strength and being able to hold up their shoulders during that timeframe actually matters. And then of course, pelvis, hips, knees, ankles, feet, all these pieces are gonna get most of the attention and we're gonna be able to look at this in two different views. As I've already said, once before, asymmetries, abnormal movement, those are just a couple of things that we're going to look for. And the basic eye can look at this. I tell even coaches, I mean, you can get a good idea of what your runner looks like or something looks off, that means something. So you don't have to be an expert. You don't have to have a bunch of 3D cameras to be able to make conclusions and get information out of watching someone run. So looking at this example here, you can see several things that are happening. You can see this whip that's happening with her foot. So you see this coming back and it's crossing midline. You can see that heel falling out into a lateral whip and you can actually pertain from this view that she actually has a lot of forward lean as well. So you can see her body is actually leaning forward and that's gonna put some stress on her back as well. So a lot of things that you can glean just from a couple pictures here, a couple in two different phases of the run gate. You also can see these kind of chicken wings. So arms sticking way out to the side, essentially seeking some balance. So you know there's some kind of instability usually at the pelvis. As you can see this drop right here while she's in her stance phase, you know that there's some pelvic instability going on there. So out of these two pictures, I can ascertain quite a bit of information. If someone comes in with a very short clip of their run gate, you may say, well, I can't do a whole, you know, complete run gate evaluation, but even those couple of clips, you can ascertain a few things from it. Even the rounded shoulder posture in this picture can give you more information too that she needs to work on her strength and that upper thoracic region too. So in terms of comprehensive evaluation, there are tons of different parameters you can look at. And so it's really finding what works best for you. This is kind of my typical programming that I went through when I did my fellowship. And so I just go through this every single time. I have a chart that's printed out and make sure that, you know, after I've done my video, I take a few moments to go through and kind of check off all these things, make sure I didn't miss anything. So a couple of things I'll look at first, even though I have it last on here is looking at cadence and overall impact. So another thing not to forget about these evaluations is listen. So does someone sound very loud when they're landing? Do they have asymmetric landings? So make sure you use all your senses when you're watching someone run. And this is where it can be helpful to know what your treadmill is like. If you're having people run on the treadmill in the office, how loud does it typically sound? Cadence is how many steps someone has per minute. And so typically we're thinking a cadence of 160 to 180 is typically a pretty good cadence. Higher level runners will typically have a higher cadence, but everyone's gonna be a little bit different. I think there's biggest takeaway with all of this is there's no one size fits all from my perspective, but there are ways that we can optimize gait. And certainly if someone's having pain, there's some ways that we can take some pressure and some forces out of the structures that are uncomfortable. So looking from a lateral view, and this is typically where I start. So I look at cadence, overall impact, what did they sound like when they're running, and then foot strike. So this is probably one of those common things that we talk about, talking about rear foot strike, mid foot or forefoot. And there's forefoot strikers have gotten a lot of attention in terms of this being kind of the goal is to run forefoot. I think there's a lot of benefit in it, but there's also some downsides with it as well, which you're gonna talk about a little bit later. Majority of folks that you're gonna see running are heel strikers, some mid foot strikers, and I probably only have a handful of forefoot strikers that I've done run gait evaluations on. Ankle positioning is important. So are their toes straight up in the air when they're landing, especially if they're in a heel strike, because that's essentially like putting on the brake. So they're really putting a lot of forces up through that chain if they're heel striking with their toes straight up in the air. Over striding, so are they landing way out in front of their center of mass? So I'm gonna show you if you draw a line right down in front of that ASIS in front of the pelvis. So if we look at this middle picture here, essentially this is looking at where the center of mass is, and then when they land, are they landing pretty close to that? In this picture here, the answer is no. This gentleman is over striding quite a bit. If we look at shank positioning at loading, that piece is really important as well. So when they are landing, are they landing with an extended knee, which is going to put more force up through that chain, or are they landing with a more up and down knee? So vertical, which is a lot less stress up through that chain. So actually the first image and the last image, they're both landing with a pretty vertical tibia. What's their knee flexion like in stance and swing? So do they have good activation of their posterior chain when they're swinging their leg through? So this gentleman in the middle has a good kick, and so that foot is coming up and over, okay with the right one, but certainly on the left one, almost no flexion with that swing phase at all. So very poor activation of that posterior chain. When we're looking at hip extension, we're looking at are they using their glute max to really push forward? A lot of times when folks are not getting good hip extension, this can be coming from the low back and the pelvis. You know, if they've got, they may be putting their low back into excessive lordosis and tilting their hips forward to get that hip out behind them, which is not going to help them very much because they can't engage their core with that, nor can they engage their glute max very well with that. Sometimes we'll also see that if we look in this picture on the far right, this is what I would consider a quad dominant runner. So their pelvis is actually posteriorly tilted, and that actually makes it very hard also to be able to get their foot out behind them and push with that glute max. And so if I showed you the phase where she was actually pushing off with that right foot, that hip is not getting extended behind her very well. And of course, this gentleman on the far left is also not getting much hip extension either. So really important to see that that glute max is doing its job to propel person forward. If it's not doing its job, sometimes you'll also see that that person is getting a lot of vertical displacements, that kind of bounding run where they're spending more energy going up instead of going forward. And I always tell folks, if we can get you going forward, we're actually making you a faster runner as well, more efficient. So pelvic tilt I already alluded to. So we look at anterior neutral or posterior pelvic tilt. So if I go back to my screen of my three runners here, this one, you can see, I know this is not a perfect view, but he actually has a little bit of lumbar lordosis and anterior pelvic tilt here. So he's not able to engage his core very well. Here, this is a pretty neutral pelvis. So he's nicely stacked up and down and nice and relaxed and that core is engaged. And then here, you've got a posterior pelvic tilt. And so that's kind of engaged in that quad dominant type gait. So you're really looking for a neutral pelvis, but oftentimes you're getting a pelvic tilt there for one reason or another. We talked about overall impact, vertical displacement. In terms of the posterior view, we're gonna look at what's happening with the heel. So pronation is normal. Oftentimes it gets this rap as being a bad thing, but you actually do need to pronate. That's how we do our shock absorption. And so oftentimes you're landing on that lateral heel, you're gonna pronate through, come back to neutral and then push off in that neutral phase. You can get some over pronation. You could over supinate. You have folks that can rapidly pronate. All those things would be considered relatively abnormal, but we do need to have pronation in order to do that shock absorption phase. You wanna look at foot progression angle. So looking at in-toeing or out-toeing, looking at heel whip. So is that heel falling in or out as that heel is coming back into that flight phase? Looking at your knee projection angle. So are your knees dropping in? Are they dropping out? What's your pelvic drop like in stance? What's the trunk lean like? And what's trunk rotation like? And again, you're looking for symmetry with a lot of these things as well and looking for any kind of excess abnormal movement. So here, I also wanted to point out actually both this first and second picture, and they both have a pretty steep inclination of their foot as they are landing, which is not helpful. So that acts as a breaking force. But if you look at the gentleman in the middle, he's running at a much higher speed and he's over striding. So that's actually gonna put even more stress up through this chain, even though this gentleman has a pretty hefty dorsiflexion angle as well. I mean, I put these three pictures next to each other to really emphasize how different posts can look. And the more you look at these images, the more you look at videos and watch people move, the more you'll be able to pick up on these things and be able to put two and two together. Folks are complaining of pain in certain locations and what their gait may look like. So this set of images, we saw this young lady in the last set. So she has a more quad dominant gait. She's got a posterior tilt here. And then if you look at this view, I just wanna point out that you can start picking up what's happening in the other plane of motion as you start getting a little bit more astute. So if you look at this picture, you can actually see that she's getting some internal rotation of that hip and this toe is starting to flare out. So this is the posterior picture that you get of the same position where this person's actually got this medial whip that's going on here. If you look at the knees, you can see this left side is dropped down. So even though I can't see her pelvis, I know that pelvis is dropped. So the glute meat on the right isn't doing its job either. And then I put this line here, especially to really exaggerate what that heel is doing. So otherwise it can be a little tough to see and relatively subtle. But this is where she's going into pronation. Relatively normal, it's subtle. What you would look for is to see that that's coming back to neutral before she's going into her push-off phase. So looking at a couple of the studies, looking at some of the different biomechanical characteristics. If we look at foot strike, rear foot strike's really gotten this kind of bad rap, but we know lots of people do rear foot strike. And so how can we minimize stress with it? So we know rear foot strike is higher biomechanical loads, both overall and at the telephemeral joints. So oftentimes when my folks come in and have telephemeral pain, this is something we're trying to minimize if we know they're a heel foot striker or rear foot striker. Forefoot striker, on the other hand, you have higher biomechanical loads of the ankle joint and Achilles tendon. So switching from rear foot to forefoot does not necessarily take away all of those issues. You're just switching where the stresses are happening. So folks who, for example, want to switch to more of a minimalist shoe wear, oftentimes they're naturally going to move more towards a midfoot or forefoot strike, and you've got to be able to prepare them for those loads at the ankle joint and Achilles tendon that are going to be different. So a lot of it's really preparing if you're going to make a significant change with gait retraining. Also important is that increased speeds associated with shorter force periods and increased peak forces. So increases in speed are going to increase your loading, and I think that's something we forget sometimes too that's important to have a conversation with your runner. Looking at tibial shock or tibial forces with strike, these are increase in rear foot and midfoot strike and the increase with increased speed. But interestingly, those forces don't increase with the forefoot strike. So someone who's forefoot striking and increasing their speed, they're not going to get as much stress through that tibia. And most of the folks that I'm seeing with tibial stress injuries, we're really looking at rear foot and midfoot strikers. So here's a few different, so these two on the left are both rear foot strikers, and this one on the right is a midfoot striker. And again, I wanted to show a couple of the things that are different, even though all three of them were basically catching