1st Trimester Recap

(secretly pregnant in these workout photos… just another day in the life!)

When my now husband and I first started seriously dating we had a talk over a diner breakfast one lazy Sunday morning that went something like, “hey I like you, this is going well and to get the life we both want we need to move quickly…” From engaged to married to expecting all during a crazy pandemic year that tipped everything sideways… I believe that is the definition of moving quickly! 2020 was the best and most insane year of my life. 

In August 2020 we pivoted away from our dream wedding and celebrated with an intimate micro-wedding that turned out more perfect than I could have hoped (still working on sharing those photos…)  Around this time we decided to let what would happen in the baby making department, well happen. Being 37 years old gave me doubts that this it be an easy road. To that end, my sincerest love to anyone struggling with infertility. I have a personal story to share another day that makes me extremely sensitive to this and the emotions of saying we were open to trying was enough to bring me to tears. After some soul searching I choose to focus on the word ‘surrender’ knowing none of what might happen was in my control.  People ask if we were trying and I have debated if that is TMI?… but if sharing helps anyone then it needs to be done. Making babies isn’t always as easy as they teach in high school!  There is a small window in a woman’s cycle when babies can happen called ovulation. This time varies for each woman and most don’t actually know exactly when this is. I wanted to approach this little journey as much like a doctor as possible. This meant using a basic drug store ovulation kit.  When the little guy flashes a smiley face that is go time. It doesn’t always work like magic but can be very helpful to learn your cycles and for us, that was it.

How did I find out? In a word, I KNEW. I am super aware of my body. There was something the tiniest bit off. Slight belly discomfort, a minuscule amount of something not even considered nausea but something. I took a very early test and voila – positive. I didn’t get too excited, knowing early tests aren’t always the outcome, but sure enough!!  I had an immediate mix of emotions from excitement to gratitude to fear to wow this is so weird! I was shocked. So shocked that even though I know some women take time to figure out a cute way to tell their husband… I instead choose to blurt it out on the next phone call.  I knew I needed his support immediately.

Everything that followed was new.  I kept telling every doctor how weird it was. I had treated many pregnant women before, but never imagined what it actually felt like to be pregnant. I also never realized how isolating it can be. It is crazy that in the time when hormones are all over the place and this huge life change is on the horizon there is taboo in telling others. There is something to be said for privacy if you choose, but this taught me it is important for everyone to tell as much or as little as they want whenever they decide to do it.

What I felt:

Tired. So tired. In weeks 3-13 I slept more than ever in my life. I am NOT a napper, but this fatigue was no joke.  I would sleep on the couch 2-3 hours in addition to going to bed early. And by early I mean at 8pm I was under the covers. I felt guilty but didn’t have a choice.  My body needed rest. Lucky for me my husband was super supportive and kept encouraging me to listen to my body. When he asked what I did that day and I said I ate a bagel and napped, I swear he said awesome great job.

Digestion changes. Many women have severe nausea or vomiting way worse than I.  But for me this was still terrible.  I was nauseous and my digestion slowed down like crazzzzy.  There was a 2 month period where dinner wasn’t something I could eat.  I would start the day with a little breakfast, do okay at lunch and at dinner couldn’t eat without being nauseous, overly full and very uncomfortable. In general carbs were my friend and a fancy dinner became saltines and a slice of cheese at 4pm.  Not wanting to fall totally off the healthy food train I tried my best to sneak in salad and protein when able. I loved eggs and avocados so much this kid is half avocado toast.

Body changes. Despite no actual bump my lower stomach became super sensitive very early. I couldn’t tolerate any seam across my belly.  Pants felt strange and uncomfortable. One of the silver linings of staying home during COVID was there was rare instance I actually needed to wear anything other than cozy sweatpants.  And then there are the boobs. People say they get bigger… and that is no lie.  Everything on the front half of my body felt swollen and hard to recognize. Contrary to most women instead of super luscious hair and nails, mine fell out and were brittle to the point of asking my doctor, but it was nothing of concern.

The usual suspects. Peeing all the time, sensitivity to odors, cramping legs at night and bleeding gums are super common issues and I experienced them all. 

Things that helped:

Listening to my body. It felt like the day after you have a bad flu… but for the whole trimester. Naps were on repeat. It was hard to feel so lazy but I didn’t have a choice. Hormones and the body changing rapidly, as well as growing an entire new organ (the placenta) means required rest.

