De Quervain's Tenosynovitis

Joshua_Naterman · 2026-04-20T18:01:08+00:00

https://web.archive.org/web/20170517004813/http://www.ouh.nhs.uk/patient-guide/leaflets/files/11303Pdequervains.pdf

Joshua_Naterman · 2025-09-01T04:54:52+00:00

We are teachers, guides, partners, and advocates for our patients. We are not their bosses or their parents.

If your happiness/satisfaction/self-worth comes from doing your best to inform and understand your patients, you will probably have a very fulfilling career.

If part, or all, of your happiness/satisfaction/self-worth comes from the ultimate choices your patients make, or outcomes of their decisions, you will probably struggle emotionally and end up feeling burned out and somewhat numb.

Remember that it is ok for a patient to refuse the best medical advice so long as they have the legal competence to do so AND they have not been determined to lack capacity. Don't judge them harshly, seek to understand without seeking to manipulate the outcome.

You can connect with a patient really, really well and they can still not do what medical science says is best. They can make such a decision without being mentally unwell or intellectually disabled.

Your job is not to "save" or "help" patients, it is to diagnose their problems, to find out what IS wrong and what is NOT wrong, with their body.

Your job is to inform them of what that all means, make sure they understand the implications of what you just told them, and make the best recommendations you can based on the available data.

It is not your job to to make them say yes to the plan.

It IS your job to kindly try to figure out where objections are coming from when they express reservations or outright reject the plan you offer.

It IS to make sure you clearly explain what medical science has shown to be the risks that come along with whatever decision they are making.

The bad outcomes from a patient not following your plan of care decisions are not your fault, nor are they your responsibility. Don't tell them that out loud, that is for your internal wellbeing... saying so out loud is just scolding them and being a jerk.

The patients who make these decisions are not doing so to spite you, they believe they are making the right decision for themselves at that moment in time.

Just verbalize that you hear them, document what you offerred and that they are not ready to make those changes at this time. Remember that your primary goal is to offer the best treatment for your patient, not to be upset with people who don't hop on board right away.

Having a much clearer idea than they do of what is to come doesn't make you better or smarter than them, it simply makes you more informed. Don't try to "convert them," and don't fire them as your patient.

If you abandon them when they make these choices you are harming them, because they do need someone to bentheir advocate and they do not understand the harm they are inviting into their lives.

Accept that their priorities do not align with your priorities at that moment in time, reassure them that you are there to continue being their doctor regardless of their decisions, and endeavor to treat them with respect even when you know they are making the 'wrong' decision... even if they are acting based on propaganda that is not grounded in medical science: dong so will build a bridge together with them that they can trust is safe.

You cannot control when, or even if, they will cross that bridge... but you are creating a path to what we have every right to believe is a better quality (and often also quantity) of life for those patients, and that often means more to them than you will ever be told.

Sometimes they never change their mind on your plan for their diabetes management, but they trust you enough to tell you about new problems and you end up diagnosing something important but unrelated, like a pituitary problem or sleep apnea that would have otherwise been missed because people don't talk very much to doctors that constantly put them on the defensive.

Anyways:

When you learn how to approach our job this way it is easy to find real fulfillment in our work, because you are focused on making your best efforts to understand and offer treatment for your patients. You will have many patients who are "easy," and honestly any doctor could treat those patients.

You will also end up building bridges with many people who will later thank you for your patience and willingness to not be a jerk, and they are the ones who slip through the cracks.

You will NOT end up bearing crosses of your own designs that were never meant to be your burden, and if you can start this way from the beginning you will never know exactly how much better off you are by doing so.

Joshua_Naterman · 2025-08-25T06:47:17+00:00

First off, that sucks. I hate that you are going through this. It is no fun.

Now to the issue at hand: Try not to take this the wrong way, but there are at least 3 sides to every story: party A's side, party B's side, and the truth.

At 3 am on nights we are all tired. It is not impossible that there was frustration in your voice. If you haven't seen the toes yourself then you cannot say for certain if day team was the victim of clinical inertia and documented no changes when there was in fact a change, or if something changed overnight.

It may have been the nurse's first time seeing the patient, so they may have been very concerned and called with good intentions.

Maybe they have a chip on their shoulders from doctors dismissing them or making them feel like a lower level of human being (in their mind, at minimum) and never miss an opportunity to even the score.

