In today's fast-paced world, many individuals are seeking alternatives to invasive surgical procedures. Dr. Tim Mazzola explains how ultrasound guided diagnosis has revolutionized the field by providing accurate and precise treatment options for patients. By using this innovative technique, doctors can identify and target the root cause of the problem, such as arthritis or ligament injuries, without the need for surgery.
Key Points
- Regenerative Medicine and ultrasound guided diagnosis is changing the way we treat arthritis and other non-surgical sports injuries
- Keys to physical exam and diagnosis of injuries to avoid surgery
- When does PRP injection make since to avoid surgery after tendon or ligament injuries?
Our Guest – Dr. Tim Mazzola
Dr. Mazzola is board certified in both Family Medicine and Sports Medicine. He is also certified in musculoskeletal ultrasound since 2013. He currently practices as a Non-operative Regenerative Orthopedist at Breakthrough Regenerative Orthopedics in Boulder, CO. He previously served as a Team Physician at the US Air Force Academy. Passionate about teaching, Dr. Mazzola is affiliated with the University of Colorado Medical School and is completing 2 SI ligament research studies with Rocky Vista University College of Osteopathic Medicine. He has taught Advanced Musculoskeletal Ultrasound and Regenerative Orthopedics for several years. He co-authored a chapter on Ultrasound Guided techniques in Regenerative Medicine Procedures in Dr. Malanga and Ibrahim’s textbook titled Regenerative Treatments in Sports and Orthopedic Medicine. He co- authored a recent review paper on optimizing PRP dose and formulations with Peter Everts and others.
https://www.orthopedicscolorado.com/
Dr. Jill Carnahan, MD
Dr. Jill Carnahan is Your Functional Medicine Expert® dually board certified in Family Medicine for ten years and in Integrative Holistic Medicine since 2015. She is the Medical Director of Flatiron Functional Medicine, a widely sought-after practice with a broad range of clinical services including functional medical protocols, nutritional consultations, chiropractic therapy, naturopathic medicine, acupuncture, and massage therapy.
As a survivor of breast cancer, Crohn’s disease, and toxic mold illness she brings a unique perspective to treating patients in the midst of complex and chronic illness. Her clinic specializes in searching for the underlying triggers that contribute to illness through cutting-edge lab testing and tailoring the intervention to specific needs.
A popular inspirational speaker and prolific writer, she shares her knowledge of hope, health, and healing live on stage and through newsletters, articles, books, and social media posts! People relate to Dr. Jill’s science-backed opinions delivered with authenticity, love and humor. She is known for inspiring her audience to thrive even in the midst of difficulties.
Featured in Shape Magazine, Parade, Forbes, MindBodyGreen, First for Women, Townsend Newsletter, and The Huffington Post as well as seen on NBC News and Health segments with Joan Lunden, Dr. Jill is a media must-have. Her YouTube channel and podcast features live interviews with the healthcare world’s most respected names.
The Podcast
The Video
The Transcript
207: Resiliency Radio with Dr. Jill: Why Go Under the Knife When you Can Go Under the Needle?
Dr. Jill 00:00
Hey guys, I am so excited to announce that the movie that you've been waiting for, the documentary Doctor/Patient, is now available for rent or purchase at DoctorPatientMovie.com. Check out the trailer here.
00:13
Dr. Jill: When I really knew something was wrong, was when I started having trouble walking up the stairs. I was supposed to be grateful and happy and healing and well and thriving, but I did not feel that way. I was so sick. Like always, I wanted to find an answer, and I had to figure it out. And I had to figure it out to save my own life. So I dove in.
00:38
James Maskell: Jill is the leading voice in biotoxin illness and chronic conditions that are driven by toxicity.
00:43
Bree Argetsinger: Oh my gosh, you're dealing with mold? You have to work with Dr. Jill Carnahan.
00:47
Patient 1: Dr. Jill is the first person that actually began to shed some light on the problem.
00:53
Dr. Jill: What I do is listen to the patient, and we together talk about what else is possible.
00:59
Patient 2: I don't know why I'm crying.
01:02
Patient 3: She saved my life.
01:06
Dr. Jill: The deepest lessons and most profound insights come in the suffering, come in the dark moments. Self-compassion is the healing transition that shifts something inside of us. It's actually the thing that we need most in order to heal.
01:26
Narrator: Doctor/Patient—available now at DoctorPatientMovie.com.
Dr. Jill 01:37
Welcome to Resiliency Radio, your go-to podcast for the most cutting-edge insights in functional and integrative medicine. I'm your host, Dr. Jill. In each episode, we dive into the heart of healing and personal transformation. Join us as we connect with renowned experts, thought leaders, innovators, and all those who are at the forefront of transforming medical research and clinical practice. Today, I want to empower you with knowledge and information to help transform you in your health journey, inspiring you to hope, healing, and new horizons.
Dr. Jill 02:11
Hey guys, if you haven't heard, my movie Doctor/Patient is out. It's at DoctorPatientMovie.com. You can rent it, buy it, share it, or gift it to a friend. I am hoping, like many of you we've heard from, that it is inspiring and impacting you in your journey, whether you're a patient or you're a practitioner. Please do share the word. And if you haven't watched it, go take a look and then let me know what you think.
Dr. Jill 02:33
Today, I am so excited to have my friend and colleague and local expert here, Dr. Mazzola. He is board-certified in both family medicine and sports medicine. He's also certified in musculoskeletal ultrasound since 2013. He currently practices at a nonoperative regenerative orthopedist at Breakthrough Regenerative Orthopedics in Boulder, Colorado. He previously served as a team physician at the U.S. Air Force Academy. He's passionate about teaching. He's affiliated with the University of Colorado Medical School and completed two SI ligament (sacroiliac ligament) studies at the Rocky Vista University College of Osteopathic Medicine. He's taught advanced “Ultrasound Guided Techniques in Regenerative Medicine Procedures” in the textbook titled Regenerative Treatments in Sports and Orthopedic Medicine. He's also co-authored a recent review paper on optimizing PRP doses and formulation with Peter Everts and others.
Dr. Jill 03:32
I am just so excited to have you here, Dr. Mazzola, because so much of what we do intersects and we had a great conversation a few days ago about this. But welcome to the show!
Dr. Tim Mazzola 03:41
Thank you so much, Jill. It really is an honor to be here and thanks for all your passion, your energy, and your efforts to get the good word out. I appreciate how you are transforming healthcare and that's my goal as well.
