Cristina Cusin, MD: Finding Solutions for Severe Depression
Episode #26 of the Charged podcast
May | 29 | 2019
Kelly McInnis, DO, is a lifelong sports lover. After completing her residency in physical medicine and rehabilitation, the former Division 1 soccer player initiated a new sports medicine training pathway that allowed her to spend time with both orthopedic surgeons and non-operative sports specialists. She has a special interest in working with female athletes and understanding the unique challenges they face. Since joining Massachusetts General Hospital’s Sports Medicine Center, she has demonstrated how her background in non-surgical care can complement the work of orthopedic surgeons. She discusses her passion for helping athletes of all levels recover and return to doing what they love.
Kelly McInnis, DO, a sports medicine physiatrist and program director of the Harvard-Spaulding PM&R Sports Medicine Fellowship program, works to develop non-operative strategies for injury management, performance and prevention for endurance athletes with a special focus on female athletes.
After completing a residency in physical medicine and rehabilitation (PM&R), Dr. McInnis developed a new fellowship program so that she could learn from both orthopedic surgeons and non-operative sports specialists in order to explore how the disciplines complement one another. She was the first woman and physiatrist to join the Sports Medicine Center at Mass General, where she works with athletes of all levels, from leisure to professional.
Dr. McInnis is board-certified in PM&R and sports medicine. She serves as a team physician for the Boston Red Sox and New England Patriots as well as a consultant for the Boston Ballet. She is the head team physician for Curry College and Suffolk University.
Dr. McInnis earned her BA at Boston College, where she played defense for the women’s soccer team, and her DO at the Philadelphia College of Osteopathic Medicine.
Dr. Kelly McInnis is a lifelong sports enthusiast and she's built a career that is 100% sports-oriented. After residency, the former Division 1 soccer player wanted more specialized training in sports medicine. Because no such training existed in the rehabilitation field at the time, Kelly proposed a new training pathway which allowed her to work in collaboration with the orthopedic surgeons to hone her skills. She was the first physiatrist and the first woman to join the Sports Medicine Center at Mass General and quickly proved to her new orthopedic colleagues how her non-surgical care could complement what they were doing in the OR.
Years later, Kelly has built a successful training program for aspiring sports medicine doctors and has devoted much of her research to better understanding the biomechanics and unique challenges faced by female athletes over their athletic careers, whether they're professional or amateur.
She also serves as the team doctor for the Boston Red Sox and New England Patriots, a consultant for the Boston Ballet, and head team physician for college athletes at Suffolk University and Curry College.
A: Thank you so much for having me.
Q: I'm always curious to know when I meet new people. You're here today. You are a sports medicine doctor at Mass General, but when you were a kid, is this where you thought you'd end up?
A: You know, when I was a little girl I thought for certain that I was going to be an NFL player. That was my, that's my first memory of what I wanted to be when I grew up. I was born in Pittsburgh, and when year born in Pittsburgh, you're born into this football culture.
And when I was a little girl, I just couldn't get enough of it. I wanted to watch football, as well as other sports. And I would watch any team, any day, any time. And I was fascinated by the athleticism, the strategy, and I thought for sure I'd be on a field. I could throw a pretty tight spiral in my third-grade class. And I could catch a football. So I thought, why not?
And then ultimately realized that there were no ladies on the football field. So then I thought, well, I'll be a coach. And then I realized there were no ladies on the sidelines either. So several years later, after playing soccer at a fairly high level, and cultivating that passion for sports and thinking about what I wanted to do in healthcare, marrying my passion for sports and my aspirations in medicine, it just was a natural path for me.
Q: If you were a kid today, do you think you would have played football?
A: [laughter] I think I probably would have played in the, you know, the Pop Warner, Little Leagues. Maybe even tried to be a kicker longer. But you know, the opportunities that soccer presented me at the high school level, at the college level, and even beyond, I don't think I'd change that.
Q: When you were getting into medicine and sort of finding your way into this field of sports medicine, can you talk me through what that process looked like?
