0:10

Welcome to the

0:10

upper hand where Chuck and Chris

0:13

talk hand surgery.

0:14

We are two hand surgeons at Washington University in St. Louis here to

0:16

talk about all aspects of hand

0:19

surgery from technical to personal.

0:22

Thank you for

0:22

subscribing wherever you get

0:24

your podcasts.

0:25

And be sure to leave a

0:25

review that helps us get the

0:27

word out.

0:28

Oh, Hi, Chris.

0:29

Hey, Chuck, how are you?

0:31

I'm doing really well. How are you?

0:33

I'm well, it sounds

0:33

like you're saying you're a

0:35

little tired. anything different

0:35

about today than other days?

0:39

Well, you

0:39

know, I have taken up the

0:41

peloton. You told me how

0:41

wonderful it was and how it

0:44

would change my life. And maybe

0:44

it has, maybe it has, but I rode

0:48

my real bicycle to work today.

0:48

And it was pretty great. I've

0:53

done it before. So it's not

0:53

totally new. But it was great.

0:57

About 30 minutes to work. 30

0:57

minutes back, it was great.

1:00

You know, you were at

1:00

the Shriners Hospital today.

1:02

I was at the Shriners Hospital. So it's really nice. I can ride pretty

1:04

much through the park almost all

1:07

the way there. So it makes it

1:07

easy makes it safe. I like it.

1:11

That would terrify me.

1:13

Why?

1:14

I don't know. I just I

1:14

would worry about you know, we

1:17

see so many bicyclists struck by

1:17

vehicles, random car doors being

1:22

flung open.

1:23

Let's be

1:23

clear, I ride in nice weather.

1:26

When it's light out, although

1:26

Friday, I'm gonna try to ride

1:28

again, I'll have to leave about

1:28

5:15 to get to six o'clock

1:31

conference. And I don't ride

1:31

when it's too cold or too hot.

1:34

You know have the all criteria

1:34

that needs to be met. So it was

1:38

fine.

1:38

Very, very strict

1:38

inclusion criteria.

1:41

Very, very

1:41

strict. We have a guest today

1:46

who we are super excited about.

1:46

So let's do a couple of things

1:49

quickly. And we'll welcome our

1:49

guest who I know is going to be

1:53

awesome.

1:54

Fantastic. Well,

1:54

speaking of guests, you know,

1:57

our last guest was from Stanford

1:57

University. And one of his

2:01

colleagues actually emailed both

2:01

of us to tell us how much he

2:04

loves the podcast.

2:05

Yes, he did.

2:05

So I would like to share Jeff

2:08

Yao's comments about our

2:08

podcast, he says, I just wanted

2:13

to let you know that I totally

2:13

binge listened to your podcast

2:16

over the last few weeks. Really

2:16

enjoyable exclamation point.

2:20

Love the format and the content

2:20

my fellows are listening too.

2:24

I'm a little bummed that I made

2:24

it to the end and I'm fully

2:27

caught up. Please keep it up.

2:27

How awesome is that?

2:31

It's fantastic. And

2:31

you forgot the best part he did

2:35

say that he's a little

2:35

disappointed that I have not

2:38

broken out into any Backstreet

2:38

Boys karaoke, a la our time and

2:42

Seoul. And Jeff and I spent a

2:42

few days in Seoul, Korea

2:45

together as part of a hand

2:45

society traveling. Traveling

2:50

group, which was fantastic. So

2:50

Jeff, thank you for telling

2:54

everybody about our podcast,

2:54

getting your fellows listening.

2:57

It's great to know that we're

2:57

reaching a number of people.

3:00

It is and I'll

3:00

be honest, I'm very proud to say

3:03

You're not the first one who has

3:03

binge listened to our podcast.

3:06

we've, we've heard that before,

3:06

Jeff. But it is it's really kind

3:10

of cool. I have to say thank you.

3:13

It's great. We

3:13

appreciate everybody, and we

3:15

love our listener community. So

3:15

thank you for, for telling us

3:19

that you love it too, that that

3:19

certainly makes it even just a

3:22

little bit easier to record on a

3:22

weeknight. I had an interesting

3:26

case.

3:26

Chris, please

3:26

tell me about it.

3:29

So it's actually a

3:29

case from a while ago that I was

3:31

thinking about as I prepare for

3:31

a case that's coming up. And

3:34

whenever you see that dorsal

3:34

ulnar corner fragment on the

3:37

distal radius fracture, do you

3:37

get excited about that? Is that

3:41

a fragment that you go after? as

3:41

part of your fixation strategy?

3:45

You know, whether it's a volar,

3:45

or dorsal approach?

3:48

Well, you know, essentially, because we have talked about that in the

3:50

podcast. And I must admit, I

3:53

probably approach it a little

3:53

differently, since our

3:56

conversations about it.

3:56

Historically, I've not been

3:59

overly impressed by that

3:59

fragment, as long as it's

4:02

relatively small, but David

4:02

Brogan's work and our

4:05

discussions and makes me more

4:05

aware of that dorsal ulnar

4:08

fragment. So I have to say I pay

4:08

closer attention to it now than

4:12

historically I have done.