Dr. Jill 03:56
We all need each other, don't we? Just recently, we had this really long conversation. We were saying, “How the time flew by in this conversation!” And we've known each other [and have] seen each other in social situations. We are both so similar as far as how we want to do medicine and treat patients.
Dr. Jill 04:13
Let's start with your journey, though. I love the story behind the story. Tell us: How did you get into medicine? And then how did you get into sports medicine and what you're currently doing?
Dr. Tim Mazzola 04:22
Sure thing. It's an ironic story. When I was a younger kid, my mom's best friend was a nurse. She was always excited in our family because we had five of us and she knew that one of us was going to be a doctor, and she pegged me. But I didn't want anything to do with it. That kind of responsibility seemed foreign to me. I really wanted to be surfing, riding my bike, and doing all the fun things in life with very little responsibility.
Dr. Tim Mazzola 04:54
I went my way through university down at UC San Diego, living on the beach, riding my bike up and down the coast, playing beach volleyball, and surfing as much as I could. I wasn't taking school very seriously because I thought I was going to be an engineer. I had two brothers that were already in the field and two uncles that were in the field. So that was my path and it was easygoing.
Dr. Tim Mazzola 05:17
That all changed when I got into upper-division engineering and realized that I couldn't pass those classes. It was the first time I'd ever gotten an F in my life and that was in the basic introductory upper-division engineering classes. I could not get through, so I was like, “Hmm, what does this mean?” I went on a bit of a journey in trying to understand that. I took a semester off. I went to Steamboat Springs, Colorado, for the winter, became a ski bum, and thought about it.
Dr. Tim Mazzola 05:42
When I came back, it was the spring of—gosh, that was back in the day—1986/87 and my best friend passed away suddenly and unexpectedly of a ruptured berry aneurism in his brain. That got me thinking because, up until that point, I didn't have a plan for my life. I didn't think much about where I was going other than just to be an engineer and that door was closing. After Mark passed, one of my efforts to keep him alive in my life was to take on some of his characteristics. The things that I wasn't doing at the time were that I wasn't thinking much about what to do with my life, and “Who do I really want to spend my time with? And how do I want to make an impact?” He was doing all of those things. With the tragic loss of Mark and because it was medical, somehow it stimulated this thinking in my mind.
Dr. Tim Mazzola 06:42
I was still trying to avoid medicine as much as possible. I tried PT and I tried doing research on the bench and all these other things, but none of them seemed to match up with what was inside of me, and something was stirring. Even though I knew nothing about medicine and I only had one person in my family who had done it, I started studying for the MCAT the next thing I knew.
Dr. Tim Mazzola 07:07
It's a funny story because I did get accepted to medical school eventually. The irony is Jill that I never even spent a day doing a clinical rotation shadowing another physician. I didn't know what I was getting into. It all moved on and I got the Air Force scholarship. That's how I ended up in the Air Force. That was my hedge because I was like, “If I don't like medicine, I only have to work four years and I can always go and do something else” because I was non-committal. You can probably tell by the conversation. I wasn't very committal. But I was getting more committal. And some things happened in my life and things changed.
Dr. Tim Mazzola 07:46
As I was driving cross-country to go to Hershey, Pennsylvania, from Southern California, mind you, all the things that I was good at—like surfing and beach volleyball—meant nothing to people in central Pennsylvania. [laughter] As I was driving across the country after about three days, I was kind of wrestling with God. What I think was going on was that I was resisting. I felt like here I was going across the country to do the hardest thing I'd ever done with nobody that I knew and all the things I was good at didn't mean anything, so I was down to nothing. In the end, the best I could come up with was: “Okay, I'll let you help me.”
Dr. Jill 08:29
Famous last words to God, right? [laughter]
Dr. Tim Mazzola 08:32
Yes. You open that door, you never know where you're going to end up. It was maybe about eight more years before I guess I would say I developed a true faith. But that, I think, has made the difference for me in my journey and my pathway and definitely empowered a lot of my passion and inspiration for what I do and how I do it these days. So that's how I got into medicine.
Dr. Tim Mazzola 08:58
And then, when I was at medical school, I was always an athlete. So I was thinking, “Do I want to do orthopedics?” The one doctor I did know was my family doctor, so I thought, “Maybe I'll be a family doctor.” I was comparing those two rather different professions. When I got into my clinical rotations, the first thing I had was orthopedic surgery. Spending my first day or two in the operating room was enough for me to realize that that was just way too violent and too intense. The attitudes and the egos were too much for me. So I spent a little more time meeting with the family physicians. They were just these wonderful human beings—balanced. So I went that path. I became a family physician.
Dr. Tim Mazzola 09:43
To my great surprise, when I was in one of my clinical rotations about two years later, I learned that there was such a thing as sports medicine that you could do as a non-surgeon related to family medicine. I knew instantly that's what I would be doing. So that's how I got into family medicine and then eventually into sports medicine. I think the rest—it's been history.
Dr. Jill 10:08
Wow! There are some really neat things that are similar that we didn't know, and I'm just listening. Number one, I was a bioengineering undergrad and I remember the physics engineering. Up until then, I could just study and learn and do anything I wanted to do. And I'll never forget [being] like, “Oh, this might be above me.” It was so hard, and it was my first less than an A grade. I just remember—it was engineering in the University of Illinois—that same exact thought of, “Oh, maybe this isn't for me.” And then the same thing—there's been no medical doctors in my family at all so I had no role models. And I hardly even thought I could become a doctor. As I'm hearing you talk, I can relate on so many levels.
Dr. Jill 10:51
And then the same thing; when you go to family medicine, it's like, “Why are you going into family medicine?” Maybe there are some stereotypes here but the genuine people who really, really want to help go into primary care usually… I shouldn't say this as a general [statement] because there are so many great, amazing surgeons, but there's a whole different mentality in the surgical realms, right?
Dr. Tim Mazzola 11:18
Yes, different personalities.
Dr. Jill 11:19
Right.
Dr. Tim Mazzola 11:20
For sure.
Dr. Jill 11:20
I can relate to that too because I ended up in family medicine, and I remember in Chicago everybody was like: “What? You're doing family medicine?” But I have no regrets. That's amazing. [inaudible] sports medicine.
Dr. Jill 11:34
What's really neat is you're very humble. But what you're doing in clinical practice is really cutting-edge. And as we even got to know each other better recently in our conversation, you've been doing some of the stuff for as long as almost anyone out there. How did you get to be one of the cutting-edge [doctors] in regenerative medicine? What does that mean to those listening who maybe don't know? And just tell us a little bit about that—diving into the depths of these new kinds of ways to treat injuries.