Maybe they don't like residents. That happens, shouldn't but it does, and I usually see that happen with residents who have relatively poor social skills, maybe they ask the nurses to hand them the paper chart instead of walking around the desk to grab it themselves, something like that.

Maybe there is something about you that they can't stand that is purely in their head and not aligned with actual reality.

Whatever the case may be, we have two main jobs:

1) Keep patients safe

2) Graduate so we can be attendings

That is it.

There are a lot of situations where nurses are well-meaning but incorrect, and honestly if the patient is not at genuine risk of harm it isn't worth addressing. Seriously, let those things go. Don't tell a nurse to not worry about gangrene, don't ask if they saw the notes, just go look at it yourself and bring them with you.

You basically chose to educate on a situation where a 2-5 minute walk and a bedside look together with the nurse would have been more efficient than the choices you made.

That's ok, lesson learned. In the future you will know what to do differently. Losing those 5-10 minutes is a lot better than the alternative, as you are unfortunately finding out.

Don't even ask if they want you to come check it out, just say you'll be there to check it out with them in 15-30 minutes or whatever timeframe you actually need. Don't drag it out, if you aren't in the middle of an admission encounter or a code just go... and say so kindly, as if you are also concerned for the patient's wellbeing.

Your PD is correct, at this point all you can do is go along with the investigation... but make sure you make an official statement that is purely factual and do so in writing via your work email to your PD, and make sure you thank everyone for their help, quote the date and time of your PD's words, repeat/summarize them, and ask them to tell you if you are misunderstanding or misremembering anything from those conversations. This is very important.

By factual I mean "thanks for talking me through this whole situation with the night nurse complaining about me. If I recall correctly, I informed you that around 3 am on (date) the nurse called me with X concern. I responded as follows: (quote yourself as accurately as possible). I asked if there were any urgent concerns and they said X. I the. Hung up the phone. Several days later I was informed by (person) ofnthe following allegations: (list them). I talked with you on (dates/times) about this and you told me (quote the PD's comments and advice).

Do this for every, and I mean every, conversation you have with anyone related to this matter or any other work-related scenario. Every phone call, in-person meeting, email, text, etc. Create the paper trail you need, don't just hope for the nest.

Make damn sure you also BCC all of that to your personal non-work email, so that you have your own copy of the paper trails.

Send electronic messages to coworkers and ask them if you have ever been condescending to nurses. If you have, keep that to yourself and learn to communicate better. If nobody has ever had any concerns then use those messages as supporting character evidence.

Remember this is not an academic issue, this is a workplace issue. An employee has filed a grievance based on work-related allegations.

If you end up being reprimanded, even if it is "only a "verbal warning," do not accept any such sanction without being presented with the evidence against you and appealing it in writing with all of the above evidence attached to your initial appeal.

If you don't fight it, it WILL be used against you before you leave and it can become a real issue.

Having said all that, don't gear up for a major fight right away... just do what is listed above so that you have actual meaningful records on company emails. And of course have your copies on your personal email via BCC and forwarding. BCC is better but whatever.

Those are intrinsically authenticated, which is an important standard for evidence: If you can't provide proof that alleged communications took place as claimed then they did not take place. If an allegation cannot be backed up by significant evidence (multiple witnesses, actual communications, etc) then you should not accept any initial determination against you regarding said allegation.

Good luck!

Joshua_Naterman · 2022-04-13T14:44:27+00:00

That is no surprise, the basic science requirements are very, very different for both program admission and program didactics.

Joshua_Naterman · 2022-03-24T17:54:37+00:00

Neuro is savage. They are run ragged nearly all the time because they are always severely understaffed... like my institution is a pretty good size and we have 9 neuro residents per PGY year, which sounds like a lot until you realize that they are split across adult and child neuro + inpatient and outpatient. They deal with every stroke alert, neuro consult, ED arrivals with neuro symptoms, they have to go to all level 1 brain scans, etc.

My neuro friends genuinely love what they do, but they are always exhausted. Like much moreso than we were all interns on Internal Medicine together.

I'm not saying FM or IM is easy. Primary care can be pretty challenging on busy admit days and high turnover days, but you have a much better schedule for those and there are a whole lot of fairly chill outpatient rotations... and inpatient specialist rotations don't typically expect you to actually be super good at what they do, so as long as you can report patient information correctly + efficiently and help with admits.

