THE SIDELINE the Official Newsletter of the Canadian Academy of Sport and Exercise Medicine What’S Inside

#83 April 2017 Le bulletin officiel de l’académie canadienne de la médecine du sport et de l’exercice Sur Le Terrain THE SIDELINE The Official Newsletter of the Canadian Academy of Sport and Exercise Medicine What’s Inside... President`s Note Page 2 Dr. Ted Percy Committee Updates 1924-2017 Page 3 Red Bull Crashed Ice Page 4 Co-Founder and Geriatric SEM Article inaugural President Page 5 of CASEM 2016 CASEM Award Recipients Page 6 Co-fondateur et Winter FISU Article Président inaugural Page 7 de L’ACMSE Research Grants New Members Page 8 Edward Percy’s great skill as an orthopedic surgeon earned him the Ask the Expert nickname Brother André, a nod to the legendary Montreal faith Page 9 healer who was canonized in 2010. Some of Dr. Percy’s patients, Warwick Agreement on including Montreal Canadiens great Serge Savard, believed the FAI Syndrome doctor could work miracles, too, sometimes resuscitating the careers Page 10 of athletes who had suffered serious bone breaks and ligament Resident’s Corner Page 11 damage. Dr. Percy died of cancer on March 2 in Saanich, B.C. Events He was 92. Page 12 ... Choosing Wisely To read the full article from the Globe and Mail - Click here Page 13-14 Job Opportunities Page 1 55 Metcalfe Street Suite 300 - Ottawa, Ontario K1P 6L5 5 T. 613-748-5851 or 1-877-585-2394 F. 613-912-0128 Friend on Facebook CASEM Newsletter Team Editors: Lindsay Bradley Follow on Twitter M-J Klett Andrew Marshall

PRESIDENT’S NOTE NOTE DE LA PRÉSIDENTE Dr. Laura Cruz CASEM President 2016-2017 Présidente ACMSE 2016-2017

Spring Forward!

Happy Spring! The days are getting longer and the warm spring weather has tempted us in more than a few cities/ towns across the country. I had the pleasure of spending two days in early March, in Ottawa with President - Elect Tatiana Jevremovic and Executive Director Dawn Haworth: it was cold and slushy and not conducive to any sport activity out of doors in my opinion (but then my "sport" was in a dance studio or in summer months on a field or track). However it did not deter us from our end goal, as we went on our annual "Presidential Tour"- an opportunity to reconnect and re- establish relationships with various stakeholders in the sport and exercise medicine "space".

We met with a variety of organizations that CASEM works together with at games, in policy advising committees or as affiliate organizations. These meetings gave us the chance to find out what other groups are doing about a variety of topics: concussion, physical activity promotion, mentoring, and novel CPD strategies. They also provided the opportunity to share CASEM's own accomplishments and achievements and to explore interest in mutually relevant projects.

On this occasion we also took advantage of the time in Ottawa to connect with local committee chairs/ contacts that are working hard on members behalf’s- communications chair Lindsay Bradley and HEPA board liaison Elizabeth Hobden. We touched base with Helen, the head office CPD coordinator- busy year for CPD-check out the MSK US courses, the Running Workshops and stay tuned for OA workshops!

Tatiana and I also learned that the website will soon be much easier to navigate (cheers!), that the Running Injury Clinics are filling up fast, and that registration for Mont- Tremblant is ahead of schedule. I strongly encourage you to check out the preconference courses- space is limited and these courses will be great CPD opportunities.

Along with the great conference in June, the AGM and elections for the next Board members will take place. If you have ever wanted to participate and contribute at a more direct level, consider running for a Board position. This is a wonderful opportunity to work with fellow SEM colleagues and play a role in CASEM's future- make sure your CASEM is doing what you think it can and should be doing!

So with renewed energy characteristic of this time of year let's Spring Forward! See you in Mont-Tremblant! Until then! Laura

Nous avançons l’heure!

C’est maintenant le printemps! Les journées s’allongent et les températures chaudes du printemps nous ont tentées dans plusieurs villes à travers le pays. Au début mars j’ai eu le plaisir de passer 2 jours à Ottawa avec notre présidente désignée Tatiana Jevremovic et notre directrice exécutive Dawn Haworth. Il faisait froid et les rues étaient pleines de gadoue – en mon opinion pas particulièrement propice aux sports extérieurs, mais mes sports ont toujours étés dans u studio de danse ou sur une piste d’athlétisme. Par contre ceci ne nous a pas prévenu d’atteindre nos objectifs de notre “tour du Président”: une opportunité de reconnecter et ré-établir nos relations avec nos partenaires dans « l’espace » de la médicine du sport et de l’exercice.

Nous avons rencontré plusieurs organisations avec qui nous collaborons soit aux Jeux, en comites de conseils stratégiques ou en tant qu’organisations affiliées. Ces rencontres nous permettent de savoir ce que ces autres organisations font à propos de plusieurs sujets incluant les commotions, la promotion d’activité physique, le mentorat et de nouvelles stratégies d’éducation professionnelle continue. Elles nous permettent aussi de partager nos accomplissements et explorer nos intérêts communs.

Nous avons aussi profité de ce temps à Ottawa pour rencontrer des membres locaux de comités qui travaillent fort au nom des membres- la présidente du comité de communications Lindsay Bradley ainsi que notre liaison au conseil HEPA Elizabeth Hobden. Nous avons aussi connecté avec Helen, la coordonnatrice d’éducation professionnelle continue - c’est une année occupée pour elle! Allez-voir les cours d’ultrason musculosquelettique, les séminaires sur les blessures de course et à venir les séminaires sur l’ostéoarthrite!