Dr. Tim Mazzola 12:03
Yes. It's quite a journey in and of itself. And it's a great question, so thanks for that one. In sports medicine historically, we are trained by surgeons how to think orthopedically. Generally, what that means is if you have a soft tissue injury, if it is mild enough that it doesn't need surgery or there isn't an appropriate surgery for it, then it just goes to physical therapy, and maybe you take some anti-inflammatory medication or get a steroid shot. And if it doesn't get better, well, that's just too bad. If it's a surgical problem, we're trained to understand what is likely surgical, and then let's put them down that pathway. What I realize is that the difference between physical therapy and surgery is a fairly large gap and Motrin and steroid shots really don't fix anything.
Dr. Tim Mazzola 13:05
To answer your question about the timing, it was very fortuitous because here I was sports medicine trained, and in 2007 at one of our annual sports medicine society meetings, there were a couple of speakers who got up and taught about musculoskeletal ultrasound and its applications in orthopedics and took the whole conference by storm. Everyone had their eyes open. We were all super excited. Some people jumped on it and some people waited. I was one of the people that jumped on it. There is an incredible miraculous story in how I got my ultrasound machine if we had the time. I eventually got my ultrasound machine in 2007.
Dr. Tim Mazzola 13:50
We were down in Pagosa Springs, so rather rural. At the time I was trying to live the mountain lifestyle, trying to be able to ski as much as possible without having to drive I-70. Anyone in the front range knows what I'm talking about. It worked for a while. But they developed a critical access hospital down there and there weren't enough physicians in town to man it all. I was literally on a path to my demise because of the hours and the lack of sleep, nutrition, and exercise. I was losing my life, so we had to move.
Dr. Tim Mazzola 14:24
But I did get my ultrasound machine while I was there. It was interesting because that's what helped me get my job working in orthopedic surgical practice in the front range eventually. The thing that differentiated me was that I had an ultrasound machine and knew how to use it, so there was some value there.
Dr. Tim Mazzola 14:40
The thing I noticed when I joined this orthopedic surgical practice in 2009 was that I could do a blind steroid shot for say subacromial bursitis or rotator cuff tendinopathy, and I could do an ultrasound-guided injection with steroid perfectly into the bursa, and I would get no difference in outcome. It was exactly the same. So, what was the value of a $40,000 ultrasound machine and a person who knows how to use it if the thing inside the syringe isn't changing anything and they're still stuck with, “It's non-surgical, go back to PT”? That was unsatisfying for me.
Dr. Tim Mazzola 15:20
At the same time, PRP (platelet-rich plasma) had just come on the scene. A year or two before, people started talking about that. And I had been reading about it, of course. So then I thought, “Maybe if I could get that in the syringe and get it accurately placed, that could make a difference.” Fortunately for me, the surgeons I worked with were more gentlemanly than the ones I trained with in medical school, and they said, “Go for it.” They gave me an opportunity. That really changed things.
Dr. Tim Mazzola 15:48
Then I started getting opportunities to treat patients who weren't appropriate surgical candidates or didn't want surgery because they preferred not to. I had an eight-year period where I was growing in my ability to diagnose with an ultrasound and treat with ultrasound-guided injections, mostly with PRP, sometimes stem cells occasionally.
Dr. Tim Mazzola 16:14
There have been so many steps along the way that it's hard to lay it all out. But we started with tendons—that's where the data was—and then a few years later, we started getting research on osteoarthritis. And that really developed. Now there was a broad range of things we could be treating. I also learned that we could treat ligaments and hydrodissect around nerves—by putting fluid around them to free up nerves that were entrapped—without surgery. Oh, my, what a difference-maker that has been! That's not even regenerative, but it's an amazing intervention that we can do with an ultrasound.
Dr. Tim Mazzola 16:48
The thing that really changed for me was the ultrasound machine. The miracle there was that really, God bought that for me. It's a true story, and we can get to that when we're talking another time. But that's what really changed things and that's what got me my job with the orthopedic group. And then I became an orthopedic specialist because I was no longer a family doctor. They told me: “You're a specialist now. Don't think [inaudible]. You need to be a specialist.” That was a bit of a transition, and it took a while, maybe a year or two, for me to be comfortable with that notion.
Dr. Tim Mazzola 17:24
That was 2009, and here we are 15 years later, and the data has evolved, and the anatomy we can find with an ultrasound without having to open up a person's body to intervene with an injury… The real surprise in all of this is that if you learn how to do great physical examination from people who aren't surgeons, people who understand soft tissue injury, then you can find injuries in the soft tissue that nobody heretofore has been able to find.
Dr. Tim Mazzola 17:57
I think that's been maybe the biggest step up that has been made—in the diagnostic realm—not just using the ultrasound to look at something, but how to put your hands on somebody and find areas of injury and weakness in the body and then take your ultrasound and go and find it and improve it with an injection. [It's] that constellation of things: Being able to look in the body, intervene in the body, diagnose, and then have a good physical examination. It's been amazing that people have been placed into my life. Everyone has come at the right time. I've been standing on the shoulders of other giants who have taught me, and now I get to teach others as well. That's a joy.
Dr. Jill (pre-recording) 18:43
Hey, everybody. I just stopped by to let you know that my new book, Unexpected: Finding Resilience through Functional Medicine, Science, and Faith, is now available for order wherever you purchase books. In this book, I share my own journey of overcoming a life-threatening illness and the tools, tips, tricks, hope, and resilience I found along the way. This book includes practical advice for things like cancer and Crohn's disease and other autoimmune conditions, infections like Lyme or Epstein-Barr, and mold- and biotoxin-related illnesses. What I really hope is that as you read this book, you find transformational wisdom for health and healing. If you want to get your own copy, stop by ReadUnexpected.com. There, you can also collect your free bonuses. So grab your copy today and begin your own transformational journey through functional medicine and finding resilience.
Dr. Jill 19:39
That is so amazing because here I am—I've been in medicine for 20+ years—and I don't think I even understood how powerful an ultrasound could be in diagnosis. One thing that you and I are both passionate about is teaching other physicians who are coming up in the ranks. We can talk more about that and the conference you did last year. I want to get there. But I think the physical exam, especially at the level and depth of understanding that you have, is a lost art. I so often hear that a patient has been to the ER and I'm like: “Did they touch your belly? You had belly pain and they didn't touch you? They didn't do an exam at all?” And I'm literally like, “Really?”
