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Host: And welcome once again to our continuing series of interviews with doctors from Summa Health. Today, we're talking to Dr. Mark Cipriani. He's a Primary Care Sports Medicine doctor. He is fellowship-trained and board-certified in Primary Care Sports Medicine. He keeps people of all ages and fitness levels active through his patient-centered, team-based care. Dr. Cipriani completed his Family Medicine training at the Mayo Clinic in Rochester, Minnesota. He served as chief resident there. He also completed an additional year of training at the Primary Care Sports Medicine Fellowship at the Cleveland Clinic prior to joining the Orthopedic team at Summa. He is currently also a team physician for Barberton High School and the Akron RubberDucks. Hey, Dr. Cipriani. Go, Ducks!

Dr. Mark Cipriani: Go, Ducks! Thanks for having me this afternoon.

Host: Thanks for being on. That's got to be a kick to be a team doctor for a baseball team. Is that a lot of fun?

Dr. Mark Cipriani: It's a great time. It's fun to see those young guys out there, performing at a high level and continue to see them succeed with their guardians here this year who are having a heck of a

season.

Host: Yeah. Again, that's a great thing, great team to watch, great to go out there and see them hustle like that. So, that's got to be fun. But primarily, though, we're talking about your entire career in Sports Medicine. So, Dr. Cipriani, can you give us an overview of what Sports Medicine is?

Dr. Mark Cipriani: Yeah. So, again, I want to thank you for having me on here. Talking a little bit today about Sports Medicine, it's an interesting thing and something that I think we, as sports medicine physicians, have sometimes even struggled to define ourselves where this began out of a process of, A, how do we take care of people who want to be active, and sort of this bore out sports medicine. But in terms of like Primary Care Sports Medicine or non-operative Orthopedic Musculoskeletal Medicine, all of these terms kind of define a little bit of the pieces and parts that we participate in because you don't have to be an athlete. You don't have to be playing a sport to be someone who could benefit from the skills and training of a sports medicine physician.

So, the way I look at it is really we're treating the musculoskeletal system, so that's going to include things like our muscle groups, our bones, joints, ligaments, and tendons. And for some youth athletes, that includes the brain, right? We do treat things like concussion as well. So, I'm looking at, again, the sort of whole of the musculoskeletal system without a surgical intervention unless needed.

Host: So, doctor, what initially drew you to the field of Sports Medicine?

Dr. Mark Cipriani: And so, for me personally, I kind of found the field as a medical student, and what was most appealing to me was the ability to work with people who want to remain active. That's one of my lifelong goals. I really enjoy, you know, being outdoors, hiking, camping, kayaking, those kinds of things. I'm not spending too much time on a field unless I've got a polo and a badge on now. But staying active, wanting to continue to allow people to really function with what they want to do. And again, that might be, you know, "I'm out on the pickleball court," or "I'm playing basketball," "I'm one of the RubberDucks athletes performing at an extremely high level." So, trying to keep people active, but also allowing them to do things that they want. It might be something as simple as, "Hey, you know, I just want to be able to bend down to play with my grandkids. I want to be able to turn my leg enough to get my own shoes on." So, trying to work through things, where I simplify this into both pain and function, trying to move that forward, helping people meet their goals for activity, wherever that may lie.

Host: Now, how is Sports Medicine different from Orthopedics?

Dr. Mark Cipriani: Fair question. There is actually a lot of overlap between what myself as a Primary Care Sports Medicine physician, and my orthopedic surgery colleagues do. And we share a lot of patients. The biggest difference here is going to be that I'm not going to the operating room, where the surgeons are. But as far as our diagnostic workups, and often made together, we are using similar exams, imaging studies, and sometimes similar procedures leading up to a potential surgery. And that's where I think the biggest difference lies, is that my surgical partners, they go to the operating room with scalpels and sutures and joint replacement parts, lots of other pieces to try and sometimes get to, "Hey, we have exhausted everything," or "We really have to put this back together. We've got something that's living in a different ZIP code from another, and we need to bring them back together." "Hey, we got to suture that together or we've got to screw that back together," so to speak. So, a lot of overlap, a lot of collaboration. Sometimes, we really need that surgical intervention and we're so glad that they have the training they do to be able to accomplish those end results. But, from my standpoint here, again, I think the biggest difference is we're all working on the same pieces and parts, just we're not going to the operating room.