A: When I was in medical school, I really knew I wanted to go into sports medicine, but at that time, the only pathway I was aware of was the surgical route, going into orthopedic surgery and doing a fellowship in sports medicine. And then throughout medical school, I realized that there was one other pathway, and that was primary care sports medicine.
And then I worked with a couple of physical medicine and rehabilitation doctors while in medical school, and I realized that there was an additional, a third pathway to being an expert in musculoskeletal care. And that, that's rehabilitation medicine essentially.
So being a physiatrist or a physical medicine and rehabilitation doctor encompasses four years of training. The first year's internal medicine, and then you have three years of rehabilitation medicine. And that basically encompasses the entire umbrella of rehabilitation, from significant impairments and disabilities such as traumatic brain injury, spinal cord injury, amputee medicine, stroke rehabilitation, to– where you spend a lot of time in-patient and a lot of time working with physical therapists, occupational therapists, with– in a team environment, where a patient is admitted for eight weeks, at times.
You really get to know the patient and their family. And you treat all their medical issues, as well as their rehabilitation issues.
At the time, when I completed my residency and I was looking into options for further training in sports medicine, there were no ACGME-accredited fellowship pathways at that point. And so, with the help of several mentors – and I've just had tremendous mentors along the way– they inspired me to propose a new training program, a fellowship program for a year, where about six months was spent with the surgeons and six months with non-operative sports specialists.
Ultimately I was able to get that training program funded, which was no small feat because at first the proposal was, "Oh, Kelly, this sounds fantastic, would you like to do this [laughter] as another year of training and not get paid for it?" And that really wasn't an option for me at the time, so ultimately it was a position that was funded.
And you know, looking back at something that I'm really proud of, that I listened to those mentors and I went forward with investigating that option. Because now, you know, ten years later, we have developed an accredited fellowship program.
And at that time, I presented the future vision of, let's try to break some ground here, develop a relationship with orthopedic surgery at Mass General. Let them know what we as physiatrists can offer. And maybe we are able to increase our presence in the Sports Medicine Division there. Maybe I'm the first. I sort of had that in mind all along, that they could use somebody like me over there, because I'd worked with them along the way, and that this could potentially be an accredited program at some point.
Q: And something I've been thinking as you've been talking, we think about sports medicine and athletes, but is it all about athletes? How did it end up being called "sports medicine"?
A: I think the better term is "sports and exercise medicine." So it would be a dream if I saw high level athletes all day long. But I also really enjoy taking care of recreational athletes and just passionate exercisers. And we know that exercise is medicine in many ways. And so, treating athletes of all levels and active individuals of all levels is what I really enjoy.
Q: I think a lot of people haven't heard the term "physiatry." Can you talk a little bit more about what that means. I would think sports medicine equals ortho. So how do those compare and fit together?
A: Well, they're complementary in many ways. It basically encompasses all of rehabilitation medicine. It's under the discipline of internal medicine; it's a subspecialty.
And during our training, we're trained to treat really all musculoskeletal injuries and impairments, as well as neurologic injuries and impairments. With a slant that's a little bit different than the surgical side.
So my orthopedic counterparts, who are all fantastic, talented individuals, their primary goal is to restore anatomy. So they're trying to surgically reconstruct or restore anatomy that's been injured. Whereas, the primary role of the physiatrist is to restore function.
We really work well together. Whether we're seeing a patient post-operatively or pre-operatively, 90% of sports medicine is non-operative. So we see a lot of athletes with overuse injuries, and we're interested in restoring function.
We're looking at the whole person, the whole picture, if I'm examining a patient with knee pain, I'm looking at the hip, I'm looking at the spine, I'm looking at the foot and ankle, and I'm trying to restore function to that entire, we call it “kinetic chain.” Because all these anatomic structures are interrelated in how the knee ultimately performs.
And so, our interest is really complementary to the surgical side. It really works well together in that I do a lot of education on rehabilitation and on injury prevention. And I really help to triage that surgical situation. So an athlete may see me and they may not know if it's a surgical issue or not. And through the evaluation process and attempting some non-operative treatment measures, they may ultimately end up needing surgery.