at the same moment when they're landing, but how different they can look. And this one, I wanted to point out to the trunk positioning. So this gentleman in the far left has a good bit of forward lean, whereas we're much more upright with these other two pictures as well. Both of these gentlemen have good kickbacks, so you can see good knee flexion here. But this gentleman has quite a dorsiflexion angle right here, a little bit less so here. But if we drew a line right in front of this gentleman, just like the one in the middle, both of them are overstriding quite a lot. So even if we had a rear foot striker, if we could decrease this dorsiflexion angle, and if we could have them land a little bit closer to center of mass, that could really decrease some of the forces going up the chain for both of these gentlemen. Here, if we look at pronation, we know that peak rear foot eversion is associated with ITBM syndrome, teletechnopathy, posterior tendon dysfunction. And so importantly, we have to remember that tendons and bones, they have certain ways that they like to be stressed. And if we stress them, especially with rotational forces, they do not like that very much. And so overpronation can certainly be a problem. Again, I'm showing this young lady who actually has relatively normal pronation, but kind of emphasizing the direction that we're looking at it. I like to use the single leg squat in the office and encourage you to do it. It's a very quick screen, and I think it'd be very helpful to identify what may be happening in the run gate. If you look at both of these folks and we get them on the treadmill, a lot of the things that they're doing on the treadmill are very similar to what they're doing with their single leg squat. So a couple of things I like to point out here, you don't need to do a very deep single leg squat. We're not squatting all the way down to thigh parallel when we're running. We're really just doing that quarter squat or really just doing that quarter depth squat is what I consider it. So we wanna see what folks look like. Of course, if you did this numerous times over and looked at their endurance, you're gonna see something else as well. But with both of these folks, you can see that that knee is collapsing inward. So you have this valgus collapse. One thing I like to point out in both of these is the jazz hands. So you have the hands that are flying out where they're trying to catch themselves and balance themselves, and that's your cue they're having difficulty with that balance, which is a really important piece of this. One thing with both of these pictures is I don't have their shoes off. And I almost always have them take their shoes off before we're coming out to do the run gate evaluation component of it. So that you can see what their feet are doing. Are they able to stabilize well? Are they having this corkscrewing action happen at their ankle? Are their toes lifting up to try to seek out some stability? All those things are really important in terms of what's happening with the foot with that balance. So some common goals that we look at when we're looking at run gate and we're talking about, well, what can we potentially adjust to decrease the stresses that are potentially causing whatever injury that the athlete's coming in? Or maybe they don't have injuries actively and we just wanna minimize the stresses and try to avoid injury. That's even better way to do it. So look at having softer landings, which is gonna take strength and balance. Having potentially an increased stride rate depending on what their stride rate looks like or their foot strength. What their stride rate looks like or their cadence looks like when we see them. Again, 160 to 180 is typically a common goal. We wanna minimize over striding. So we're not increasing those initial ground reaction forces with landing. We wanna minimize impact, minimize vertical displacement, have more forward momentum. We want good pelvic stability. So good glute activation for hip extensions. That's your glute max, as well as improving any kind of pelvic drop that you're getting in that stance phase. That's gonna be the gluteus medius. Runners are typically not spending a lot of time doing lateral movement. So we've gotta make sure we add that to their repertoire to keep good pelvic stability. Intrinsic foot strength is really important. I frequently recommend short foot or foot doming exercises to strengthen the arch. And then also being able to isolate the great toe versus the lesser toes because we use so much balance in that push-off phase through the hallux. Single leg balance is important. Balancing very well. When you're standing statically, you can imagine the dynamic motion balance probably is not much better and you're putting a lot more micro motion through those joints. Posterior chain mobility is super important. Oftentimes some structures that are tight, part of the reason they're tight is because they're weak. And so we need to strengthen them. And kind of controversial is, should we be having more of an anterior foot strike? Some people would recommend that we do, but we have to remember that if we do that, we've also got to strengthen the ankle and Achilles tendon as well. So when we do counseling, there's a few things that I like to do. So I have the runner get on the treadmill. I've gotten video. We've come back up to the room. I usually take a few minutes to go through things and make sure I've covered every component on my checklist. And then I'll go back in and talk to the athlete. And the first thing I do is I set the stage. I tell them, a lot of these athletes that I take care of are professional runners or they're collegiate runners. They're very good at what they do. And I let them know that you've done a lot of things right to get where you are, but we're gonna nitpick and really find the things that we can optimize and improve to make you a better, faster runner. And so then I really delve into a few of the good things that I really like that I don't want them to change. And then we try to address the things that are not quite as optimal and things that we need to work on to change. Most importantly, I point out lots and lots of different patterns, but really I remind them that most of these patterns, if we change one or two things, all those different things are gonna fall into line. So I don't want them thinking about 20 different things, where their feet should go, what their back should be doing, what their hips are doing. Really, we need to find the one or two cues that help all of that just fall into place. And that's the role that I leave to my physical therapists who work with runners. So in summary, I wanna make sure that we address biomechanics. Don't forget this component, even if you just look at a single leg squat, you look at what folks look like when they're hopping, you watch them jog down the hall, you get a couple of views of them running a couple of snapshots, anything that you have, those things can be really important and give you a lot of insight into what they look like when they're moving and how we may need to address that to prevent recurrent injury. And thank you all for your time. Thank you. Thanks, Dr. Reiser. Every time I hear you talk about that, I just really appreciate the systematic and simplified process. And I think the point of this hour is really to communicate how valuable mechanical analysis can be to expand on your injury evaluation. So we'll loop back for some Q&A at the end of the hour and we'll move over to Dr. Bowers to talk more about mechanics and the throwing athlete. All right. Let's see. Using a totally new computer, so give me one second. Have to change my... Settings to allow. Let's see. Dr. Reiser, I think, well, Dr. Bowers is gonna pull up, there's a question in the chat for you. Are there certain abnormalities that you typically address first? I'm guessing most runners have more than just one or two abnormalities. Yeah, absolutely. So what I typically do is I try to boil it down to three different areas. Oftentimes pelvic instability is a big one. Usually we're also looking at something like cadence and then usually there's one other issue. So usually I have three things that we're gonna work on and then I let physical therapy kind of make that decision. Obviously, if there's something that's grossly abnormal or it specifically looks like specifically related to the injury that they're coming in with or recovering from, then we'll put a little bit more emphasis on that. But usually I give them basically three things to work on and then I let the school therapy kind of take the guidance from there. That's a great question. And then kind of on the flip side for residents or fellows or even early attending sort of think about doing more motion analysis or gait analysis, putting all that together in one go can be intimidating. Do you have any recommendations for people who are just kind of trying to start with some fundamentals and build from there? Yeah, for sure. Pick a few parameters. I mean, looking at heel strike, looking at cadence, impact and looking for any major asymmetries or heel whips. I mean, just those few things in and of themselves can be sufficient. Looking for a lot of pelvic drop from that posterior view can be very helpful too. And a lot of that you can even see with that single leg squat. So looking at what's happening at the hip, the knee and the foot, just with a single leg squat can give you a lot of information and help guide next steps for sure. So yeah, I think it's very reasonable just to pick out a couple of parameters that you're looking at from either view and guiding on that. I had one of my mentors, he had a treadmill in his office and would have folks hop on the treadmill and treadmill for 30 seconds to a minute, this is impromptu, he'd be able to gather all that information. And that was also a really good learning point for the residents that worked with him is you get just a couple of pointers from both views and be able to give them immediate feedback within your 20 minute session. Awesome, thanks. I think I just got a thumbs up from Dr. Bauer. So if anybody has any more questions that come up, drop them in the chat and we'll circle back on both presentations. Okay, I did get an alert that in order to record my screen, I would need to leave the meeting and jump back in. Can I do that real quick? Yeah, I think that should be fine. I'm gonna do it real quick. Give me one minute, okay. Dr. Reiser, if you're still there, I did have one more follow-up for you. So obviously, you're seeing a lot of runners, and you do quite a bit of gait analysis, and I appreciate how you fit that into your practice, but what's the decision point between just doing your normal physical exam with a runner and when you decide to do the more extensive gait analysis? Yeah, I think there's a few of them. Obviously, folks who are having major injuries or recurrent injuries, or we've had a really catastrophic bone stress injury, oftentimes they're motivated to go through with a run gait evaluation. Honestly, I encourage them all to do it. I think it's very helpful. I have a physical therapy group that I work with who also does run gait evaluations, and they're able to incorporate their physical therapy component in with it as well. So it can be really helpful to have them actually meet with them, but I also think it's really educational for the athlete to go through the run gait evaluation and be able to go through the different points, the counseling in and of itself and having them watch their own videos and see what they're doing. I think there's a lot of insight that's developed from that. So I think anyone can benefit from it, and we do a lot of preventive ones as well. So I have especially a lot of our collegiate athletes, for example, they'll come in and we'll just take a look at their gait and see where we can identify even just some weaknesses and things to work on from their strength training standpoint. So I think there's a lot of utility in looking at run gait, and if it was free and everyone had the time to do it, I think more folks would do it. So I think there's definitely benefit from a number of different standpoints, but definitely when there's catastrophic injuries, really biomechanical standpoints or risk factors, then I'd really encourage them to go through with that. And anyone going through the recovery phase, I encourage them to see a physical therapist who is going to look at their run gait, because I think that's a really important component as they're coming back from injury. Awesome. Thanks. We'll circle back again for more questions later on. Dr. Bowers, are you all set? Yep. Good to go. All right. Perfect. Sorry about that. I've used Zoom a zillion times in the last few years and just totally did not think about the fact that I'm using a brand-new computer. So sorry about those technical issues. All right. So we come up here. Okay. So we will talk about biomechanics of the overhead thrower and the kinetic chain. Forgive me if I sound a little off. I have to clear my throat. We're dealing with a little of the elementary school crud in my family with two kids in school. So just a sidebar there. So we'll go ahead and get started. You know, one thing I did want to mention