Dr. Jill 20:18
Some of the students coming out, of course, trained during COVID when things were more virtual and they learned these virtual kinds of things. There's nothing like laying the hands on a patient. I think you and I understand too. Even just that physical touch is part of the healing. I'm guessing that you're passionate about teaching this because I feel like it's hard to find good teachers of the physical exam anymore.
Dr. Tim Mazzola 20:42
Yes, that's exactly right. I am so passionate about that. And that's interestingly the hardest part to convey. It really takes a workshop. You have to have time with people where you can have a patient in front of you and then you can walk them through the physical examination because it's something that's never been taught. Like I said, historically we've always been taught orthopedic examination by orthopedic surgeons, and what they're really looking for is: Is this surgical; is this not? And that's very appropriate in their hands. What we're looking for is: Can we treat this non-surgically or not? And what is the problem? What is the nature of reality? And if we can get to understanding, or at least as close as possible to, “What is actually the problem?” then we can come up with rational treatment approaches for that.
Dr. Tim Mazzola 21:32
Yes, I hear this all the time: “I went to the orthopedic surgeon. He came in the room. He sat down for five minutes. He told me my MRI and said I didn't need surgery. And he said, ‘I can't help you go back to PT.'” Or, “We looked at your MRI and it showed you had a labral tear so therefore we can do surgery.” But no physical exam. Just completely making decisions based on an imaging study that shows: What is the status of the hydrogen ion in that tissue? On an MRI, probably 70% of people over age 45 will have a labral tear on their hip MRI, but not 70% of the people that have a hip labral tear on an MRI need surgery. Do you feel me?
Dr. Tim Mazzola 22:17
So you have to be able to discern and distinguish: What is the root cause of that labral tear on an MRI? Is it a tear? Is it maybe just a signal that's volume averaging from something next door? Is it a cleft in the labrum? Is it an actual tear? Is it just degeneration? Is it a little too much pressure that the labrum is experiencing because maybe they have sacroiliac ligamentous laxity and then a rotated pelvis? If this is the femur and this is the acetabulum and this is the labrum right here, if you have a rotated pelvis, you can see how if you go into hip flexion, you're going to compress the labrum. Whereas if you're not rotated, then you can clear easily. If I can find that it's the rotation from the sacroiliac ligament laxity, then we don't even need to talk about your labrum because once we've stabilized your ligament posteriorly, there's no pain anteriorly. And that happens routinely.
Dr. Jill 23:14
Amazing! I want to go into a few patient examples and stuff, but before we do, I want to tell you a real quick story of my N of 1, which is me. I think you'll relate, and you can certainly comment on it. Maybe 12–15 years ago, when I moved to Colorado, I had just been in mold exposure. I was inflamed. I'll never forget one of the flights out here to look for housing and where I was going to work—this was probably 2009 or 2010—I was in a wheelchair getting off and on the plane because I had such bad low back pain. I mean excruciating—I have a very high pain tolerance. I ended up getting the MRI, and you can imagine there was severe degeneration—L4 and L5, L5-S1. The height of the disc was like half. There was bone inflammation. And there was nerve impingement. I am not the expert on reading MRIs so forgive my layperson's terms. The bottom line was it looked bad. I was in my late 30s. I was in severe pain.
Dr. Jill 24:12
Why the functional medicine and what you do are so interlined is because I had severe, severe mold toxicity and severe inflammation—my gut was inflamed as well, which hits on the psoas in the low back—and stress because I was moving. All of those things. And thank goodness I didn't have surgery; I didn't have any sort of procedures. But what I started with was functional movement. Like: “How do I move? How do I hold myself? How do I use my spine?” I relearned how to move, how to walk, and how to squat. Everything was off. Today, Tim, I have no pain. I could look at the same MRI, and I'm sure it hasn't changed a whole lot on imaging, but I don't have back pain any day of my life—I don't—15 years later. But that's the power of decreasing inflammation, looking at the root cause.
Dr. Jill 25:00
I'm saying that because I bet you have a lot of people who bring in their MRIs and they've been told, “You need surgery” or “You need some sort of very significant intervention.” And like you talked about with the hip labrum, when you're looking at this from more of a functional perspective and regenerative perspective, how often do the images correlate? And why is ultrasound a better tool sometimes for us to look at?
Dr. Tim Mazzola 25:22
Wow, that's a great story. Yes, you nailed it. Your explanation of the MRI was very good, by the way, so give yourself credit. You nailed that. I think your point about your MRI is only going to be worse 15 years on. It's only going to be worse. “Let's see what's going on in there.” That's the lingo that is used around MRI. “Let's get an MRI. We'll see what's going on in there, and then we'll make some decisions based on that.” I used to buy into that, and I used to say those words, and I absolutely do not any longer.
Dr. Tim Mazzola 26:02
Most thoughtful orthopedic surgeons that I talk to now almost consider MRI like a tool of the devil. They don't like it all that much unless they're just looking to get surgery from it because there's so much nuance that has to be discussed in light of that imaging. It's data; it's not information. It's just data. And there's a big difference between the two. Data is just another piece of that, and then information is when you put that in the central processor and it has to meet up and has to correlate with other things like physical examination and history and the rest of the picture, like: Is this a healthy person or not?
Dr. Tim Mazzola 26:37
I think the question about ultrasound is a good one too. Almost like the MRI, though, I have patients come in and they're expecting me to ultrasound the entirety of their low back and tell them what's wrong. And I have to dispel that myth. I'm like: “I'm so sorry if that was your expectation but that's not how we do things around here. I'm going to do a physical exam and listen to what you tell me, and then those two things are going to point me in a direction. And then once we have a pretty good idea of what we think is going on, we might use the ultrasound to confirm that.” But I have to tell you a still image of an ultrasound, although it is more—
Dr. Jill 27:21
Is it maybe dynamic because you're seeing movement in real time?
Dr. Tim Mazzola 27:26
Yes. There are two things. It does have a higher sensitivity than MRI. You can see things more clearly, like on a TV that has more pixels or something like that. It's more detailed. That's number one. And then number two—yes, there are dynamics about it. You can compress the transducer. You can ask them to move their arm or to squeeze their muscle and see things move.