Tatiana et moi avons appris que notre site web sera bientôt plus facile à naviguer (yay!), que les séminaires se remplissent vite et que l’enregistrement pour Tremblant progresse plus rapidement que prévu. Je vous encourage tous à explorer les cours pré-conférence-les places sont limités et ce seront des opportunités d’apprentissage fantastiques.

En même temps que notre fantastique conférence sera notre réunion générale annuelle et les élection pour notre prochain Conseil. Si vous avez déjà eu de l’intérêt pour s’impliquer plus intimement considérez joindre le Conseil. C’est une opportunité fantastique de travailler avec vos collègues et de jouer un rôle au sein de notre organisation en s’assurant qu’elle fait ce que vous pensez qu’elle peut et devrait faire!

Alors avec un regain d’énergie commun à ce temps de l’année, bondissons vers l’avant!

On se revoit à Tremblant! A bientôt! Laura

SELECTION COMMITTEE – UPDATE By Committee Chair: Richard Goudie Test event number one: done.

We have been working patiently for quite some time to review, update and improve the score sheet, otherwise known as “the Grid”, for Major Games applications. We have also developed a congruent application form allowing the evaluators to assess each application more objectively and with more inter-assessor reliability.

The call for applications for the 2018 Commonwealth Games and Winter Olympic Games were the test event. Over 50 applications came through for those events allowing many chances to test our new system. We have found many areas to improve and this will be our next focus. I will list various issues that should be known by each applicant to improve all further applications:

• The application form you have filled can always be updated from your computer. It can be resent with new information for all future Game. Unfortunately, due to the improvements we are investigating, it might change before it is known as the “final copy”.

• It is imperative that you devote quality time to fill it out in the utmost detail. You only shortchange yourself because in the words of the CMPA:” If you didn’t write it…it didn’t happen.” Which basically means we can’t give you a score.

• The members I recruit to help me score each individual application are volunteering their hours for this. It takes a lot of time for us to go through every application. Please be respectful and do not assume it’s an easy job and a quick task. If you decide to not fill any details and state: “Please see CV”, it makes the whole process quite complicated and much more time consuming. Basically, if you don’t think it’s worth your time to fill out this application then it’s not worth ours to spend time sifting through your CV to see what is relevant.

• Please understand the inherent hierarchy of Major Games. After a long lull in the desire for volunteering, there is a surge of applications in recent Games. That is positive. The reality is if you have never been part of a multisport Game, have only helped out at a local running race and worked with one of the varsity sports during your fellowship: you will not be selected to be part of the Olympic / Paralympic / Pan Am / Parapan Am / Commonwealth Games core team. Experience in developmental Games is required before a CMO will decide to include you in their HST for the Major Games. We respectfully ask that applicants be selective of the Games they apply for, as we still have to devote time to review your submission.

• If you do not have a Diploma of Sport Medicine you cannot apply for any Major Games other than Canada Games and Jeux de la Francophonie, which are considered the developmental Games.

• Because the applications precede the Diploma exam, don’t submit your application stating you are “sitting the examination this year”. Your application will not be reviewed, as there is no certainty you will be successful at the exam.

• I understand it takes a long time but we cannot score adequately if you write: “I have worked with many local teams” or “I worked many marathons”. Be specific and there’s an infinite amount of events you can add.

• It is very different to have worked at one OHL hockey game in one year versus being at 15. Both are considered “MD part of the medical staff”. You can easily see the involvement is different. Please add comments in the box below each separate section on the application to define your work better and help assessors understand what you do or have done.

Those were a few comments that came up during a telephone conference last evening as we assessed the new system. It will be changed and improved some more to be better for you, more objective for the assessor and smoother for us to review the information you submit.

Thank you for all of those who are looking to be engaged in Major Games’ participation.

Dr Richard Goudie Chair Selection Committee. escendre, à des vitesses allant Pour un événement de la sorte, nous devions jusqu'à 60 km/h, une piste glacée définitivement nous préparer pour le pire parsemée de courbes, sauts et (nous étions même prêts à aller récupérer descentes abruptes... En quelqu'un au fond du canal Rideau!). Dcompagnie de trois autres athlètes qui ne Cependant, la plupart des blessures qui sont veulent que te battre à la ligne d'arrivée... survenues étaient des contusions et des Chaussés de patins... Qu'est-ce qui pourrait ecchymoses. Les thérapeutes ont été de loin mal virer??!! les personnes les plus occupées (ce qui était parfait pour nous!) La ville d'Ottawa, au sein des célébrations du 150e de la Confédération, était l'hôte de la Nous avons eu les meilleurs billets pour finale du Championnat du Monde 2016-2017 assister aux victoires de Mirko Lahti (juniors), du Red Bull Crashed Ice. Durant ces 4 jours, Jacqueline Legere (femmes) et Cameron Naasz nous avons eu la chance d'admirer ces (hommes). Nous seulement furent-ils talentueux athlètes dévalant une piste victorieux de leurs courses respectives, ils ont complètement FOLLE insérée entre le également remportés les titres de champions Parlement et le Fairmont Château Laurier, à du monde. l'intérieur même des écluses du canal Rideau! Je tiens à remercier chaque intervenant ayant En tant que médecin en chef (mon 3ème fait partie de l'équipe médicale de cet Crashed Ice!), j'ai eu la chance de travailler événement hors de l'ordinaire. Votre travail et avec une équipe de médecins très compétents votre expertise furent grandement appréciés! (David Mai, Meaghan Rollins, Jay Pollock, Taylor Lougheed, Chris Raynor, Ryan Shields, Et juste au cas où quelqu'un se le demande: Keith Morgan, Val Hindle et Katie Yelle). Nous non, je n'ai pas essayé de étions également épaulés par des descendre la piste. Je suis physiothérapeutes et des massothérapeutes loin d'être assez fou... afin de s'assurer que les athlètes étaient prêts et en sécurité! Nous avions aussi le support de Dr Jérôme Ouellet, MD la Patrouille Canadienne de Ski afin de se FRCPC DipSportMed charger des évaluations et des extractions sur Médecin en chef - la piste. Nous avions même avec nous un RBCI Ottawa 2017, ancien membre des Forces Spéciales, expert Québec 2015, des évacuations en terrain difficile! Québec 2014