is from the previous talk, I'm a huge proponent of ultrasound for nerve pathology. So I'll just second what they said, especially if we're trying to get information. And sometimes you can even bypass the EMG. So just another person that's a huge proponent of nerve diagnostics for nerve ultrasound. At any rate, disclosures, no financial disclosures. And then some of the content in this talk, Dr. Zaremski, who I do a lot with in the baseball medicine world, a couple of the slides are from him. Kyla Holtz, again, she's in baseball, softball medicine, hugely involved in that. And she's a physiatrist in British Columbia, in Vancouver area, and played for the Canadian Olympic team. A couple of the slides are hers. And then Dr. Kenyon, I lifted a couple off him here recently, based on some projects that we're doing together. So with that said, we have a baseball medicine program in Emory that I'm the director of. It's on our website. There are a couple of resources on here for anyone that's interested in the throwing athlete, see if there's anything on there that may be interesting. There's an arm care program that we've put together that you can give to an athlete if you're interested in it. A couple of papers on the overhead athlete that we've published here in the last year in the PM&R Purple Journal. I'll just throw them up here because we'll talk about mechanics and the kinetic chain and breakdowns in that kinetic chain. We do a couple of these nerve issues that are in the throwing extremity. So just wanted to point those out if anyone's interested as well. So before we get into mechanics, we want to talk about the kinetic chain and just understand that in throwers and throwing mechanics, it's not just about the throwing arm. It's about the entire kinetic chain from the legs through the scapula to the throwing arm. And so just understanding that any deficiencies along that entire chain, whether it's in the foot or the ankle or the knee or the hip or the scapula, any breakdowns there are going to put the throwing extremity at higher risk. So you have to understand that when we're talking about examining the thrower, you want to examine the whole body. You also want to train the entire body as well. Kinetic chain in the baseball pitcher, this is a little bit wordy, but when it comes to the mechanics, it's a sequence of body movements where you're starting with lifting that lead foot up into the air and that's progressing to a link motion up through the hips and the trunk and through the scapula that culminates with the ballistic motion of the upper extremity to propel the ball. So your lower extremity and trunk, that's going to generate the force. You're going to transfer that energy and that force through the scapula to the upper extremity. So you'll hear me say this probably a couple of times in this talk is a scapula is the force funnel. So you generate the force through the lower extremity and then the scapula is going to act as that force funnel that's going to take that force and impart it into the throwing arm. And so that's why the scapula in a throwing athlete is such a huge aspect. So the pitching motion should not just be considered an upper extremity action. It's an integrated motion. The entire body just happens to culminate with the rapid motion of the upper extremity. And so we want to optimize everything through, you know, leading with bringing up that lead leg and starting with force through the lower extremity and bringing that up and imparting it onto the throwing arm. And so it's going to be optimization of the entire motion, the entire throwing mechanics from a pitcher standpoint that is going to reduce the injury risk on that throwing arm, the throwing shoulder, and the throwing elbow. So here are the six phases of throwing. I'll just put this up here. They're intricately coupled for efficient generation and transfer of energy from the legs to the throwing arm. So phase one is your wind-up phase, which is going to end with kind of the maximum height of that lead leg. So you bring the leg up when it's maximum height, when you're on that stance leg. That's the end of the wind-up phase. You then go into the stride phase where you're bringing that lead leg forward. Stride phase is going to end when that front foot contacts the ground. You're then going to go into the arm cocking phase. The cocking phase is going to end when you reach maximum external rotation of the throwing arm. So that shoulder is going to be abducted around 90 degrees, and when you reach maximum external rotation, it's going to be when that cocking phase ends. That leads into the acceleration phase, and so that's when you're bringing the ball forward. The acceleration phase ends with ball release. Then you have arm deceleration, which is phase five. When that ends, it's a little bit subjective as far as when deceleration ends, but most say it's when the shoulder reaches maximum internal rotation and then follow through is phase six, and it's when the pitcher's in that fielding position after they let the ball go. You just see in the cartoon on the bottom, it just shows a little bit more, just kind of breaks it down a bit more through these phases and when they stop and when they begin. Wind-up phase, maximum leg height here. Stride phase ends at foot contact. The cocking phase ends at max external rotation. The acceleration phase ends at ball release. Arm deceleration phase ends at max internal rotation of the shoulder, and then you have the follow-through phase at the very end. And again, very similar. It just shows you through the motion, and we'll get into some videos here as well. This is just saying the same thing here and just shows you not just the stills of each phase. It kind of shows it through the motion here. So here's a video that Charlie took. I lifted this slide off of Charlie, and so we're going to see all the way through. He has them labeled very nicely through this. Here you see it goes from wind-up into the stride, foot contact. Stride phase is going to end, cocking, ball release, and then follow-through. And so as you see, once you get to the two longest phases, you're going to be your wind-up phase and your stride phase. And once you get into cocking, acceleration, deceleration, follow-through, it's really rapid. Let's see. Wind-up here. Wind-up's going to end at that maximum leg height. Get into the stride phase. And that foot hits. And the stride phase begins cocking. So we're starting here. Cocking phase is going to be really fast. Maximum external rotation is right here. I paused that. I was lucky that I paused it perfectly. So you get that max external rotation here in the cocking phase. You see Charlie even did the measurement. Get to about 161 degrees of external rotation, which is, you know, ideally we talk about 180. That's not really ideal. It's just we kind of mentioned that. So 160 is very good. And, you know, I'll say here, there's some talk about, you know, too much external rotation is a bad thing, which we know from the literature, excess external rotation could lead to injury. We're going to go into acceleration, which is super quick. Ends at ball release. Let's go back here. Okay. And we have this kind of matched up with some of these cartoons. And we can see, you know, Charlie has put through this down here, the transfer of force. And you're taking a transfer of force from the legs through the hip. As you come up through here, Comes up through the trunk and through the scapula onto the throwing arm. So it's a good video looking at the motion and then also understanding where the transfer of force is along the way there. Now, if we break it down even further, I'm going to pause this one. So we've wind up phase here. So we've broken it down. So you just see the windup phase. In each of these videos. And again, Charlie is spliced all this. So he has done all the work for this. We'll pause the windup phase. Go to the stride phase and to foot contact. We'll then go into the cocking phase. And you see how as a quick phase. This is one of our Georgia tech pitchers. I forgot to mention. He actually was drafted by the nationals last year. It was pitching in their organization. So we see the acceleration phase is very short. Going from max external rotation to ball release. You're going to get your deceleration phase here. And you're going to max internal rotation. And then you'll have your follow-through here. So again, going through these phases. That was kind of like beating a dead horse. Sorry about that. So just kind of going through videos and still photos. And beginning and ending of when those phases end. So when we talk about the phases, as I mentioned, the energy is created by the lower body and core. And it's transferred to the arm leading up to ball release. So the windup phase is going to position your body in preparation for forced generation. Your stride that initiates the velocity through linear forward movement. And then when it starts to place that arm in the cocking position and your pelvis begins to rotate towards home, not your upper trunk, but your pelvis begins to. And the cocking phase, the cocking phase is when we're going to see a lot of the shoulder and elbow injuries that are going to be countered in cocking phase. And it's not just based on that phase alone. A lot of times that cocking phase, when you see the maximum torque on the shoulder and maximum valgus stress placed on the elbow. And so that's where we talk about slap tears in the shoulder. We talked about UCL tears in the elbow. A lot of that is due more to break down in, in your mechanics earlier on that just means you're not efficiently transferring that energy so that then your, your throwing arm is the one that has to make up for that. You're going to place undue stress on the shoulder and the elbow, and you're going to get these injuries at the cocking phase, where it's actually breakdowns and your ability to transfer the, you know, through the scapular or transfer through the hips. And we'll talk about some breakdowns in some of the phases that will lead you to this. So really the energy transfer from the lower body, the upper body is it rotates towards that, or that begins when that lead foot hits, hits the ground and the cocking phase begins with acceleration, you're transferring all of that energy from, from the lower body and the trunk onto the throwing arm. And then you get explosive power through the shoulder internal rotators. You get explosive elbow extension and wrist flexion to throw the ball with deceleration. The ball's released. The internal rotators are slowed. The rotator cuff resists that anterior distraction of the humoral head in the glenoid. And with follow through their motions completed, your body's going to be in that fielding position. I feel like so rarely now do we actually see like a Greg Maddox pitcher because a lot of times mechanics are, are so explosive now. A lot of times pitchers are falling off to the side, to their throwing side. So left-handers towards third base, right-handers towards first base. You don't see pitchers. Like you used to see Greg Maddox was always in that fielding positions, but let them to win so many gold gloves back in the day in the road, he's always in that fielding position. And he just wasn't falling off to the side of which we see so much now. So I mentioned some of the common injuries and a lot of the injuries that we think that are much more common in throwing athletes as opposed to the general population. We see them, they occur during the cocking phase because of that increased torque on the shoulder. And because of that increased valgus stress on the elbow. And as I mentioned before, it's due to breakdowns in the mechanics before then that's going to lead you to getting to having these issues. There are other things that play into some of these injuries as beyond the scope of this talk also beyond the scope of this talk is talking about these, these particular injuries and, and, you know, diagnosis and treatment of those things. But just some of the things that we think about in throwers, they happen during this phase. And a lot of it is due to breakdown the mechanics. And so with the shoulder, we talk about very very much more common in throwers. And we see general population, internal impingement, type two slap lesions and the elbow. We have little leaguers elbow and UCL injuries, things of that nature. So again, as, as I said, and we're kind of beating a dead horse with these key points with the throwing motion wind up in stride position, that position, the lower extremity of the trunk for, for effective performance through the kinetic chain. So you're coming into that wind up and then you're taking your back leg and you're pushing, you're generating that force from your lower extremity. That's going to be transferred up through the legs and the trunk. So the legs and your trunk would be your main force generators. And that's through that wind up in stride phase. You then you generate that force and with efficient mechanics, you then take that through the trunk and into the scapula, which acts as a force funnel, as I had talked about. So you take all of that force and funnel it through the scapula. That's going to facilitate energy transfer from the likes of the trunk to the upper extremity and to