And so, by the time I send them to a colleague, they're neatly packaged, they're ready to go. Their expectations are set, which really helps my partners in terms of efficiency and developing a relationship with the patient.
And then sometimes I'll see that patient in the post-operative period as well alongside the physical therapist to counsel them on getting back to their desired activities and desired sports.
A: I'll see really anything musculoskeletal, from head to toe. Whereas, surgeons in sports medicine generally do knee and shoulder. Now, some have specific training. At Mass General at least, at a large academic institution, their niche is quite small. So it's helpful to have more of a general musculoskeletal care expert to help with all of the non-operative issues.
Q: Thinking back to early in your career, when you joined the orthopedic service, and you are the first physiatrist and the first woman to join that service, a little bit of an anomaly. What was it like to come in as someone who was different from the norm?
A: Well, I realized that there would be quite a bit of education necessary and educational gap in what it is I do. So I tried to set the staff up for that. And for me, that was the first challenge, is have the staff understand what I do so that they could appropriately triage patients.
I had worked with most of the surgeons during my fellowship, so they knew what I was capable of from a clinical standpoint. So I didn't really feel I had to prove my clinical skills. But in sharing patients with them and in the patient feedback that the surgeons got, I think that's when they were really convinced that it was an important role, and it was one that could really complement their surgical practices.
I didn't really encounter any barriers in being a woman, that I recall. I've always felt very supported.
I think the bigger challenge was educating those not only in orthopedic surgery, but internal medicine and many other departments at Mass General what a physiatrist is. I'm not a psychiatrist, I'm not a podiatrist.
So it's been good though because I've given lectures to different disciplines and medical students and residents and internal medicine. And to me, it's one of the best-kept secrets in medicine. So I'm always really excited to share it with others.
Q: And I'm wondering about sort of gender parity across the field. I know a lot of orthopedic departments tend to be more men than women. Is that the case in physiatry?
A: So in physiatry, we're pretty evenly split between males and females in terms of diplomate board-certified physiatrists across the country. The disparity is in leadership positions and award recognitions, just like has been identified in many different specialties.
In sports medicine and exercise science, there is even more gender disparity in just sheer numbers. So there's the primary medical society for, physiatrists and other primary care sports medicine providers is the American Medical Society of Sports Medicine, the AMSSM.
And if you look at their membership, it's about a quarter women and 75% men. But then if you look, dig deeper into the leadership roles, it's really male-dominated.
And so, one of my goals is to, as a fellowship director, is to identify young talent, whether it's male or female, but I'm specifically very interested in the female talent and those residents that I think have leadership potential. Because I just, I think that the more women we have in leadership positions in major, national societies, as well as with teams, with professional organizations, like the Patriots and the Red Sox, and even with college, Division 1 colleges. There aren't a lot of head team physicians that are female.
So I think the more that young people can see that we can be successful in these roles, the more women will be inspired to follow that lead. So there are disparities, but I think that each year it's improving and the opportunities are growing.
A: One of the things in the immediate future that I'm very excited about is our annual Harvard sports medicine course. It's a collaboration with orthopedics, musculoskeletal radiology, athletic training, physical therapy, physical medicine and rehabilitation, primary care sports medicine.
There has been a lot of attention in sports and exercise medicine courses where these high level courses across the country, nationally, internationally, have primarily male faculty. And that results in these expert panels that are completely dominated by men.
And so, we have made a concerted effort to involve a lot of our talented female faculty in the city.
Q: So I want to pivot a little bit and talk now about the work that you do with athletes. You were an athlete, probably still a leisure athlete, but bringing that into your work life. What is it like to work with athletes?
A: I think what is probably most appealing to me and what really attracted me to sports medicine as a field was working with generally healthy people that are motivated and want to get better, and they're willing to work with you to get back to an activity that they're passionate about.