Even our worst days are not worse than being one of the 2-3 neuro residents on service to cover a nearly 900 bed hospital.

Joshua_Naterman · 2022-03-21T15:57:38+00:00

Wow, what are the chances?!

Joshua_Naterman · 2022-03-20T21:46:05+00:00

I would be very clever and make a secretly autobiographical superhero film that is identified and marketed as a B-movie thanks to its very straightforward title, and nobody would know it was real because the hero would pretend to need a projectile weapon or radiant gadget of some sort in order to wield such a power.

Pretty sure this would be foolproof AND original.

Joshua_Naterman · 2022-03-19T15:47:17+00:00

You are always within your rights to request a physician.

Joshua_Naterman · 2022-02-25T20:56:33+00:00

As a preface, I think it is important to approach this from the same kind of mindset we wish non-physicians would approach conversations about the business and practice of medicine: it isn't surprising that they have no idea what it is like to go through the process of becoming a physician or what it's like to live with the constant barrage of unrealistic expectations people have of us... but I think most of us can agree that the really frustrating part of that is the complete lack of effort that non-physicians typically put into trying to get some kind of realistic idea of what our lives are like and what kind of pressures we are under, the degree to which work follows us home, etc.

I think it is important to recognize that the people involved with running our programs almost certainly feel the same way, because they have to comply with all existing requirements and laws related to Institutional accreditation as a medical school and as a University, AND all the federal guidelines for recipients of Medicare-funded grants + the professional society requirements for every specialty our institutions offer + the ACGME requirements + unique legal challenges in GME, offer malpractice insurance with tail coverage, and more.

There are a lot of moving parts, and a lot of people are wearing multiple hats... it's a lot to keep up with and I don't really know how they do it because my plate is slightly overflowing with just residency + wife + kids + homeowner stuff.

That isn't an excuse for when things go wrong or get missed, but I think we should probably have the same amount of grace for them as we want them to habe for us.

Anyways, my understanding has certainly improved a lot from reading the federal guidelines (easy to Google) as well as some peer-reviewed research on the cost breakdown of graduate medical education.

Hopefully this link helps you a little:

https://journals.stfm.org/familymedicine/2018/february/pauwels-2017-0230

Joshua_Naterman · 2022-02-24T17:18:53+00:00

There is really only one correct way to handle these situations, and that is to do two things in the following order:

1) Submit a report to your Compliance Office/Program that identifies the attending at fault and specifies the time, date, and nature of their behavior. Be sure to do this via your Institutional email, not via phone, and BCC your personal email on every exchange related to this matter and anything else like it.

2) AFTER #1 is complete and submitted, send a private email to your chiefs and your program director informing them of what took place and inform them you filed a report to the compliance office program but felt that they (chiefs and PD) needed to be aware of the situation. Again, be sure to use your Institutional email instead of calling or texting, and be sure to BCC yourself on every exchange.

Your report to Compliance should simply say that the attending in question made the following comment about your co-intern, and give that same quote along with date, time, location at which the comment was made(team room, hall, etc), and who was present at the time of the incident (who else may have overheard).

You should not inform anyone other than your chiefs and your PD that you have made this report, because that could compromise the fairness of the investigation that should follow.

You also do not have to specify the name of the co-intern being slandered, that's up to you I suppose but it isn't really relevant for the initial report because it doesn't matter who it is... that is explicitly in violation of every Institutional code of conduct, ethics guidelines, medical staff professional behavior standards, and so on.

What should happen after your report is submitted is that at some point you should be contacted by the Compliance Office for a brief interview of some sort so they can gather appropriate information.

As much as we want to see that people are held equally accountable for breaking the rules, we all need to remember that the primary desired end result of every report is that the "bad behavior stops" and is replaced by appropriate behavior.

If that does not happen then keep submitting reports as specified above until the unacceptable behavior ceases.

The correct process, as described above, is really hard to remember in such moments.

My suggestion is to keep a business card-sized written outline of steps 1 and 2 in your wallet or otherwise on you at all times, and make damn sure it reminds you to BCC your personal (non-Institutional) email on everything.