that throwing arm. And so the scapula is so important. So scapular dysfunction is going to prohibit optimum energy transfer. So with scapular dysfunction, you have more stress on the shoulder and on the elbow, and you're going to have increased injury risks. So we'll talk about some key points in a bit, when it comes to your exam in the office in a thrower, but you have to always look at the, at the scapula. There's not a perfect test for the scapula. You're you're basically having to move and looking for dyskinesis or looking for a little bit of winging on that throwing side compared to the non-throwing side, but just understanding that with a thrower, you have to focus on the scapula, both within exam, a clinical exam in the exam room. And then also once they get into therapy, working on scapular mechanics is a huge deal. This is just another mechanics checklist that Kyla Holtz put together. And I mentioned Dr. Holtz before she put this mechanics checklist together and I've been using it for, for a couple of years in some of my talks. And we can just look at a mechanics checklist. Again, this is just a different video that we have of a picture that's in the lab at the university of Florida. And so if we begin this video here, we have him in the windup phase, kind of get that lead leg is at max height. And this is at a different, you know, this from behind, as opposed to in front. And so we look at this and things look pretty good. His trunk is upright. You don't see him falling forward too much. And so that's the biggest thing with windup that we want to look for is you don't want to see them falling forward because you fall forward, your mechanics are shot from the get-go. And so we see him nice upright, his hips are level. And so that's what we're looking for with the windup. We'll talk about why that's such a big deal and why that happens in a few minutes here. Stride. We're looking here. Here's really just generating that force that back leg pushing off rubber. Stop with foot flat here. We're starting to get in it at foot contact. You want to land with your right-handed pitcher. Want to land with your foot slightly towards third base and slightly inward. You don't want to land with the outward. You don't want to land with it too far towards third base gear thrown across your body. And you don't want to land with a wide open towards first base because you're kind of, your shoulders are going to fly open. You can be thrown with all arm. And so when you land, you want to be a little bit towards third base, a little bit towards first base and a left hander. And that foot's going to be turned slightly inward. Shoulder abduction ideally is going to be at 90. I'm not going to, I'd say if I'm nitpicking his shoulders a little bit low here. And as we come through the video, It's probably going to come up and abduct you in a bit in that shoulder external rotation. If you're thinking about that as zero, it's going to be at about 60 at this point before you really get into that cocking phase. And we'll see in the cocking phase, I'll start it again. You'll see that pelvis rotate and you're followed by upper trunk. You don't want them coming together. You have pelvis first upper trunk after that. And then that shoulder is going to further externally rotate to, you know, 160 to 180. And we'll try to catch that here. I see it right about here. You see the pelvis comes forward. Then the upper trunk arms externally rotated here as good flexion at the knee here. You don't want to land with that front knee stiff because you want to be able to push through that knee to generate force as you're throwing the ball. So he has good front knee flexion. You'll see as we go through, he's going to push off through that front leg. And so we'll talk about in the acceleration phase, that knee is going to extend. You're going to see elbow extension, forceful elbow extension, forceful shoulder, internal rotation, wrist flexion, and that front knee is going to extend. Different things to look for. And you see that there. And then as you come in your follow-through, your trunk is going to tilt away from your arm side. And then you'll see, we'll get in a kind of deceleration and follow-through phase here. And you'll see, this is just one of those pictures that I've talked about before, kind of falls over towards this opposite side from throwing. So just an easy mechanics checklist based off of the literature. Here, this is from a review paper in Sports Health back in 2010. And it just talks about points of breakdown in the kinetic chain in a thrower. And so if you prematurely tilt forward in that wind-up and stride phase that I was talking before, that arm kind of lags behind the body and it breaks down your mechanics really before you even get started. You come up on that stance leg and you kind of start falling forward and it breaks down your mechanics. You come up on that stance leg and you kind of start falling forward and it just shoots your mechanics from the get-go. We talked about where that stride foot lands. You can see in this picture here, if it lands too far in the right-handed pitcher towards third base, you're throwing across your body. And if it lands too far towards first base, your shoulders are flying open and you're throwing kind of all the arm with that. Through here also talks about as you lose external range of motion, external rotation range of motion in the shoulder, which sometimes we'll see in throwing athletes over the course of a season, you're just imparting those forces over a shorter distance when you don't have that external rotation. And so there can be some breakdown there when you start to lose that total range of motion of the throwing arm over the course of a season. And then certainly with scapular dyskinesis that we had talked about, scapular dyskinesis is going to inhibit that force funnel that we had talked about before. And it's just going to place, you know, it's going to shoot your mechanics and place you at higher risk for injury. So one thing, if you're going to remember one thing from this, just remember it's all in the hips as our friend Chubbs would say, or at least for 90s kids like me, one of the classics, Happy Gilmore, even though it's a golf movie and not a baseball movie, it really is all in the hips from the get-go with a baseball pitcher. So you can see your lead leg is coming up here. So we're just talking about the windup phase here. So when this lead leg begins to come up, you bring that lead leg up. And if your glute medius and glute medius and minimus aren't strong enough to stabilize your pelvis and keep you level. So Dr. Reiser talked about this in runners. And this is really important to do in runners, just as it is in baseball pitchers, is doing that single leg squat test. We're going to do that in the office for a runner. We're going to do it in the office in our throwers because it's a huge deal in throwers as well. If you don't have the strength in glute med and glute min to stabilize the pelvis and keep it level, that body, like we talked about, when you're in that windup phase, you're already leaning forward. You see how this body's leaning forward here and your mechanics are shot from the get-go. And so hip strength is a huge deal and specifically hip abduction strength is a huge deal in baseball pitchers. And it's something that, you know, even if they're coming in for an arm problem, have them do a single leg squat and it'll tell you a lot as well. It just tells you that if they're really weak there, that their mechanics are not going to be optimum because if they're weak with their hip abduction and they can't do an effective single leg squat and stay level, then we know where to start. And we know that needs to be part of their therapy program. So this is just a paper from Gretchen Oliver, who does a lot of great work in baseball and softball medicine. And so if anyone's interested in baseball and softball medicine, just look at her work. She has tons of great papers out there. Dr. Jeremski and myself and Dr. Holtz were lucky enough to get on a paper with her that we submitted here recently to AJSM that I think throws a wrench into a little bit of this, but we don't need to get into that. Not this in particular, but some of the other things that we've done. Some of the other things that we'll talk about, but just realizing that the pelvic and the scapular stabilizers are hugely important in baseball pitching. So gluteus medius, gluteus minimus, your serratus, your lower traps, your lats, all of those are very important in baseball pitchers. And they're just things that should not be overlooked just because it's a throwing, it's a throwing athlete, you can't just focus on the throwing arm. And so in this study in particular, we look at the conclusion for injury prevention in baseball pitchers. So you gotta focus on your lumbopelvic and hip and scapular muscle strengthening, as well as coordinated strengthening of pelvic and scapular stabilizers. And so kind of a take home that we'll take from this talk is that hips and scapula are hugely important in throwers and something when you take away the throwing arm, you focus on the scapula and you focus on the hips and that at least gets you started with these athletes. And so in the office, if you are a resident or fellow and you see a throwing athlete, you can't just examine the arm, you wanna examine the scapula and you wanna examine the hips for range of motion and for hip abduction strength. And we'll get into that as well. Again, don't forget to look at the hips. These are just a couple of papers that show that it's not just hip abduction strength, it's also hip range of motion. And so if you have tight hips and don't have good range of motion in the hips, we've been shown in the literature that that also is correlated with throwing arm injury in the shoulder and in the elbow. So don't forget to look at the hips, hip strength and hip range of motion. And this is what all of these papers are telling us. This last paper here, it just tells us that over the course of a baseball season, just like we'll see some changes in total range of motion of the shoulder, we'll see changes in total range of motion of the hips and those hips can get more stiff over the course of a season. So it's something you wanna keep in mind with baseball players over the course of the season because as that hip gets more stiff, it places the athlete at higher elbow and shoulder injury risk. So that's just what I mentioned there. So hip external rotation, shoulder external range of motion changes that occur over the course of the season can lead to increased injury. So just keep that in mind with the throwing athlete hips and scapula. And if we wanna take it a step further, total range of motion of the shoulder. I'll do a quick sidebar into total range of motion. You'll hear a lot in throwing athletes, glenohumeral internal rotation deficit, it's called GERD. You'll hear that a lot and it's really, it's not really about GERD. You'll hear that so much with the throwing athlete. It really is more in that throwing arm about total range of motion. So it's not just about losing internal range of motion, it's about losing that total arc of range of motion. So if you hear a GERD, just realize it's really more about total range of motion than just about GERD. This slide is just telling us from a couple of these studies that the hips are also important with elbow injury as I had mentioned before. And so we'll see here baseball players diagnosed with ulnar collateral ligament tears demonstrate decreased balance compared to healthy control. So that balance is in hips. Also see here athletic hip injuries in major league baseball pitchers are associated with ulnar collateral ligament tears. So again, hips with range of motion and strength is really hugely important to injury, not just at that area, but of the throwing arm in the baseball or the throwing athlete. So again, as I've noted, we're kind of beat a couple of dead horses in this talk and I'll wrap up here pretty quick. There's not a lot left, just a couple of minutes. Hip weakness or tightness, as we've talked about, decouples the kinetic chain and leads to decreased performance and increased upper extremity injury risk. And that decreased performance is gonna be your inability to efficiently transfer energy from the lower extremity to the upper extremity due to your mechanics breaking down. I mean, decreased hip rotation flexibility. So really stiff hips in a thrower is a big deal. One of the guys for the Braves that, just saw in his extension today, Spencer Strider, has great mobility and hip range of motion. So that works in his favor. Hip abduction weakness. So your gluteus medius, you look at that positive Trendelenburg, you get valgus knee collapse on a one-legged squat like this. And so you have them do a one-legged squat, you get that valgus collapse in the knee. It tells you that you have weak gluteus medius, allowing that pelvis to stay level and kind of drops down and you'll get that knee valgus. And so huge test, something really important to do in the office on a throwing athlete. And we'll see here from this study in 2000, decreased hip rotation flexibility and hip abduction weakness were seen at 49% of athletes with arthroscopy proven slap tears