4:14

You know, I think that

4:14

I had a case, probably, I think,

4:18

six months or so ago, that I

4:18

went after that fragment,

4:21

because mainly because of

4:21

David's paper and some concern

4:24

about the way that the fracture

4:24

in the carpus was displacing on

4:28

the X ray. And I did a you know,

4:28

perform my standard volar

4:31

approach and apply to volar

4:31

plate. But then I also made a

4:35

small accessory dorsal ulnar

4:35

approach and used a separate

4:38

interfragmentary screw for that

4:38

piece. And I was very satisfied

4:42

with that. And the situation

4:42

hasn't come up until a case I

4:45

have coming up at some point in

4:45

the future. And I'm wondering

4:48

whether to go after that

4:48

fragment. So when you go after

4:51

that fragment, do you base your

4:51

entire strategy dorsally or do

4:54

your standard volar approach

4:54

then maybe either get a dental

4:57

pick or a finger on that

4:57

fragment dorsal ulnar and then

5:00

put a screw from volar to dorsal.

5:03

Not to give a

5:03

vague answer, but my vague

5:05

answer is, it depends. It

5:05

depends on the size of the

5:09

fragment my confidence in my

5:09

ability to reduce it closed, I

5:14

have to say I typically do

5:14

approach these from volar. And

5:19

either try to capture with a

5:19

longer volar screw or make a

5:23

separate incision for a dorsal

5:23

screw because if the fragments

5:25

big enough, and we can obtain

5:25

and maintain the reduction in a

5:29

closed fashion. I'm very

5:29

comfortable with trying to hit

5:31

it with a screw. But it really

5:31

does depend on the specifics of

5:33

the fragment.

5:34

Yeah, I think that

5:34

that fracture matters to me if I

5:37

think it's going to change my

5:37

post op rehab. So if I can

5:40

capture that fragment and not

5:40

worry about the carpus,

5:43

subluxation dorsally, or any

5:43

DREJ instability, I'll tend to

5:47

be a little more aggressive

5:47

about that fragment. So I can

5:50

put them in my, you know,

5:50

standard volar plate move early

5:52

kind of protocol.

5:54

Yeah. For me,

5:54

it's really more about the DREJ.

5:57

And again, that's what David

5:57

taught us. And that's what we

6:00

have to pay attention to how,

6:00

what percent of that joint does

6:03

this fragment encompass? So I

6:03

think it's a really important

6:06

topic, the volar owner fragment

6:06

gets so much attention today,

6:10

and so the the stepsister should

6:10

not be ignored.

6:13

Well, let's hop into our guest.

6:15

I would love to introduce I was trying to remember how long Mark Halstead

6:17

and I have worked together. It's

6:20

definitely been at least 10

6:20

years, but I'm not sure exactly

6:23

how many When did you join the faculty?

6:24

17 years ago now.

6:24

Well, actually, no. Yes. 17. 17

6:28

this month.

6:30

Well, Chuck, Chuck, I'll be very clear. I mean, this is an audio media. But you know,

6:32

Mark has a lot more hair than

6:36

you.

6:38

I've got a

6:38

couple more years of faculty

6:41

experience and a lot less hair.

6:41

That is very true. I am jealous

6:46

of that. But seriously, Mark,

6:46

thanks for joining us. So Mark

6:50

is an associate professor here

6:50

at Washington University. He is

6:54

a non operative sports

6:54

physician, I do want to know

6:57

whether that is the way you

6:57

prefer to be introduced. I've

7:00

interacted with Mark most

7:00

commonly in the care of the

7:03

athlete, and that's athletes at

7:03

every level. Mark's experience

7:06

is amazing. So he worked with

7:06

the St. Louis Rams, he's worked

7:09

with the Cardinals. He works

7:09

with numerous high schools, and

7:12

obviously Washington University.

7:12

He's the medical director of the

7:16

young athletes center. And

7:16

really, you know, your expertise

7:20

is broad based, which we're

7:20

grateful for. But your

7:22

concussion work, probably, for

7:22

me at least is where I feel you

7:25

have most carved out a niche.

7:25

So, welcome. Thanks for joining

7:31

us. And Chris will add one more

7:31

tiny pearl that is really

7:35

relevant to this podcast.

7:37

So I can't I can't one

7:37

of the faculty after Mark had

7:40

really established himself and

7:40

you know, every time I look at

7:42

our CME programs, and anything

7:42

that we do nationally, Mark's

7:46

name is prominent. He's really

7:46

well known in these areas as one

7:49

of our sports medicine experts.

7:49

And Mark has taken the mantle of

7:55

going after those side hustles

7:55

so he has the pediatric sports

7:59

medicine podcast. You can check

7:59

that out at

8:02

www.pediatricsportsmedicinepodcast.com,

8:02

that's all together no dashes,

8:07

no spaces, and then the healthy

8:07

young athlete podcast which is

8:10

at

8:10

www.healthyyoungathletepodcast.com.

8:14

Can you tell us a little bit

8:14

about you know, your podcast?

8:17

And of course, welcome to the show.

