#264 ‒ Hip, knee, ankle, and foot: common injuries, prevention, and treatment options

Hey everyone. Welcome to the Drive Podcast. I'm your host Peter Attia. This podcast, my website and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness and we've established a great team of analysts to make this happen. It is extremely important important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. If you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of a subscription. If you want to learn more about the benefits of our premium membership, head over to peterattiamd.com subscribe My guest this week is Dr. Adam Cohen. Adam is Board certified in both orthopedic surgery and sports medicine and has extensive training and expertise in various sports medicine injuries. He's the Director of Sports Medicine at Ortho Manhattan and serves as the team Physician for Horace Mann Athletics. He also holds academic appointments at the NYU Langone Health System and the Mount Sinai Health System. Adam previously served as the Assistant Team Physician for the New York Yankees and and served as a consultant for the US Open Tennis Championship as well as provided orthopedic coverage for the New York City Ballet. This episode is in some ways a follow up to the episode I did with Dr. Alton Barron which focused on the upper extremity. In this episode with Adam, we're going to focus on everything you need to know about the lower extremities. This includes of course, the hip, knee, ankle and foot. For each of these we walk through the anatomy, what can go wrong, what causes injuries as well as what surgical and non surgical management of these things looks like. We then end the conversation looking at how someone can go and find a good surgeon if they need any of these issues addressed as we discuss them today. In addition to our conversation where Adam of course uses these images and models, he also runs me through the typical exams that he will do for each part of his assessment. These exams will make a lot more sense if you can see them rather than hear them. So for the audio portion of this podcast, we will not include any of the exam content. It simply won't make any sense. So if you choose to listen to this in audio, you may still want to go and check out our YouTube page to look for the exams. Of course you may just choose to watch the entire thing on YouTube so that you can see his images. So without further delay, please enjoy my conversation with Dr. Adam Cohen.

Hey, Adam, thank you so much for coming from New York to Austin. Very excited to do this. And of course, this needs to be done in person. We're going to do today what I did with your colleague Dr. Baron a little while ago on the upper extremity, which is everything you need to know about the lower extremity and its orthopedic injuries. So for each of the major issues, the hip, the knee, the foot, we're going to talk about the anatomy, talk about what goes wrong. We'll talk about the surgical and non surgical management for those things. So thanks very much for joining.

Sure. Great. Thanks for having me. Appreciate it.

Let's start with the hip.

Yeah, let's jump right in. So let's talk about the anatomy of the hip. The hip joint is a ball and socket joint. I have a model here. Unlike the shoulder, it's a very contained concentric joint and much more stable under normal circumstances than the shoulder. It's a deep socket. The socket is called the acetabulum. This is the femoral head, and the femoral head is covered with cartilage. Let me place this down for a moment. If we just focus on the proximal femur, we have the head, as I mentioned, the neck, and this is the subtrochanteric region, and this is the trochanteric region. The acetabulum is formed in utero. It starts about fourth week in utero, and then by the 30th week it starts to develop. And I think that's a good starting spot because a lot of the problems that we see or a number of the problems we see in the hip really start that early. There is a condition called developmental dysplasia of the hip, used to be referred to as congenital dysplasia of the hip. But we felt that there are more factors involved than any congenital ones. In particular, basically what happens is if the hip is not concentrically reduced as either late in stages of pregnancy or in early childhood, the first several months of life, in fact, the acetabulum will not form properly. So, for example, if the ball is shifted out of the socket, let's say due to positioning in utero, where it's not completely in, the acetabulum will not form correctly. What that means is, is that after birth, if it's sitting outward, this deep socket will not form and it'll be quite shallow. That has major implications later in life, because if it's not deep in the socket, it's sitting on the edge of the socket, which means there's greater pressure here. And that pressure can lead to mechanical overload and arthritis. So even conditions that happen much later in life can start quite early.

So a child that's breached, for example, during pregnancy. One of our kids was breached as soon as he was born. They immediately said he has hip dysplasia. He was in a brace for nine months. He was in a splayed, open brace for nine months. And I remember sort of freaking out, thinking, oh, my God, he's never going to be able to do anything. And they're like, no, he'll be fine, like, as long as you keep him in this brace. And he was in that brace 23 hours and 45 minutes a day. He basically only came out of it for a bath. It was actually hell on my wife. But nine months later, his hips were fine. That's kind of remarkable.

So it's called a Pavlick harness, and it actually is quite comfortable for the child. You can put it on and take it off without much of a fuss, no more fuss than normally. But we know that if the ball is not sitting in there, in that socket, it will not form properly. So the harness keeps that positioning until the acetabulum forms properly. You know, the exams that pediatricians do, we always check the hip, and we want to make sure that it's in the socket. I think going forward, a lot more physicians and orthopedic pediatric specialists are using ultrasound to better quantify that the hip is in the socket, because we really don't want to miss any. Any dysplastic hips. If you have a dysplastic hip, you are going to get arthritis. Now, it doesn't mean it's going to be symptomatic necessarily. It doesn't mean you're going to need a hip replacement. But people who have dysplastic hips, that is an acetabulum that did not form properly, are going to get arthritis. It's a mechanical problem where the forces are unevenly distributed across that ball and there's edge loading, and that will break down over time. And no matter what you do, do.