in the shoulder. And so again, hip range of motion and strength is a big deal in throwers and put you at, if you're lacking range of motion or lacking strength in the hips, it's gonna put you at higher risk for shoulder and elbow injuries. Again, don't forget to look behind, as I mentioned before, if you want any information on scapular dyskinesis and the scapula in throwing athletes, look up any papers from Dr. Kibler, who's a legend in this area. So any papers from Dr. Kibler is gonna give you great information on the scapula and the throwing athlete. So as I mentioned, the scapula supports funnel. You just wanna have them in the office. You bring them into forward flexion. You bring them into abduction. You look at that scapular motion and see if you can focus and find any dyskinesis. You can also put your hands on the scapula. Sometimes you can hear or feel it clunk a bit. So somewhat subjective tests, but always wanna look at the scapula in a throwing athlete. And when they go to therapy, a lot of times it's gonna be focusing on hip strength, hip range of motion, scapular mechanics, scapular stabilizers. Kinetic chain and prevention of injury, core and hip strength and lower extremity balance. We're gonna focus on testing of hip abduction and glute strength. Here are dynamic tests for that in the office, being realistic, it's gonna be your single leg squat. There's a wide balance test, which I didn't put in here. It requires some equipment. It takes a little bit of time. It's not really feasible to do in the office setting when you're kind of strapped for time. So that single leg squat is gonna be a big deal. You wanna look at hip and trunk range of motion, try to identify any asymmetry and external or internal rotation of the hips because we know those are associated with shoulder and elbow injuries in throwing athletes. And so you really need that stable base to efficiently transfer energy from the lower to the upper body to control the forces that develop at the shoulder and the elbow. And then we know as we go through with our pitchers from youth to professional, the injury cycle is gonna start in your youth and pre-high school pitchers. So it's really important to focus on mechanics in your youth pitchers and your adolescent pitchers kind of before they start to get into high school where they really increase the velocity they're throwing with when they're still skeletally immature, because if they get to the point where they start to become skeletally immature and they start to increase their velocity and their power and they have poor mechanics, it's gonna put them a lot higher risk for injury. So in our youth pitchers, it's really important to focus on mechanics. And so the translation here, if good mechanics are not taught by high school and power begins to increase, there is increased risk of injuring the shoulder and the elbow. And we see that in papers like this. We see their conclusion of youth pitchers with better pitching mechanics generate lower humeral internal engine motion, torque, lower elbow valgus load, and more efficiently than to those with improper mechanics. And so proper pitching mechanics in youth pitchers can help prevent shoulder and elbow injuries. So when we look at assessing mechanics, a lot of time we talk about mechanics in we're going to Metro Mechanics, both of these marker-based systems or you're in a biomechanics lab, it requires a lot of equipment, requires a lot of money. And then you also have these other things like the driveline pulse, which you put on the throwing arm. It can give you some measurables, but maybe not everything you need to know about mechanics. Those are the things we have at our disposal now, but what can we do that's low cost that you can do in the real world? And that's what we're trying to develop here at Emory with a multi-year project that Dr. Kenyon is helping me out with, and Dr. Jayanthi is involved as well. We're looking for a reliable method to systematically assess pitching mechanics. We're creating a point-based tool that is going to be reliable, easy to use, and teach at low to no cost. And we'll eventually, we're working on developing a longitudinal study and collecting data on that to see how our pitch efficiency rating, this point-based system that we put together, develop its relationship to injury. And so again, we're looking to create an efficient, user-friendly, cost-effective tool to assess pitching mechanics using just an iPhone and a point-based system based on we put together through the literature. And I think we're on our way to that. And I think we're on our way to doing that. And we see that here, we have a reference table where you look at, so this is stride, and then you can look at the table and we have reference pictures. And so you can take a picture, a video of a pitcher, and you can pause it at their foot strike and say, okay, this pitcher, here's our reference table. What score do I give them? You go through the entire thing, through your windup, your stride, your late cocking, your acceleration, your deceleration, a follow-through. They'll get a one through three score on all of these different areas. And then their total out of 36 will be here. And then through what we're working on now to determine, okay, are these PER scores, what scores are associated with injury? And so that's coming in the coming years as we wrap all this up. So with that said, kind of a whirlwind. Any questions, happy to answer them now. And thanks again for having me. Thanks. Awesome, thanks, Dr. Bowers. Thanks, Dr. Reiser. Any questions for Dr. Bowers? We can drop in the chat. We can probably get to a couple here. Dr. Reiser, you're still on. There was one question for you that we didn't get to before, but it was that, I'm sure it varies widely, but when you're setting expectations for a runner, how long should a runner give themselves to recover and address abnormalities? In general, they're always pushing to get back to running as soon as possible. Yeah, so I think the biggest thing for this one is it depends. Ultimately, folks wanna get back to running. And so I certainly don't prevent them from doing so unless it's a pretty extraordinary circumstances. I recently had a high school runner who fractured her femur from a stress fracture and ended up having an IM nail and she had a lot of gated symmetries. And so we're trying to prevent her from pushing through those asymmetries. So that's a pretty big deal in terms of slowing them down until those abnormalities are addressed. But typically we're looking at folks that were trying to just work on strength, working on hip strength and trying to get intrinsic foot strength improved and things that are a lot more subtle. And so trying to make those adjustments slowly. I don't do a whole lot in terms of a lot of gait retraining from kind of a verbal cue standpoint, make big changes from a heel foot strike to a forefoot strike, that sort of thing. And so really we're looking at subtleties and strength deficits and imbalances, those sorts of things. So that would be kind of typical through their recovery with physical therapy as they're coming back. So I don't try to slow them down unless something major is going on like a big gait asymmetry from having a kind of catastrophic fracture, that sort of thing. Yeah. That would also flip that question to Dr. Bowers in terms of the thrower kind of in two parts. You know, if somebody is making mechanical adjustments, what time in the year is a good time to do that? And then, you know, one concern that has come up with throwers I've worked with in the past is, you know, this is how I've done it for X amount of years. You know, I'm worried if I make this change that the research says, you know, maybe a more efficient position that then the athletes worried that making that change will affect both their performance and their injury risk moving forward. Yeah, I think from an injury risk standpoint, I mean, we know for a large part what the injury risks are. And so I can talk them off the ledge from an injury risk standpoint and tell them, no, if you make this adjustment, you're going to be at less injury up to this point. So that really just comes down to the risk versus reward talk, honestly. And the same talk we have when we talk about weighted balls, and we don't have to get into that, but it's just, okay, if you feel like your performance is good and you're a high school pitcher and you've got colleges looking at you or pro scouts looking at you and they're not necessarily willing to make mechanical adjustments, then you just talk with them about risk versus reward. But the best that we can do is tell them, look, this is what we know about mechanics and injury risk. And if we want to put you at low risk for injury, these are some of the mechanical adjustments you probably need to make. And so it just comes down to a risk versus rewards talk from that standpoint. Awesome, thank you. And just kind of as a parting observation from both the talks, similar to what we talked about in the ultrasound hour, kind of taking all the information in as a early learner can be intimidating. But one thing I appreciated from both of your talks was picking just a few high-yield things to focus on initially, whether that's foot strike or say hip strength and mobility in a thrower. I definitely concur with those points that you don't need to tackle all mechanics all at once, but to identify a few couple of high-yield things can really serve you well as you're going from those stages from student to resident and resident to fellow. So if either of you has any parting points, you're welcome now. Otherwise, thank you for tuning in. You got anything, Sarah? Nope, go for it. Thanks for the opinion, appreciate it. Yeah, I took a lot of time to say very little. I really could have just talked for three minutes and said, if you have a thrower, check their hips and check their scapula. Those are the high points. And so that's really that's what I want you to to take away from. And I know understanding the phases of the throwing motion, I think is important. But but if you have a thrower come in the office, they have a their their arm hurts and they have a throwing related injury. Just remember, when you're examining their shoulder, their elbow, also look at their scapula and also look at their hips. So I'll give you some clues if there's breakdowns in the in the mechanics going forward. So we could have just saved time and I could have just said that to all of you. But but instead, I took 40 minutes to. Longer, longer than I should have. So but at any rate, thanks for having me. Absolutely. And for anybody that's tuning in, I believe both Dr. Reiser and Dr. Bowers are both going to be out in Baltimore next week. So if you see him roaming the hallways, they're all always, you know, great to stop and say hi and you know, do some networking in person that way. So thank you guys for for joining us. And we'll transition to our fellows panel. Have a good night. All right. Thanks, everybody, who is you know, in here for the long haul, we move from our two to our three. So it's changed a little bit since we with the recording and zoom everything we thought about doing some small groups. We thought it'd be easier just to have everybody together. So I welcome the panelists to turn on your videos. I'll do a brief introduction, but then we'll probably go around and have you all introduce yourselves to just so we don't miss anything. But we'll have Lindsey Booker, who's currently a sports medicine fellow out of Utah, Kevin Cipriano, who's out here at Emory with me. I appreciate Kevin joining. I know we got early ultrasound didactics tomorrow morning, so we'll see you then. We have Jamie Montanino joining us from Stanford, Georgia Negron from Rochester currently, and then Kevin Osment from Mount Sinai. But we can kind of start top to bottom with just a little introduction. You know your name. I didn't say where your residency from. And maybe maybe fun fact. What's your favorite thing about fellowship so far? So we'll start with Lindsey. Everybody, I'm Lindsey Booker. I'm currently at the University to like Charles was saying, I did my residency at the University of Utah. And I would say my favorite thing about fellowship so far is one. I have three co-fellows. So it's really nice to have a group to work with. And then also it's been awesome just being able to cover like a breath of sports already in the first couple of months here. So, yeah, those are my favorite things so far. Awesome. Thanks. How about you, Kevin? Hey, everyone. Kevin Cipriano. I'm originally from Long Island, New York. I did my residency at MedStar Georgetown, D.C. in PM&R. Favorite thing about fellowship so far, I think our program is really well-rounded. You get to work with all levels of athletes from high school to professional and you get to see a lot of acute injuries, which I know we don't see as much of in PM&R. So it's been definitely a great learning experience so far. And Jamie, how are you doing? Good to see you. Hey, I'm doing great, Charles. Thanks for having me. I contrary to what Lindsay said, she also went to University of Washington for residency. So we were there together. My favorite thing about fellowship so far, I've always wanted to be a team physician. And