Host: Now, when should a patient see a Sports Medicine doctor instead of an Orthopedic doctor?

Dr. Mark Cipriani: Yeah. So, in a lot of cases, it's very reasonable to begin with a Sports Medicine doctor. And in many cases, that is how this is practiced around the country. It's not to say that we're the gatekeepers for Orthopedic Surgery or that you always have to see a Sports Medicine physician prior to a surgeon. But in some cases, it's about trying to figure out and identify the pathology or the problem that's going on first to best determine what needs to be done.

And in some cases, you know, as the field of Medicine has grown, as our understanding, our procedures have become more not only complex, but more efficient at treating a problem or our understanding of what is the right procedure for the right pathology. A lot of times, in figuring out again, who's the right person for us to see. And as a Sports Medicine physician, we kind of really do go head to toe. So, that doesn't mean we specialize just in knee and hip replacement. We're not just shoulder specialists. We're not just dealing with the spine. So, we have background and the ability to diagnose and treat kind of all of those areas. And if a surgery is necessary, either urgently because of the pathology at hand or because we aren't able to work through the conservative measures to get that better, we're going to get you to the right orthopedic surgeon, if that's needed.

Host: So, what are some of the most common sports injuries that you see in your practice?

Dr. Mark Cipriani: I think on the Sports Medicine side and the sports injury side, we think about some of our big joints. And that's going to be shoulders, especially for our throwing sports and throwing athletes, and knees as well, for really any sport primarily. But, as we're thinking about summertime here and fall sports are knocking on the door, we've got football and soccer coming up. We definitely see a lot of knee and shoulder injuries. But again, like I said, we really do go head to toe. So, that might be youth athlete concussions, necks, backs, hands, elbows, wrists, all the way down to the toes, you name it, we'll be seeing it. And like I said, again, trying to work through what's going on here and how best can we approach and treat this?

Host: So, doctor, take us through your process for diagnosing a particular sports injury.

Dr. Mark Cipriani: Yeah. So, I think the most important part, and this would stand for a lot of things within medicine, but really is the story, the history about what's been going on for how long, was there an injury that prompted these symptoms, whether it be pain or instability, swelling within a joint, just trying to understand the background for each individual patient. Because while there are definitely patterns within medicine, that's not to say that everything follows the exact same way it should or, "Hey, this is how I read about it in school and this is how it's always going to show up, because there's always exceptions to those rules."

So, the history from the patient does really become an important part of this to try and identify where do we think we should begin. And then, I think beyond that is a really thorough examination from a physical standpoint. We like to go through and look at, you know, special testing with the joint in question or the muscles in question, trying to, again, just isolate and localize, best understand what do we think might be driving this problem? Is this a soft tissue injury to a stabilizing ligament? Is this a tendon that's been injured or torn? And if so, to what extent? Are we worried about the structures inside of a joint or the bones themselves? Is there a break or fracture? And trying to go through and, again, identify where are these symptoms coming from.

Sometimes our nerves, which course throughout our body give us pain and sensory feedback, but also allow us to move our muscles. Sometimes, they can cause referred pain. So, again, trying to get to the root source of this, identifying where are these symptoms coming from, so that if we decide to do other diagnostic workup, which we often do, we're choosing the right studies. So, that's an important part of the process for the sports and orthopedic side is imaging, seeing things that we can't with our eyes or can't feel necessarily with our hands always. So, we'll often begin with x-rays of the joint or body area that we're suspicious is driving the symptoms or, say, someone comes in with knee pain, yeah, it's going to be very likely that we might get some knee x-rays. And then, in that workup or evaluation, choosing very specifically, very carefully, which views of those joints that we want so that we can get the best picture, because just one snapshot in time and one alignment may not be enough information. We may not see that really subtle fracture, or we may not see the that there's narrowing of that space until we move the joint in a different alignment and then take a picture in that way. So, imaging does become a very important part of the diagnostic process. And typically, that's going to begin with x-rays.