Trying to make healthy food choices as much as my body allowed- although I ate more bagels than in years, I gave myself grace.  This wasn’t a free pass to follow every craving.  I was very aware it was easy to say I craved pizza… when honestly when do I not crave pizza? I also kept in mind the nutritional needs for this tiny addition are in fact tiny. If I could stomach a few pieces of broccoli those nutrients were enough!

Exercising as I could. I wanted to try to keep something from my normal routine even if it had to be very limited.  I prioritized daily walks to feel better physically and mentally. I went on slow bike rides while my husband ran alongside (running was out of the question with that weird stomach sensation). I stretched nightly to try to help with leg cramps. 

Hydrating. Normally I am terrible at drinking water. It is a job hazard. Seeing patients all day means no time to stop to drink or use the bathroom. But after I made hydration a priority – 80+ oz per day, tracking it on free app on my phone – I noticed a huge improvement.  I was worried about going to the bathroom a million times per day. But my sister in law said it best reminding me I was doing that already- at least this way I was hydrated. And it actually made bathroom trips better because I needed to go as opposed to just having the sensation. 

Preparing. Carry the big purse at all times. Trust me. I had citrus fruit, sparkling water, pretzels, crackers, and plain bread on hand anywhere I went. I’m not sure anything really helps during this phase, but having something to try gave me the sense of control I desperately desired.

Onto the next trimester…

Need to know: Ankle Sprain

The ankle sprain… One of the most common reasons patients see me in the office. Here is all the information you need to know if this happens to you.  It will be just like if you were visiting me in the office!

An ankle sprain occurs when your foot rolls in or out putting extra stress on the ligaments.  This causes the ligaments to stretch/tear, which is by definition an ankle sprain. If your ankle rolls where sole is facing in, it is called an inversion injury (most common). If your ankle rolls where with your sole facing out, it is an eversion injury. These injuries can happen during sports, basketball and volleyball are common, or in any setting when athletes can land awkwardly from any jump or step. Sometimes though for the unlucky patient the injury can occur during day-to-day activities, something as simple as stepping off a curb wrong at the grocery store.  I have seen all of the above (and more) in my office!

During the sprain, the ligaments are stretched/torn which causes pain and swelling. The great news is these ligaments are not typically the type we need to fix with surgery, and most people heal quickly without long-term problems.  However, more complex types of sprains do exist that take longer to heal or may need more intervention.  For example, a “high ankle” sprain results from a more forceful twist that injures the ligaments above the ankle between the lower leg bones in an area called the syndesmosis. With other high energy injuries, you can also injure ligaments lower down in the foot or even break the bones.  If you are a kid and still growing, your growth plates are weaker than the ligaments.  Because of this when you twist your ankle, the bones may be more likely to break than for a ligament to tear.  This is a commonly missed injury by non-orthopedic physicians, can take longer to heal, and needs a correct diagnosis to be treated properly.

 Today we focus on the essential adult ankle sprain, the inversion (sole of foot turning in) injury that tears ligaments mainly on the outside part of the ankle. The most common injured ligament is called the ATFL, or anterior talofibular ligament.  If you look at your right foot it is that approximately at the 2 o’clock position on the top of your foot about 1 cm from the ankle joint. 

The injury causes a tear/stretch of this ligament resulting in pain, swelling, and bruising. 

 Treatment is usually very straightforward. I recommend starting with ice for the first 24-48 hours with rest (doing as little as possible) and elevation (at or above the level of the heart) for swelling. You should only do light activities that do not increase pain. If you have a more significant injury and you cannot walk normally, sometimes I recommend using a brace or other support device like a medical grade boot short term.

The timeline for recovery is variable and depends on how bad the injury is and what your goals for return to activity are. If you have a small injury and are doing low impact movements (sitting/walking) a full recovery is quicker than if you have a larger injury and play sports that require cutting, jumping, or pivoting. 

The biggest risk with an ankle sprain is repeat injury. Once the ligaments are injured, your ankle is more unstable and weaker.  You are more likely to sprain it again or injure it further if you have not fully regained all your strength, balance, and coordination lost with the initial injury.  Your body normally controls ankle stability (balance and strength) with proprioception. Proprioception is a protective sensation where your brain sends a signal to a joint and the joint responds with position updates.  Think of it like you brain asking your ankle, “Hey, how’s it going down there, which way are you pointing, how stable is that ground?” And your ankle responds, “I am okay, pointing straight ahead, ground stable no cause for concern.”  This happens constantly and nearly instantaneously with movement.  Consider this – don’t you always know where your ankle is without even having to think about it?  When you have an injury that feedback communication does not work as well.  The ankle’s response can be slowed and inaccurate.  This causes an increased risk of a second injury.