And so, to me, that's the heart of it. It's extremely gratifying to return somebody to what they have done for years, what's such a big part of their life, whether it's running or a ball sport. Whatever drives them. It's such a big part of their mental health, it's a big part of their physical health. And the fulfillment in returning somebody to what they're most passionate about is really what I think drives me on a daily basis.
Different sports have different demands. I find it fascinating how the different movement patterns in different sports, whether it be the upper extremity, their lower extremity, learning about sports that I didn't play, that I didn't know much about in terms of what tissue is stressed – Why did you develop this overuse injury? Do we need to change your form? Do we need to change your technique? What muscle groups are imbalanced here? What do we need to strengthen, what do we need to lengthen?
And working with the athlete on that, too. And understanding what their body needs to do has always been extremely fascinating to me.
Q: You're talking about different sports, as a former soccer player, are those your favorite athletes to work with?
A: I don't know about that. I enjoy a variety because like I mentioned, I get to learn about other sports and what other athletes go through in terms of training and what's most important to them in terms of the highest level performance.
I enjoy working with men and women. Female athletes are really interesting to me because we, women have different movement patterns. And this starts in adolescence, in puberty, during growth spurts and hormone changes, where little girls start to move different than boys. So girls at a certain age in puberty land different and plant and pivot different. And this ultimately leads to females being more at risk for certain injuries, such as anterior cruciate ligament tears, ACL tears, which is a devastating injury to an athlete that keeps an athlete out anywhere from, you know, eight to 12 months.
But that's not the only injury. There are several overuse injury patterns that develop in women that have movement patterns that are the same movement patterns that put them at risk for ACL tear. And that starts young. And so, the greatest risk of ACL injury is in high school.
And so, I'm interested in trying to capture some of these younger athletes and educate coaches and athletic trainers. Because at many high schools, the athletic trainer is really the go-to person for all advice regarding training.
In fact, a lot of these kids have never spent time in a gym, and have never done any type of strength training and conditioning. If they're a cross-country runner, that's what they do; they run. And they run and they run and they run in that same plane of motion. And they're not worried about building up certain core muscles or gluteal muscles that might end up helping to prevent overuse injuries.
Some of the deficits that women tend to develop at an early age compared to male counterparts has always been very interesting to me.
Q: Can you talk a little bit more about what those deficits are? I'm someone who was one of those young athletes and dealing with knee problems. And looking back, I always wonder what could I have done?
A: When a young girl reaches adolescence and there are certain hormonal changes that occur. And as they get taller and their femur lengthens and their tibia lengthens, they don't have a one-to-one correlation with muscle development and muscle strength, muscle endurance. Boys have a testosterone kick that allows them to develop more strength and endurance around the growth.
And so, what ultimately happens is females develop this pattern of movement that's very characteristic. It's been described by some as "miserable malalignment syndrome." Which I think we can probably better name. [laughter] And what that is, is a lack of control, lack of strength around the core and around the gluteal region that ultimately leads to the knee veering towards midline with any landing or any plant pivot.
So the hip muscles, the gluteal muscles are what control that position in space. And when those aren't strong, the knee ends up in a position that's vulnerable. And so, the knee becomes a victim. The ACL becomes the victim. There's a host of other knee injuries. And they're all can be related to this pattern of deficiency or weakness in the core and gluteal region.
So the prevention efforts are focused not only on just sheer progressive strength training, but also on neuromuscular patterns, teaching women how to land and to be conscious of landing with their knees over their toes and their hips controlled. And that has shown some promise in terms of injury prevention, not only at the knee, but in other areas of the kinetic chain.
Q: The other thing I'm wondering about, Kelly, is, so as women, as young girls, you know, we have these challenges. If we were to do more strength training, we can kind of set ourselves up for success.
A: Um hmm.
Q: But then what about the other end of the spectrum? So you know, as women age and if they're staying active, what's the other side of the equation?
A: There are changes that occur as women age and as women go through pregnancies. And our women, as well as our men, are exercising a lot later in life. So if you look at just the numbers on participation in endurance events – in marathons and Iron Man triathlons – across the country, the female representation is very high; it's almost 50%.