8:19

Well, thanks for

8:19

having me. It's great to be with

8:21

you guys. I listen as well. I am

8:21

impressed that you have a

8:25

listener who binge listen to

8:25

your podcast because you guys

8:28

have a lot more episodes than I

8:28

do. And I just can't imagine

8:32

sitting down and binging and

8:32

getting all those in because

8:34

that's a lot to take in, in a

8:34

short period of time. But But

8:38

kudos to your listeners. Yeah,

8:38

the two podcasts that I do. The

8:42

pediatric sports medicine,

8:42

podcast, really creative name

8:44

there. Of course, that one we

8:44

really focus on just addressing

8:49

anything pediatric sports

8:49

related, we cover everything

8:52

from musculoskeletal topics to

8:52

right now. This month we're

8:55

covering since it's Mental

8:55

Health Awareness Month, we're

8:58

doing some mental health related

8:58

topics. That's kind of our focus

9:02

this month, we kind of theme

9:02

things a little bit here and

9:04

there. With that, and we have

9:04

people outside of the medical

9:08

profession and obviously inside

9:08

from standpoint of physicians,

9:12

athletic trainers, physical

9:12

therapists, orthopedic surgeons

9:16

from the standpoint as well as

9:16

non operative physicians and to

9:19

answer your question, Chuck, as

9:19

far as non operative sport

9:22

surgeon, that's a big debate

9:22

actually, in our world too. We

9:25

like the word sports medicine

9:25

physician, some have even

9:28

proposed sports and exercise

9:28

medicine physician, which is

9:32

what they use actually in

9:32

Europe, it makes a lot more

9:34

sense for those that are doing a

9:34

lot more in the general medical

9:37

world rather than just sports

9:37

medicine because we are dealing

9:41

with people of all ages and all

9:41

exercise levels. It's not

9:45

necessarily just the athlete

9:45

that we're focusing on. And then

9:48

the other podcast, the healthy young athlete podcast that's actually kind of one that I

9:50

don't put as much effort into or

9:54

as much time into because I

9:54

really kind of taken on the

9:56

pediatric sports podcast but

9:56

that one actually is more geared

9:59

towards towards parents towards

9:59

coaches towards athletes

10:02

themselves a lot of answering

10:02

like the common questions we get

10:05

in the office. So like my, the

10:05

last episode we did was when

10:08

when should my kid get a CT scan

10:08

after their concussion. So kind

10:12

of simple little straightforward

10:12

things like that of the little

10:14

nuts and nuggets that you need

10:14

to take home from those clinic

10:18

visits, potentially, that you

10:18

may have missed when you were

10:20

listening to the doctor the first time.

10:24

I love it. I have a bunch of questions. First, I guess a comment. So

10:27

when we, Chris and I were

10:30

looking to launch more than a

10:30

year ago, you were one of the

10:34

first people I talked to, and I

10:34

don't know when your first

10:36

podcast started. But I you know,

10:36

we're obviously grateful for the

10:41

words of wisdom that you gave

10:41

us. And we've gone a little

10:43

different route with our cadence

10:43

of publications and kind of

10:46

doing it ourselves. I think a

10:46

little more maybe than you do.

10:49

And also the fact that we, you

10:49

know, Chris, and I feed off each

10:52

other, you know, your ability to

10:52

do this solo, and I do believe

10:55

you regularly have guests, but

10:55

it's not easy doing these things

10:59

by yourself. I wouldn't think

11:01

No, that that's

11:01

true. It's almost like giving a

11:03

lecture so that I really

11:03

honestly haven't done any

11:06

pediatric sports medicine

11:06

podcast episodes solo, I've

11:09

always had somebody there

11:09

healthy young athlete podcasts,

11:12

I've done some of my own because

11:12

they're, they're quick little

11:14

things. And again, kind of, like

11:14

explaining the common questions

11:17

we have in clinic. But you're

11:17

right, it is a lot easier when

11:20

you've got people to chat with

11:20

rather than just talking to

11:23

yourself. It's I mean, it's,

11:23

it's no different than giving a

11:25

zoom lecture in the morning and

11:25

you don't know who's listening

11:28

and who's brushing their teeth

11:28

and doing something else, when

11:32

that's going on. So I think in

11:32

that standpoint, it is great

11:35

having someone to banter with

11:35

and, and I've always appreciated

11:38

your guys', discussions with

11:38

each other, it's always

11:41

interesting to hear your essays

11:41

and bantering back and forth.

11:44

Now, one of the things

11:44

that we got early on was that we

11:47

don't disagree enough. And one

11:47

of the things we disagree about

11:51

is how much we enjoy

11:51

interactions with athletic

11:53

trainers. And I like athletic

11:53

trainers, just like as much as

11:58

the other doctor, but just for

11:58

the purposes of this discussion,

12:01

you know, I don't, I don't find

12:01

it to be the most fulfilling

12:06

experience. But Chuck, and I'm

12:06

presuming you do? So tell me how

12:10

you approach that interaction

12:10

Mark, as somebody who is a

12:14

sports medicine physician who

12:14

interacts a lot with these

12:17

trainers.

12:18

Yeah, so I mean,

12:18

I owe a lot of what I know, in

12:21

sports medicine, to the athletic

12:21

trainers that are out there. I

12:23

mean, there is no not a single

12:23

place that I have done training

12:28

at whether it was at Wisconsin

12:28

as a resident or Vanderbilt as a

12:31

fellow or here now at WashU

12:31

working with athletic trainers

12:36

at all levels that I've not

12:36

gleaned something on. And from

12:40

and I think it's, it's, it's a

12:40

it's an interesting interaction,

12:43

it's it's, again, the best thing

12:43

about sports medicine, it's a

12:46

team, as medical providers, just

12:46

as it is a team for those that

12:51

are on the field or on the

12:51

court. So you know, I think it's

12:55

it's a two way street there. And

12:55

and I love having them as my

12:58

eyes and ears so to speak, for

12:58

especially for at the high

13:02

school level, because that's

13:02

where we may not have as much

13:04

direct contact with them,

13:04

because we're not necessarily

13:07

going to see them at their

13:07

school at high school level. So

13:10

I really rely on them to be my

13:10

eyes and ears and to help give

13:15

me the kind of the behind the

13:15

scenes scoop because we don't

13:17

always get the full story. And

13:17

I've always had the approach

13:21

where I really like to directly

13:21

communicate with the athletic

13:23

trainers, I tend to send an

13:23

email to our athletic trainers

13:26

that after I see one of their

13:26

kids in our office, that's just

13:29

what I've done for a long time

13:29

because I think too much gets

13:32

lost in translation from

13:32

athletic trainers, to the

13:36

athletes to us, and then back

13:36

the other way. And so then we're

13:40

miscommunications happen. And

13:40

then we're really not getting

13:43

the right treatment and

13:43

management plan and what's

13:45

what's the next step for them

13:45

returning to play. So I've

13:49

always kind of taken that

13:49

approach and had that kind of

13:52

relationship with the athletic

13:52

trainers that I work with around

13:54

the St. Louis area.