We can improve the ankle’s ability to communicate via proprioception, as well as its strength and our balance with physical therapy. A physical therapist can assess how the ankle is moving and what needs to happen to retrain it to be pain free and moving well. In my office I see people with the initial injury and then depending on the degree of injury will either send them straight to physical therapy or will send after a period of rest. It takes several weeks to get the ankle back to moving normally, but most often after doing so people do very well.  

One common question I get is why the swelling lasts so long after the injury, even if they are progressing well otherwise. This is usually not cause for concern. In addition to injuring the ankle ligaments the other soft tissues around the ankle were injured.  Because of this, swelling can persist for many months even after your ankle feels better.  Another common question is why the ankle feels stiff or not quite like the other ankle.  The stiffness is from the lack of movement in the early recovery and from scar tissue that forms during healing. The great news as that the stiffness dramatically with time and work with physical therapy. 

My goal with treating an ankle sprain is to get patients safely back to all the activities they love as soon as possible.  At my initial evaluation we make a plan for what one should expect in the next few days to week and schedule a follow up to assess progress.  Having two visits helps me understand your trajectory for healing – two data points helps me see the line of how quickly you are progressing much better than single point.  Once physical therapy is started, I continue to monitor progress and help determine when one can return to sport activities. 

A final word on return to sport.  I return most people cautiously.  As I mentioned, recurrent injuries happen.  I unfortunately see patients that have long term chronic ankle pain or instability due to having multiple sprains.  This is a harder problem to fix and may even require surgery.  Getting the physical therapy right from the first injury can help prevent this problem.  For those with recurrent sprains, optimizing a physical therapy program and integrating ankle rehab into your exercise will absolutely be helpful and may also prevent the above. 

Any questions about ankle sprains? Let me know!  Share this with anyone you know that may find this useful. 

The ACL Tear.

As we approach the end of football season, there is one injury that we have heard of several times throughout the year (and past years as well). The ACL tear.  Most sports fans have seen this listed on the injury report and heard the announcers talk about concerns for this when a player goes down on the field, but what is it? Why is it a big deal, how does it happen, and what is typically done about it?  

First, knowing a little anatomy of the knee is important. The ACL – or anterior cruciate ligament – is an important structure inside your knee joint.  We have 4 ligaments in and around that area, named for where they are located. Anterior (front) and posterior (back) cruciate ligaments, and medial (inside) and lateral (outside) collateral ligaments.  Today we focus on the ACL because it is usually the most ‘tragic’ when injured in sports. By tragic, I mean the one that is the most worrisome for an athlete because of the long treatment and recovery process that often alters one’s career short and long term. 

The ACL connects the bottom bone in the knee (tibia) to the top bone of the knee (femur) from front to back.  It plays a key role in stabilizing the knee. In medicine we would say it “resists anterior translation of the tibia on the femur.”  Stick with me here… this means in regular language that it stops the bottom bone of the knee from sliding forward in relation to the top bone during normal movement, aka inside the knee joint where it bends.  This bending is what allows us normal knee motion needed for walking, running, jumping, playing.  But we need something to help keep the bones attached to one another or else the knee may feel unstable (jelly-like) when we put stress on it.  [Think of the knee as a door hinge where the ACL is the pin that connects the two pieces of the “hinge”; without this the door can swing open and closed gently, but if it’s pushed too hard the hinge may not line up properly and may become damaged].  Not an ideal situation if one is interested in getting back to doing higher impact activities like playing football. 

If the ACL is torn the knee becomes unstable because the bottom bone can shift away from the top bone.  The cool thing the human body is that there are often redundant systems.  For the most part (although not always for every person) normal walking and low-impact day-to-day life can still be achieved without the ACL because the other ligaments and muscles around the knee can pick up the slack to provide stability.  This means even without an ACL, for daily life activities, many people move about fine.  The problem is with any sudden or shifty movements, such as cutting in sports or in high-impact jobs like law-enforcement or firefighting where folks are required to do movements that aren’t straight forward or backwards. These types of movements are more complex and require more stabilization, so without an ACL the knee can feel unstable and even give out.  For football and other sport athletes, one also would not get the control or explosive power she or he needs to play.   