We have a sense of what the incidence is of congenital dysplasia, or whatever.

The new name is, your developmental dysplasia of the hip?

As far as how many children born, or for every thousand kids that are.

Born, I think it's about one in a thousand. I think I might be wrong. I would need to check on those numbers. The important part is that we shouldn't miss any. And if we're basing it solely on an exam, I think we're going to miss more than if we base it on ultrasound. And the ultrasound is really not that hard to do and certainly teachable. But that confirms that the ball is in the socket and the socket is healing properly. There was a study once done many, many years ago where it was an animal study and they put a cube shaped object in the acetabulum and the acetabulum formed in the shape of a cube. It is going to develop based on what is sitting in that area. And if you wait too long, what happens is the soft tissue deep in the socket will become hypertrophied and it's harder to get in. So I have patients that I've seen who they come in to see me because their hip hurts. They're 28, 29 years old, never had a problem before, did not suspect anything wrong. Get an X ray of the hip and they have arthritis. And it's quite a shocking development because you don't know, you don't necessarily know.

And for folks just listening, the plain X ray is a good enough tool for that diagnosis because you'll see the absence or thinning of cartilage where you should see it, as in that diagram there.

Yes. For arthritis that becomes symptomatic, we can usually see that there obviously is a spectrum where the process starts to happen before we're even clinically aware of it. And I think that's the future. That's the trick, is to find out before someone has clinical arthritis, do we know about it and what can we do to avoid it. And I also think it's important to really discuss what arthritis is, because I know just from my own patients, I say you have arthritis and there's a lot of conversation of what, what actually does that mean? The surfaces, the ends of all long bones have cartilage at the end. It's a layer, it's a very smooth layer. And the only reason joints move pain free without friction is because of that cartilage. The coefficient of friction of cartilage is so smooth, it's smoother than ice on ice. There's no man made substance. I mean, it's smoother than Teflon and it's a biologic substance. It's constantly remodeling, albeit slow. It is a biologic tissue that can adjust to the pressures. So part of arthritis is the loss of that cartilage, The Cartilage starts to thin. The chondrocytes, which are the main cellular, is the cell of cartilage. Its job is to create proteins to make the extracellular matrix so that it remains healthy. But chondrocytes, the cartilage itself is avascular. It gets its nutrition through diffusion from joints. And they're not very efficient at making the extracellular matrix, which is imperative. So if there is overload of the cartilage, the chondrocytes will respond. And sometimes they die, sometimes they go into senescence and cartilage. If you take the Knee, for example, 2% of the cartilage is chondrocytes. They don't have a lot of leeway when the load is substantial.

So when a person comes to your office and they're complaining of hip pain, what is the most. I don't know. Call it the three most likely sources of that pain. We'll go through some of the examinations so people can sort of see how you will go about gathering that information. But what would be the top three most common diagnoses you'll encounter for a person with hip pain? And let's maybe bracket this by saying a person under 50.

So, you know, someone comes in with hip pain, right away I'm sort of thinking about the different layers of the hip. So in my mind I'm thinking, is this a bone problem? Is it a bone cartilage problem? Is it a connective tissue problem? That is a ligament problem? Is it something, Is the capsule too loose? The ball is held in the socket by a capsular layer. Is it a muscle and tendon problem? So we sort of from deep to superficial, we have bone cartilage, and then we have connective tissue, ligaments capsule, and then we have muscle tendon. And then we also have to recognize that sometimes hip pain is referred pain, that is, it could be coming from your back. So we're thinking about those separate layers, and then we're also thinking about locations. So someone who has pain in the front of the knee, sorry, the front of the hip is different than someone side of the hip, back of the hip. So we need to tease all those factors out. So someone under the age of 50, you would not necessarily be thinking about arthritis, but it obviously is always on your mind finding out a clue to what the diagnosis often depends on when it hurts, where it hurts, and what their activity is. So, for example, you know, I think about patients, they come in, they say, you know, we have the endurance athlete, we have the power athlete, we have.

The non athlete, presumably the Non athlete.

The individual who is flexible gymnast, ballet dancers, they sort of have different patterns of hip problems. If we start with the endurance athlete, let's start there. Endurance athletes is we start deep down in the joint. The first thing we have to rule out is that this is not a stress fracture. Stress fractures can happen in a lot of different areas in the lower extremity. And we separate them out is to high risk stress fractures and low risk stress fractures.

Risk of bad consequence if not treated.

Correct. So if someone comes in and they have a marathon coming up and they say, my hip hurts, we have to make sure that this is not a stress fracture. Femoral neck, stress fractures. And just this is the femoral neck. So this here you can have a stress fracture right in that area. And it usually just starts as a little.

So just differentiate a stress fracture from a fracture.