13:57

I think that's

13:57

that's great advice. It is

14:00

interesting being I guess what I

14:00

would call a specialist where I

14:04

don't have the day in and day

14:04

out interactions with the

14:07

trainers. For me, and I hope it

14:07

doesn't come across the wrong

14:10

way. I feel like my job is to

14:10

see kids when the trainer, or

14:16

adults, when the trainers refer

14:16

them or suggest that they be

14:19

seen. And then I think the real

14:19

my real job is to, as you

14:24

suggested, get back with the

14:24

trainers and tell them what we

14:27

thought was going on what we're

14:27

going to do next and that

14:30

interaction seems to be really

14:30

appreciated, which makes me

14:33

think that it doesn't happen

14:33

enough. Is that a fair

14:37

assessment, Mark?

14:38

Yeah, I would say

14:38

that's definitely the case. I

14:40

mean, I do get comments that

14:40

from athletic trainers that

14:44

certainly I tend to communicate

14:44

more than than others that

14:47

doesn't, you know, again, that's

14:47

not necessarily a bad thing.

14:49

That's just the approach that

14:49

I've taken. I you know, I think

14:51

that's an important part and

14:51

obviously don't do with every

14:54

single school, every single

14:54

athletic trainer that's out

14:56

there we have several that we've

14:56

had relationships with and in

14:59

that we Partner with through

14:59

WashU that we have more of that

15:03

direct line of communication

15:03

with but if I know the athletic

15:06

trainer and I mean, it's helped

15:06

build my practice. I mean,

15:09

there's no question about that

15:09

when you have someone that you

15:13

are there at the school there

15:13

and they know who you are, they

15:15

know kind of how you manage

15:15

things and how you deal with the

15:18

athletes and that they know that

15:18

you're going to get them

15:20

communication back directly. I

15:20

think that that kind of builds a

15:25

lot for your practice and your

15:25

reputation as far as what you

15:27

do.

15:28

Well, maybe I'm wrong

15:28

about it. You know, I think

15:30

maybe I've been biased by a

15:30

couple of interactions that have

15:33

not been great. But I love what

15:33

you're saying about having the

15:37

eyes and ears, and the

15:37

communication and kind of

15:39

teamwork aspects. And honestly,

15:39

that's how I view my

15:41

interactions with a lot of the

15:41

hand therapists for the nerve

15:44

stuff that I do. And obviously,

15:44

for all the other hand surgery

15:46

stuff, so I'll reconsider, I'd

15:46

be open to it.

15:51

Well, I would

15:51

say in all seriousness, there's

15:54

a few things that I've done to

15:54

help build my practice. And I've

15:58

mentioned one, which is I call

15:58

patients after surgery. I think

16:01

this is probably the second most

16:01

important thing I've done to

16:04

build a sports type hand

16:04

practice. And so these

16:08

relationships, drive referrals

16:08

for sure. And my interest in

16:12

sports, and my willingness to

16:12

get kids back to play ASAP now

16:16

safely is obviously it has to be

16:16

safe. But I really do strive to

16:20

get kids back in some capacity

16:20

as quickly as possible. And I

16:23

think that mentality, rather

16:23

than dancing around in fear of

16:27

getting kids back too soon, I

16:27

really don't have that approach.

16:31

But I think it's the

16:31

interactions. And it's the

16:33

recognition that sports at all

16:33

levels are just really

16:37

important. And so as soon as we

16:37

can get kids back to play safely

16:40

in some capacity, we have to and

16:40

Mark, I know you deal with that

16:43

day in and day out.

16:44

Yeah, and and

16:44

again, I think we're going back

16:47

to that team kind of approach. I

16:47

also agree with you, Chris, as

16:49

far as just the physical

16:49

therapist, and having that

16:52

communication there, too, that's

16:52

valuable as well, especially I'm

16:55

sure for you guys.

16:55

postoperatively. And getting

16:57

that feedback back about how

16:57

your patients doing as well.

17:00

But, you know, I think the other

17:00

part of that too, is I honestly

17:05

feel that out of everybody in

17:05

our sports medicine team, the

17:07

athletic trainers are the

17:07

hardest working, and the least

17:11

recognized, the most underpaid.

17:11

And I think, you know, giving

17:16

some back to them, and and

17:16

again, recognizing them and

17:19

valuing what they do for us, in

17:19

general in the sports medicine

17:23

world, I think is important. So

17:23

you know, again, I, for me, it's

17:27

it's just part given back from

17:27

all the education I've received

17:30

from them. And those

17:30

relationships I've built with

17:33

them and various athletic

17:33

trainers over the years. And

17:37

it's just been a really great

17:37

part of my practice.

17:39

So Mark, I want to ask

17:39

you a question that's been on my

17:42

mind. I mean, I consider myself

17:42

a bit of a lay person with

17:44

regards to much of the sports

17:44

medicine issues. But the thing

17:47

that keeps coming up in a lot of

17:47

podcasts, news media pieces, is

17:52

this thing about early

17:52

specialization of sports, and

17:56

how we should approach that, you

17:56

know, because you have, you have

17:59

somebody like Tiger Woods, who,

17:59

you know, basically was born

18:02

with the golf club versus

18:02

somebody like Roger Federer who

18:04

played every sport under the

18:04

sun, even though his mom was a

18:07

tennis coach, and didn't come to

18:07

tennis until very late. So how

18:10

do you approach that in terms

18:10

of, you know, perhaps as a

18:13

parent, but also as somebody who

18:13

deals with a lot of athletes?