Sometimes, we'll escalate to other types of imaging modalities, things like ultrasound, which many of my partners and I trained specifically to do musculoskeletal ultrasound as part of our toolkit here for diagnostics and some treatments that we'll talk about here as well. Things like CT scans enable us to look very well at bones, and very quickly, look at a lot of bony anatomy there. MRI is probably the most commonly known and talked about now from a standpoint of being able to look at some of the soft tissue structures, again, within the joints or of the muscles, tendons, those types of things if there's high suspicion for tear or symptoms that fit with something that might be soft tissue, we're not able to see on the x-ray that we're concerned is injured, we might pursue something like an MRI. And again, choosing the right type and specifications for those studies becomes an important part of our evaluation if necessary.

Host: What part of our bodies tends to be the most injured in typical athletic endeavors?

Dr. Mark Cipriani: So, I think it depends a little bit on our age, to be honest, and what our activity is. So, you know, in thinking about, for example, our RubberDucks players, you know, we're definitely going to be thinking a lot more about upper extremity injuries from a shoulder and elbow standpoint; where with our football athletes, we're going to be thinking more about the lower body with tackles and cuts on the field, those kinds of things. We'll be thinking a lot about knees and ankles. As we age, and maybe we aren't playing contact sports as frequently or as readily, we're going to be thinking about, you know, what type of activities, again, keep us active or what do we do for a living, right? Somebody who is walking a lot, you know, we may be seeing symptoms related to their feet or ankles. We do think about those weight-bearing joints as we age, as far as the potential to develop arthritis. It's not to say it's always a guarantee that we develop arthritis as we age, but it is a very common thing that many, many, many people experience. And I'm sure we all know someone who has dealt with, either personally or professionally that we know has some arthritic kind of aches and pains that come up.

So, that is something that, you know, we treat throughout the body in looking at some of that, what we refer to as osteoarthritis or wear and tear is sort of the common vernacular for that type of arthritis, although we do think that that is probably a multifactorial thing, not just the age of each person, but things like prior injuries or our biologic sex. Our genetics we think play some role as well. We don't fully understand that yet. But there are different types of arthritis, which could be a whole lecture series of its own, but things like autoimmune conditions, rheumatoid arthritis, or things like axial spondyloarthropathy, these kind of more rare things that do happen. And that's part of again, that diagnostic process that we were just talking about. Sometimes, we will evaluate with some lab work if someone has a picture here that fits with a more systemic problem. And then, while we may be trying to help manage some of those symptoms, we might be recruiting other specialties like Rheumatology, who might help us with some of those underlying inflammatory disorders at times.

Host: We're talking with Dr. Mark Cipriani, who's a Primary Care Sports Medicine physician at Summa Health here in Akron. How do you handle situations where an athlete, especially a young athlete or a professional athlete, is eager to return to play before they're fully healed?

Dr. Mark Cipriani: Yeah. So, I think, you know, as athletes and really just every day, every day people in general, we're always looking to get better, get back to doing what we want to as fast as possible. And so, it's trying to find the right balance. And I use the analogy of our cars pretty regularly here. You know, when's the right time to hit the gas? When's the right time to hit the brake as far as, you know, trying to get our athletes back out in the field? In the same way, when somebody is admitted to the hospital, the first thing that we're trying to do besides figure out what's going on is get them out of the hospital.

So, I would look at that from the Sports Medicine side. When an athlete is injured, well, yes, we want to identify what is the problem here. We want to try and figure out how do we get them back to doing what they want to do and competing against others or themselves as quickly as possible, but as safely as possible. So, it depends on the context of the injury in a lot of scenarios. If this happens, you know, on the sideline and on Friday nights, most falls, you'll find me on the Barberton football sideline. We're trying to look in very short order at what just happened, what can the athlete tell us, what did we see with our eyes, and go through a brief sideline exam. Is this something that we are worried that there's something really wrong here that says, "Hey, no, you can't go back in, you can't give this a go here," or you can prove to us that, yeah, this might hurt a little bit, but everything's stable in here, the bones seem like they're intact, everything's in the right place and prove to us on the sidelines that, hey, you can do, let's say in this example, football moves, and you can go out and perform at your position all the things that you need to do, and we might let them play through a little bit of pain. So, it depends a lot on the injury. And then, it comes down to, again, all right, hey, if there's something that's going to say, "Hey, you really can't go with this. How do we start to work through that?" We want to try and maintain as much of their fitness level as we can.