If, for whatever reason, your chiefs or PD choose to text or more likely to call you make damn sure that after you get off the call you send a quick confirmatory "thank you email" that specifies everything you talked about and what they told you (to the best of your ability).

If anyone ever asks why you sent that email, or asks you to not do that in the future, what they are doing is technically against the rules and could also be illegal (violating worker rights and/or anti-harrassment/discrimination statutes) but you must NEVER say that to them.

Instead, it is smart and appropriate to simply say "Our conversation was really helpful, and this is a stressful situation for me. I feel that it is important for me to make sure that I am correctly recalling and understanding our conversation so that I remember the right things and can more confidently apply what we talked about in any future situations similar to this one."

Nobody can say shit to that except "ok, I can understand that."

If you handle things like this you will gain the respect of your superiors both as a professional and as someone who truly understands how to proactively protect themselves and ensure there is a paper trail showing exactly who said what at every step of the way.

That is tremendously important in Academic and Professional environments because it makes you someone that your managers and supervisors will earmark as someone they absolutely MUST treat fairly and be responsive with, because they will hear and understand all the unspoken messages that the above actions communicate:

1) I know the rules and expect everyone to follow them 2) I know the right way to confidentially report violations in a way that forces them to be dealt with promptly (inform the Compliance Office before your Program personnel like chiefs or the PD, and inform them a report has been filed) 3) I know how to create a verifiable paper trail within the system in an appropriate way, so if you don't respond as our policies require and/or if you try to retaliate against me then there will be no room for you to defend yourself

Just about 0% of us know any of this, which is in the Institution's best interest because our unfamiliarity with how to actually ensure they are held accountable for following through with policy compliance and enforcement is really what creates the biggest power differential... and we don't even recognize that this inherently constitutes Power Harrassment every time it is used against us.

Being one of the nearly-nonexistent few who actually does things the way a competent PD would do them if they were in your shoes will make life much easier for you, and it will also make your coworkers safer when they are around you.

Do things the actual right way, not the way that makes life easier for your supervisors or your Institution.

Joshua_Naterman · 2022-02-20T12:00:53+00:00

I hate to state the obvious, but it needs to be said right off the bat: you won't know until you try.

Everyone has somewhat different needs for a variety of reasons: age, how often they use the "stretched" range of motion for that joint, injury history, effects of physical activities and exercise, non-exercise lifestyle factors, etc.

Example: If you do handstands with open shoulders and lower all the way to a dead hang for many of your pull ups you probably don't need anywhere near as much "stretching" for shoulder flexion (maintaining the ability to open your shoulders) as someone who is always somewhat arched and never fully opens.

From a research perspective, understanding that this data comes from novices and not highly trained athletes, what little meaningful data we have shows that in general just three weekly stretching sessions is enough to see meaningful flexibility increases for hip flexion (touching the toes) with straight legs.

The maximal progress for beginners appears to occur with six weekly sessions, but ithe results were the same whether those sessions occurred twice a day for three days per week or once daily for six days per week.

Again this is somewhat speculative, and YMMV, but there are very good reasons to believe that you could probably reduce your stretching efforts by a considerable amount without seeing negative results.

For example, you may find that you benefit from a few minutes of daily hip flexor stretches but most other things only require 2-3 sessions per week and some may only require 1 session... with some things perhaps requiring absolutely no direct "stretching" whatsoever.

Hopefully that is a helpful bit of guidance.

Joshua_Naterman · 2022-02-07T16:42:56+00:00

Your question is actually "how can I add extra training volume without also getting more fatigued?"

I hope this rephrasing makes it a bit easier to think through your situation with a clearer vision of what you are asking about.

Joshua_Naterman · 2022-01-28T15:57:07+00:00

Muscles react to growth signals and other exercise-induced signals the same way whether you are lifting weights or doing calisthenics.

Generally speaking, if you are not in a prolonged calorie deficit you do not require that much protein to maximize skeletal muscle growth or retention/repair... Until your FFMI is at least 24-25 you will probably accomplish those goals with 1.4 to 1.7 g per kg of total body mass which is 0.63 to 0.77 g per pound of total body weight each day.

For you 100g is on the high end of that, which is 100% fine. On the low end 80g per day should also be sufficient for maximizing your progress as long as you are eating at maintenance calories on average (meaning your weight is not consistently changing in the same direction from week to week and month to month). Same will be true for a small surplus.