oing downhill, at up to 60 km/h, make sure these athletes on a track filled with sharp turns, were ready and safe! We also jumps and drops... Along with had great support from the Canadian Ski three other athletes who want to Patrol for trackside management and Gbeat you to the finish line... Wearing skates... evacuation. We even had with us a former What could go wrong??!! Special Forces expert in charge of tricky extractions! Ottawa, as part of the Ottawa 2017 celebrations, was host to the 2016-2017 Red For such an event, we definitely had to Bull Crashed Ice World Championship Finals. prepare for the worst (we were actually Over the course of 4 days, we had the ready for someone falling INTO the canal!) chance to admire these talented athletes However, most injuries that occurred over going down that INSANE track jammed in the week were basic contusions and bruises. between the Parliament and the Fairmont Let's just say that the therapists were by far incredible event. Your work and expertise Chateau Laurier, down into the Rideau Canal busier than we were (which we prefer!) were greatly appreciated! locks! We had first row seats to see Mirko Lahti And just in case someone was wondering: As Chief Medical Officer (my 3rd Crashed (juniors), Jacqueline Legere (women) and no, I didn't try the track. I'm not crazy Ice!), I had the chance to work with a Cameron Naasz (men) take home not only enough... wonderful team of physicians (David Mai, the win but also the World Championship Meaghan Rollins, Jay Pollock, Taylor titles. Dr Jérôme Ouellet, MD FRCPC DipSportMed Lougheed, Chris Raynor, Ryan Shields, Keith Chief Medical Officer - RBCI Ottawa 2017, Morgan, Val Hindle and Katie Yelle), I would like to take this opportunity to thank Quebec City 2015, Quebec City 2014 physiotherapists and massage therapists to everyone who worked with me on this Bringing new meaning to the “Golden Years”: making the case for Geriatric Sports and Exercise medicine Jane Thornton MD PhD

Frenchman Robert Marchand’s name has become synonymous with incredible achievement two months ago after setting a new track cycling world record… at 105 years of age. Astounding as this is, it has only served to confirm something many of us sport docs already know: the body is built for adaptation.

When French researcher Veronique Billat and colleagues put Mr. Marchand on a Jane Thornton MD PhD training plan and studied the results (1), they noticed something remarkable - Marchand was over 100 years of age and more aerobically fit than most 50-year- olds. Even more remarkable - he is still making improvements.

But if this were globally true, why do most health care practitioners see the opposite trend as a general rule? Too many older adults are sedentary, and instead of thriving during these years, they are simply surviving - with complex, chronic diseases. In Canada, for example, 14% are over the age of 65, yet account for almost half of health care costs. These numbers are only expected to rise.

We know the numbers of Masters athletes are climbing and their performances continue to amaze and inspire. Can these stories not push the limits of what we know for ageing and chronic disease as well?

In my opinion, this is one of the most interesting emerging fields to hit sport and exercise medicine in a long time.

We know that there are several positive changes in disease markers in the older adult with an increase in physical activity, but we’re still learning ways to tailor these interventions for optimal effectiveness (2), especially in light of increased hospital visits in this population.

Hospitalization can induce atrophy and profound muscle weakness throughout the course of a relatively short stay, particularly targeting the all-important hip flexors. This can lead to a drop in functional independence and increase fall risk.

A recent prospective cohort study at an academic medical centre in northern Israel (3) evaluated 177 patients over 65 years of age hospitalized in two internal medicine units. With a relatively minor and inexpensive intervention, attaching an accelerometer to a patient’s ankle, they were able to observe that walking more than 900 steps per day (approx. 500m) results in lower hospital- associated functional decline (HAFD). They observed a strong dose-response effect, and the beauty of it was that it is one of the first to link normative data to functional outcomes.

What about those too frail even too walk? Dr. Michelle Kho and colleagues at McMaster University in Hamilton, Ontario, examined in-bed cycling for frail and critically adults in the ICU (4). They found that these patients can safely pedal using a specialized exercise bike that rolls over patients’ beds. Using a built-in motor can move patients’ legs for them or allow them to cycle on their own.

Marchand’s case may help to challenge our beliefs about what is possible to achieve, regardless of how old we are. Outside of the elite older adult’s performance, however, the biggest gains will likely be observed in a growing population - the frail and hospitalized patient. Studies like Dr Michelle Kho’s and others in the field should give us hope that physical activity earlier on in rehabilitation can reap multiple benefits.

The critical need for research and advocacy for physical activity in the older adult will only intensify as the world’s older adult population continues to grow and their health needs continue to escalate.

When caring for older adults, we physicians should not only be talking about medication, but also about what can be done as an adjunct to therapy or in some cases to replace medication altogether (5). This also means getting older adults involved in preventative measures like strength and balance training before they wind up in the emergency department with a broken hip.

Let’s move beyond counselling on just not being sedentary and encourage our patients to embrace the joys of sport and physical activity at any age.

We may yet come to see that the “Golden Years” become even brighter.