18:17

Yeah, so I have

18:17

three teenagers now, one who

18:20

will be heading off to college

18:20

this year, a freshman and a

18:23

sophomore. Two of my three are

18:23

involved in athletics, my my

18:27

middle guy is not. But in the

18:27

big picture, things we never did

18:32

any of the early sports

18:32

specialization, I always was of

18:35

the approach that our family

18:35

time was more important than

18:38

traveling around the country,

18:38

and various states, going to

18:43

different games, whether that's

18:43

right or wrong, I, we went on

18:46

their interest and what they

18:46

wanted to do. And you know, at

18:50

the time, there wasn't that much

18:50

interest now that they've gotten

18:53

older, you know, they've had

18:53

interest in running, which is

18:55

what both my wife and I did in

18:55

high school, and then what she

18:58

did in college, so, you know, we

18:58

really never had any kind of big

19:02

push, personally in our

19:02

families. You know, there's

19:05

there's lots of thought

19:05

processes. As far as this goes,

19:08

as far as early sports

19:08

specialization. I think we're

19:12

kind of getting different kind

19:12

of takes as far as it goes, you

19:15

know, should a kid be doing a

19:15

repetitive sport at the age of

19:19

four or five and saying that

19:19

that's the right thing to go?

19:22

Probably not. I mean, there are

19:22

sports, obviously, that lend

19:24

themselves to having to

19:24

specialize at a younger age.

19:27

Gymnastics is a perfect example

19:27

of that. You don't see many

19:31

young adult gymnasts that are

19:31

out there that are performing at

19:33

a high level consistently. And

19:33

you know, whether that's a

19:37

matter of that we because we are

19:37

starting them so young, and

19:40

we're breaking them down. I

19:40

mean, it's a sport that we see

19:42

plenty of overuse injuries in at

19:42

that younger age. But I think

19:48

it's just everybody's got that

19:48

keeping up with the Jones's

19:50

philosophy. You know, I start

19:50

younger, so Well, my kids got to

19:53

start a little bit younger. I've

19:53

got this sports enhancement

19:55

program that's out there. Well,

19:55

hey, I got to put my kid in that

19:58

sports enhancement program. But

19:58

I think one of the things that

20:01

we come back to a lot in

20:01

pediatrics is we're missing a

20:04

lot of the foundation that a lot

20:04

of these kids have with basic

20:07

movement skills, which is when

20:07

we translate to the overuse

20:10

injuries in our office, we're

20:10

seeing kids that don't come in

20:12

with good foundations of core

20:12

strength, they don't have good

20:15

foundations of strength in

20:15

general. And then they're going

20:18

out there, and they're doing all

20:18

these sports related activities,

20:21

and their body's just not ready for it. And then they're breaking down, and they're

20:23

getting injuries and problems

20:25

because of that. And we spent a

20:25

lot of time in the office

20:27

talking about those things with

20:27

families, and some of them will

20:30

buy into it. And they have a lot

20:30

of questions. Well, why you're

20:32

saying My child is weak in these

20:32

areas, they do sports all the

20:35

time. I'm like, Well, what are

20:35

you doing to actually do

20:37

strength training to get that

20:37

there? And then sometimes that

20:39

hits home? sometimes it doesn't.

20:39

But it I mean, it is a problem.

20:43

There's no question about it.

20:43

It's just how do we fix it. And

20:47

I think it's got to be an

20:47

overall system wide approach to

20:49

fix this, it's not going to be,

20:49

you know, a few doctors saying

20:53

that, hey, this is an issue,

20:53

it's got to be taken up at the

20:55

sports organization levels and

20:55

addressing it there, which they

20:58

have done some the NBA is a

20:58

perfect example of that the NBA

21:01

has a development program that

21:01

they've put together an

21:05

appropriate way to get kids into

21:05

basketball at various levels. So

21:08

they've been proactive about it

21:08

compared to other leagues and

21:11

other sports.

21:12

Yeah, it's so

21:12

complicated. Like you I've lived

21:14

it with a couple of athletes.

21:14

It's interesting, my youngest

21:18

has been the least interested in

21:18

sports, and she actually may

21:22

have the best mentality and

21:22

physical skills to have been

21:24

successful. And she's getting

21:24

into things a little late, but

21:27

with no real interest to pursue

21:27

sports at a, at a college level.

21:31

But it is interesting, as a

21:31

parent seeing it from all sides,

21:35

and it is so complex, because

21:35

some of the kids absolutely love

21:39

it, you know, and you can never

21:39

play too much of whatever sport

21:42

it is, and other kids, you just

21:42

get the sense they're being

21:44

dragged around a little bit. And

21:44

those those are the ones that

21:47

get me and when you you're

21:47

sitting in a room with a parent,

21:50

and I don't want to pick on

21:50

gymnastics, and potentially a

21:53

gymnastics mom or dad and, and a

21:53

young gymnast, and you see the

21:57

overuse injuries, and it just

21:57

pains me and and mom or dad is

22:00

doing all the talking. And those

22:00

are the hardest ones for me for

22:04

sure.