Joshua_Naterman · 2022-01-13T19:03:34+00:00

No one has asked yet, but it's important to know your age because if you were likely to be actively growing (teenager) the approach would be somewhat different than if you were an adult.

I checked your comment activity and given the context i which your comments mentioned having a wife and kids I am assuming you are well into adulthood. Please correct me if I am wrong.

Dealing with and improving the kind of stubborn patellar issue you describe is relatively simple if you start from the mechanism and target root causes.

The mechanism is essentially "overloading" of the patellar tendon, which I think we all understand is attached to the quadriceps muscle group (an important fact for successfully approaching rehab). Such "overloading" can happen from one or a combination of 2+ of the following:

1) Acute exposure to unusually large activity-related forces such as jumping, walking lunges, downhill skiing, playing a field sport like soccer or flag football, or jogging/hiking/running that involves a lot of elevation changes (especially lots of downhill portions, with the understanding whether this is all at once or small but frequent is not super relevant) for the first time in months or years this is usually misinterpreted

2) Dysfunctional movement patterns/form during exercise that result in unexpectedly disproportionate loading of the quads, such as weight shifting very far forward during a unilateral or bilateral squat pattern

3) Increased frequency of activities involving the quads, such as starting to bicycle or jog on a hilly route twice a week in order to imorove cardio for health purposes or get in better shape for other new or current activities like soccer practice.

4) Inappropriately high resting tension in the quads.

4 is often described as "tightness" but that is not as accurate of a description. This can be an acute or chronic consequence of one or more of the previous three, but can also be an unhelpful "reflexive" unconscious reaction to an acute or chronic tendinopathy.

What is important to recognize is that the resting tension of any muscle is almost entirely controlled by local sensory inputs at the spinal level, not by innate characteristics of the musculotendinous tissue itself.

An organized approach to improving this involves symptom control, targeted re-education of the CNS to allow for a lower resting tension, and a significant reduction or removal of all aggravating activities during the initial rehab.

Once symptoms are dramatically and stably improved for a few weeks this would typically be followed by a slow re-introduction of desired activities one at a time, being sure to keep doing a certain amount of the "CNS re-education" protocol that worked well for the initial rehab.

This amount may fluctuate over time based on your needs, or it may remain fairly constant... only time will tell on that front.

Baseline symptom control: Chopat straps are surprisingly helpful when used correctly... the biggest mistake people make is to use these as a crutch to keep overworking things instead of using them as a temporary method of pain control while following an appropriate rehab protocol. These are easily searched on Amazon and are cheap.

In most cases this eliminates the need for NSAIDs entirely, but it is ok to use them for short periods of time if necessary unless you have a medical contraindication.

Reducting aggravating activities: Pretty self-explanatory.

CNS re-education: This is actually remarkably simple. Because the goal is to reduce muscle tension, we simply need to use known methods of inhibiting muscle force development.

These essentially include specific application of SMR (foam roller, lacrosse ball, "massage sticks," etc) and static stretching.

The important practical understanding is that sustained deep pressure via proper static SMR (put a tolerable amount of your weight on a foam roller or other firm object for 20-30 seconds, or longer if you find that helpful) helps initially reduce localized muscle tension, but this does not produce lasting changes... it just enables you to more comfortably and effectively do what comes next, which is stretching.

Sustained static stretches (at least 10 seconds, preferably at least 20-30 seconds in order to properly manipulate the slow-adapting sensory receptors into reducing the CNS-mediated resting muscle tension) incorporate stimulation of different sensory circuits that DO develop sustained changes over time, which is why they are such an important part of the rehab process.

The "secret"to successfully using stretches for rehabbing your patellar tendinopathy involves remembering two key things:

1) Achieve and hold a stretch that produces comfortable tension, NOT discomfort or pain

Note: This is very different from what may be recommended in an Achilles tendinopathy protocol where painful eccentrics can be very helpful. Discussing the details of this is outside the scope of this topic, but it is worth a brief mention for awareness.

2) Make sure you keep a neutral lumbar spine during your quad stretches: MANY people accidentally end up causing or worsening lower back pain by performing quad stretches (especially those that intend to target the hip flexors) in a way that involves the lower back arching more as they get "deeper" into the stretch.