References: 1. Billat V, Dhonneur G, Mille-Hamard L, Le Moyec L, Momken I, Launay T, Koralsztein JP, Besse S. Case Studies in Physiology: Maximal oxygen consumption and performance in a centenarian cyclist. J Appl Physiol 2017 Mar 1;122(3):430-434. doi: 10.1152/japplphysiol.00569.2016. Epub 2016 Dec 29. 2. Buford TW, Anton SD, Clark DJ, Higgins TJ, Cooke MB. Optimizing the benefits of exercise on physical function in older adults. PM R. 2014 Jun;6(6):528-43. doi: 10.1016/ j.pmrj.2013.11.009. Epub 2013 Dec 19.

3. Agmon M, Zisberg A, Gil E, Rand D, et al. Association Between 900 Steps a Day and Functional Decline in Older Hospitalized Patients. JAMA Intern Med. 2016 Dec 5. doi: 10.1001/ jamainternmed.2016.7266.

4. Kho ME, Molloy AJ, Clarke FJ, Ajami D, McCaughan M, Obrovac K, et al. (2016) TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients. PLoS ONE 11(12): e0167561. doi:10.1371/journal.pone.0167561

5. Thornton, J.S., P. Fremont, K. Khan, P. Poirier, G. Wells, J. Fowles, R. Frankovich. Physical activity prescription: a critical opportunity to address a modifiable risk factor for the prevention and management of chronic disease: a position statement by the Canadian Academy of Sport and Exercise Medicine. Br J Sports Med doi:10.1136/bjsports-2016-096291 Congratulations to CASEM’s 2016 Award Recipients

Congratulations to our 5 CASEM members being honoured with an award. These awards were created to recognize CASEM physicians who have contributed to the sports medicine world in a significant way, whether it be through community work , through teaching and mentoring the next generation of sport medicine physicians or by contributing to the advancement of sport medicine in Canada.

Darrell Menard Julia Alleyne Louise Walker 2016 Community Sport 2016 Lifetime Membership 2016 Educator/Mentor Physician of the Year Award Recipient Award Recipient Award Recipient

Jamie Kissick & Richard Goudie 2016 Medal of Service Award Recipient

The awards will be presented during the AGM at the upcoming CASEM-AQMS meeting this June in Mont-Tremblant, QC. Winter FISU Almaty, Kazakhstan 2017 had the honour of representing team Canada as As a medical team, we had a lot of success while in Almaty! the Chief Medical Officer (CMO) at the recent We were able to have a doctor present at all of the higher risk events FISU 2017 Winter Universiade in Almaty, (alpine, snowboard, hockey), and provided therapy coverage at the I Kazakhstan. The Winter Universiade is a remainder. Although our clinic could not be open for the entire day, multisport Games that takes place every 2 years for we were always accessible and open typically in the morning and university registered athletes. This year’s Games were hosted by the night. Lucky for our entire team, the Canadian delegation was quite city of Almaty, the largest city in this central Asian country, and ran healthy for these Games, which allowed us to really see multiple from January 29th- February 8th, 2017. 2481 athletes from 57 venues and support the athletes on site! Between the buildings and countries participated in 13 different events. Team Canada had 87 outdoor venues, many of them were simply breathtaking to be at! athletes participating in 8 sports (men’s/women’s hockey, men’s/ Many of us also had the chance to experience the city, including the

women’s curling, snowboard, alpine skiing, cross country skiing and beautiful subway system, the local green bazaar, the chocolate that biathlon), and were supported by staff including coaches and team the country is famous for, and the splendid Turkish baths! leaders. I was part of an AMAZING mission staff of 10 which including 3 operations, 2 media, and 5 medical staff. This is the 25th anniversary of diplomatic relations between Kazakhstan and Canada. With our country’s 150th birthday Having previously had the opportunity to take on the role of approaching, Shawn Steil, the Canadian ambassador to Kazakhstan, the CMO at the 2014 Youth Olympic Games, this was a chance to was present to support our athletes. USports and the embassy held a learn from that experience and apply it to a more senior level event. I joint community event to build an outdoor ice rink in an was supported by a fantastic medical team including our Chief underdeveloped area of Almaty. There was a large local and Therapist Jason White (athletic therapy), Dr. Erika Persson (U of Canadian turnout, including our men’s and women’s hockey teams! Alberta), physiotherapist Geneviève Renaud, and athletic therapist They offered some hockey skill sessions with the local children, and Connie Klasson (Camosun College). We had the challenge of played a friendly game of shinny at the end. balancing the support of our athletes at as many venues as possible, which were up to 2 hours away from the central athlete village with I definitely learned a lot in my role as the CMO at these providing on site clinic coverage for those that might be ill or injured. Winter University Games. The relationship that you have with your team and fellow staff is the key to success; a cohesive team leads to Almaty was the first time that the Winter Universiade has great results for both the staff and athletes. I was so happy to be had a central athlete village. This included everything such as our prepared going into these Games by having an experienced medical dining hall, international mixed zone, a bank, gift shop, athlete team, by reviewing our medical supplies, and completing medical file lounge, salon and fitness centre! We even were able to enjoy some reviews in advance. It gave us the chance to address any potential gourmet coffee from some local baristas! This gave our team the medication conflicts and any TUEs that might be needed. And chance to really enjoy the multisport Games experience, meeting finally, we were always as present and available as we could be, to athletes from other delegations and sports, and learning about their ensure that the staff and athletes had as much support as possible. training habits and sport experiences. The FISU Games are an excellent opportunity to build on I had an outstanding experience, both personally and experience that you may have had working in a multisport Games professionally in Almaty. I had the chance to learn about environment or with other sport teams! I’ve definitely built a Kazakhstan’s diverse history as a nomadic culture, their separation relationship with several athletes, and made some new friends and from the USSR in the 1990, and their growth as country leading up to colleagues along the way! these Games as well as the upcoming Expo 2017 in the capital of Astana. They are a country that is SO very proud, and made us feel very welcome. You could feel the spirit of the country during the Dr. Lee Schofield opening and closing ceremonies, which were held at the figure skating arena and just OUT OF THIS WORLD! Congratulations Dr. Jack Taunton on being awarded the Silver Medal of Service by the Doctors of BC

The Silver Medal of Service is awarded for long and distinguished service to the Doctors of BC as well as outstanding contributions to medicine in BC.