Dr. Tim Mazzola 27:55
But what's the best, Jill, is not either of those. What's the best—and this sounds crazy to my patients—is if I can get a needle in there and I can inject it into that tissue, I can see the tear opening up before my eyes. And if it's in an Achilles tendon or a rotator cuff tendon, oftentimes when you're scanning just looking directly, you don't see it. You cannot see the tear because the collagen fibers are all aligned and they've compacted on one another. But when you have the hydrostatic pressure of the fluid of the numbing agent injecting in, you'll see a little opening in the tendon for a moment while you have pressure on the plunger. And then when you let go, it closes again. It's like peek-a-boo lesions. You can find those anywhere, really—inside of an Achilles tendon or rotator cuff tendon—but more importantly, in these unusual places like myofascial injuries, for example.
Dr. Tim Mazzola 28:46
My lovely medical assistant today was talking about [how] her shoulder blade is grinding on her ribs when she tries to lift overhead or do reverse flies. She's trying to exercise her back and stay fit, but she's getting all this crunching of her shoulder blade on her ribs. What we're able to now assess is that she has an injury where a couple of different muscles come together and meet with a piece of fascia between them. With the ultrasound, then you can look and get a sense that, “Yes, maybe there's some injury there,” but then when you inject, the tears open up. Then immediately after that injection, when you take away that pain generator, the strength of her shoulder totally improved. And we did the same thing for her low back.
Dr. Tim Mazzola 29:26
I guess my point is that it's a lot more than just an ultrasound or an MRI. It has a lot more to do with ways of thinking, ways of examining, and ways of beginning to interpret reality better than we used to be able to do so without opening up the body. And that's the beauty of ultrasound: You can find these things in real time with an ultrasound and a needle if you can get it accurately through the tissue. And then you can reassess patients immediately and then determine, “Okay, that makes you look strong and functional, so that's what we need to treat.”
Dr. Jill 29:59
Wow, it's like problem-solving at its best, right? We talked about this too. And that may be our engineering background. It's like the pattern recognition of these things. And sometimes there's this intuitive sense, or at least for me, it's like sometimes even God gives us wisdom. We've talked about that too. You're like, “I don't know how I knew that, but that was…” I love that though, because you're bringing to light your clinical experience over these years. And then, to me, I feel like you're on the cutting edge of discovering even new ways to think about and do things, which our next generation of physicians needs. That's exciting.
Dr. Tim Mazzola 30:35
Yes. It makes me super passionate about working with the medical students. At RVU—I get to work with their students—we're doing research projects together, as you mentioned in the intro. A few of them come up and rotate with me and they get to see what we're doing, and they get excited. I think they like being able to see things that are done differently, thinking in a new way, and thinking deeper.
Dr. Tim Mazzola 30:58
But it takes time to think and it takes time to do these kinds of examinations. For example, Jill, when I first opened the clinic six years ago—it's Breakthrough Regenerative Orthopedics in Boulder—my new appointment times were 60 minutes and my follow-ups were 30 minutes. And I thought I was really putting it out there. Then I met up with a couple of other of my colleagues from around the country, and one of them had three-hour initial visits. And I thought, “Gosh, he's really inefficient.” I kind of judged that a little bit.
Dr. Tim Mazzola 31:35
But he is a genius. His name is Bradley Fullerton, and he's out of Austin, Texas. He is an incredible innovator in the physical examination in thinking about fascia, how muscles integrate with fascia, and how we're one big tensegrity system. And when there are breakdowns in the whole, then it shows up with weaknesses and they can have far-reaching effects. In any case, what I'm now doing is 90-minute new evaluations. I've been humbled and I had to take a little bit more time because I was running out of time trying to explain what I was finding to my patients.
Dr. Jill 32:12
Yes, because part of what your role is is teaching too, not only the medical students but the patients. One thing I thought earlier that I think is such a big thing that we need to teach is… So many patients have seen an MRI with an orthopedic surgeon or someone who's caused fear. And then they're stuck; that image is stuck in their mind. And that can, I think, create illness where there maybe wasn't because they fear this image that told them that they had this injury that's uncurable or whatever. How often are you explaining to patients the limitations of imaging and taking away some of that fear that's maybe been created by other medical providers?
Dr. Tim Mazzola 32:52
Yes, it's such a good point, Jill. Just yesterday I had to do it twice. Yesterday was my intake day and follow-up day for new patients. And today was procedure day, so today was more fun. Yesterday I had two patients exactly like that, very focused on the MRI images of their lumbar spine, just exactly what you described. And they had had surgery for a herniated disc, and they had some persistent, ongoing symptoms. One of them was certain it was the disc. It was quite an educational process for me to show her in three or four different ways through physical examination that, “Look, I'm really not concerned about your disc. I know that's on the MRI; your surgery worked.” I was validating the surgeon did a good job. After having surgery on a disc, the surgeon rightly doesn't want to do another one because then you start getting into scar tissue, further issues around the [inaudible].
Dr. Jill 33:47
And immobility.
I want to go back to fascia too, because I think that for me, that's the biggest aha. Maybe you can tell our listeners: How much fascial training do we get in medical school? [laughter]
Dr. Tim Mazzola 34:02
That's just the glistening stuff you have to cut through to get to the tissues you want to look at in the cadaver.
Dr. Jill 34:07
Right. It's like the appendix and the thymus—why would God ever give us any of these things that we don't need, like fascia?
Dr. Tim Mazzola 34:16
Historically, it has been completely disregarded. If you look at anatomy textbooks, it's the thing you have to get through to get to the muscle.
Dr. Jill 34:25
By section, exactly.
Dr. Tim Mazzola 34:28
And then the muscle is the empowering agent that moves the limb. The nerve is what takes the message from the brain to the muscle. In both of those cases, the but is that fascia is structurally super important. And many muscles in the body take their origin from fascia, not from bone. That's number one.
Dr. Tim Mazzola 34:51
And then number two: When it comes to messaging within your body, there is no system that's as fast as the fascia. By the way, they have little myocytes in them—little muscle cells—within the fascia and they can become chronically tensioned, usually in an effort to stabilize the segment that is unstable. For example, when you are walking down the sidewalk in wintertime—it's a little icy, and you don't see that little piece of ice—and your foot slips, but then you do the correction really fast, that doesn't get to your brain. That's just fascia, actually. And [with] your reflexes communicating through your muscles and your fascia that fast, the brain can't get involved in that. It's just too slow. So that's your fascial system riding the ship, if you will. That's why you need to keep moving, you need to keep it breathing, and you need to keep it well vascularized—blood flow in, blood flow out. You don't want to get too tight, but you don't want to get too loose.