An ACL tear most likely occurs when the leg is forced in a way that stretches the ligament too far.  Remember, the ACL blocks forward movement of the bottom part of the knee.  Consider a  a football player whose foot is planted to the ground when his knee gets pushed backwards, pushing the top bone away from the bottom bone. Pop!  The ACL is overstretched and gives way.  This is just one example, and there are of course other ways this happens.  Sometimes it involves a collision with another player (as described above) and sometimes it involves getting the leg in an awkward position when a person is running or jumping with the knee buckling inwards/backwards due to the force of the jump or a bad landing.  In this case, it is simply the lack of control and force of the jump landing or cut that causes the tear.  We tend to think of these “non-contact” tears occurring most frequently in young female athletes (maybe a teenage basketball player) that hasn’t developed full hip/knee control. 

The tearing of an ACL is an abrupt injury and not usually subtle.  Sometimes people hear a pop (but not always), feel a pop, have sudden onset of significant pain, and usually fall to the ground.  Most of the time the injured can’t walk easily (if at all) and don’t usually keep playing the game after.  The knee swells up from the inside due to the trauma (effusion).  I usually ask patients if it swelled up like a water balloon as an analogy.  A former mentor of mine taught me when I was learning about knee injuries that a young person running or cutting during sports with a sudden burst of pain with a pop in the knee and large swelling is an ACL injury until you prove otherwise.  This still rings true for my patients today.  #mentor

To diagnose the ACL tear we first talk about what happened when the injury occurred in great detail.  Then, we do an office examination of the knee, as well as the hips and lower legs.   Looking at the other nearby joints is important! Just because it seems that it might be an ACL tear it doesn’t always mean that is our answer.  We complete a few special maneuvers that help clue us in to what possible problem could be happening inside your knee. These maneuvers are helpful to distinguish other injuries that present in the office like an ACL tear.  This exam also helps us determine what next steps to take or if there is concern for other associated injuries (ACL tears often occur with other injures such as MCL tears, meniscus problems, and bone or cartilage injuries).

So you tore your ACL, what now?  Since it is such a crucial ligament for knee stability, most highly active people or athletes should discuss surgery to repair or reconstruct the ligament in the knee.  It does not grow back. It does not scar into place or heal. That said, it is important to note that older patients or people who are less involved in side-to-side/cutting sports or activities may not need surgery.  Be sure you have a discussion with your doctor about what the benefits of surgery are for you, the associated risks of the procedure, as well as the expected long term outcomes.  We practice medicine using the guide of high quality research, and if the studies show that you may do just as well without surgery, that may be the best way to treat your specific injury. Most important is to have these discussions with an orthopedic sports trained surgeon.  They will discuss options, the optimal timing to have surgery if it is thought to be best for you, and also very importantly your rehabilitation and expectations for recovery.  

Whether one has surgery or is treated without operation, he or she will need extensive physical therapy/rehab.  It takes many months for one to get back on the field!  One has to be patient.  For professional athletes that have dedicated athletic trainers and rehab specialists, these are season ending injuries. Often with great rehab, they can return in 6 months (at the earliest) though it can take 1 or more years to reach the prior level of sport.  But these are gifted individuals with many many resources.  For the average injury, it will be at least 1 year before one may feel 100%. And keep in mind, once a person has had an injury, and then had surgery, it is quite possible the knee will never feel 100%.  [Stay tuned for my article discussing preventing injuries like ACL tears.]

Stay healthy-

Our Engagement Photos!

First all credit for this amazingness goes to Lauren Scotti (www.laurenscotti.com).  She is the genius behind both our engagement and wedding photos (I have those too and l can’t wait to share!) And to say I am obsessed is a huge understatement. One of my favorite moments has been when I am sitting at my desk and my laptop screensaver comes on flashing a mixture of both photo sets. I find myself watching the screen like a movie and loving every single one, every single time. I will cherish these forever. 

engagement photo
engagement photo
engagement photo

I want to share a few highlights and the story behind the photos, not only because they are so dang awesome but also because we almost did not take them at all. 

I mean… come on…  we almost did not take these?? 

engagement photo

We were engaged in March just before the California stay at home in order and in a time when COVID-19 was on the top of everyone’s mind.  We knew we were not going to have a long engagement and set our sites on August for our wedding.  We found an amazing wedding planner and secured my dream photographer.  By then we were approaching two months from our wedding date and the schedule was tight.  Unfortunately there were also restrictions in place in the state on outdoor activities, venues and other businesses- including photographers.  We were unsure if we were actually going to be able to move forward even if we planned a date unless these restrictions were altered.  

engagement photo
engagement photo
engagement photo

As with everything in life during this time my hopes were to proceed but knowing that it may not happen put a little damper on the excitement. In the back of my mind were thoughts like: Do we really need more photos of us? What about the added cost? Our wedding is so close… shouldn’t we just wait and call it a day?  Honestly how many photos of ourselves do we really need there are only SO MANY WALLS in our house?! Haha.  