22:04

Yeah, and that's always something that we need to consider as physicians, you

22:06

know, when the kids coming in

22:08

with injuries, that just the

22:08

pain that just doesn't seem to

22:10

want to go away. And you can't

22:10

find anything objective, you may

22:15

have done imaging and everything

22:15

seems normal, but the kid keeps

22:17

hurting all the time. That's the

22:17

kid you need to worry about the

22:21

kid that's burnt out and just

22:21

really does was trying to find

22:23

an excuse to get out of their

22:23

sport. And we certainly see

22:26

that. And I think it's always

22:26

important to bring up that

22:28

question at some point is, do

22:28

you really want to do this? And

22:32

I always have had the approach

22:32

as a pediatrician and trade by

22:36

training is I always talk to the

22:36

kids, I always direct my

22:39

questions to the kids, I will

22:39

let the parent bring their input

22:43

in but I always want to hear

22:43

from the kid first I want their

22:45

take because they're the ones

22:45

who know it. The parent doesn't

22:47

know what their pain is like they don't know where their pain is. They can kind of project and

22:49

things like that. But it's it's

22:54

it's much more interesting and

22:54

valuable to me when you talk to

22:56

the kid and get the answers from

22:56

the kid rather than getting it

23:00

starting from the parent first.

23:00

I always get a little nervous

23:02

when it's the parent who's

23:02

driving the whole conversation

23:04

in the office. And it's not the

23:04

kid doesn't get any input.

23:07

I think that's that's a great point. And that's great advice. And, and it's

23:09

easier sometimes than others.

23:12

But I think we have to strive

23:12

for that that is so true. I

23:15

think pitch counts are the are

23:15

you know, for me, it's it's

23:19

gymnast and baseball players

23:19

where I see this problem the

23:22

most. And part of that's because

23:22

I'm an upper extremity surgeon,

23:26

and that's where they get their

23:26

injuries. But talk to us a

23:29

little about what's your what's

23:29

your thought process on pitch

23:33

type, pitch counts, and how well

23:33

baseball has done with trying to

23:38

improve the concerns around

23:38

overthrowing?

23:42

Well, I think

23:42

we've got some good information

23:44

about there as far as baseball,

23:44

I mean, the American Sports

23:47

Medicine Institute down in

23:47

Alabama has put together some

23:50

great guidelines, they've had

23:50

great research over the years.

23:53

So we know out there from data

23:53

that's out there that the kids

23:57

that are throwing more, and the

23:57

kids that are playing year-round

24:01

ball. Those are the kids that

24:01

are going to wind up having more

24:05

likely to have troubles with

24:05

shoulder and elbow pain. I mean,

24:08

it's it's been proven time and

24:08

time again, you know, when we

24:11

look at pitch counts, ideally,

24:11

hopefully that those things are

24:15

followed. You know, little

24:15

league baseball, the

24:17

organization itself has some

24:17

pretty strict criteria. But you

24:20

know, in our state, Missouri,

24:20

there's no Little League

24:23

Baseball under that umbrella

24:23

teams. So we're relying on a lot

24:27

of these clubs around the area

24:27

here locally, to hopefully

24:31

endorse and use those pitch

24:31

count recommendations that are

24:33

out there and it's not just the

24:33

pitch count it's also the days

24:36

of rest. Is your kid both

24:36

pitching and catching? Which you

24:41

know I stress with these kids at

24:41

you know at age 12 you got to

24:44

make a start making a decision.

24:44

Are you going to be a pitcher or

24:46

catcher but probably not both.

24:46

And I use the analogies you know

24:50

since we're in Cardinals land

24:50

for these kids I go you would

24:52

never see Yadier Molina tell

24:52

Adam Wainwright, hey, it's my

24:56

time to get up on the mound

24:56

there and pitch and vice versa

24:58

Adam to kick Yadier out of there

24:58

and get behind the plate and

25:00

start catching it's, it's just

25:00

too hard on these kids to do it

25:05

over and over again. And going back to what I talked about earlier, as far as just the

25:07

overall strength deficits, we

25:10

see so many of these kids that

25:10

don't have any arm care programs

25:13

in their offseason and they're

25:13

not doing any strengthening, get

25:15

their arm ready to throw. And

25:15

they go out there and they start

25:18

throwing a time. And then they

25:18

wonder why they get these

25:20

overuse injuries and the little

25:20

league shoulder and Little

25:23

League elbow that we see so

25:23

commonly in our office.

25:25

So mark up to

25:25

piggyback on that, can you tell

25:28

us a little bit about how you

25:28

approach things like the little

25:31

league elbow and shoulder

25:31

issues, and we have a lot of

25:34

hand therapists and obviously a

25:34

lot of hand surgeons and

25:37

orthopedic and plastic surgery

25:37

residents and fellows who listen

25:41

in So what are some things that

25:41

we can incorporate into our

25:44

practice, and also, you know,

25:44

the common deficiencies that we

25:47

can address, either when we see

25:47

them in the office or when we

25:50

have them in the therapy suite?

25:51

Yeah, so you

25:51

know, obviously with and we'll

25:54

we'll probably we can address

25:54

little league elbow, I mean, the

25:56

only shoulder kind of comes on

25:56

that is as well. You know, it's

26:00

going to be your medial

26:00

epicondyle pain, they're going

26:03

to be tender in that area, they

26:03

may have some pain with valgus

26:06

stressing and what have you. But

26:06

I think one of the areas and

26:09

this is where I teach the residents that rotate with me for pediatrics is I always want