Dr. Tim Mazzola 35:46
Bradley Fullerton in Austin, Texas, has been the biggest advocate of “We need to tighten up the loose injured fascia.” And then myself and then Phillip Steele out of Helena, Montana, we're bringing up that we need to free up the fascia much more like the bodyworkers do when we're doing fascial release. We can do that with fluid on a needle like we do around our nerves. We can do it with the fascia to free up a tissue plane, desensitize the nerves that are in that tissue plane that might be stuck in that tight fascia, get more glide and more motion, and decrease pain. But it's true that in some cases you want to tighten; in some cases, you want to loosen. So Brad's right; we're right. It's just that you have to be able to learn and discern who's right when and in which situation.
Dr. Tim Mazzola 36:32
We've had a tug-of-war over the last five or six years. And we've teamed up—we call ourselves “the meeting of the minds”—and we get together once a year and we evaluate patients over a weekend. We take two hours with the patients and all three of us get to lay hands on, scan, ask questions, and do physical. And we teach each other and we all get better. For our patients who get those two-hour sessions, it's a real gift.
Dr. Jill 36:53
That is so fascinating. I've learned just because I have a massage therapist who's really into fascial work and then a physical therapist who does counterstrain and strain and that kind of work. Both of them have taught me the power. And it's interesting because I'm on the spectrum of mast cell activation and Ehlers-Danlos types of patients, which are the ones that are super mobile. And I see all kinds of cervical… You name it. It can be very severe symptoms when things aren't holding up your brain, for example—the cervical spine. I'm sure you deal with that.
Dr. Jill 37:24
I want to have you share maybe a couple of examples of patients. If people are listening out there and are like, “Could this be helpful for me?” what are some of the common things or some of the really cool cases you've seen? Do you want to share one or two of those?
Dr. Tim Mazzola 37:37
Yes, sure. In general, when you think of regenerative medicine, I think for the listeners and for the physicians that are listening, the main two areas that have proven benefits are in chronic tendinopathy with interstitial tears… The best studied are lateral epicondyle, so tennis elbow. I would say gluteal tendinopathy has amazing data. There's some evidence around Achilles tendon and rotator cuff, but it's not as good. Patellar tendon—it's kind of mixed messages.
Dr. Tim Mazzola 38:11
I can poke holes in most of the studies that are negative, Jill. You have to be able to read these critically. And I don't want to get too political about the whole thing. But I'll tell you this: The articles that end up in JAMA are the ones where it's always negative: It doesn't help. They want it to be pharmaceutical or surgical.
Dr. Jill 38:30
Yes, the same as fish oil or CoQ10, or, you name it—anything that might be helpful. It's the negative ones that get published in the large journals.
Dr. Tim Mazzola 38:37
Yes. The craziest thing is that the top two I think of in orthopedics are glucosamine and chondroitin for osteoarthritis, and then I think of PRP for Achilles tendonitis. Those are two big ones that were published. In both cases, what's the craziest thing is that both the control group and the treatment group did amazing. The conclusions that are drawn are really bizarre, actually. The conclusion in both of those studies should have been like: “Wow, why was the placebo so effective? And look, this other stuff's really effective too.” But instead, it was: Oh, it didn't separate from placebo; it must not be very good. And the way they set it up in both cases was like they were intending for it to not be able to show no difference. But that's my small political statement.
Dr. Tim Mazzola 39:24
But tendonopathy and then osteoarthritis. Knee osteoarthritis—I will tell you this: There are, I think, if not 11 for sure, maybe 12 meta-analyses. So a study of studies has been completed. It's usually one a year because those are easy studies to do, and people just add on the next one or two studies that have been published since the last year. And then they get their name published on something. But what they do is they say, “What's the best injection for knee arthritis?” And they compare PRP to hyaluronic acid to steroids to maybe prolotherapy or saline, or something like that. Year in and year out, the meta-analysis concludes the same thing: PRP is the best thing that we have for knee arthritis at this point in time. It's at least 11, if not 12, meta-analyses now. Usually, one meta-analysis that's in favor of something is enough to change the standard of care.
Dr. Tim Mazzola 40:15
If we have studies that've been done that have changed the standard of care to the 12th power, there is maybe nothing we have in medicine that's as well proven, but insurance will not pay for it. And I think there are reasons why that has to do with dividing up the medical pot of money in the medical pie. Device makers and operating rooms need to run and all the rest of it. In any case, I don't think those are probably ever going to be paid for, unfortunately, because of that.
Dr. Tim Mazzola 40:45
So tendinopathy and knee arthritis are the top two. And then, of course, you can do ligament laxities. [inaudible] chronically sprain their ankles or an MCL strain of the knee, those would be good examples of ligaments that are easily treated with regenerative medicine.
Dr. Tim Mazzola 40:59
The more interesting cases for me just keep getting more and more interesting the longer I practice. I'm getting more and more complex patients. And I think that's because that's part of the deal. As we grow in our ability to help people, we get more challenging things coming our way. Sacroiliac ligament laxity has been a focus of mine for a number of years now, and I was fine with treating it. It was just something that people were missing. I had learned from some prolotherapists. It was really helpful for people with chronic hip pain, low back pain, and sometimes leg and knee pain.
Dr. Tim Mazzola 41:35
But then I met Kristen—I think it was the first year I was open in Boulder—in 2018, and that was the case that changed the course of my career, if you will. And now I really have a lot of energy around SI ligamentous laxity, learning how to diagnose it, how to treat it, and then teaching about it. I think it's one of the biggest holes in orthopedic medicine that's not been understood.
Dr. Tim Mazzola 42:01
People end up blaming posterior hip pain, sometimes anterior hip pain, and even low back pain on either the spine or hip. So they go to the spine surgeon; they get an MRI. Sometimes it'll show some things, sometimes it doesn't. They're like, “Well, it must be your hip.” They go to the hip surgeon, and they say: “Well, you've got a little labral tear, but it doesn't quite meet the criteria. It seems like it's posterior hip pain. It should be in the front. You probably should talk to the spine guy.” Then they get an epidural steroid injection and they get radiofrequency ablations and they see the pain management person. They inject their piriformis and everyone's blaming the piriformis. But what's not well understood [is that] there's anatomy around the SI ligament that's really important.
Dr. Tim Mazzola 42:39
And this has been my discovery: Between the ilium and the sacrum, you have the SI ligament, and it stabilizes that hemipelvis. And then you have it on the other side too, and the pubic symphysis in the front. If one of those is unstable relative to the other, you have asymmetry in your pelvis, and then you're always going to have rotations—I mean always.