So I naturally did what everyone would do in such circumstance.  I googled it.  “Do you really need engagement photos” “Why get engagement photos” and so on.  I read all the blogs, articles and theories I could find.  The answers were variable and solidified that my thinking was similar to many brides before me.  Next I asked my fiancé, wedding planner, friends, random strangers I passed on the street…. okay not really the strangers part but almost. 

Reflecting further got me nowhere.  Finally some business were allowed to open locally and it was during my first haircut in months I heard something that first stuck.  My hairdresser said not getting engagement photos was the one thing she regretted from that period of time before she was married. She said there was something to be said for having those photos to represent that time of your life. Boom, loud and clear.  My wedding planner also encouraged us to have more time to work with our photographer to get used to the direction in front of the camera prior to our wedding day.  She also recommended it because “Sometimes it’s nice to have nice photos where you are not wearing a wedding dress”, haha!  Seriously, as an adult other than my terrible work ID photo when do you get professional photos taken? Never. 

Once California eased restrictions we worked with our photographer to find a location, talk vibe etc.  I trusted her implicitly to guide us having seen her prior work. I sent thoughts on some casual jeans/tshirts and a little flow dress I had ordered. In the back of my mind I also had a dreamy jumpsuit ordered for our rehearsal reception from Rime Arodaky.  And when I say dreamy, I mean DREAMY!  By now we had realized that the dream wedding was postponed until 2021 and I decided this jumpsuit deserved to not be in my closet for a whole year waiting to be worn…  I sent pictures of all options to our photographer.  She suggested all 3 and had a space in mind in downtown LA.  Done deal.

engagement photo

If you have never been to the fashion district in DTLA it is similar to that area in New York or think crazy street vendors, lots of traffic on small streets, people walking everywhere and overall a very high energy urban environment.  We arrived with our luggage in hand and masks on.  Yes, luggage.  Unfortunately I am very good at dressing myself but dressing a man for a photo shoot was another story.  The one thing I figured out was for my dreamy jumpsuit (our most formal) I wanted him in a dark suit.  Which is actually another funny story.  A few nights before I had him pull out his current suits to try on for the shoot… And we realized immediately that he looked like he was trying on his father’s clothes as a kid.  They were HUGE! Haha. Have mercy.  We rushed down to Suit Supply (who had made his wedding suit… more on that in another post) and ordered him one as quickly as possible.  Looking at the photo above I think they pulled it off.

engagement photo
engagement photo
engagement photo

So there we are in downtown LA and head inside the studio.   Another photo shoot was finishing up. “How insane is it we get to do this” kept running through my mind.  The space was open and white, grand and urban, and very, very cool.  The light coming in was amazing.  I will never forget what an amazing experience it was to be able to use a professional studio in downtown Los Angeles, dress up and work with such an amazing photographer. We had a blast. Here we are behind the scenes before images and our reward after…

I received the photo set 11 days before the wedding. I am so happy we took the time, money and effort and made it work. I say this not only because of the photos but the memories we created taking them.  These photos represent a snapshot of our lives (literally and figuratively) in a time when we were working through a really crazy world together as a team.  They illustrate learning how to love each other during a quarantine.  They represent the excitement of planning a beautiful wedding that we will one day get to share with our family and friends (see you in 2021).  They show our laughter, our playfulness and our inability to make normal faces in front of the camera 99% of the time and they document fully just how in love we are in that moment. A moment we will never see again.  I am so grateful it is documented in such a beautiful way.

engagement photo

The ICU is not what you see on TV.

Sunrise over our local hospital.

But you don’t want to find this out first hand.

I saw a picture of a group of physicians and nurses in the “COVID ICU” on social media today. It was the same intensive care unit I worked in for years as a medical trainee. I recognized it right away with its beige tiled floor, clear glass rooms, and that awful yellowish paneled wood work area. Suddenly a flood of emotions passed over me. Memories unrolling one after another. And I realized something…

After all these years I still feel deeply the pang of the long hours in that ICU spending hour after hour with the sickest of the sick. I still hear the alarm beeps. I smell the cleaner in the air and feel the cold as the temperature drops in the wee hours of the morning only rectified by the overly starched heated hospital blankets. And I still remember the patients.