so getting to be around such amazing student athletes and successful collegiate programs has been really neat. And I think my next favorite thing is going to be getting to travel with the football team to their Notre Dame game this weekend. So it'll be fun. That's awesome. Gio, are you surviving up north? I know it's going to be fall time up there. I'm surviving. Hey, guys, I'm Gio. I'm originally from the South. I was born and raised in Miami, Florida. I did my residency PM&R training at Emory University. I am now at Mayo and Rochester, Minnesota. I think my favorite portion of fellowship has been the training room has been just fantastic experience, especially having an ultrasound there. I just came from the training room a couple of minutes ago, actually. But the ultrasound training and trying to implement that in the training room is really kind of like the icing on the cake for fellowship here. Very nice. And then, Kevin, how about how about you? How's it going in New York? Oh, it's going well. Thanks. Thanks for having me. It's good to see everybody. I recognize you all from interviews about a year ago. But I'm from Texas originally. Did my residency out in Chicago at Northwestern Shirley Ryan. Now I'm here at Mount Sinai. Yeah, I agree with a lot of everything everyone said. I think I would say my favorite thing has just been the diversity of any given day. It's pretty fluid here. So we may have a floral procedures in the morning. Go do ultrasound injections and diagnostic scans and end the day covering some kind of unique sporting event. So the whole day ebbs and flows with different opportunities. So and every day is different. So that's one of the positives, for sure. Fellowship's fun. Lots to look forward to. Awesome. Thank all you guys for for joining. I know it's Monday in particular in football season is busy with training rooms and everything. So appreciate everyone tuning in for everybody's, you know, tuning in. Feel free to drop any questions in the chat or even the small group here tonight. So feel free to pop open your video, ask a question the old fashioned way. I guess kind of continue with the conversation. You know, a lot. One thing that intimidates a lot of people going from residency, like right into fellowship in the busy time of year with football season is, you know, being out there on the sideline and being more or less like independent for the first time. Do you guys have any early fellowship experiences or stories that you can speak to in that regard? I would say that, you know, even though I myself had a lot of student athlete experience playing, I feel like my first couple of games being on the sideline by myself, there was just this sense of like, I know how to do an ankle and foot exam, but it's like in the state, you know, things are happening. The athlete wants to go back in and it's crazy. And just like the first time I felt like I went dumb for a second and forgot like everything I've ever trained for. So just being like prepared, you know, for that feeling and just, you know, taking a second to collect yourself was really helpful. And thankfully, at first, even if the attending wasn't on the sideline with me, there was always somebody available by phone call or text. So that was really helpful. Thankfully for Stanford sidelines, there's always several attendings on the sideline, but we cover some community college where we are by ourself. And I find both experiences really, really valuable, especially when we're autonomous. It really helps prepare me for next year. But I learn a lot by observing as well. Yeah, I'd echo that point you made there. Like, you know, here in Atlanta, we're also in a big city and there's pro stuff, college stuff, all these things going on. So I think when people are evaluating programs, I'm a huge advocate for having that breadth of experience. Like, you know, it's super cool. And we get to go and hang out like on the Falcon sideline or anything. But, you know, in those cases, we're usually just observing. And I feel like the best learning happens when you're more independent, whether it's at your high school or a Division Two college. A lot of times I'm out there by myself as well. So I think it's important to have that that balance of those different experiences, for sure. I have a question for you guys, if now's a good time. Thanks for hopping on and joining us. I was curious, you guys all ended up at great programs, obviously, if you could touch on maybe some of the things you were looking at at your respective programs as a, you know, a resident interviewing and also maybe talk a little bit about some of the things you wish you'd looked more at or some of the things you paid a lot of attention to that maybe weren't as important as you necessarily thought, because I think I had a handful of those, you know, criteria for residency interviews. And I'm just kind of curious what you guys were looking at for fellowship. Absolutely. Andy, thanks for joining us. You mind introducing yourself a little bit? Yeah, yeah. I'm a third year resident at the University of Kansas Medical Center. I'm obviously interested in sports medicine. So very cool. Lindsay, I'll put you on the spot. Yeah. Nice to see you, Andy, on virtual. I know we talked a little bit on the phone. Yeah, I think in terms of what I was looking for, I think it's kind of generic to say, but obviously like a well-rounded program. So having the clinical experience in clinic, just seeing a breadth of different sports pathology that comes through. I also wanted to have sound ultrasound training as well. And so that was one of the things that I actually like started to ask a little bit more as I was going through interviews and just asking about what the ultrasound training was actually like and what did they mean by having like an ultrasound curriculum and how that played out in our day to day in residency. So that was important to me personally. And then another thing that was important to me was just having a lot of different sports to cover. So here at Utah, there's similar to Emory in terms of having like high school all the way up to the professional level. Because we're in Utah, there's also a lot of like winter sports opportunities as well. And so once the winter time starts, we'll have ski clinic once a week, which will be a lot more acute injuries, acute fractures, dislocations and things like that up on the hill. So I thought that that was like a unique opportunity to be able to rotate in a clinic like that. And then just being able to I think that, yeah, the just having the different types of coverage opportunities throughout the year even was one of the things that I was looking for. And then also mentorship and research opportunities. One of our attendings here does a lot of research, and he's like the head of research for the entire sports and ortho department. So being able to find different opportunities for projects to jump on to. Sorry, excuse me. Or even to present my own ideas to get a project off the ground as well. So those are a few of the things that I don't want to take up all the time chatting about it. But those are a few of the key points I was looking for in a fellowship program. Hey, I can chime in. Lindsay, that was fantastic. I kind of just had like same sort of pointers, but I think one of the biggest things that during the fellowship trail that I really kind of had to hone on and it kind of like transform towards the end of the fellowship trail, but just kind of sticking with the priority list in your head that I think like there's all different kind of flavors of fellowship programs. There are different kinds of flavors in terms of like the coverage that they have, the opportunity for ultrasound, the mentorship, the educational components and creating that priority list in your head of what exactly can certain programs offer me and keeping that list in your head and then asking those questions and making sure you ask those questions, because once those interviewed that once the interview day is over, you can't have the relationship of having like a live feedback of how a program is within their sort of outside of the Zoom realm is kind of gone. So at that point, like create a priority list in your head. Figure out what exactly you're looking into to what would you like a fellowship program to offer you to become the sports doctor that you want to become. And that can kind of go like personally for me, like a good sort of priority list was ultrasound, good mentorship, the research opportunity. But also the teaching opportunity and having that relationship between like what are your relationships with the either the family medicine programs, the PM&R program, the EDIM, all these people kind of the opportunities that you have to teach in there. And that's that's kind of like a good question to ask. I think one thing I didn't really think about was kind of getting to work with different disciplines, and they do a great job here at Emory where you get to work with pediatricians that are sports med trained, family medicine, PM&R, you get to work closely with the surgeons. We have a really good relationship with orthopedics, so that's a good relationship. Get to work with hand and foot and ankle surgeons, people doing ACLs all the time. So getting that different experience and different thought process from different training backgrounds is super helpful and something I really didn't think of. Every clinic is so different from the people that are more a little more PM&R specialized and a lot of degenerative changes, arthritis mixed in with some athletes, whereas some of the sports med people are seeing, you know, 10, 11, 12, 17 year olds that are coming in, you know, a day after dislocating their shoulder. And that's just something I wasn't comfortable seeing. And so I'm getting a lot of experience with that. So just something to keep in the back of your head as well. I'll add, I felt like the fellowships were much more diverse and different from program to program compared to residencies. So like what I'm doing is probably a lot different than each of the respective programs up here and all having different experiences. So keeping with that priority list, whether it's like three main things and then dictating, like kind of determining, do you want to do spine or not, I think is a big deal. Like out here, we do do quite a bit of spine, and that was on my list. But others, you know, it definitely wasn't. And even in my top programs, there's programs that only did ultrasound, did a lot of spine. There's like a good mixture ultimately. But sticking to that, and I think seeing how much autonomy you actually have. So like in procedures and team coverage, like delineating what that actually meant. And then I'll say just like how much administrative work do you have? Like, are you a secretary in certain roles or are you actually learning and really taking as much as you can out of the year? I think I've learned that might be something I would ask a little bit more about is like, are you checking people's inboxes and having to do all that? That's not as much educational, I feel. But. Yeah, I totally agree with having like the three things. And for residency, it was can this program get me to the next step, which I had a feeling was Sports Medicine Fellowship. Is this going to be a nice, safe place to bring my kiddo? And of course, get spousal approval. I know I'm not the only one that needed that here. And then, you know, pre-Zoom interviews, I highly valued the culture vibe, you know, when I was there. Like, are there are the residents happy? What's their quality of life? Do I feel like I'm going to fit in here and thrive here? And that was just really, really tough to do over virtual interviews. And so I guess my best recommendation is to really do some retrospective thinking and to like, because first of all, you're going to get asked this pretty much everywhere. But you also need to know, like, where do you really see yourself in five years? What do you want your practice to look like? Because there's so many variables at different fellowships. So I think trying to know yourself and then finding a program to help get you there is is my best advice. Yeah, I mean, I definitely agree. I'm a big advocate for, you know, transparency both ways in the interview process. So, you know, like Jamie, I was also coming into fellowship, you know, as a parent and wanted to be very clear, like that that was going to be an important part of my life. And I'm like, you know, we'll work hard and do all these things. I also need a certain amount of flexibility and to be able to maintain that and mentorship. And a big part of coming out here was recognizing that, you know, my program director and a lot of faculty were all family oriented. And while everybody's working hard, everybody has that respect for each other and knows that, you know, a little bit of flexibility can go a long way. So whatever that might be for you, what your priorities are, you know, I think it's important to communicate that in the process. And, you know, if that is the thing that makes it not a good fit, then my argument is that probably wasn't a program that was the right place for you to be anyway. So. But, you know, I think a common question that, you know, Kevin