Dr. Tim Mazzola 42:59
The other problem that I noticed and couldn't quite explain was that every time I found SI dysfunction, [which] is what I called it at the time, they'd always have glute weakness. When I'd do sideline gluteus medius assessments, they couldn't hold their leg up. And like, “What's that about? Why can't they activate their glute?” So I dug through the literature. I watched your movie, by the way. Thank you so much for inviting me to watch that. That was fascinating. But every time you got yourself a new diagnosis, you just dug in, and I love that curiosity and your persistence. And I am the same way. When I have a problem I can't solve, it's like, “Okay, I need to figure this out.” So I've dug through so much literature.
Dr. Tim Mazzola 43:36
Essentially, what I've come to realize is that the posterior gluteus medius, which is one of the most important hip muscles—the most important muscles in our body for staying upright and on our feet and being able to walk—attaches to the SI ligament. This has not been published. This is something I'm in the process of publishing. I'm doing research on cadavers to make this known. There's a physical exam. You can test for SI ligamentous laxity. It's from Diane Lee. She's a physical therapist—she taught at my conference—and I think maybe the smartest PT in the world, maybe the best critical thinker on physical examination in the world I've ever met. She created this physical exam working with Andry Vleeming, who was a leader in the concept of SI ligament laxity back in the early '90s—'92, I believe it was. It's gone completely untaught, except for the people that go to work with Diane. Fortunately, she has a woman in town named Dawn Sandalcidi, a great PT friend of mine. Lovely human. Just retired. Way to go, Dawn. Dawn came up and taught me the examination after learning it from Diane.
Dr. Tim Mazzola 44:47
Kristen, the patient I'm going to tell you about, had a really bad case of SI ligamentous laxity. I was prepared for that because of Diane and Dawn. Kristen is also a physical therapist, and she's a lovely human—one of the nicest people I know. But it was the first day I'd ever met her, and she was going to tell me her story. I said: “Hey, you're a PT; just give me the quick story. I really want to do my physical exam” because I only had 60 minutes at the time. She was like, “I can do it in 10 minutes, no problem.” I was like, “Great!” Forty-five minutes later, after she finished her story, you know what she concluded with? She said, “Tim, I feel like since I've had my pregnancies and I had my babies, my SI ligaments got stretched out and they just never recovered.” And she was absolutely right.
Dr. Tim Mazzola 45:32
And I cried. We broke down in tears because it was just so sad that this physical therapist who had worked in our system for six years was trying to find help from the spine surgeon, from the hip surgeon, from the pain, epidurals, the whole thing, and just couldn't get help. And she was out of work for four of the six years. She had to quit work. She couldn't sit for 20 minutes to go out and have coffee with a girlfriend. It was affecting her social life, her professional life, and obviously her marriage. She couldn't drive up to the mountains with her kids to go skiing. She couldn't ski. That was the last thing she was going to do. So we got her treated, and within about a year, she was back to doing most of the things that she wanted to do.
Dr. Tim Mazzola 46:12
She was the leadoff speaker at my conference. She presented the case of a woman with SI instability, and people did not know it was her. When they got the big reveal—when she said, “And I can tell you that this patient met their long-term goals of being able to sit for 8 to 12 hours to drive their kid to college”—there was not a dry eye in the place. It was fantastic. That was a really great case where she's back to work. She's now teaching others. She was teaching at my conference. It was so neat to see her full circle.
Dr. Tim Mazzola 46:51
There are others that are like that. I could go on. But the most recent discovery I think that we put together at this conference is Dawn—who I told you about, the PT in town—and my buddy Phil from Helena, Montana, got together. She flew up to Montana, and they worked on a couple of patients and also figured out that the lumbar multifidus inserts onto the SI ligament too. That's kind of a new discovery. So we have the multifidus and the gluteus medius meeting at the SI ligament. Now I'm not just treating the gluteus medius in the SI; I'm also treating the multifidus. And I think that's the next frontier to change people's lives for the better. It's fun.
Dr. Jill 47:29
That's so fascinating. In this area with SI, the symptom—again, forgive me for my ignorance, because this is your area of expertise and not mine—would they mostly complain of inability to sit without pain or inability to squat? Or what would be a physical manifestation of these SI issues for someone day-to-day? What would they tell you?
Dr. Tim Mazzola 47:48
There are a few different ones. It depends on, as Diane Lee would say, meaningful task. For some people, it's the ability to walk and to ambulate. For others, it is to sit. And for others, it's to lay down. The most common is sitting difficulty. Sitting tolerance is the limitation that I see the most, and then walking tolerance is number two. It's usually manifested as pain in the butt—the posterior gluteal region—that oftentimes will affect their low back and wrap around to the front of their hip too, because remember, they're going to have that rotation. So they're effectively getting a femoral acetabular impingement in the front of their hip when their hip is rotated that way. If it's rotated the opposite—if this is the cuff, this is the ball, and it's rotated back—now it's functionally like a dysplastic hip that's uncovered, and the labrum is at risk in a different way. In both cases, the labrum is at risk, so they oftentimes have anterior hip pain, and then their other muscles are now all in spasm trying to stabilize the pelvis.
Dr. Jill 48:50
Exactly. Oh, fascinating.
One thing I want to be sure to talk about before we let you go is your conference. Tell us the title because I love the name of the conference. And then how did this come about? Because I think this is the next level of what you're doing in the world, and I'm so excited to share.
Dr. Tim Mazzola 49:08
Yes, for sure. It's called the Collaborative Care Collective. That is our website, CollaborativeCareCollective.com. We call ourselves C3. We've had our first annual summit. That's all we're starting with, but we'll probably eventually do things like this—do some educationals and do some webinars and whatnot.
Dr. Tim Mazzola 49:29
The way that it started—I guess I'll just say I was given a calling. It was one of those days—I had probably been fixing people's SI ligaments for three or four years and seeing [how] life after life changed—and I was overwhelmed by: “This is so sad that it's just me who's doing this” and maybe my two buddies. And there's a few others that do it around the country, no doubt, and they do it a little bit differently. It was weighing upon me—this Kristen situation. And I was like, “It feels like it's just not good enough for me to go to the grave knowing this and having discovered these things.” So I think that was the call that was placed upon me. It was like, “You need to make this knowable to other people.”
Dr. Tim Mazzola 15:16
So that's when I started doing the research. Like, “Okay, first I need to establish that the anatomy is real. And then I have to establish that there's a physical exam that can be done and it's valid. And then I will be able to publish data that shows that when I treat this, people are doing way, way better.” It was that constellation of those three things.