Sure. So a stress fracture is something that occurs slowly. So a stress fracture at baseline, potentially normal bone with a substantial load to that bone that is in excess of what the normal healing capacity is of that bone. That is, bone constantly remodels. Every time we put stress on it, the microarchitecture is changing. There's small, tiny micro fractures that occur from. From normal weight bearing. The body is very capable of adjusting to that load and making new bone. When you start exercising or working out or running, the bone will get stronger based on the stresses that that bone sees. So for runners, for example, if you are training properly, there's no reason to expect that that bone can't adjust to the increased load that it's seeing. But oftentimes due to over training, where you're not giving that bone enough of a chance to heal, you develop these tiny little micro fractures that aren't given enough time to then heal. And then it gets compounded when you go run the next day and the next day, and you're increasing not only the number of times that you run, but you're increasing the distance and the speed all at the same time. You get groin pain because that's where stress fractures of the femoral neck hurt right away. We know we need to rule it out. And they tend to occur in the femoral neck. And we have two locations. Either this is called the compression side and this is called the tension side of the neck. And tension sided fractures, where you get a little crack in the bone here, are much more severe than compression side. But the bottom line is that we need to know that this exists.

And the patient will feel groin pain, which is otherwise difficult for them to differentiate. I Mean they're not going to come in and say, my femoral neck hurts. Correct. What is the actual feeling? Does it feel akin to what you would feel if you pulled a muscle in your groin?

It does, except it's very weight bearing dependent. So most people come and say, I think I tore a muscle, I think I have a muscle strain. I don't see a lot of muscle strains in runners without an injury, you run, you're training, you're not necessarily going to get an acute injury like that. So sort of the presentation's slightly different, but it hurts in the groin. And right away you don't let them run until you find out if it's the stress fracture. And here's why.

Sorry. The MRI is the gold standard.

It is so X rays, we always need to get X rays to make sure you're making sure that the joint looks healthy. There are other conditions that can cause groin pain, but it's usually negative. It's usually hard to detect a stress fracture right when the pain starts. The MRI is the gold standard to see that. It used to be bone scan, but that is impractical. And an MRI really is excellent at looking because you can see the architecture of the bone and you can see basically what we call edema in the bone or a bone marrow lesion and sometimes a crack in the bone. And it's graded. There's stress reactions and then there's stress fracture. A stress reaction is like a pre stress fracture. And the reason why it's a high risk stress fracture as opposed to a low risk is if it becomes a complete fracture. Which was the other part of your question, what's a complete fracture? It's where this completely separates from the ball. And that's very important in this area because the blood supply to the head comes from this direction. So all of the nutrients that the ball sees comes from this direction. If this breaks and the blood supply is disrupted and that's not corrected quickly, then the bone in that area no longer has blood supply, it will die and can't support the cartilage anymore. The cartilage will collapse and you get AVN of the head. And that is a hip replacement, which is obviously difficult for anybody. But for someone who's in their 20s, 30s, 40s, it's.

So the treatment for this when you make the diagnosis is rest.

Is rest, typically. So if it's on the compression side, this is the compression side. You can go on crutches until you start to have no pain with weight bearing. Once you have no pain with Weight bearing, you can continue along that path. Takes six to eight weeks to heal, and then you can slowly start up your exercises to regain some of your endurance, physical therapy, et cetera. And oftentimes I'll get a follow up MRI to make sure that it is healing and not increasing. If the stress fracture is on the tension side the other, because you can imagine if it starts to crack on this side and the whole weight of your body is coming down this way and it can more likely displace mechanically, that often will need to get surgery, which is to put pins in. We will often just put three pins from here to here into the femoral head and it will heal and they heal quickly. And oftentimes you can let that individual bear weight sooner than you.

So paradoxically, the riskier stress fracture usually has the quicker recovery because they go.

To surgery as opposed to the tension sided stress fracture. You can often end up getting, walking around doing what you need to do in your normal life too. I've had patients with compression sided stress fractures who are having so much difficulty with just their getting onto the subway, getting to work with the crutches, they wanted to have the surgery so that they can do that.

Are there any differences in hip injuries between men and women? I mean, one thing that stands out to me is just having taken care of a number of patients is again, at least in the under 50 population, it seems that far more female patients of mine have had hip issues than male patients. I've had a number of females who have had hip resurfacing, labral repairs. Again, these are all young women, so they're typically in their 40s. Is that just a small number issue? And that's actually not a disproportionate finding. Or do women, based on the anatomy of their pelvis, are they more susceptible to labral tears or other types of injuries in the hip?