And there's a big emphasis on at this time too, and it's interesting, you know, in hearing some of the Olympic athletes here as we're ramping up for the summer games here in Paris this summer, talking about mental reps. And so, even if you can't be out on the field going through physically every route you're going to run or every drill with the ball that that you might be dribbling through as an attacker on the soccer field, we go through these mental reps of what is expected of an athlete on the field, on the pitch, on the course. And that becomes an important part of the rehab process so that they maintain engagement, not only with their team, but with their sport, everything that they're supposed to be doing.

And then, we're oftentimes working with athletic trainers and physical therapists on targeted rehab approaches what can we do to keep them in shape, what can we do to improve the function of the affected area after an injury? And then, getting them back just absolutely as soon as possible. Again, kind of that proof that, hey, while there may be some discomfort here, and we're not in any danger with the injury itself and able to go out and perform at the level the athlete expects of themselves and to help in a team sports scenario, make sure that their teammates are supported in the best way possible as well.

Host: Now, how vital is it for the someone to go through a proper rehab process and see it to the end?

Dr. Mark Cipriani: I think that is very important, as far as we look at this not just from a standpoint of, okay, we're going to rehab this injury, that very much is a big part of some of the things that we do, especially in an acute, meaning just now, this just has happened. We want to be able to work through this and try and get this injury better. But we also look to rehab in a way that we take a little bit more of a systemic approach and look at, "Hey. Is there a reason that this injury may have occurred? Are there deficiencies in certain small muscle groups?" Or "Hey, one side is really a lot stronger than the other." And this is predisposing you to an injury where things like stress injury, stress fractures might come up or overuse of certain tendons and muscles might derive injuries or pain symptoms that could limit someone again, whether it be on the field or hobbies, work, just daily living. So, it is really an important part of that process that, again, we get to the root cause as best we're able to and target those maybe small things, these biomechanical factors that are going to, in the long run, help to hopefully prevent injuries in the future, but also to keep us as strong as possible and as active as possible, even for things like arthritis, where we can't necessarily change the bony anatomy with a medicine, with physical therapy, with an injection. Well, we can't change the anatomy, we can change how that joint is stressed. We can change its environment in many ways to try and, again, improve those pain symptoms and optimize things functionally without changing the anatomy unless absolutely necessary.

Host: Well, you mentioned that you don't only treat athletes and one does not need to be an athlete to see a Sports Medicine physician. So, tell us more about your practice and the treatment of non-athletes.

Dr. Mark Cipriani: Yeah, absolutely. I would say the grand majority of my patients that I see at Summa Health, and this has largely been my experience through my training as well, is through non athletics. And that means, you know, people of all ages. I want to say one of the oldest patients I've seen was about 105, and the youngest we see at Summa Health is down to about the age of eight, so really spanning a broad spectrum of life here. But when we think about people outside of idea typical athletic age in youth sports, especially the highest volume of athletes, when we get into adulthood, we start thinking about, again, some of these processes where we have a little bit of mileage on these joints now, and it doesn't always mean, hey, there's a big injury that prompts this. This may be something that comes up over time. And it starts to become increasingly painful or increasingly limiting. And things like arthritis or changes inside the joint of the cartilage that cause pain and inflammation, that is absolutely in our wheelhouse. Tendon problems, what we sometimes refer to as an umbrella term of tendinopathy. And tendinitis might be the most commonly used term for that, but it's not always an inflammatory problem with our tendons. And that's something that we've been learning more and more about here in medicine over the last 10 to 15 years. And again, finding what is the driving factor underneath here? And is this something that we can address with medicines, with therapies? Do we need other types of interventions, whether that be injections or special procedures, surgeries, et cetera, to try and address? So, absolutely, we see people of all ages. And like I say, most of my practice, I would say 90% or more are patients who are not involved in competitive athletics or organized sports in any sense. We are treating musculoskeletal problems.

Host: Now, Dr. Cipriani, can you tell us about, say, a time you collaborated with other members of the Orthopedic team, such as physical therapists, trainers, surgeons, to put together a successful treatment plan and explain how that works?