Dr. Tim Mazzola 50:38
So what did I do? What I realized was that Kristen's case—and I have another woman, Kathleen, who was the closing speaker at my conference—was another case of terrible SI instability. What was common in both cases to their success was that it wasn't good enough for either of them to have just met me. They had to have also had a really talented lumbopelvic physical therapist on their team and also somebody who was good at fascia work, like myofascial release or visceral fascial release or something like this.
Dr. Tim Mazzola 51:07
One of the gals had three of us on the team and the other had four on our team. What I realized is that we had developed a collaborative care team. We were texting each other and the patient didn't have to communicate all the messages back and forth. We were friends. It kept the patient at the center of our care team. We didn't make them come and interpret everything back and forth to us. We handled that so they could rest. And the goal was “Let their autonomic nervous system just calm down” and [for them to feel] that somebody's got them—that feeling, you know?
Dr. Tim Mazzola 51:38
What we realized is that we had something special—what we were doing in Denver. So then I reached out to a couple of them and said, “Hey, what do you think about…” “Would you be willing to consider…” They loved the idea, and they jumped at it. Then I got my physician colleagues from around the country—the guy from Austin and from Montana—we put together a team, and it took us about two years of meeting monthly to figure out: What are we going to talk about? And how do we get this message across? It was just beautiful, really. And the conference ended up being much more than just a medical conference. It was more like a love-in.
Dr. Jill 52:12
You're sharing the heart of it. I could just feel that. It's so important.
Dr. Tim Mazzola 52:16
Yes. Everyone just loves each other—all of our teammates on these collaborative care teams. We really appreciate one another. We all have the same heart for the patient. It seems that the people that we attracted had that similar kind of heartbeat. A lot of people—I can't tell you how many—came up to me and they were like: “Thank you for following your calling. I feel like I found my medical home.” Because none of the physicians on the group feel like we have one group that addresses all the things we're trying to accomplish, and this is as close as we can get. So that's what we're trying to accomplish—give people a home where we can learn to collaborate.
Dr. Tim Mazzola 52:53
And we were very strategic; we forced physicians, PTs, and allied healthcare workers, like bodyworkers, to all sit at the same tables to present cases and we'd make them talk to each other. That was intentional with the goal, like, “Guys, you need to start talking” and realizing what other people know that you don't, because the common theme was that had either of those gals who we presented at the conference only seen one of us, they wouldn't have gotten better. They really needed to be seen from three different points of view.
Dr. Tim Mazzola 53:22
And functional medicine falls right into that, Jill. That's why I've sent you two patients since we chatted on Sunday. I've always believed in the importance of functional medicine and getting our patients healthy enough for their bodies to heal when I do whatever treatment I'm going to do, because that's our underlying philosophy: The body can and does heal, and under normal circumstances, it does so routinely. In orthopedics, at least, when something's out of whack or broken beyond repair, then we need to give it a little assist. We just use our God-given cells of platelets and stem cells. That's how our body normally heals—with platelets and stem cells. Then they facilitate all kinds of cellular communication that elicits a healing response.
Dr. Tim Mazzola 54:03
So that's our underlying philosophy—that the body can and does heal, and we're going to facilitate that. And then our goal at Breakthrough, the big thing is we want to get people back to doing the things they love to do with the people that they cherish. That's really our buzzline of why we exist. And I can see it in your practice too. You want to see people doing and thriving. Anyway, I share that heartbeat with you.
Dr. Jill 54:28
Oh, I know. I love just getting to know you more, and today even more deeply, because it really is so common. I love your humility, and I hope I bring the same thing because I so much realized my limitations on how much I rely on people like you and PT. Even in my office, we have massage and all these different things, and everybody does their part. And that collaborative care—I love that idea!
Dr. Jill 54:53
The other thing that we share is that God's given us these places where we can serve and help people. But unless we're teaching the next generation, it's all going to be in here. I love that we connect on that level too, and I think it's so important for us to continue to teach the teachers and change the way we do medicine.
Dr. Jill 55:13
If you could go back, I'm thinking back to that surfer in California who had no idea what God had in store, what would you say to him? Or looking back at your younger self 20–30 years ago, what words of advice would you say now that you're where you're at with this perspective?
Dr. Tim Mazzola 55:31
No one's ever asked me that question. I have no idea what I'm going to say. I would probably say, number one, be gentle with yourself. Have self-compassion. And then understand what it means to love people well.
Dr. Jill 55:56
Yes. Oh, that's good. Now I've got goosebumps because, at the core—you and I, and hopefully anyone out there who's really, truly doing medicine in the right way—it's just loving people. It really, really is that simple. Granted, God has given us wisdom and all the other things, the skills, but truly, the heart of healing is that loving compassion, which you're doing with the conference and you're doing every day. Oh, Tim, thank you for the work that you do. Thank you for the joy and energy that you bring.
And where can people find more about you and your clinic? Where's your website?
Dr. Tim Mazzola 56:32
The medical clinic is Breakthrough Regenerative Orthopedics. I think it's BreakthroughOrtho.com. That's all kind of one big word. And then the conference is the C3. But you have to type in “Collaborative Care Collective” because there are a few other C3s out there. CollaborativeCareCollective.com. It would be those two things.
Dr. Jill 57:01
If you're out there and you're in physical therapy, fascial work, or any of these areas, check out that conference. I really want to see that grow, because, Tim, I think it's so critical. I think more than ever with the pandemic, people felt isolated. But I think even practitioners and physicians, we're all on our islands. Even you and I in functional medicine and regenerative medicine, I'm so excited about the collaboration because we all need one another.
Dr. Jill 57:24
Well, thanks for the work that you're doing. Thanks for following the call to medicine. I really, really love the work you're doing. And I hope all of you listening will go check this out and then, if you're in those fields, you'll check out the conference as well.
Dr. Tim Mazzola 57:38
Yes. Well, thanks, Jill. Thank you so much. And yes, I look forward to more opportunities to work together. I really do. I'll have to talk with my planning committee, but I hope we can get you maybe to come and say some words. It's right here in Denver. You don't have to travel. It makes it easy.
Dr. Jill 57:54
I would love that. You can count me in. [laughter]
Dr. Tim Mazzola 57:56
Okay, excellent. I'm looking forward to it.
Dr. Jill 57:58
Thank you.
* These statements have not been evaluated by the Food and Drug Administration. The product mentioned in this article are not intended to diagnose, treat, cure, or prevent any disease. The information in this article is not intended to replace any recommendations or relationship with your physician. Please review references sited at end of article for scientific support of any claims made.
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