touched on a little bit is this question of like spine versus not spine and how you kind of start differentiating programs. For me, I recognize some unique research opportunities at Emory, and I decided that that was more important to me than doing spine procedures. So, you know, if I said if I was going to do one or the other, I'd rather spend that time doing research stuff. And, you know, that was my decision. But I know it's different for everybody. And like Kevin said, you know, everybody here represents very different programs across the country. So, you know, curious to hear more about that thought process for anybody. And it's something that I remember talking to you a little bit last year when you were trying to make your decision. Yeah, for sure. I definitely saw a different kind of flavors, especially those flavors in the PM&R sports program. So PM&R oriented sports programs have that flavor of spine because that's what starts our training. So they incorporate that. There are certain programs that essentially are like sports and spine programs. There's other programs that they have a component of lumbar sacral. And then there are other programs like mine. And Emory's are very much like we don't do spine. And we're really kind of sticking with like bread and butter sports medicine, but implement the ultrasound as more of the procedural training. So it depends. Also, like I think it was one of us, I think it was Jamie. What practice do you see yourself in? Because actually some regions allow PM&R people to have that flexibility with sports and spine, like the Northeast, New York programs and all that stuff. But as you go in different regions, for example, in the south, where I'm originally from, they don't really have that kind of like flexibility with such a practice unless you're like doing private practice more. So like you kind of take that into account and what you're kind of going through your fellowship and realize, OK, well, I want to kind of end up in this particular region. So what kind of techniques, procedures and training am I supposed to get for my future job opportunities? And if it doesn't really need spine, then you can kind of go into that algorithm of like, OK, let's do a more sports specific fellowship training than I'm sort of sports and spine. Charlie, I think you're muted. Good for one every Zoom. As I say, Lindsey, from what I remember out at Utah, you guys get some early exposure, but also some flexibility in the amount of spine. Is that a fair statement? Yeah. There's a lot of programs that have X amount and a lot of programs that have this flexibility tuned to your learning. Yeah. My fellowship program is mixed. I'm the PM&R fellow, and then we have an EM fellow, a family medicine fellow, and a pediatrics fellow this year. They offer us all the opportunity to do fluoro, including all the primary care fellows as well. They typically work with one of our attendings who does primarily peripheral joints. She doesn't do any spine fluoro. But then some of the other attendings that I'll work with do a mix of both. They'll do some large joints and then they'll also do spine as well. Each quarter, we get about a half day, a week of fluoro time if you choose to do it. They encourage us all to try it at least for the first quarter because our schedules switches every three months. Then fellows have the opportunity to drop that off if they don't want to continue on. Like one of my co-fellows, she's like, I don't want to do any fluoro at all. They were like, well, you should at least try it for one of the quarters. She's going to do it next quarter. They encourage it more so because of the anatomy and seeing where everything's at doing those procedures. Even if you're not going to do it, it's really helpful even to take that anatomy and apply it to your injection skills as well. That's how it's set up here and it's been really nice to have the opportunity and also have some flexibility there as well. I'll add because I am still like a toss-up in terms of if I want to continue that in my practice and what that looks like. Just trying to figure it all out. Yeah. I remember to that point, a lot of programs having that flexibility, either crank it up or crank it down, especially as you come up to the middle of the year, maybe some people are starting to get their jobs figured out and need to tailor a skill set for that. I think there's certainly programs out there that have some flexibility. Karen, on that point too, I feel like coming from most PNR programs, people are going to have a foundational spine skill set, whether that involves interventions or not. I know talking with Gio and their Emory experience here, they come out with a significant more amount of hands-on injection experience than we did at Washington. But that being said, we saw plenty of spine patients and I feel like I can triage and manage that comfortably. Jamie, if you have any comments to that point, because I guess I don't believe there are a lot of spinal procedures, if any, out there, but you certainly, as I did, had a lot of hands-on experience with the management of those issues in residency. Yeah. It's here, the spine procedures, if you want it, it's just difficult. It's like you really have to want it and seek it out. I think we rotate every other block with the other PMNR fellow here and you get a Monday morning elective. So it's like you would have to be on that elective all six months in spine, I think, to even have a chance at doing that in your own practice here. But we see zero spine patients because Stanford has such a great spine program here. But I definitely got enough management of back and neck pain that when it came up with a football player just this weekend, he had an episode of TQ and I was the only rehab person there and I was the only one that really knew quickly how to manage it. So I certainly still use it, but probably less likely that I'll seek out enough spine procedures to do that later. But I also may be going back to the South, like Gio said, where it's less implemented. I also want to chime in that certain programs also incorporate EMGs in your training too. I can think of two programs that already incorporate EMGs in their training. And if you'd like to kind of have a balanced practice with EMGs in your belt, there are sports programs that implement that too. And I think Mayo offers it if you really, really want it, kind of like what Jamie said, if you really want it, then they can make an elective for it. Absolutely. That's a good point. Just all this together, I think it shows try to go somewhere that's flexible and caters towards what you want or at least has those opportunities. And like you said, some of us find out a job halfway through and then we know like, all right, now I got to do EMGs or now I got to do spine or I'm not doing spine at all. I'm only doing diagnostic ultrasounds. Like going somewhere where you vibe with and you can talk to interviewers who are like, yeah, we will adapt and prioritize like your education because you are taking an extra year. We could all be attendings right now, you know, like in general PM&R. I know people who are general PM&R and they're doing ultrasound guided injections all day, MSK practice. And, you know, so remember this is an extra year for you. So you should don't, you know, focus on yourself and what you want to get out of it. Steve, you got a hand up there? Yeah, I have one up, but I want to, I know Alexandre had his hand up before me. Oh. So if he wants to go ahead and ask, that's totally okay with me. For sure. All right. Hello everyone. I'm Alex from the University of Montreal in Canada. So thank you all for sharing your experience today. And I have a quick question. So I know you guys had virtual interviews and I was wondering if you guys did on-site visits to the program where you matched prior to the interviews? I will go ahead and say, I didn't go on-site to any of the programs. I feel like I actually ended up doing like residency program interviews at a lot of the places that I did like fellowship interviews. So I at least was like familiar with a lot of the areas that I was applying to, but in terms of like a second look or going to visit on my own, I didn't do that during the time period of like fellowship interviews and before match or anything like that. Same, I didn't know how to name it. Yeah, same. I think I just, most places I had interviewed for residency. So I had been there. I think I know of one program I interviewed at that offered like a kind of formal second look for you to come check it out. But it's up to you. I think they are, sorry, are being kind of careful about that because you don't want to introduce, you know, some sort of financial bias. If people can make all these second look trips, they shouldn't be favored over those that maybe can't. So I don't think they were offered, honestly. Yeah, it was really rare. I had two that were in person. They were both through family medicine or one was through family medicine, one was a mix. And I think one offered a second look, but that's out of like over a hundred programs. So it's pretty rare. Yeah, I was going to say there was one program that I applied to that was thinking about doing a second look. And I think they pulled all of the applicants and they were like, eh, okay, we're actually not going to do this. Okay, yeah, that's the one I'm thinking of, yeah. Yeah, we're all thinking of the same program. I will let you know, though, after the interview day, I think one of the best advice that I got is to kind of just keep communication with even the fellow, because it was just very nice to listen to the fellow's perspective and just seeing their day-to-day basis and kind of like stay in that connection. So you can have less when you're at the end of the fellowship trail, you're going to have so many questions and you just have to stick to that priority list that one of those things that you can just do is to kind of open those communications with fellows, with prior fellow graduates. That's what I kind of did with through AMSSM and AAP Menorah has that too, with kind of like their networks. Sounds good. Thank you very much. Yeah, I know they, in general, that is still kind of like an ongoing process, right? Like what's the interview process going to look like moving forward? And I think people are realizing there's a lot of benefits to virtual interviews, but still, like I said, you know, getting to know the individual culture of the program as obviously a little bit easier in person, but I think that's something that, you know, both on the residency and the fellowship level that everyone's kind of continuing to think about and figure out, but I would just echo what Gio said too, whether it's, you know, you and I have, you know, connected through social media and then got to meet each other at the AMSSM last year. So I was, you know, things like that, I think are super handy and just staying in touch with each other because, you know, sports medicine, but especially like the PM&R sports medicine, just increasingly a tighter knit group. And for the most part, everyone is very willing to keep in touch and network and exchange ideas and information. So, you know, keep it up there for sure. Steve, I know you have a question, but I'll add like talking to people you interview with, I think is helpful. I know like me and Lindsey texted a lot, or like, you know, like, you know, like, you know, Lindsey texted a lot, or like she would pick up things that I didn't notice or bring up. Oh, but they didn't have a continuity plan for fellows. Like, oh crap, I didn't realize that. Or they didn't like spell out what their ultrasound didactics was. So like, you know, everyone's, I think is pretty nice, like sharing information. So when you meet people on the trail, just chatting, like as you go, like what were your, did you do anything that was a big red flag or how'd you like it, stuff like that. So I thought that was helpful to talk to people. Go ahead, Steve. Thank you all so much for taking the time late on an evening. I know you all have very busy schedules, so I appreciate it. I'm Steve Lubert. I'm a current fourth year resident at the zoo, the university of Missouri, Columbia. And I am in the midst or kind of up to my eyeballs in the interview trail right now. Um, and so, uh, trying to think ahead and not get totally swallowed up in that, but when do you, is there an official time where people start the job hunt? Do they start looking for that before they, uh, match? Do they start? Is it different for everyone? Uh, just kind of curious. I've heard a couple of different answers, but wanted to hear from you all. Yeah, I can, uh, kind of start laying that off. So I'm in a little bit more of a unique position. I'm doing a two-year fellowship track at Emory. Um, so when I committed to that coming in, you know, I didn't worry about it much last year at all, but, you know, I would say it's never like too early to start, especially a place you have relationships, like stay in touch with those people. And, um, you know, there's four residency during residency out otherwise. Um, but, uh, my co-fellows last year, uh, Rosa decided pretty early on that she wanted to stay in Atlanta. And so sometime like late fall, winter, an opportunity came up