I can see the cancer patient getting treatment with medications making them so sick they could no longer breath on their own. In the corner I see the young cystic fibrosis patient praying for a miracle transplant. I remember standing in a pool of blood putting giant tubes down throats for patients with massive stomach bleeds on the brink of death. And I will never forget the numerous patients so sick with infections in their blood all their organs were failing them, one after another. I hear the ‘code blue’ alarm ringing and nurses yelling for help. I can feel my stomach drop and my heart race a bit as I run towards the room for CPR. 

Sometimes I was there with you alone at 3am, doing everything possible to save you. And other times your family was at your bedside when the ultimate tragedy struck. Tears could not be stopped on either side of our exchange as they said goodbye.

Seeing that picture I remembered everything so vividly my heart felt heavy in my chest. I realized suddenly very few people know this experience. Very few ever have the emotional experiences attached to seeing that ICU. Most Americans (luckily) have never personally witnessed the wrath an ICU on the delicate human body. Most have not had a loved one suffer through countless procedures or treatments, with lines and tubes sticking in and out of every body part possible. They haven’t seen their beloved spend day after day hooked up to breathing machines and machines mimicking kidneys when their bodies basic systems start to fail. They haven’t seen the trees of pumps with IV medications surging into large veins in the neck and groin, while their loved ones lay paralyzed and asleep in a bed growing more and more swollen from the fluids trying to sustain life. This isn’t the television version of the ICU you have been shown before. It isn’t glamorous. At all. People don’t always survive and there is nothing TV viewable about the actual ICU experience.

I know one thing for certain. Be happy you haven’t been there and don’t know that experience. But more importantly just because you haven’t seen it doesn’t mean it isn’t real. It is real. It is the most tragic existence you’ll never be able to imagine.

Wear a mask. Stay home. Stay distanced when you must go out. Please avoid groups. And keep yourself safe. You don’t want to learn what the ICU is really like, trust me.

Don’t delay routine medical care, even during a pandemic!

Given the ongoing COVID-19 pandemic it is easy not to feel safe leaving our own homes, especially if our destination is a place we feel at higher risk.

One of the settings where you may feel more at risk is your doctors office. The reassuring news is since the pandemics onset hospitals and medical offices have instituted many protocols and policies which make it safer to visit. Protocals that you may notice include temperature checks upon arrival, questionnaires about possible COVID-19 symptoms and exposure, limited capacity waiting rooms, visitor regulations and mask requirements (I reviewed those in this post). These changes make coming to your appointment safer, but it is clear that patients are still avoiding the doctor. From the CDC, as of June it was estimated that 32% of Americans had delayed routine care due to COVID-19. (1)

Continuing to seek out routine medical care, preventative health screenings and other medical care is vital even during an event such as a global pandemic to prevent long term increases in morbidity and mortality for all medical conditions.  

The reason why we have routine medical screenings and preventive health appointments is exactly what it sounds like- these visits prevent future problems.  Unfortunately delaying these visits can delay diagnosis and treatment of conditions not only now, but also in your future. Delays in diagnosis means the disease can make you more sick, or worse, cause earlier death.

For the average adult there are a few routine maintenance visits to consider.  First, a visit with your primary care physician can get you on the right track.  These visits are a great way to evaluate any health changes you may have had in the last year, as well as check for early signs of issues to come. Getting your blood pressure checked and discussing what you may need for your age/lifestyle/risk factors may seem simple, but it is these parameters that give your doctor insight into your current and future health needs.  Some of these needs may include lab tests to evaluate your cholesterol levels, blood sugar, or referrals to other specialists for more specific care.  These routine visits, although seemingly simple for most people are very important.  

Another screening needed if you are female may be seeing your OB/GYN for a women’s health exam.  Depending on your age, marital status and sexual history this may include a pap smear and pelvic exam, lab screening and again further referrals if needed.  Both males and females need to consider seeing a dermatologist to evaluate for any skin concerns, and let’s not forget about routine visits with the eye doctor and dentist. 

Another area to consider in addition to these routine visits are those that are dedicated to prevention.  The main appointments focus on preventive health for age-related screenings for malignancies (cancer).  Your primary care doctor is a great start to determine if you need one of these type of visits based on your age, risks factors and family history.  For women, mammograms are an extremely important and we know that early detection of breast cancer is vital to survival. For men, you may consider an evaluation of your prostate health and have any appropriate screenings required. For both males and females of appropriate age, you need a colonoscopy.  There is great evidence that routine colonoscopy screening is vital to early detection and treatment.  Unfortunately if these screenings are missed or delayed due to the pandemic the delay could precipitate short and long term consequences.