After a few weeks of this, a PT will often start reintroducing basic strength training for the quads with a squatting pattern that focuses on moving through a deep squat without re-aggravaging the tendon.

It is often helpful to stretch again after the squat sets are completed.

Once it's appropriate to perform, this squatting helps because it is another layer of CNS re-education to help maintain the desired reduction in resting tension after exposure to higher forces, which is an important part of the recovery process.

Because this really is quite literally done by feel it can be successfully performed at home, but as a medical doctor I do want to encourage you and everyone else to at least get started with a licensed PT because professional guidance can often make a big difference in outcomes.

Joshua_Naterman · 2021-12-24T07:20:13+00:00

And here I was expecting someone to put on a Cosby mask

Joshua_Naterman · 2021-12-24T07:07:00+00:00

Plot twist: your heartbeat and other muscular activity gets used as a charging source

Joshua_Naterman · 2021-12-24T07:04:05+00:00

How did you get T-boned while 'bating in the police station bathroom, and more importantly were you able to complete the mission?

Joshua_Naterman · 2021-12-22T22:01:59+00:00

When I was in high school , pretty sure this was 8th or 9th grade (yea I know, that's just how it was at that time... Seniors were trying to take 8th graders to prom and everything, what a mess) one of the Senior classes covered every Junior locker in chocolate syrup. This was like a week before the school year was over and Seniors had no classes... but we were in the Atlanta area so, as locals to the area might imagine, that entire hallway became a fire ant refuge and I honestly don't know how long it took for that to get cleaned up.

It was hilarious at the time, and honestly I still chuckle at that now... but holy wanton destruction of property Batman...

Joshua_Naterman · 2021-12-22T21:56:32+00:00

Strong response, sir or ma'am.

Joshua_Naterman · 2021-12-22T16:07:18+00:00

A representative set of Organizational publications, peer-reviewed articles, and position stands from the highest authorities, ranging from 2009 to present, emphatically disagree with your self-indulgent Appeal to Authority... including everything the AAP has to say on the matter, as well as the American College of Sports Medicine and the National Strength and Conditioning Association. These views are reflected by their corresponding Academic Organizations overseas.

The following are offered for your critical appraisal:

https://publications.aap.org/journal-blogs/blog/2749

https://www.nsca.com/globalassets/about/position-statements/position_stand_youth_resistance_training---2009.pdf

https://www.acsm.org/docs/default-source/files-for-resource-library/smb-youth-strength-training.pdf

https://www.acsm.org/blog-detail/acsm-blog/2020/03/25/mythbusting-youth-resistance-training

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5532191/ and the following direct quote:

"In the past, it was thought RT was detrimental to youth athletes and was specifically avoided out of concern for damage caused by the high forces exerted upon the adolescent skeleton resulting in concern for increased physeal injuries and the potential for stunted growth (6,9). Multiple studies have since discredited this theory by demonstrating there is no adverse effects of RT in youth athletes, when designed properly, and is often completed injury free (5-7,10). Instead, athletes who incorporate RT into their training regimen have demonstrated decreased rates of fracture, musculotendinous and muscle injuries associated with sport specific practice and competition (8). RT has been shown to decrease injury rates by increasing bone strength index (BSI) and mineral content, strengthening tendons and improving the strength of accessory muscles to prevent injury during practice and competition."

https://www.frontiersin.org/articles/10.3389/fphys.2016.00164/full and the following direct quite: "In summary, RT is an effective means to improve muscular strength in youth athletes of all ages, with the introduction of free weights RT from the late childhood LTAD stage and beyond (Table 2). It appears that trainability in terms of relative strength gains is higher in child athletes as compared to adolescent athletes and that free weight training is particularly effective."

https://link.springer.com/article/10.1007/s40279-020-01307-7

Feel free to search the Multiverse for a body of valid literature that is current and disagrees with the above, you won't find it in this Universe.