There are different patterns. There are certain conditions of ligamentous laxity that are more prevalent in women. Developmental dysplasia is more prevalent in women. And so sometimes that sometimes is the inciting issue. There are other types of hip problems that are more prevalent in men. There's a condition that we often have to treat that has implications to a lot of the structures around the hip. It's called femoral acetabular impingement. Femoral acetabular impingement is, we think, at least the prevailing theory is. Let me tell you what it is first. Basically on the neck, right around here, it's actually sort of in the front, a bump develops. If I Look at the model, a model here of the femoral neck. And there's sort of one here. And this is typically the location of it. And I'll just color it. You get a prominent bump of bone. So this area, it's called a cam lesion. And what happens is it changes the shape at the head and neck junction. So it's not really spherical. It's sort of this oblong shape. So that when it goes into the acetabulum, it can pinch on the acetabular rim. And on the acetabular rim is not only the cartilage, but the labrum. Let me show a picture. So if we open up the hip and we look inside, again, here's the cartilage, this blue hue, and this lining is called the labrum. So if the ball is no longer spherical but oblong, the cam lesion will pinch on the labrum, and the labrum will tear and will injure the cartilage that is connected to that area. So how does this happen? We think it happens because the growth plate, which closes in males, late teens, slightly earlier in females, because of repetitive stress from certain sporting activities, hockey, football, basketball. If there's impingement because of those high stress sports, that growth plate will have a delayed closure and it will close later and a new bone will form in that area. And that's important because one of the risks of FAI that continues is you can get arthritis, because if the cartilage is being injured, then it increases the risk of needing a procedure later in life. That's more common in men. Fai, it's certainly prevalent in women, too. Not as sometimes it's different sports, but I think it's because the growth plate closes a little earlier in women that it may not be as much of an issue. It also may be the type of sport, the power type sport, where there's a lot of ground reaction force when you land tends to make this situation worse.

Now, in the shoulder, the labrum creates effectively the socket. So if you have a person who's never had a subluxation of their shoulder, that labrum is creating kind of a vacuum around the glenoid head. This seems to be a much more stable ball and socket than the shoulder. What is the role of the labrum in stabilizing that joint? I can understand how asymmetries can cause arthritis, but just in terms of pure stability, you don't really hear about dislocations of the hip very often. Obviously. The most famous example I can think of is Bo Jackson, which maybe we can talk about that case a bit. But what is it that the labrum is doing from a stability standpoint? Or is it simply just providing a clean and neutral articulating surface for the cartilage?

It also helps to create a seal around the ball. So it is a sort of a suction effect, too. And it's very similar to the shoulder. We have dynamic stabilizers in the hip. It becomes more of a concern when the hip isn't formed normally, so.

Because then that acetabulum becomes flatter, which actually mimics the shoulder a little bit in terms of lack of stability.

Correct. And some of those patients who have instability of the hip, because maybe they have some dysplasia, so the ball never really is in the hip. They have greater motion. I mean, ballet dancers would be a perfect example.

That comes at the cost of less stability.

That's right. And some of those individuals who actually have a hypertrophic labrum, it actually gets bigger because it's being asked to do more. There's also, I mean, you could see in the picture here, there's a ligamentum teres. I don't know if you remember that.

From medical school, only slightly.

It's basically called the round ligament, and we didn't think it did that much. It provides some blood supply early on in life, and then later on, doesn't really provide much blood. But for people who are unstable, this provides a secondary restraint because the ligament connects the ball to the socket. So one thing we need to be aware of whenever you're operating on the hip is to leave that alone in individuals who are unstable because it's providing a bit of stability to that area.

Got it. Is this a good diagram to show how you do a total hip replacement or a hip resurfacing, or explain what some of those procedures look like?

Sure. So in a hip replacement, basically, you're taking off the neck, you're cutting this off, you're inserting a metal stem down the shaft of the proximal femur. And then in this area, you're putting a metal cup in that region. And then there's different ways to do this, but the metal cup then has a plastic liner on the inside.

And is that still made out of ultra high molecular weight polyethylene?

Yes.

That's amazing. That's what they were doing 25 years ago. Why has that operation become so tolerable compared to the version of that operation I saw in medical school? Today, it's an outpatient surgery. The people go home. They seem to recover so well. People used to be debilitated by that operation 30 years ago.

So a lot of the approaches are different now. And honestly, in every aspect of the surgery, technology has helped us. So back when I was training as a resident, almost all of the hip replacements were done through a posterior approach, an approach through the back muscles.

So which muscles were actually getting cut?

So the gluteus muscles, which are huge. Right. And now you go anteriorly. Now, I don't perform. It's not one of the surgeries that I perform, hip replacements, but it's much easier to spare the muscle and the ligaments when you do an anterior approach, that is an approach from the front.

So you're saying less of the morbidity is due to less muscular damage on the approach.

Also, just the way we medically manage patients around the surgery, there's. We give medicine to decrease blood blood loss. And so the whole process has become much more efficient and safer, to be honest.

And a resurfacing leaves the femoral head intact and only addresses the acetabulum? No, it's the opposite.

Yes.

Okay.

And I don't do this. I'm not going to speak to the different intricacies of that, but there are ways to preserve the amount of bone that you're taking if the individual is as young. I think that's done less now, actually, lately.

So we talked a little bit about what are kind of the problems that people will show up with when they're young. When people are seeing an orthopedic surgeon north of 60, 65, I'm guessing it's arthritis and fracture that would be the dominant injuries. Is there anything else that's showing up as significant?

In addition to those problems, we also see muscle and tendon problems. In particular, we see issues with the tendons on the side of the hip. And this is actually not just in older individuals, but all individuals. The main abductor of the hip is the gluteus medius, which you could see coming out. It sits on the back of the pelvis and attaches at the edge on the lateral or the outsides of the femur. And these muscles help to.

Is that glute med and min?

Yes. Correct.

And glute max is not shown here?