The final area to focus on for routine medical care is vaccinations. Vaccines are becoming more of a hot topic with the push for pandemic mitigation and recent data release for the COVID-19 vaccinations awaiting emergent FDA approval for use. However, there are other vaccines that both children and adults need regularly. When you go for a visit, ask if there are any additional vaccinations that you need. This year more than ever the influenza vaccine is at the top of the list. (And I’ve had mine!) The concern here is this year’s flu season could be even more challenging given the current pandemic.  The fear of doubling the sick population (with flu patients on top of our already stretched hospital system trying to provide care for covid patients) could be insurmountable.

And since I try my best to practice what I preach in all areas of medicine and health… if you follow me on Instagram (@sportsdrmorgan) today you will see my experience at my doctor visit!

  1. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250–1257. DOI: http://dx.doi.org/10.15585/mmwr.mm6936a4 

What is a stress fracture? And when should I worry?

Given the state of the world, people are increasingly turning to outdoor recreation and exercise. More people than ever are out running! This is awesome. However, with this, comes the possibility of new injuries. Runners are some my favorite patients because as a runner myself, I see the motivation and time commitment as well as the joy that being a runner can provide. Unfortunately, when I am seeing patients in the office, usually, they are having pain or have had an injury. An injury that has presented more often recently due to people turning to the streets for exercise is something called a stress fracture.

A stress fracture is essentially breakdown of the bone that occurs from repeated small forces. When we run or do other high-impact activities (jumping, plyometrics, or other exercises when both feet are off the ground at once) our bones break down and then heal when we rest. This is a normal process that happens on the microscopic level and is the way the bone stays strong by regularly “remodeling” itself. When the balance between breakdown and healing becomes unequal, we can develop a stress fracture. This stress fracture is a weakness in a small area of the bone that does not have a chance to heal before the next round of impacts, an overuse injury.  

Other factors sometimes contribute to the development of the fracture.  Remember I said that they start by a disruption in the balance of breakdown and healing of the bone. For a person training for their first marathon it seems that an increase in the breakdown forces would be the cause.  Well, what about the other side?  What if the breakdown hasn’t changed, but the healing side can’t keep up?  This can also be a reason why stress fractures occur.  Why does this happen?  The reason we have slower healing can often be attributed to nutritional factors, hormonal factors, weakened bones from medications, or simply aging.

The main symptom of a stress fracture is pain usually described as an achy sensation deep in the area of the body that is affected.  What can be tricky is most people can continue to run but then experience this achy pain after the run or even at night. The lower extremities are where stress fractures usually develop.  This makes sense as are often due to the impact of running.  Common places are in the lower leg bone (the tibia) and the foot bones (metatarsals).  Occasionally, one can also develop stress fractures in the small bone on the side of the leg (fibula), in the upper large leg bone (femur), or in the hip socket or pelvis. How serious the stress fracture is depends on a few factors, and one of the most important is where it is located – that is, some locations are more high risk than others for bad problems!

When I see someone in my clinic that has a stress fracture, the story they tell usually goes a little something like this… they have increased their mileage, or they changed their running routine in some other way.  They may have started to train for a marathon having never done one before, or maybe they are just training harder to get to a faster race time. Maybe they are new to running… 

They usually report pain in a small area in one of the body parts we mentioned before.  

After we talk, I do a physical examination.  We get an x-ray that gives me a basic overview of the bone shapes, structures and the space between them. 

Sometimes we can see the stress fracture on the x-ray. If we do see it, we see a slight change in the contour of the edge of the bone that I like to refer as a “scaffold” (think scaffold on the side of a new building being built). This is what your body does in response to a stress fracture developing. It works overtime to build this scaffold to try to patch (heal) and protect the bone. If that scaffold continues to get abused by your activities (i.e. you kept running despite the pain), the body can’t keep up and the scaffold breaks down as well.  This shows up on the x-ray as a dark black line through your bone and is a more serious problem, the so-called “dreaded black line.”  This means that the stress fracture has progressed, is no longer microscopic and is a more serious problem.  In this instance, x-rays are great tools.  But keep in mind not seeing a stress fracture on an x-ray does not necessarily mean you do not have a stress fracture.  If only things were easy right!  So, what do we do if we highly suspect you have one and don’t see anything on the x-ray? Sometimes we need more information, and in this instance, we may do an MRI to evaluate the bone structures further. The MRI gives us more information because it not only shows us the bone but also can show swelling in the bone, the bone matrix in more detail, and any “black line” cracks are very apparent. Both imaging modalities can be helpful, and you don’t always need one or the other.  (We try to be thoughtful about ordering tests in medicine, so if things will not change the treatment, we just use the history and physical examination!)