Call for Research Grant Proposals - 2017 DEADLINE May 1st, 2017

The CASEM Research Committee invites submissions of research grant proposals for funding. These grants are made available through generous unrestricted contributions from CASEM. The following three grants are available this year: a. Two $10,000 CASEM Research Grants. All CASEM members are eligible to submit a proposal for these two grants. No existing or matching funds are required and there is no restriction of the topic of the research other than that it must have direct relevance to Sport Medicine. b. One $10,000 CASEM New Investigator Grant. In order to assist new investigators in developing their research in Sport Medicine, one $10000 award will be restricted to “new” researchers. c. One $20,000 Multi-Centered Research Grant

Full details and submission guidelines can be found on the CASEM website http://casem-acmse.org/education/research/

NEW MEMBERS

Lisa Somera—Brossard, QC Kyle Irvine—Telkwa, BC Maude Rivard-Cloutier—Québec, QC Marie-Eve Tremblay—Sainte-Agathe-des-Monts, QC Maxime Girouard—Mascouche, QC Mallory Quinn—Grande Prairie, AB Ask the Expert Find Answers to your Sport Medicine Questions

Treadmill versus Outdoor Running

Q: The winter weather at my current posting is a lot colder than I am used to. While I love running, I find it hard to motivate myself to train outside when the temperature drops below minus 25C. So I find myself running on a treadmill more than I ever have. Someone told me treadmill running is easier than running outside. Is this true, as I am running a half marathon in May and want to be properly prepared? Lt(N) Fairweather

A: Dear Lt(N) Fairweather: Congratulations on deciding to start treadmill running. This is an excellent training strategy particularly during our unpredictable Canadian winters. Many athletes have questioned if treadmill running provides the same benefits as running outdoors and research has shown these two forms of running are different. The most significant difference is that treadmill running is physiologically easier than running outside.

This reduced workload occurs because the treadmill belt assists leg turnover thus making it easier to run faster; treadmill runners don’t experience the wind resistance that comes from moving through the air and from Mother Nature; and the treadmill platform provides some give which reduces the shock absorbing demands made on working muscles. The great news is that by setting your treadmill at a 1% incline you can compensate for all these differences. Treadmill running offers a number of important advantages. It may be the only way to get in a good run on days when the roads are buried under snow or slippery because of freezing rain. Many athletes find the treadmill allows them to do speed work throughout the winter – this includes doing intervals, time trials and tempo running.

Treadmill running may also be a safer alternative to running in an area where you are uncertain about your personal safety. Some treadmills can even be programmed to simulate race courses. Ideally during your race preparation I would recommend you try to run 2-3 days/wk on the road and one of those days should be your long run of the week. Combine this with 2-3 days/wk doing speed work on the treadmill and you will enjoy the best of both worlds.

The bottom line is that treadmill running is a great way for you to prepare for your half marathon and by setting the incline at 1% it will be as physically demanding as running outside. Hopefully you are blessed with an early spring so you can do less indoor training and enjoy more “fair weather” running outside. Good luck in race.

Dr. Darrell Menard MD Dip Sport Med

Dr. Darrell Menard is the Surgeon General’s specialist advisor in sport medicine. He has worked extensively with athletes from multiple sports and has covered Canadian teams competing at multiple games including the 2012 Olympics and the 2016 Paralympic games. These articles were originally published in the Canadian Forces Journal, the Maple Leaf.

The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this Website page. CASEM recently endorsed: The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome) : an international consensus statement. BJSM 2016; 50:1169-1176 Doi:10.1136/bjsports-2016-096743, D R Griffin et al.

Emerging attention is being given by physicians to the entity of FAI contributing to hip pain and pathology in a ‘younger cohort’ of patients. This international multidisciplinary agreement used a framework whereby six questions were formulated, and current evidence reviewed to arrive at consensus answers to these questions around the diagnosis and management of patients with FAI.

Below is the Summary of the Warwick Agreement. For a full reading of the paper, please refer to the BJSM citing above.

SUMMARY OF THE WARWICK AGREEMENT ON MANAGEMENT OF PATIENTS WITH FAI SYNDROME

What is FAI syndrome? FAI syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings. It represents a symptomatic premature contact between the proximal femur and the acetabulum.

How should FAI syndrome be diagnosed? Symptoms, clinical signs and imaging findings must be present in order to diagnose FAI syndrome.

Symptoms: The primary symptom of FAI syndrome is motion or position related pain in the hip or groin. Pain may also be felt in the back, buttock or thigh. In addition to pain, patients may also describe clicking, catching, locking, stiffness, restricted range of motion or giving way. Clinical Signs: Diagnosis of FAI syndrome does not depend on a single clinical sign; many have been described and are used in clinical practice. Hip impingement tests usually reproduce the patient’s typical pain; the most commonly used, flexion adduction internal rotation (FADIR) is sensitive but not specific. There is often a limited range of hip motion, typically restricted internal rotation in flexion.

Diagnostic Imaging: An antero-posterior radiograph of the pelvis and a lateral femoral neck view of the symptomatic hip should initially be performed to obtain an overview of the hips, identify cam or pincer morphologies, and identify other causes of hip pain. Where further assessment of hip morphology and associated cartilage and labral lesions is desired, cross sectional imaging is appropriate.