Correct. The glute max comes across here and attaches a little bit lower down on the femur, and that's not depicted here. So this muscle is incredibly important. In fact, we consider this to be the rotator cuff of the hip.

Just those two?

Just those two. Correct. The gluteus medius and the Gluteus minimus. And it has a very similar profile. And just as in the rotator cuff, it starts to degenerate after a certain age. Same thing happens in the hip. This will weakness of the gluteus medius is very difficult because it's incredibly painful. Doesn't have great healing potential. We also see this in endurance athletes as well, from the repetitive stress. And we also see this in unstable patients because those muscles are trying to dynamically keep the ball in the socket, so they are working harder. Ballet dancers in particular have incredibly large gluteus medius minimus. Powerful. Part of the reason is because they're asked to do a lot to stabilize the hip. So we see tears there all the time. And we often approach that just like a rotator.

So are most of the injuries you see here under use or overuse? It sounds like they're mostly under use.

I don't think so. It depends. So the older we get, it doesn't necessarily matter whether it's overuse or underuse. These things will happen because that is just a normal trajectory of tendon problems, tendon pathology. The tendon cells, over time start to degenerate, just like all of our cells. And they go through process of senescence, like all tissue. And those senescent cells produce those factors that lead to degeneration of the tendon, causes inflammation, incredible amount of pain, and it's hard to treat, it's hard to reverse the process. Now, if you knew it was happening before it started, would you be able to do anything? We don't have that ability yet, but that's what we're trying to figure out, how to intervene before these injuries take place.

There's two things that jump into my mind here. The first is the obvious need for, I hate to use the word physical therapy because that really gets misconstrued a lot. But basically deliberate exercise that strengthens those muscles. When I used to be a cyclist, one of the challenges of that versus any sport truly is you're sort of in one plane, one dimension, right? So you get very, very strong quads, glutes and hams. You're glute med and min do very little. You're not really doing any abduction of the hip. And as such you get a very tight tensor fasciae latae. A lot of cyclists get really bad IT band pain because they just lack that strength there. And so an obvious way to fix this, which I was very lucky that I was able to fix this non surgically because I was having debilitating it. Band pain was simply doing a lot of strengthening for the abductors. So that at least suggested to me that you could be preventive in some way.

If I had any muscle that needed to be worked on and I had to pick one muscle group, it would be that muscle group. Starting from early teens. It is implicated in so many lower extremity injuries at the hip and the knee. A weak gluteus medius. Weak abductors can cause a lot of injury. And I do believe that the stronger they are, it's almost like bones. The higher the bone density you get.

Early on, the higher your glider, the longer it.

That's right, because it's going to degenerate. It is just going to happen. And so the stronger and healthier the tendon is at a starting point. This is sort of how I think about this. First of all, not only are you likely to have less injury, and I'm talking about ACL injuries too.

I'm talking about knee injury. It holds back the valgus. Everything that we're going to talk about in the knee.

Exactly. Hip fractures, which we started to talk about a little in the elderly. That too. These muscles are incredibly strong. And the hip flexors too. There was a study done out of South Korea that looked. It was an imperfect study, but it was pretty decent. They took a group of. It was retrospectively evaluated, but they took CAT scans of people who were in for a hip fracture, femoral neck fracture, elderly population, and they measured the volume of their psoas muscles. So this is the psoas muscle and this is the iliacus. Together they make the iliopsoas muscle attaches here.

And this is what picks your leg up.

That's what lifts your leg up. So if you stumble, you pick your leg up to save yourself. The volume of that muscle was significantly smaller than that of an aged matched control group who were getting CAT scans for other reasons. Now, we don't know why they were getting CAT scans. So that's, you know, it's a little bit confounding, but it showed that there was a significant decrease in volume in those patients who have hip fractures. So we know that hip muscle strength. So the important to get the abductor strong, the hip flexors strong. The problem with the hip flexors is that we're always sitting. Even if they're strong, they're often tight because we're always in this position. So it's important to see how your hip flexors are, make sure that they're flexible, because an IMBALANCE in the flexibility of that muscle group will also impact the antagonistic muscles in the back. The gluteus maximus, which extend the hip, and the hamstrings, which also extend the hip. You know, it's fine balance, but if I could work on anything to help prevent these things later, I think this is a good place to start.

The other thing that I've really migrated to over the past decade, as I've become very obsessed with all of these muscles, in particular those hip adductors, is the importance of training them not just in concentric phase, but also eccentrically. So there are these exercises we do in a training, I don't know, for lack of a better word, philosophy. Dynamic Neuromuscular Stabilization. DNS. There's a position called DNS. I was just doing it this morning, so I'm doing this stuff most days and you're laying on your side. So if I'm on my right side, you know, my right elbow is down, it's sort of like a plank. But you're on the knee and your hips are up and you're extending yourself forward as you're putting the hip back. So you are eccentrically loading the adductor as you go back and then you're concentrically loading it as you bring yourself back up. Now, for anybody who's done this, we've demonstrated these things in other exercise videos. I mean, five reps of this slowly, you feel like someone is jamming an ice pick into those muscles. It is remarkable how difficult it is, but you don't need to do a lot. Just doing a little bit of that stuff every day does so much in terms of lower body maintenance. And looking at this picture, I think it's pretty clear why it's such small muscles that have such an unfavorable angle at their attachment, right? In terms of like the contraction, you know, it has such an unfavorable lever arm for what it needs to do. So it really has to be strong.