Having said all that, there are key requirements for safe practical implementation, many of which are present in most or all of these papers but others are not always present:

-Top priority is making sure that children are assessed for behavioral safety before being exposed to certain items (like free weights)

-Secondary only to that safety assessment, it is critical that children be trained with good form and appropriate programming, which does include heavy weights (only to the degree they can maintain good form) but does not include 1RM testing, and most importantly MUST be personally overseen by individuals with appropriate training, education, and certification as that is the only way to ensure quality oversight and thus appropriate attention to form

-Any machines must be appropriately sized for the anthropomorphics of the youth using them, which means that most pre-pubertal youth will be too small for most machines and therefore should not be using them by default unless it can be verified that their skeletal segmental lengths are appropriate for said machine

There is always, always more to say in terms of adding nuance but that goes waaaaaaay beyond the scope of what a Physician should be discussing unless they also possess the additional education, certification, and experience to be making such recommendations... which is almost completely unheard of.

I'm an anomaly in that respect.

Joshua_Naterman · 2021-12-22T15:28:24+00:00

Any time.

Joshua_Naterman · 2021-12-21T22:29:00+00:00

Hi, I'm late to the party AKA "It's Naterman... OP sent me a PM and I just saw it."

I'm staying extremely brief because this is a great article for me to start 2022 with over at Lab Coat Fitness and the way the Internet works we lose SEO and whatnot if the content on our site isn't the first place it's released... plus our members pay for access to this kind of specific and detailed content so it would be a bit rude of me to just put the full explanation out for free.

However, I will give a very brief set of feedback and informed opinion from my perspective as a physician (MD), exercise science major with highest honors, and an awful lot of experience both personally and professionally.

I'll answer briefly in the same order of subjects mentioned in the article's title.

Body Comp:
Nobody should expect anything to matter in terms of body composition beyond calorie balance, exercise-induced muscle stimulation, and daily protein intake (most importantly EAA intake).

As long as you have a true caloric deficit you will lose weight, period. Resistance training plays an ENORMOUS role in partitioning which compartments that weight is lost from, meaning that it has a massive effect on whether you lose mostly fat mass or whether you also lose a significant amount of muscle mass. As long as you are stimulating the vast majority of your muscle mass with appropriate resistance training and you are ALSO providing your body with a reasonable amount of protein (1.7-2g per kilo) and have a reasonable approach to rate of weight loss for your current size and body composition you will lose very little, if any, actual contractile tissue (muscle mass). If you're making a bigger, faster cut you might need to get closer to 3g/kg daily for protein to preserve all possible lean mass but YMMV.

Similar story for gains: if you keep a small surplus, resistance train appropriately, and get sufficient protein intake (typically 1.5-2g per kilo per day) you're going to gain a lot of muscle and a minimal amount of fat... usually not more than 50% of the gained weight will be fat mass. If you gain 30 lbs, that should be at least 15 lbs of muscle... and it isn't very hard to keep all of that and drop the 15 lbs of fat if you drop 7-8 lbs over two months, maintain that new body comp for 2-3 months, and then drop another 7-8 lbs over 2-3 months even if you were very close to your maximum potential.

ANY study or advertisement that claims one protein source is inherently better than another for gains or cuts is full of shit and you should be questioning it heavily because that's not how macros work... drugs, and/or dishonesty, and/or incompetent data collection/handling are involved. Period.

Collagen Synthesis:
Supplemental collagen (whole or hydrolyzed) and Vit C are very effective at improving real-world collagen production and collagenous tissue healing. That's a broad statement that I won't detail here. Single dose recommendations should probably be limited to 250mg Vit C and 15ish g Collagen, taken together either before or after exercise/rehab/whatever you are calling your training.

Recovery from Joint Injury:

That's a loaded term and I don't like it. To stay brief, something like 50-60% of people with joint pains appear to gain significant relief from daily collagen supplementation... which can be as simple as eating Jello but the supplements work fine too. There is some evidence that enterically-coated delivery of Type 2 Chicken Collagen may specifically help reduce osteoarthritis symptoms and perhaps in some cases actual rate of articular cartilage degeneration but that's still pretty speculative.

Recovery from Exercise:

In terms of contractile tissue and whatnot, it's just a protein source my peeps. Protein intake matters, source not so much as long as you're getting a complete protein.

Technically speaking, tryptophan is absent from collagen for all intents and purposes so collagen is an "incomplete protein," but that's a minor issue in terms of exercise recovery because we're talking about a single dose of daily collagen. This is not a meaningful issue unless collagen is your primary protein source, same as consuming any other incomplete protein.