And a lot of these women are over the age of 40. And so, we're seeing a lot of overuse injuries in women that don't necessarily keep up with the strengthening and conditioning. Or it was never really a part of their regimen. And so, especially runners that have existed in that one forward plane of motion. You fire certain muscles, certain muscles are strong. And then there are other muscles that are weak.
And so, as we age, those muscles become a little less robust. And then when you're post-menopausal, you have a little bit more fatigue of the muscles and some atrophy of the muscles. And so, it becomes more of a challenge to strengthen those stabilizers. And it becomes that much more important if a woman wants to keep up the same level of training that they were accustomed to in their 20s and 30s.
And then, you know, women have kids and there are structural changes that occur when you have a baby. [laughter] And when you have three babies. Whether you have a C-section or a vaginal delivery. And recovery from that can be an issue in terms of regaining that strength.
Because really, even if you exercise through a pregnancy, which we encourage, it is a period of relative rest. Most women are not engaged in the same level of cardiovascular fitness, especially in the third trimester. So then getting in shape again after pregnancy, women tend to just want to get back to, if they're runners, they just, six weeks later, whenever they're cleared from their OB, they want to go out and run five miles. But they don't realize that they've lost that strength and endurance in their core and gluteal musculature. And that those muscles cannot support that mileage.
And so, there's a lot of counseling that occurs in athletes that I treat that have gone through a pregnancy. And then, as the decades pass, that counseling needs to continue.
Q: It feels like it's another one of these things that like, ugh, as women, here's another thing that we have to deal with, our bodies do these weird things that–
Q: –cause problems. Is there an equivalent in the male body?
A: [laughter] That's a very interesting question. I'm sure there is an equivalent that I'm just not identifying. I think that as women our bodies were built and structured and made, especially our pelvis, for bearing and delivering a child, not for being high level endurance or speed athletes. The male body was more prepared for that.
There are issues that men go through with changing hormonal levels as they age, with changing and decreasing testosterone levels that affect their muscle mass and muscle performance and energy levels. So I guess that may be the parallel in terms of battling against the aging process and the importance of strengthening and conditioning.
Q: Are we learning more about the female body to catch up with what we know about the male body? I know in cardiology they're starting to realize we've been treating all hearts the same, but really we need to differentiate. Is there a gap between female and male physiology knowledge?
A: I think at the highest levels there is a gap because we have so many subjects we can study in male professional teams. We have female Olympians. We have female professional sports, but not nearly the numbers. And so, we've learned a lot about the female knee and how it's different than the male knee. We've learned about this pattern of movement that I've discussed.
But there's still gaps in terms of our knowledge about hip structure and function, and potentially even foot and ankle structure and function. And I think that as our methods of research become more sophisticated and as more female athletes are engaged in athletics longer, we'll be able to study the female athlete across a lot longer period of time.
Q: I'm curious, too, for any female athlete who wants to stay healthy, is there a common advice you give to women to keep their bodies working?
A: I'm always trying to convince ladies, especially women that have been high level athletes at one point, that they're maybe not as strong as they used to be. So nothing is more convincing of that than having them perform repeated single-leg squats, or an exercise that really challenges their core and demonstrating to them how weak they are.
And I think that's a good start in motivating them to be stronger, to support that exercise that they want to do on a daily basis or a weekly basis to prevent injury.
Q: This reminds me of something you said earlier and I wanted to ask you about. The mental piece of working with an athlete. We have this concept of ourselves and our body and what we can do, and when it gets injured part of that can be a mental hit. Do you work with athletes on that mental piece?
A: I think that's one of my favorite parts of my job, is connecting with people, whether it be a female athlete or a male athlete. And I think that that's where the advantage comes in of being a former athlete myself. I like to think I still am. But just being able to talk the talk and being able to find a way to reach them and to get them to buy in to what I'm saying, and that what I'm proposing in terms of a rehabilitation approach. We may shut you down for a month. You may not be able to do what you were previously doing for four weeks. But after that, we're going to build you back up. So we're going to build you up during that time and then we're going to reintroduce the things that you're most passionate about.