Right?

Let's talk a little bit about fractures. Put aside just, you know, the 25 year old skiing accident freak acts, you know, you're going to see that all day long. But let's talk about the more predictable and far more catastrophic fractures to quality of life, which are these fractures of the femoral neck that are occurring in people due to osteoporosis and osteopenia. Now I talk about these stats all the time and nobody believes them because they're so absurd. But if you're 65 or older and you fracture that Hip, depending on the study, 15 to 30%, one year mortality.

Right.

Can you explain why that is? How do these people present to you and why is it so challenging to take care of that fracture?

A large percentage of those people, it's usually another disease that has overtaken their lives. And so they may have advanced stage cancer, they may have advanced renal disease. And it's almost the last event, the last straw. It's the last straw.

The hospitalization alone is just catastrophic.

That's right. And so, and it's very hard to when you're elderly. And if you don't, first of all, you break your hip, you come to the hospital. There has to be some medical management to make sure that it's safe to proceed with surgery. And everybody who has a hip fracture needs surgery. You can't treat this non operatively. It would be essentially a death sentence to do so. Because the goal is to mobilize as quickly as possible. Because for even the people who don't have the mortality of 20 to 30% within the first year, that's been a stable number for decades. I mean, every time they look at it, that's a stable number and that's within one year. So our goal is to get you.

Up and Adam, how much of that is really acute? It's pulmonary emboli, fat emboli, Michigan because of surgery versus, you know, two weeks out, they're okay, but then they fail to thrive and they die within the year.

It's not so acute. It really is spread out. The management of these patients is very important early on. So we like to get a full team on board.

Right.

A geriatric specialist, you need a team approach because you need them medically optimized before surgery so that they could safely go through the surgery.

How long can they take to get tuned up before surgery?

So it should be done within 48 hours.

Wow.

Before we had the medical management sort of model of hip fractures, you oftentimes were able to get the surgery done quicker. An orthopedist comes in, say, let's just do this right now. Everybody signs off, we have to do this. Let's go. When we have sort of the team approach, the medical doctors are like, listen, we have to get an echo. We have to do these other things. We need to make sure the bloods are okay. That has delayed the surgery slightly, but.

Probably gives better outcomes perioperatively it has.

At least in the studies that I've seen, people are able to get discharged sooner, which is a good thing.

But their long term Outcome is it.

Still seems to be about 20%.

Wow.

And part of the issue is, first of all, obviously, you broke your hips. There's a good chance you're weak. You now your npo. The first day you come in, they won't. No one will feed you anything. You don't get a meal. And then in bed for two days, where I have surgery, in bed for.

A week, you're probably getting dehydrated.

And then even for the people who don't pass away, who don't die, there's a decrease. About 50% lose a level of function. So if you were using a cane before, you're using a walker. If you're using a walker before, you're now in a wheelchair.

If you were walking normally, you might be using a cane. So there's 50% of people that go down a level in performance.

I once had a patient who was early on in my career. I was a junior attending and resident calls me and says to me, we have a patient with a femoral neck fracture. And he says, so tell me the story. He says, well, he's 40 years old. He was riding on the west side highway and he crashed and he broke his femoral neck. I said, well, I'm coming in now. Let's fix this right away. I said, just go consent him for the surgery in which the resident was a junior resident. He goes and talks to the patient about all the risks that and benefits of the surgery. I go in to see the patient and he's got this. Obviously, I expect him to be miserable, but he really was like. And I explained. And he goes, he said to me, he says, your resident just told me I have a 30% chance of dying this year.

He kind of forgot to age. Adjust that. Yeah.

I said, well, don't worry, you're not going to die. Somebody else is, but not you.

As you were talking earlier about the degeneration of the hip, obviously the first thing that comes to my mind, and I'm sure everybody's mind listening to this, is where do stem cells play a role here? Now we're going to talk about stem cells through all of these joints, but we might as well start here. When I hear that the tendons of those muscles and those muscles themselves are going to weaken, when I hear that my cartilage is going to weaken, when I hear that the osseous structure of the bone is going to weaken, all of these things make me wish I. I could just have newer and younger cells there. So what do we know about the utility of stem cell therapy here. What's the state of the art today?

This is a great conversation. And there's a lot of layers to this conversation because there's, you know, the dark side and the bright side of this. You know, when we talk about orthobiologics or biologics in general, basically, biologics, it's a class of therapies that, that are using your own natural resources to promote healing. So you're using a biologic product to encourage healing of diseased or injured tissue. So the most commonly used ones are blood, specifically platelets, bone marrow, bone marrow aspirate concentrate is called, and also fat. So if we sort of go through those three just to start there for prp, what are we doing?

So we take rich plasma, platelet rich.