with Grady. And I think she had that finalized by like January, February. Uh, and my other co-fellow, um, Stacy, she, um, was very focused on what she was looking for, for, from a job. So she got a lot of interviews. She definitely, you know, is awesome and would have had any job that she wanted, but, uh, she ultimately decided to do another fellowship year at the new woman's health, um, program out in Boston, uh, with Dr. Ackerman out there. So, um, you know, she, you know, went through the process and, and, you know, just, uh, based on our priorities, um, wasn't ready to commit to the long-term job. And then, uh, for me kind of at that transition, um, last year, I started, uh, connect with some people and, um, you know, more and more cranking up, uh, here's the coming to annual assembly and through there. So, uh, there's no right answer, but I think in general, like it's never too early to start kind of like networking and putting feeling feelers out there. Um, I know, you know, just from being friends with a couple of people on the panel that, you know, they, you know, started pretty early, um, asking around and kind of stay in touch with people too. So I don't know if anybody wants to expand on, on what their experience is. It is very overwhelming when you're like, just, you know, doing a big move, starting fellowship, you're in football season. Um, but it's always kind of in the back of your mind right like that's like Kevin said the whole reason that you're doing a fellowship is to get a job, ultimately. So, it's a, it's a lot but you know again it's a very like tight knit and supportive network so. I'll say like academics takes longer. If you're interested in academics, because they got to like look at budgets and have all this different stuff in. So I've always, I mean I think if you start more in the fall time of like around So academics just takes it just a slower process. And then I know people interviewed private practice and April, at the end of their fellowship, and then get a job, you know, so I think just academics if you're interested starts a little earlier. And also if it's region specific then you're also limiting yourself, even more. So if you're open to that, that, that's what I'm noticing now like trying to focus on job opportunities in the south. So, getting those limiting my scope. But if you have an open scope is, I mean, an open to wherever you are, you're going to have an easier time than limiting your scope to a particular region. Yeah, I would echo to Kevin's point that the academic, you know, departments have been talking to or, you know, you know, possibly have have growth opportunities but there's going through, you know, different budgets and transitions and it's just kind of a lot of coordination that that takes place there so I think staying in touch with people and also reaching out to department chairs are just incredibly busy people right so there's been a couple people have set up networking calls with when it's from the time that they're, they are open to setting up meeting they're all about it but just the way their schedules work out it just has to push out a bit so, you know, it's just a process for sure. Gotcha. Thank you all and I hate to double dip I do have another question. Go for it. We're here. Thank you. Is it. Is there like a time or should you even like consider reaching out to programs who you haven't heard from yet in the process. And if, if you should at all and then if you should like when should you. That's a tough question. Um, I, because I was sharing information with two other co residents, going through the same process was, you know, very aware of when invites had already gone out, I would say that I wouldn't personally wouldn't go asking for several but if there was like, uh, I really had my heart on this one program that I didn't hear from. And you either plead your case on your behalf showing your high interest in their program for this reason, or if you have an attending or other mentor Yeah, I would echo Jamie's point in that, you know, I'd be targeted targeted with that and I think more so to the point of, you know, if there's somewhere you have a lot of interest in because of a very specific reason, then I think it's, you know, more could be very helpful on on both ends to to reach out and just kind of reiterate like this is why I'm interested in your program. And XYZ that I think that is, you know, completely fair game. You know, our class was pretty open we had like a group me threaded that pretty much all of the PR and our applicants on the same text chain. So, so again, like I think somebody set up a spreadsheet and something like that too. So it was is decent transparency in terms of that, but You know, certainly coming in to the bulk of the fall, it's As your schedule fills up, certainly it's Hard to like hold a spot for for a program that you're not sure if you're going to hear about or not. So I think reaching out and expressing that interest can be helpful, both for you and, you know, maybe the programs trying to You know, assess different factors and if that strong interest for a particular reason is there. I think that can can move the needle. Sometimes so I wouldn't, you know, blast every program. But, you know, those couple years have genuine sincere things to comment on. I think that's, you know, completely professional and okay Thank you all so much. Yes, I'm Stephen. He's my for the Georgetown program. A couple of the programs I've interviewed with see seem like you'll have full autonomy at a high school team at whether it's like high school football. And then when you're covering, say, like a collegiate team that might be with an attending in the training room, but then also with games. Is that a common theme that you've experienced and you guys are all like currently experiencing or is it more variable than that. Yeah, that seems like my experience. At least with collegiate football. It seems like for us, we have to primary care attendings into ortho attendings there and then four of us fellows are there at the games. But we have had like some hands on opportunities. Some athletes have beginning like IV fluids and some have needed like a block before a game and their foot for like an hour or so. So, they let us jump in on those opportunities. And when they're seeing if there's like an injury during the game and they're going back in the tent we sort of just trade off so there's not like, you know, all four of the attendings are in there, plus all four fellows and try to give them some space and take a little bit of a turn for the other sports, though, like soccer and basketball. And was able to be in the training room with the attending after the game and evaluate some of the players with her so football for me was a lot of fun. For the other sports, though, like soccer and volleyball it's usually for at least here, or with one of the attendings and so yesterday for example, covered women's volleyball and was able to be in the training room with the attending after the game and evaluate some of the players with her so football for me like high school wise, technically like the team physician with an attending, but I'm the first line of coverage and so all the questions from the at come straight to me and we just discuss all the cases together. So that experience has been nice to have more of that leadership role. Yeah, I would say, I think the experience is different and different fellowships so the others can probably chime in on how it's going for them to. Yeah, that's what it's here to sorry again. I'll just keep it quick. We sometimes will have non football Stanford events like I'm covering field hockey right now I'm sure like for all of the wrestling matches there will always be an attending there because that's so high yield. college football games which are like surprisingly high risk for energy injuries I think we had three concussions and ACL tear and something else just just all in one football game. And we were by ourself and quite autonomous so we definitely see both. Mine is not, I cover a d3 college football and my training room experience is a little bit more independent, I go into training room and the athletic trainers kind of stacks all the athletes for me, and I make clinical decisions there but then I can communicate with my attending afterwards on through like an email or a formal or actually can make formal notes on on the MR system, but it, that's my sort of training room and here at the Rochester program it's more like local coverage in terms high school and track meets, and, and there's a wrestling matches coming up in two weeks, but that's to say I'm not seeing I'm seeing a lot of injuries just more so I think I'm getting actually a lot more autonomy than what I was what I thought I was going to get. Just because it's just because it's d3. I'm just kind of getting everything, and I'm the only in this particular program there's only one fellow so it's just me. So, everything kind of just goes to me, but that has been my experience. Yeah, I agree. d3 or d2 may not be as sexy but you get more independence, actually, and it could be on your own which is scary sometimes. And then like at the high school level I think it's pretty normal there's a variability but I think we do like a lot of like unique sports that I like USA boxing USA fencing MMA, stuff like that that we get more and more autonomy, we get to do like marathons on our own, stuff like that so we don't have a big D one college, you know that type of exposure. So I can't speak on it but some of the more like niche, niche sports or smaller events like you, you get to go and be on your own so it's a different way of learning. But I think there's a lot of pros and cons to like what level of athletes or sports. Hey Joe, good to see you. So for us we cover a little bit of everything high school, you're pretty much on your own we have our attending by phone if needed. And then for Emory is also d3 so kind of going off with Kevin and geo said I walk in and then you know we get an email saying there's five people to be seen that day by the 80s running it and they have their charts we go over things beforehand and then I'm seeing them in the training room we can use the ultrasound if needed. So basically you're making the decisions and then you can, if you need to talk to your attending and kind of fill them in and clinic afterwards of what was going on or if you need help you can run things by any of the attendings actually all really awesome even if it's not their school so that's kind of how it works with Emory and with high school Georgia Tech is kind of somewhere in the middle where you get to evaluate a little bit but there's ortho fellows there a bunch of attending so it's kind much evaluation you're doing. And then pro team coverage is, you know, mostly shadowing beginning to see the ropes and how that works so just really depends on what you're doing. Thanks a lot guys, that was really helpful. Yeah. Yeah, so that earlier in the talk to just really just a huge advocate for having that diverse set of experiences. I think, on the one hand, like you, your decision making changes so much, or needs to be flexible I guess is the best way to say it, depending on the setting and the resources that you have and things like that so like being in Atlanta is crazy because, you know, I can be in a city high school, one day, you know, the next day I can be in a rural high school you know an hour north. And then like last week I was, I was in Abu Dhabi with the Atlanta Hawks, like, literally like this, and it's each each setting is just a different skill set, different set of like learning how to have that independence in your decision making and that confidence and so I think it's really important to have all of that and, you know, one thing that was really apparent to me, going and interviewing everywhere and everybody here is from fantastic programs but I, I really didn't feel like I interviewed anywhere where I was like this is not a program where I would be supported and be able to be the best physician that I can be so I think it's just a tremendous community and, you know, speaking of that just the fact that I can, you know, send a text to all these people and they're like oh yeah I'm going to be there, no question. You know they're working with their attendings to be flexible and get out here and it's priority from be here and talk to everybody. So, you know, much loved all you guys and appreciate everyone making out. You know, feel free to reach out to any of us at any time whether it's bumping into us whether you're interviewing at any base program, you know, definitely keep an eye out for everybody. And I do want to give one shout out to Megan Struble who's been the AP and our staff behind the scenes with us today. Thank you, Megan, thank you for all the staff and make these community days, you know, possible, and we're looking forward to getting together with everybody who's able to make out to Baltimore so thank you everybody for for tagging us on to a long Monday and it's great to see everyone and looking forward to connecting in the future as well. Thanks Dr Kenyon have a good night everyone. Thank you, Megan. Thank you everybody. Bye bye guys.

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