And I always start by telling an athlete what they can do and not what they can't do. So if we're going to need to shut down impact exercise because they have a stress fracture, then they can't run, they can't hike, they can't walk for exercise. But I don't start with that; I start by saying, “These are the things that we're going to do to maintain your cardiovascular fitness and your aerobic capacity: We're going to aqua-jog. You may not like the pool, but you're going to learn to like the pool. And you can use the elliptical machine. You can do spin classes. You can go to Pilates classes. You can challenge yourself in other ways during this time. You just can't run. But then after we're done with our rehab and building you back up, we're going to reintroduce the running.”
And my goal is to get you back to your previous level.
A: Some people are harder to reach than others. But that connection, that moment in time when you reach a person and they're buying in and they trust you and they know that you have similar goals and that's, to get them back to their previous level of performance. That's when it kind of all comes together and I realize they're going to come back in four weeks to see me again. [laughter]
Q: In looking forward, I know there's a new female orthopedic surgeon coming to join the practice at Mass General, which is super exciting. How will that change the department? And what you looking forward to?
A: I think it's very important for our division of sports medicine, our Sports Medicine Center, and for the Department of Orthopedics. I'm really personally looking forward to it because this individual – her name is Miho Tanaka – ran a women's sports medicine program at Hopkins. And so, I'm looking forward to working with her on a women's sports medicine initiative at Mass General, which we have not had before.
And I do a lot of that already, so I'm looking forward to putting that together in an organized way. And with her experience, I think that that's going to be, it's going to be a great partnership.
Q: Looking five or ten years down the road, what does your dream program look like?
Research will be a big part of it, and Dr. Tanaka has very rich research experience that she'll bring to the table. And so, collecting data on our female athletes of all levels – professional to recreational – will be important. And I think that we have a chance to build a really fantastic multidisciplinary approach to the care, the health and wellness of active females and athletes.
Q: So Kelly, before I let you go, I have my final five questions.
Q: What is the best advice you've ever gotten?
A: I think the best advice I've ever gotten is: surround yourself with good people. To me, it's all about the people that you're working with. It's colleagues that motivate you to be better at what you do. And so, I've always tried to be a team player and surround myself with the best possible team.
Q: What rituals help you have a successful day?
A: You know, I try to mentally prepare. And I think there's a parallel to sports to sports and athletics as well here as, I often would mentally prepare prior to a game. So what am I going to encounter tomorrow in terms of patient care, in terms of my list of procedures? What challenges do I foresee in trying to potentially troubleshoot those ahead of time? And just be in a mindset where I'm ready to go the next day.
Q: How do you recharge?
A: I would say that probably my method of recharging is exercise where I'm just alone with my thoughts and getting a sense of really [laughter] really in touch with myself through exercise. And I also recharge through spending time with my kids. And laughter.
Q: I like that. What's your favorite exercise?
A: So I wish that I was playing competitive soccer. Every time I get this question, I'm regretful of not still playing. I stopped playing competitive soccer two years ago. Now what I do for exercise is I run.
Q: And if you weren't a doctor, what would you be?
A: I think I would either be a chef, because I love to eat; I'm fascinated by food and flavors. Or I would push that dream to be some type of strategist in the NFL, whether it's player recruitment, player development, or learning a coaching skill.
Q: And what advice would you give your younger self?
A: Always keep the big picture in mind, never be too overwhelmed by the smaller challenges along the way, and always keep in mind that the most important thing in life are family, friends and the people, the people around you.
Q: Sounds like a great future.
A: [laughter] Thanks so much for having me. This is a great honor.
Q: Thank you, Kelly.
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
Episode #26 of the Charged podcast
In this episode, Dr. Frances Hayes discusses the importance of providing multidisciplinary care for transgender patients in a supportive and affirming environment.