Dr. Mark Cipriani: And so, I would say that that is just a part of every day for me. There's not a day that goes by that I don't send someone to see most likely the physical therapy team as far as working on things. If I'm seeing a high school athlete, I'm working with their athletic trainer and my surgical partners. Like I said, when this is appropriate, I am not here to play keep away from the surgeon. I'm here to get you to the right one. The person who's going to be best suited to take care of the problem at hand.

I think maybe a common scenario here where we'll work together as a group outside of athletics is, let's go back to an example here, a patient, let's say, is in their 60s and they have some hip osteoarthritis or some they're starting to experience some groin pain, some difficulty getting in and out of their car, maybe putting shoes and socks on. And we see them. We get some x-rays. We know, "Hey, there may be some mild arthritis in here. Let's try and work on some things to correct the mechanics around this joint. Let's strengthen everything up as much as we can to avoid stress on that joint." That's going to be done with a physical therapist. We might prescribe a medicine to try and take as needed to help with pain symptoms. If those symptoms are progressing, let's say, a year or so goes by and, hey, we're still having some more pain here, things got better for a little while, but this is just getting to be a little bit more difficult. We might think about things like targeted injections, image-guided injections into the joint to try and help decrease that inflammatory response. And we might do those with some regularity as long as we're seeing some improvement with that.

There's no magic time frame that says, "Hey, this is exactly how often we have to do this or need to do this." And we may get to a point where, "Hey, you know, this has been working pretty well, but this is just getting even tougher for me. That motion is getting even worse. I'm still having some pain symptoms." And, hey, wouldn't you know it, when we look at those x-rays again a few years down the line, we're seeing advanced arthritis, and now we're going to talk to the joint replacement surgeons about a hip replacement that might be able to correct that underlying problem now that we've sort of exhausted some of those base cares, where it's not appropriate with mild arthritis to say, "Hey, we just got to replace this straight away here." So, it's a collaborative approach throughout sort of the life cycle there of the joint. And again, this can vary wildly, depending on the person, their pathology, severity, et cetera. But absolutely, the musculoskeletal system is a team sport on and off the field.

Host: We have about a minute left, doctor. What are some of the latest advancements in Sports Medicine that you're using now at Summa Health?

Dr. Mark Cipriani: Yeah. So, I think a couple I'd like to just highlight real briefly, some image-guided injections. So using ultrasound in the same way that we would to look at a heart or the baby in the uterus, we use ultrasound to visualize specific joint structures, muscles, tendons, and nerves to do targeted injections, various different types of injections that we'll do. But using that imaging guidance allows us to be as accurate and safe with our procedures as possible.

A couple of things that are sort of on the newer side here with Sports Medicine, we're doing procedures that we call percutaneous tendon and fascial debridement. So, just a small incision in the skin, we go in with a tool to help kind of suck out scar tissue within those soft tissues, much less downtime than a traditional open surgery. So in the right patient, that might be something that could be a great option that a sports medicine or primary care sports physician might be able to perform.

The final thing I'd highlight is something that one of my partners and I are doing as a procedure called Iovera. And we're basically freezing small sensory nerves, typically around the knee joint to try and decrease pain. And someone who is anticipating they may need a knee replacement or may not be healthy enough to have a knee replacement, another alternative for us to try and help address those pain and function symptoms.

Host: Once again, Dr. Mark Cipriani is a Primary Care Sports Medicine Physician at Summa Health. Dr. Cipriani, how can somebody get an appointment in the Sports Medicine Department at Summa Health?

Dr. Mark Cipriani: Yeah. So, for Sports Medicine, we actually don't have to have a referral. We do get a lot of referrals from our Primary Care and Emergency Department partners, which we're, of course, very grateful for. But you don't have to have a referral to see us on the primary Care Sports side. You can give our office a call. It's going to b 330-835-5533, and myself or my partners would be happy to see you.

Host: Excellent. Dr. Mark Cipriani, Primary Care Sports Medicine physician at Summa Health and a team physician for the Akron RubberDucks. Keep those RubberDucks going, man. I'd like to see those guys playing well. And we'll talk to you hopefully sometime in the future. So again, Dr. Mark Cipriani, thank you so much for being with us here on WNIR Kent, Akron. And we wish you a lot of luck in your career and, again, a lot of luck with working with those high school and professional teams.

Dr. Mark Cipriani: Thank you very much. I appreciate the time.