What is the appropriate treatment of FAI syndrome? FAI syndrome can be treated by conservative care, rehabilitation or surgery. Conservative care may involve education, watchful waiting, lifestyle and activity modification. Physiotherapy-led rehabilitation aims to improve hip stability, neuromuscular control, strength, range of motion and movement patterns. Surgery, either open or arthroscopic, aims to improve the hip morphology and repair damaged tissue. The good management of the variety of patients with FAI syndrome requires the availability of all of these approaches.

What is the prognosis of FAI syndrome? In patients who are treated for FAI syndrome, symptoms frequently improve, and they return to full activity, including sports. Without treatment, symptoms of FAI syndrome will probably worsen over time. The long term outlook for patients with FAI syndrome is unknown. However it is likely that cam morphology is associated with hip osteoarthritis. It is currently unknown whether treatment for FAI syndrome prevents hip osteoarthritis.

How should someone with an asymptomatic hip with cam or pincer morphology be managed? It is not known which individuals with cam or pincer morphologies will develop symptoms, and therefore FAI syndrome. Preventive measures may have a role in higher risk populations, but it is rarely indicated to offer surgery to these individuals.

Which outcome measures should be used to assess treatment for FAI syndrome? Specifically designed and well validated patient-reported outcomes measures should be used to assess treatment for FAI syndrome. The international Hip Outcome Tool (iHOT), Hip and Groin Outcome Score (HAGOS) or the Hip Outcome Score (HOS) are recommended. Residents` Corner Current surgical management of Meniscal Injuries - brief review of evidence Dr. Yan Sim

Meniscal tears are responsible for approximately 700,000 arthroscopies each year in the US and approximately 4 million worldwide. Many of these tears occur in athletes of all levels and can have a considerable impact on patient’s ability to participate in sport and exercise. Most athletes want to return to play as soon as possible and often present to sport medicine physicians with a belief that they require arthroscopy for any meniscal tear and it can be difficult to educate patients as to why they may not need surgery and may benefit from a trial of physical therapy or other non-surgical treatments. As such it is often challenging to counsel patients on what are the best treatment options for their injury.

Recent studies since 2002 have shown that arthroscopic meniscectomy for degenerative meniscal tears are no better than sham surgery and are no longer supported other than for a clear history of mechanical locking. 1,2 Furthermore, a recent article by Beal, et al. (2016) have shown that a significant number of athletes (120/386 athletes) have asymptomatic meniscal pathology including intrasubstance meniscal damage and meniscal tears. 3 Additionally, Zanetti et al. (2003) showed in a study of 100 patients, horizontal or oblique tears were more frequently encountered in both asymptomatic and symptomatic knees while radial, vertical, complex or displaced tears (as well as other soft tissue injuries) appear to be clinically more meaningful. 4 The purpose of this brief review is to focus on any evidence that can predict what kind of meniscal tears are more likely to benefit from partial meniscectomy, repair or physical therapy.

In 2014, Mezhov et al., reviewed the literature on arthroscopic partial meniscectomy (APM) compared to conservative treatment and repair. 8 studies (6 RCTs and 2 Cohort studies) were chosen. APM was found to not be superior with most symptomatic meniscal tears, however APM was found to be superior to conservative therapy in regards to painful intra-substance medial meniscal tears. This was based on a study by Beidert et al (2000) with a study of 23 patients. However, it must be mentioned that 75% of patients still improved to normal or near normal with regards to their International Knee Documentation Committee Scores in the nonoperative group thus avoiding surgery. 5

In regards to meniscal repair, among the 5 RCTs and 3 cohort studies, only two cohort studies showed improved functional outcomes as compared to APM. Melton et al (2011) showed that functional scores were improved when the meniscus was repaired in conjunction with ACL reconstruction as compared to meniscectomy in conjunction with ACL reconstruction. Additionally it was noted in Sommerlath (1991) and Stein et al. (2010) that repair was associated with less progression of osteoarthritis. 5 Finally, with respect to conservative treatment, the review by Mezhov et al. noted that 5 RCTs were found to show physical therapy to be non-inferior than APM with physical therapy. The only situation in which surgery had a better outcome was in regards to intrasubstance tears. These articles supplement previous evidence shown by Khan et al. (2014) and Azam et al. (2016) to support non-operative management of degenerative meniscal tears even in setting of mild osteoarthritis. 6,7

In regards to newer potential treatment options, regenerative therapies such as platelet rich plasma are currently being studied and may offer an alternative treatment avenue for patients with meniscal tears. An individual case study published by Betancourt et al. (2016) observed that leukocyte-poor platelet rich plasma treatments was associated with pain improvement in a knee with an atraumatic degenerative meniscal tear. 8 Further studies, are needed to further validate whether platelet rich plasma can alter the meniscal symptomatology in the absence of osteoarthritis.

In conclusion, while there has not been a significant change to the literature regarding management of meniscal injuries, this review among others have provided further evidence for appropriate selection of patients who would benefit from arthroscopic treatment. For a sports medicine clinician, consideration should be given to look for MRI evidence of radial, vertical, complex or displaced tears as these could potentially be more amenable to surgery than physical therapy alone.. 4 Additionally, for symptomatic intrasubstance tears, conservative therapy alone may not be adequate and APM should be considered for these patients whose symptoms are not resolving with an adequate course of physical therapy.