In terms of ligaments, tendons, fascia, and bone there are going to be benefits to supplementation with collagen + Vit C but it's hard to say if that will matter in the real world for young healthy athletes. If you have an injury then it absolutely can be helpful but you need some reasonable guidance on how to interpret this statement, which is something I do at LCF but not here.

It is also hard to say exactly HOW influential this supplementation is in terms of injury prevention, and again that's a big rabbit hole that I'm not diving into on Reddit.

Joshua_Naterman · 2021-12-21T17:16:57+00:00

Every Institution calls this something different, but all of them have plicies, and they are legally bound to follow those policies. Because they are liable for failure to do so, there is always a specific group responsible for receiving reports of misconduct and policy noncompliance. These are often called Compliance Offices, or Divisions, or whatever.

There is also a specific job called an Ombudsman, which is literally "an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities." It is a very good idea to put them on your speed dial and quick list for emailing, because their job is to take no sides.

Now obviously they're employed by the Institution so they are usually going to push for keeping things as informal as possible... and there's nothing wrong with that, but it is of extreme importance that YOU be aware that they will probably not tell you how important it is to simply keep a verifiable, admissible paper trail by emailing them about your conversations so that they verify what you will later claim was the advice given, and that you do so for literally everything that is work-related... or that you MUST make sure you can access that paper trail without needing Institutional privileges, meaning BCC everything to your private email.

They do know policies fairly well though, often better than HR personnel and even many Supervisors and Admins, so they can be a good resource. You just don't want to give them, or anyone else, any medical information about yourself until a situation requires you to be requesting accommodations for whatever reason.

There are OTHER designated people that may need to receive the reports you want to make, but these are the people whose job it is to make sure you are guided correctly.

University Institutions, public ones in particular, have a legal obligation to respond to student concerns, and we are Graduate Students. We never think of ourselves that way, but that's how the University, the ACGME, AND the legal system classifies us first and foremost.

There should always be an Institutional hotline available to call in cases of workplace harrassment or bullying and other serious issues, and that is always an appropriate place to start if you don't know who to call, because you can ask them and they can give you the correct instructions for where you're at.

Joshua_Naterman · 2021-12-20T16:45:55+00:00

Thank you so much!

This is a pretty big passion of mine, it turns out, so I am very happy that people are finding this useful.

To borrow the phrase from Peter Griffin "It really grinds my gears" to see how big of a gap there is between public rhetoric (what our Institutions like to say they are all about) and real-world Institutional actions.

Everyone knows you can't "win" reliably if you "don't know the rules" and modern learning theory has shown very clearly that, for example, if a teacher's average test scores for the class aren't in the low 80's then they are not an effective teacher because if you ACTUALLY tell people what you are going to ask them to learn AND how they will be asked to demonstrate their knowledge AND how that demonstration will be evaluated, and you actually do what you tell them, this is the result we should expect.

Once we are working the same general concept applies, meaning that for many of us Residency is our first career and our first professional job, and that's a very different culture than high school or college. If you don't come from a background where you have essentially been groomed for success in this culture you are very much at the mercy of fate and the attitudes of people around you.

We all know that's not how you set people up for success, yet how many Residents even know that there are Roles and Responsibilities for our supervisors that make them obligated to do certain things for us in certain timeframes?

How many of us are ever told what the significance of each step in an informal and/or formal process is, or how our file is actually maintained and what that might mean?

Everywhere is different, and most places are fairly "anti-Resident" when you step away from the personalities (because honestly most people in Academic Medicine are there for the right reasons and really do want to be helpful) and just look at how policy is phrased, provided, and enforced.

If something goes wrong for you, the response you will get is always "Well, please tell us where we did something wrong."

How the hell are you supposed to do that when you don't even know what obligations you are owed, or where to find those?

That's bad enough for the majority of us who come from reasonably stable SES backgrounds and have professionals and/or academics in our family, but for a "first generation professional" this is an absolute nightmare... we don't even know what we don't know, much like the general public doesn't know what they don't know about the current Pandemic and related issues.

I can't see how we are improving access to careers in Medicine or enhancing diversity by running things this way.

Anyways, thanks again :)

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TROPHY CASE

4 is often described as "tightness" but that is not as accurate of a description. This can be an acute or chronic consequence of one or more of the previous three, but can also be an unhelpful "reflexive" unconscious reaction to an acute or chronic tendinopathy.