Plasma, we take your blood, we draw it, and we take it down the hall, and we spin it in a centrifuge. And the centrifuge machine will separate out the different elements of the blood based on the density of those elements. So after you're done spinning it, you have a layer called the plasma layer, which is rich in plasma and platelets. And it separates out the red blood cells and a lot of the white blood cells. Now you could spin it twice. You could do two spin technique. You can spin it so that you're keeping some of the white blood cells. So we've categorized it into leukocyte rich PRP and leukocyte poor prp. And this is a very simplified way that we think about it right now. And there's certainly. If we fast forward 10 years from now, this will be a ridiculous conversation because we just are sort of in our infancy of understanding what we're doing here. So the principle is we take those platelets which are involved in healing. We know this because if you cut yourself, the first thing that happens is the platelets come to the surface to form a blood clot and to form a scar, and then you heal. So platelets are associated with an incredible amount of. Of growth factors and healing Factors, including the 800 to 1000 proteins within the plasma. And you inject that into tendon, a joint with arthritis muscle, and see what happens. The problem is, is that as a physician, you are allowed to do that procedure. There's no rule that can't say that anybody comes in and they say, I have this injury. Can I have stem cells? And you say, oh, sure, let me give you a prp. And I spin it and I inject it. What does the actual science say about what's actually working. And what we've learned is that it works for some things pretty decently and other things not well at all. And we can only go by our randomized controlled trials and systematic reviews of randomized controlled trials to find out what seems to work.

What are those best case scenarios?

So tennis elbow seems to work with PRP. There's good data to suggest, like Tier 1 data, maybe Tier 2 data that suggests that it works for tennis elbow. It works pretty decently for gluteus medius tears and for tendons. That's about it. Some will argue maybe in the hamstring tendon, it works. But I'm not convinced.

And just to be sure, are you talking specifically about PRP or are you talking about the broader umbrella of stem cells?

Broader umbrella of stem cells don't seem to work. And I think it's important to bring up a very important part, which is these aren't stem cells. And I think that's one of the major problems, is that there is no stem cell therapy anywhere.

Unless when you go to Mexico and get stem cell therapy, what are you actually getting?

I don't know, but they're not stem cells. I mean, I can only speak what's happening in the United States. But the only stem cell therapy therapies approved in the United States are for blood disorders, blood diseases. There is no stem cell. In fact, the FDA has a big warning page with a video that explains there are no stem cells. Stem cells implies that I'm going to inject cells into you, and those cells are pluripotent. They have the ability to become something else. And those cells are now going to become your cartilage. They're now going to become your tendon. That doesn't happen. In fact, right now, what seems to.

Be happening, what's the identity of the stem cell? In other words, what is the signature that allows that doctor to know or at least believe they have a stem cell? Because these are not autologous typically at these clinics. Right. Aren't they?

Are we talking about Mexico or.

I only say that because everybody I know is basically going abroad, Although I know some people that have done this here. You know, they tear the rotator cuff, you know, and they go and get stem cells injected, and six months later, the rotator cuff is fine without surgery, Sort of that type of.

First of all, it's illegal to actually give stem cells. So a few years ago, people were able to get products that were manufactured by companies who were selling umbilical cord blood or some derivative of umbilical cord, some umbilical product as stem cells. Wharton's jelly, some of it's called exosomes. All these things are not allowed. The FDA will not let you inject this into anybody.

What's the reason for that?

The FDA has a division that regulates the use of human cells, tissues and products.

Even if autologous, even if they're your.

Own, you can use your own as long as it's not manipulated or. Or what we considered minimally manipulated.

So spinning is not a manipulation.

That's right. So you can take your bone marrow out of the pelvis and we get it from the pelvis and you can concentrate that, but you can't give any enzymes to it. You can't digest it, you can't make any changes to that product. You can only give it as is now with fat. Cause fat has actually shown some promise with osteoarthritis of the ankle. Very good studies on ankle osteoarthritis and fat injection. Same with knee. You can do that because you're minimally manipulating the fat. You are taking it and making it into smaller fat particles, but you are not essentially altering the fat itself.

I mean, you're basically breaking down adipose tissue into individual fat cells.

It's micronized. It's called micronized. It's micronized fat.

And the idea is that micronized fat regrows as cartilage.

No.

What does it grow as?

So that's what we don't know. So right now our best understanding of biologics in reality is that it reduces symptoms, it is symptom modifying treatment, and it's a good symptom modifying treatment when it works. Because we don't have a lot for, let's say arthritis tendon problems. Our toolbox of things to use when someone comes in with knee arthritis or hip arthritis are pretty pathetic. You're going to go to PT because that's been shown to help. I'll give you a brace. Maybe that might help. Maybe take some COX2 inhibitor anti inflammatories and some cream we don't have. The repertoire of what I prescribe is pretty.

Yeah, the non surgical treatment for these things is pretty weak.

So here's an opportunity with the orthobio, the biologic field to reduce symptoms in a safer way than let's say cortisol, because cortisone is quite effective and safe as long as you're not injecting over and over again. There's a space for this that is very reasonable and the randomized controlled trials show that it works for knee arthritis probably better than anything. If we like looking forward as to what this.