26:11

to make sure that we're

26:14

assessing their strength of

26:14

their shoulder and their rotator

26:16

cuff, and their scapular

26:16

stabilizers, which tends to be

26:20

very deficient in these kids in

26:20

their throwing arm. And parents

26:24

are amazed when we talk to them

26:24

about that, but I show them

26:27

their shoulder blade mechanics

26:27

as well. And looking at scapular

26:30

dyskinesis. And addressing those

26:30

types of things. Because again,

26:33

if anything along that kinetic

26:33

chain, and if you're if you're

26:36

not familiar with the kinetic

26:36

chain concept, you know anything

26:39

from the tip of your, your

26:39

longest finger on your throwing

26:44

hand down to the tip of your big

26:44

toe, on your plant leg from

26:48

throwing, if anything there is

26:48

not working right or injured,

26:51

that can affect your throwing

26:51

mechanics. So if we're not

26:54

assessing that whole type of

26:54

that chain, which you know,

26:57

obviously has a lot of us as

26:57

specialists, we kind of focus on

27:00

the area that hurts, we may not

27:00

address some of those other

27:02

areas, these kids may be deficient in their core strength, they may have some

27:04

issues with mechanics that's

27:07

because of that. And that can

27:07

lead to that problem. So if

27:10

you're just looking at the elbow

27:10

itself, and not looking at those

27:13

other areas there, you're going to miss some of these things. And then you may just rest them,

27:15

which is appropriate, we'll

27:18

we'll rest these kids from

27:18

throwing the start off with I

27:20

get them into rehab while

27:20

they're resting to work on some

27:23

of those throwers exercises, to

27:23

get them stronger in those areas

27:27

there, then I'll reassess them

27:27

in about four weeks. And then if

27:30

those kids are doing better, I

27:30

will then put them through an

27:35

age appropriate return to

27:35

throwing program for their

27:37

position. There's various ones

27:37

that are published out there

27:39

that you can use, and I'll have

27:39

them go through that program

27:42

first, before we let them get

27:42

back to full unrestricted play,

27:45

I do let these kids bat so they

27:45

can be a DH, I do let them work

27:50

on fielding skills during that

27:50

but I don't let them do the

27:52

throwing during the time of

27:52

their rest. And I find lots of

27:56

value also in the the X ray,

27:56

contralateral X ray, when I'm

28:02

looking at little league elbow

28:02

because if you just get the

28:04

single X ray of the AP and

28:04

lateral view, you may not notice

28:09

the widening that's there of the

28:09

medial epicondylar apophysis,

28:12

yeah that that contralateral

28:12

view is very helpful. I mean,

28:15

nine times out of 10. If you

28:15

have a radiologist Look at that,

28:18

they're gonna say that it's normal, even though it may be widened compared to the opposite

28:20

side. So So I find lots of

28:23

value, I'll just do a bilateral

28:23

AP view of each elbow and then a

28:26

lateral view. And that's kind of

28:26

my approach from a radiographic

28:30

standpoint.

28:31

Yeah, I love a

28:31

couple of things you said, first

28:34

of all, you know, in my adult

28:34

population, I take care of some

28:36

workers compensation patients.

28:36

And I get those patients those

28:41

work comp patients back to work

28:41

ASAP, in a limited capacity, but

28:45

get them back into the office,

28:45

there's mental health benefits,

28:48

and what you suggested with

28:48

kids, get them back out there in

28:50

some capacity as soon as you

28:50

can. But there's nothing good

28:53

happens if they're stuck at

28:53

home. And you don't want them to

28:56

lose touch with the game. And

28:56

there's so much they can do to

28:58

continue to build their skills,

28:58

and maybe even take advantage

29:01

whenever I have a basketball

29:01

player that has a right wrist

29:03

injury, I let them go you know,

29:03

put them in a cast if they need

29:06

a cast, and I let them go and

29:06

and tell them work on your left.

29:09

I mean, it's an opportunity. And

29:09

so I love that concept. The

29:12

second thing I really

29:12

appreciate, which resonates with

29:15

me, probably because I've been

29:15

guilty is you know, you put an

29:18

injury in front of a surgeon,

29:18

especially an orthopedic surgeon

29:21

not to overly characterize us,

29:21

and either the bone's broken or

29:25

it's not. And, you know, we tend

29:25

we can be and again, maybe I'm

29:31

self projecting, overly

29:31

simplistic. And so these types

29:34

of sports injuries require a

29:34

little more finesse and an

29:39

appreciation of the entire

29:39

kinetic change. And so it

29:42

changed. And so if I don't have

29:42

the full understanding, then

29:45

hopefully I have either a sports

29:45

partner like yourself, or a

29:48

physical therapy partner who can

29:48

again put, you know, put

29:52

everything together for the kid

29:52

and for the family. And really

29:55

engaging the parents I find to

29:55

be as I'm sure you do as well.

29:58

The right parents can make all

29:58

the difference in the world in

30:01

recovery.

30:03

Yeah, absolutely, if you have the right approach to it, you know, I get always a

30:05

little worried when when it

30:08

seems like the parents more

30:08

upset about the kid being out

30:10

than the kid is upset, that

30:10

always is a little bit of a red

30:14

flag to me that we may have a

30:14

little bit more of a struggle of

30:16

keeping this kid in check. And I

30:16

acknowledge with these families,

30:20

too, it's gotta to be hard for

30:20

some of these younger kids to to

30:23

hold them back from certain

30:23

things. And, and I think that's

30:25

the important part, you know,

30:25

from the sports medicine side of

30:28

things of knowing the sport, if

30:28

you don't know a sport, and all

30:32

the demands of that sport, and

30:32

what things they may be able to

30:35

still do in that sport that are

30:35

still okay, then you're right,

30:39

you may sideline this kid and

30:39

they don't, they may not be able

30:41

to do something, or you know,

30:41

anybody who's athletic, they

30:44

like to have alternative things

30:44

to do. You know, I see lots of

30:47

runners in my practice as well,

30:47

just in general. And, you know,

30:50

the the reason why most runners

30:50

hate going to the doctor is

30:52

because usually the recommendation is well stop running. So well, then what's my

30:54

alternative to do and for a lot

30:57

of these people, that's, that's

30:57

like their drug. And if they

31:00

don't get to do it, and they

31:00

don't get to exercise that's

31:03

horrible for them. So hey, well,

31:03

maybe we can let you cross train

31:05

and do an elliptical or get in

31:05

the pool and pool run, or do

31:08

something as an alternative. So

31:08

I think that's one of the

31:11

approaches that we do need to take when we're seeing these athletic individuals, as we need

31:13

to make sure that we're giving

31:16

them some alternative thing to

31:16

do. In the meantime, to and that

31:20

helps pass the time a little bit

31:20

to from their injury that

31:22

they're recovering from.