References: 1. Khan M , Evaniew N , Bedi A , Ayeni O , Bhandari M . Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Oct 7;186(14): 1057-64. 2. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81–88. 3. Beals C T, Magnussen RA ,, Graham WC , Flanigan DC . The Prevalence of Meniscal Pathology in Asymptomatic Athletes. Sports Med 2016 Oct;46(10):1517-24. doi: 10.1007/s40279-016-0540-y. 4. Zanetti M , Pfirrmann CW , Schmid MR , Romero J , Seifert B , Hodler. Patients with suspected meniscal tears: prevalence of abnormalities seen on MRI of 100 symptomatic and 100 contralateral asymptomatic knees. J . AJR Am J Roentgenol . 2003 Sep;181(3):635-41 5. Mezhov, V., Teichtahl, A.J., Strasser, R., Wluka, A.E., Cicuttini, F.M. Meniscal pathology - the evidence for treatment. Arthritis Res. Ther. 2014;16:206. Cicuttini 6. Azam, M., & Shenoy, R. (2016). The Role of Arthroscopic Partial Meniscectomy in the Management of Degenerative Meniscus Tears: A Review of the Recent Literature. The Open Orthopaedics Journal , 10 , 797–804. 7. El Ghazaly SA , Rahman AA , Yusry AH , Fathalla MM . Arthroscopic partial meniscectomy is superior to physical rehabilitation in the management of symptomatic unstable meniscal tears. Int Orthop. 2015 Apr;39(4):769-75. 8. Betancourt JP , Murrell WD . Leukocyte-poor platelet-rich plasma to treat degenerative Calling all CASEM Residents! We welcome any submissions from Residents to include in the next Newsletter, including article reviews, Hot Topics, Clinical Pearls etc... Please contact Dr. Taryn Taylor ([email protected]) with your email address to get connected with all of the other Sport Medicine Fellows in Canada.

UPCOMING EVENTS UPCOMING

Don’t miss out—Register now and join CASEM and AQMS in Mont Tremblant, QC June 7-10th 2017 at the Fairmont Tremblant

Click on the course title for more information and registration

Pre-conference Courses in conjunction with Annual Symposium in Mont-Tremblant 1. Emergency Sidelines Course – Tuesday, June 6, 2017 2. Exercise Prescription in Primary Care Workshop – Tuesday, June 6, 2017 3. Junior Hockey Course – Wednesday, June 7, 2017 4. Summer Endurance Sport Medicine Course – Wednesday, June 7, 2017

5. Mise à jour sur l’antidopage (french only) – Wednesday, June 7, 2017

Other CASEM Courses 1. Running Injuries Workshop- Saturday, April 22, 2017- Vancouver, BC 2. Running Injuries Workshop-Friday, May 26, 2017- Ottawa/Gatineau Region 3. Upper Limb Basics MSK Ultrasound Course – Saturday, June 3, 2017 – Ottawa, ON 4. MSK Ultrasound Guided Injections-Upper Limb-Saturday/Sunday, June 3-4, 2017- Ottawa, ON

For more information visit www.casem-acmse.org Sport and Exercise Medicine

Five Things Physicians and Patients Should Question

Don’t order an MRI for suspected degenerative meniscal tears or 1 osteoarthritis (OA). Degenerate meniscal tears and osteoarthritis (OA) are extremely common in the general population. Early degenerative changes in the meniscus can be found in many subjects under the age of 30. By 50 to 60 years of age, full degenerative meniscal tears are commonly found in 33-50% of subjects. Unless associated with the presence of osteoarthritis (OA), these degenerative meniscal tears are most often asymptomatic. Magnetic resonance imaging (MRI) is not recommended for degenerative meniscal tears unless there are mechanical symptoms (e.g., locking) or lack of improvement with conservative treatment (exercise/therapy, weight loss, bracing, topical or oral analgesia, intra-articular injections). MRI is not recommended for the diagnosis or management of OA. Weight-bearing X-rays should be ordered instead.

Don’t prescribe opiates as first line treatment for tendinopathies. 2 Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Although acute inflammatory tendinopathies (i.e., tendinitis) exist, most patients seen in primary care will have chronic symptoms (tendinosis). Multimodality options (e.g., relative rest, activity modifications, physical or athletic therapy, etc.) should be considered as the first line treatment of tendinopathies. Opiates should not be used in the initial phase of treatment.

Don’t order orthotics for asymptomatic children with pes planus (flat feet). 3 Pes planus is common in children. Although it rarely leads to disability, it is still a major concern for parents and is a common cause of clinic visits for pediatric foot problems. Most pediatric pes planus cases are characterized by a normal arch during non-weight bearing, and a flattening of the arch on standing. They are often painless, non-problematic, and resolve by adolescence. The current evidence suggests that it is safe and appropriate to simply observe an asymptomatic child with flexible pes planus.

Don’t order an MRI as an initial investigation for suspected rotator cuff 4 tendinopathy. Initial management of rotator cuff tendinopathy includes relative rest, modification of painful activities, and an exercise program guided by a physical therapist or athletic therapist to regain motion and strength. The addition of subacromial cortisone/local anesthetic injections may be helpful. Should conservative management fail to relieve pain and restore function of the shoulder, consider plain radiographs to rule out bony or joint pathology, and ultrasound to assess for rotator cuff and bursal pathology. MRI or MRA (MR arthrogram) should be considered if symptoms don’t resolve with conservative therapy and there is a concern of labral pathology.

Don’t immobilize ankle inversion sprains with no evidence of bony or 5 syndesmotic injury. Ankle sprains are among the most common injuries seen in the ER or physician clinics. Ankle sprains cause a high incidence of absenteeism in professional and physical activities with important economic consequences. There is good evidence to show that functional bracing of the ankle instead of rigid immobilization is associated with improved and earlier functional improvement and an overall shorter recovery period. For ankle inversion sprains with no associated bony or syndesmotic injury, early mobilization using a functional ankle brace and physiotherapy/athletic therapy should be considered instead of rigid immobilization.