To heal a stress fracture, we must first rest from the insult that was causing the problem.  Second, we must address what if anything in your body that caused a deficiency that the bones couldn’t keep up with. That is very important. If we just allow you to rest from running, and then you start back doing the exact same thing at the exact same speed and pace that you were before without addressing all the other factors, it is extremely likely that the stress fracture will recur. 

We also investigate why the stress fracture developed. This may mean you need an evaluation of your running gait and the strength and control of your lower extremity muscles. Sometimes all we need to do is discuss your specific training program and see how their progression and amount of running, volume of training, volume of cross-training, and rest all may have contributed to the injury (as a sports medicine physician my favorite part is to help you get back to running and sport ASAP!)  We also discuss nutrition, and whether finding a way to optimize this or other associated factors (think hormones, vitamins, blood tests, etc…) are needed as well. More on these topics another day.

If you have, questions about stress fractures let me know!

Life changes.

If you have made it over to my website today, you are probably wondering what the heck is going on in my life and why I left Los Angeles.  Or maybe you are just wondering why I have been completely off the grid for the four weeks.  Haha, I get it! But it happened. And in times of change we sometimes need to take a step back and allow ourselves time to process. So I did exactly that. Now I am ready to share.  

What you are about to read in the next few life update posts I am planning will give you insight.  Although it may seem crazy, it is the right choice for me and I know that.  The hardest part of all of this has been allowing my emotional self to catch up with my cognitive self.  What I mean by that is that even though I know it is the right choice, I needed time to emotionally catch up to what I was choosing. Hence me being off the grid.  I have learned that I can reason my way through most any problem, but being the emotional person I am my heart takes a little longer to adjust.

First, I would be remiss to not start by saying how grateful I am for the time spent in Los Angeles, the opportunities that were given and the people who made it such a special adventure.  It was quite literally the best time of my life.  After spending years in Cleveland learning medicine and also exploring who I was LA was my chance to grow fully into everything I truly am.  It was nothing short of magical.  I experienced more during my short time in LA than in the many years prior by simply feeling like ‘saying yes’ to anything and everything. Yes was always the right answer in LA. The city is such a special place and it will always have an exceptional place in my heart. I will be visiting often.  Who knows where the future will take us right? Better I stay in touch with the magic. 

Loving life this summer in LA.

The reason for leaving is complex. But drilled down when I weighed what I was doing against who I wanted to be something was maligned.  I have always believed you must follow your gut in these moments. You must lean towards who you want to be in this world and fight to go there ferociously.  That gut feeling is a guiding light.  Our instinct.  When who I know I am was clearly at odds with the nuts/bolts aspects of my day to day existence it was time to consider change.  

Lucky for me, my husband and I had started this conversation a while ago and when it came time to pull the plug per-say, we had a plan in motion.  It was a gut wrenching decision (to say the least) and the execution of what happened next moved faster than I could have imagined.  After all was said and done and I was driving away from our little beach home with the last of my belongings in the car (and Francis riding shotgun of course) I felt calm, but also still a little blown away by the fact that I was actually leaving.  


This rushed goodbye was complicated more by COVID-19 (as is everything in life right now).  The usual way I say goodbye would be having having dinners with friends, giving hugs and going to one last hoorah at all my favorite spots in town.  Because of the restrictions and pandemic closures, as well as the safety concern surrounding spread of this miserable virus, I didn’t get to do any of that.  I had to sneak away without a proper goodbye.  And it sucks.  

Last family photo before we drove away

So here we are on the other side of transition. Not much worse for wear- other than poor Francis who despite being a trooper through yet another move/roadtrip/hotel/home experience developed a corneal ulcer and had eye surgery.  We are going on 5 weeks in the dreaded cone, eye drops and medications four times per day.  We are holding it together helped immensely by the fact that I have been able to be home with him during this time.  Let me also say four times a day medications is terrible and I will never prescribe them in the future if other options are available. It’s a full time job to wrangle this wiggly bowling ball of a pup once let alone four times everyday!

Sunbathing in the cone vs new satellite dish?

I am sure the question in your mind is so “what are you doing now?”  Currently, (besides wrangling this pup) I am rebooting.  I am working from home on projects that I need to catch up on.  I am reflecting greater on where I came from and who I want to be.  And I am focusing hard on my future and creating the sort of medical experience I know I want for patients.  I am becoming more me everyday and can’t wait for you all to see it! 

With love and hope,