31:23

Yeah, for

31:23

sure. So as we wind down, I want

31:27

to both give you an opportunity

31:27

and ask if there's anything else

31:30

you want to say. But I think

31:30

what I'd like what I really

31:32

like, and this is sort of

31:32

putting you on the spot is to

31:34

ask, you know, you have an

31:34

audience of hand surgeons and

31:37

therapists and trainees, what do

31:37

we need to know that we're not?

31:41

What do you need to teach us

31:41

about this population that you

31:45

wish we knew or wish out? make

31:45

it personal? Again, wish Chuck

31:49

knew to do more often? Like what

31:49

can we do better with this

31:52

population?

31:54

Boy, that's a tough question to put me on the spot for that one, as far as

31:56

what you can do better, you

31:59

know, again, and I'm not I'm not

31:59

blowing smoke here, I've got the

32:02

great advantage of I got several

32:02

partners in my, my practice here

32:06

that that are readily accessible

32:06

and have been very helpful

32:09

during my career of something

32:09

that, hey, if I don't know

32:12

what's going on, I run it by

32:12

them. And it's been vice versa,

32:15

too. So I think that's, that's,

32:15

I think, first and foremost, if

32:19

you're in that group, and

32:19

especially if you're an

32:21

orthopedic surgeon, you do have

32:21

some sports medicine physicians,

32:24

whether they're physiatrists, or

32:24

the non operative folks like

32:27

myself, you know, understanding

32:27

what we do, and how we do it,

32:32

and how we approach it, and how

32:32

we can be a value to you and

32:34

your practices, as well. I think

32:34

that's, that's, I think, just

32:39

getting to know our skill set, I

32:39

think is helpful. If you do have

32:43

people like that in your practice or in your community, if you're in private practice as

32:45

an example. I think, you know,

32:49

like I talked before, I think

32:49

the most important part is is

32:52

again, for me always is just

32:52

listening to the kid. I can't

32:58

stress that part enough. Again,

32:58

I've had so many interactions in

33:02

my office over the last decade

33:02

and a half where I just see kids

33:07

get this dejected look on their

33:07

face when their parent starts

33:09

dominating discussion about how

33:09

they're doing and, and it's,

33:14

it's really frustrating for me

33:14

and I again, I am automatically

33:17

turned back to the kid. And I

33:17

asked them the same question

33:19

because I want them to answer

33:19

and I want them to be recognized

33:23

and understand that, hey, I

33:23

value their opinion, as their

33:26

physician just as much as their

33:26

parent's input. And I think

33:31

that's valuable. And I think you

33:31

gain a lot of trust with your

33:33

pediatric age patients when you

33:33

do that, rather than just

33:36

talking with the parent all the

33:36

time. And that's an easy thing

33:40

for us to default to. Because we

33:40

may think that the kid may not

33:43

understand but we probably are

33:43

selling a lot of these kids

33:46

short.

33:48

So thank you for those

33:48

words of wisdom. That's Dr. Mark

33:51

Halstead, everybody. We

33:51

appreciate having you on. Really

33:55

check out Mark's podcasts. He's

33:55

got the pediatric sports

33:57

medicine, podcast and healthy

33:57

young athlete podcast. Both of

34:00

them are on iTunes. I'll read

34:00

you a little bit of his last

34:04

five star review for the

34:04

pediatric sports medicine

34:06

podcast. It talks about how the

34:06

podcast is research based and

34:11

loaded with clinically relevant

34:11

information. The host that's you

34:14

mark does a great job asking the

34:14

guests questions and providing

34:17

recap and highlights. So

34:17

clearly, you've got some

34:21

traction. Great audience,

34:21

everybody, please check out

34:23

Mark's podcasts. And, Mark,

34:23

thank you for enlightening us

34:26

and we hope to have you on sometime soon.

34:29

Yeah, thanks for having me. I got to get some mugs for my podcast as well

34:31

sometime.

34:33

Well, we will

34:33

share with you a mug for the

34:36

upper hand to inspire you.

34:36

Awesome. Thanks for joining us.

34:41

Have a great night.

34:43

Thank you.

34:45

Hey Chris. That was fun. Let's do it again real soon.

34:48

Sounds good. Well, be

34:48

sure to check us out on Twitter

34:51

@handpodcast. Hey, Chuck, what's

34:51

your Twitter handle?

34:53

Mine is

34:53

@congenitalhand. What about you?

34:56

Mine is @ChrisDyMD

34:56

spelled d y. And if you'd like

34:59

to Email us, you can reach us at

34:59

[email protected].

35:04

And remember,

35:04

please subscribe wherever you

35:06

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35:07

and be sure to leave a

35:07

review that helps us get the

35:09

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35:10

Special thanks

35:10

to Peter Martin for the amazing

35:12

music. And remember, keep the

35:12

upper hand. Come back next time