Released January 26, 2017; Last updated January 26, 2017 Médecine du sport et de l’exercice

Les cinq examens et traitements sur lesquels les médecins et les patients devraient s’interroger

Ne demandez pas d’IRM lorsque vos soupçons se portent sur une 1 déchirure méniscale dégénérative ou sur l’arthrose. Les déchirures méniscales dégénératives et l’arthrose sont extrêmement fréquentes dans la population générale. Les lésions précoces s’observent chez de nombreux sujets de moins de 30 ans. Lorsqu’ils arrivent à la cinquantaine ou à la soixantaine, de 33 à 50 % des individus présentent souvent une déchirure dégénérative complète du ménisque. À moins d’être associées à de l’arthrose, ces déchirures sont le plus souvent asymptomatiques. L’imagerie par résonance magnétique (IRM) n’est pas recommandée pour les déchirures dégénératives du ménisque à moins qu’il y ait des symptômes de conflit mécaniques (p. ex., blocage) ou absence d’amélioration avec un traitement conservateur (exercice/physiothérapie, perte de poids, attelle, analgésiques topiques ou oraux, infiltrations). L’IRM n’est pas recommandée pour le diagnostic ou la prise en charge de l’arthrose. Il faudrait plutôt demander des radiographies avec mise en charge.

Ne prescrivez pas d’opiacés en traitement de première intention pour les 2 tendinopathies. La tendinopathie est un terme vaste qui englobe les lésions douloureuses à l’intérieur et autour des tendons en réponse à une surutilisation. Même s’il existe des tendinopathies inflammatoires aigües (p. ex., tendinite), la plupart des patients vus en médecine de premier recours présentent des symptômes chroniques (tendinose). Des options multimodales (p. ex., repos relatif, modification des activités, physiothérapie ou thérapie sportive) sont à envisager comme traitements de première intention des tendinopathies. Les opiacés ne doivent pas être utilisés à la phase initiale du traitement.

Ne prescrivez pas d’orthèses aux enfants qui présentent des pieds plats 3 asymptomatiques. Les pieds plats sont fréquents chez les enfants. Et même si cela entraîne rarement une incapacité, il arrive souvent que les parents s’en préoccupent et consultent un médecin à ce sujet. La plupart des cas de pieds plats chez les enfants se caractérisent par une arche normale en l’absence de mise en charge et un aplatissement de l’arche à la station debout. Les pieds plats sont souvent indolores, non problématiques et rentrent dans l’ordre à l’adolescence. Selon les preuves actuelles, il est sécuritaire et approprié de simplement observer un enfant s’il a les pieds plats, s’ils sont flexibles et asymptomatiques.

Ne demandez pas d’IRM comme épreuve diagnostique initiale si vous 4 soupçonnez une tendinopathie de la coiffe des rotateurs. La prise en charge initiale de la tendinopathie affectant la coiffe des rotateurs inclut le repos relatif, une modification des activités douloureuses et un programme d’exercices guidé par un physiothérapeute ou un thérapeute du sport afin de récupérer l’amplitude de mouvement et la force. Les infiltrations de cortisone/anesthésique dans l’espace sous-acromial peuvent aussi aider. Si le traitement conservateur ne permet pas de soulager la douleur et de rétablir le fonctionnement de l’épaule, envisagez des radiographies simples pour écarter un diagnostic de pathologie osseuse ou articulaire, et une échographie pour évaluer une éventuelle pathologie de la coiffe des rotateurs ou de la bourse sous-acromiale. L’IRM ou l’ARM (arthrographie par résonnance magnétique) peuvent être envisagés si les symptômes ne rentrent pas dans l’ordre à l’aide du traitement conservateur et qu’on s’inquiète d’une possible lésion du bourrelet glénoïdien.

N’immobilisez pas les entorses de la cheville causées par un traumatisme 5 en inversion en l’absence de signes d’atteinte osseuse ou syndesmotique. Les entorses de la cheville sont parmi les blessures les plus souvent vues dans les services d’urgence ou les cliniques. Les entorses à la cheville sont à l’origine d’une forte incidence d’absentéisme dans les activités professionnelles ou sportives et ont de ce fait d’importantes répercussions économiques. Des preuves solides montrent que la pose d’attelles fonctionnelles à la cheville plutôt qu’une immobilisation rigide est associée à une amélioration fonctionnelle plus marquée et plus rapide et à un abrégement global de la période de récupération. Pour les entorses de la cheville en inversion sans lésions osseuses ou syndesmotiques associées, une mobilisation précoce à l’aide d’une attelle de cheville fonctionnelle et la physiothérapie/ thérapie du sport devraient être envisagées plutôt qu’une immobilisation rigide.

Publié le 26 janvier 2017; Dernière révision le 26 janvier 2017

Limiting the risk of osteoarthritis after anterior cruciate ligament injury: Are we missing the opportunity to intervene?

Researchers and clinicians from Ontario, Nova Scotia, Manitoba and British Columbia are interested in understanding what information clinicians who treat people with Ante- rior Cruciate Ligament (ACL) injury provide about the risk of knee osteoarthritis (OA). This survey will ask about the OA risk factors you do or do not discuss with your patients and any management recommendations you provide. This survey is voluntary and anon- ymous. This survey should take approximately 5 to 10 minutes to complete. The results of the study will be used to assist in helping us understand how best to support people in managing knee OA risk following ACL injury.

Job Opportunity

High Point Wellness Centre (HPWC) is a modern multidisciplinary clinic serving the Etobicoke/Mississauga community for 40 years. Our practitioners take an integrated evidence based treatment approach with a focus on biomechanics, movement patterns, and active rehabilitation. We have an opening for a part- time sports physician. Patient caseload includes amateur, professional, and recreational athletes. HPWC offers excellent remuneration, flexible hours, full administrative support, equipment, modern facilities, marketing, and potential for growth. Candidates interested in applying must be in good standing with the College of Physicians and Surgeons of Ontario and licensed to practice primary care Sports Medicine.

All interested applicants please contact Dr. Danson at [email protected]