Yeah. Why do we have bigger. Why don't we have RCTs that can answer these questions definitively? Because there are a few things that I discuss with people in medicine that create more sort of polarization around treatment than the use of these biologic therapies, where the people who have had these procedures will swear up and down by them when they work, which is. You don't understand. I couldn't move my arm and in six months I was fine. Of course, we always failed to have the counterfactual here, which is, it's possible your arm was just going to get better on its own. It's possible that the initial MRI showed something, but the follow up MRI didn't show something or it just healed on its own because it was going to heal on its own. So, you know, the only way you can ever escape that is with randomized controlled trials. Are they being done?

Yes. And so to that point, if we inject saline into somebody's joint, a number of those patients are going to get better. So that's sort of the standard we use. How does PRP work in comparison to saline? And there are a lot of studies, there are dozens of studies, randomized controlled trials, looking at prp, and many of them have excellent results.

For example, tennis elbow.

For knee arthritis.

For knee arthritis. Okay.

Of all the data, that's the tier one best data. But, you know, we know so little about this because it doesn't seem to work well in hip arthritis.

And why do you think that would be? Is it just possible that the studies haven't been done correctly?

Maybe. And I think this brings up a very important point. When you do a randomized controlled trial, let's say for a medicine, a hypertensive medication, you know what dose you're giving and you're comparing it to some other treatment where you know the dose. Platelet rich plasma. I'm taking your platelets of unknown concentration.

Unknown quality, of unknown quality.

I'm spinning it in a machine either once or twice. Different machines concentrate those platelets differently. And so then I end up with a product with a certain amount of platelets and then I inject it back into you. I don't even know your disease process specifically. So when you put people into these studies, you get a lot of crappy data. So what the future holds is, and there's a push in our industry and there's a particular association called the Biologic association, which is like an association of associations internationally where they've formed something called the barb, which is a biologic association registry. It's a bioregistry. It's a registry and a bioregistry that is they have lots of centers and they want to know everything about what you're injecting. They want to know what's the concentration of the blood of the patient you're.

Taking, what percentage of docs who are regularly giving this therapy are participating in the registry to the point where we can generate information.

Oh, compared to the total amount, Very few. But it's enough people that we can get really good data to find out what's the dose, what's the critical dose of platelets that we need to affect change and other things. We can do a proteomic analysis of the actual fluid itself and you match that with outcomes data from the registry. So you have a biorepository and a registry combined who did well and what did they get. And they save samples of that stuff.

But at best, this can only inform what an RCT should do. Those data by themselves don't tell us anything, Right? Correct.

But this gives information about to actually lead to the trial. So you say, okay, it looks like this works. Let's try this particular dose.

So right now PRP looks more effective at reducing symptoms than cortisone in the knee for arthritis. Is there any reason to believe it can delay the requirement for total knee replacement?

Maybe if we look over the course of a year. Because this is what those trials looked at. Cortisone works very well in a short time frame. It's pretty impressive. The first couple of weeks you get one and it helps. There are some people who the pain comes right back. So it doesn't have staying power. When you compared steroids to prp, the prp, if you look out over a year, they're doing better. Hyaluronic acid, which is another thing we inject, also is doing better than cortisone, if you look out, if you combine.

Now, isn't hyaluronic acid considered biologic?

It's not.

Because it's an FDA approved product.

Yes, and I don't even know that it's a drug. I think it's even classified differently like a device. But I'm not 100% clear on that. So there's a number of studies or I don't know about a number study. I know of a very well done study that looked at, at hyaluronic acid and prp. Together and that seemed to be more effective. Not astronomically more effective, but more effective than the treatments that we have. It's more effective the combination of those two. But is it disease modifying? And that's the big maybe because that's your question. And there are studies that show it may be pushing off knee replacements for those patients. But I think this is where we still don't really know yet. But there's so much deceitful behavior out there with regards to stem cell therapy that the organizations involved and the FDA and the Federal Trade Commission and CMS are all trying to crack down on the problem of people advertising. Come onto my clinic. I have stem cells. I will inject you. It's 100% guaranteed to help you. I'm going to give you new cartilage. One of my colleagues at NYU did a study where they looked at a thousand websites and 94% of those websites who were promoting stem cell therapy were making inaccurate statements. And it just engenders distrust between doctor and patient. When you're going for a treatment and you think they're telling you something that. I had a friend really like this is about two weeks ago, my close friend from high school sent me a brochure because he wanted to get an injection from his doctor of something like an umbilical cord or Wharton's jelly injection, which is not allowed. And I look at the brochure, I said, send it to me. You know, I made the bigger. And I circled it and on the brochure because it's from the company, the company sells it to the doctor, the doctor gives it the patient. On the brochure it said this is not intended to treat any condition. And I just circled it and I send it back and say nevermind.

Before we leave the hip, what is the role of cortisone as a treatment to delay the need for surgical intervention? Is it particularly efficacious or do you not muck around with it?

I don't love it because we worry about what it's doing to the cartilage. Listen, I think because it's such a successful operation, I'm more opt to push for the hip replacement in the appropriate patient than a cortisone injection because satisfaction rate 90, 95% for hip replacement surgery with low complication rate. That's not to say that I don't do it or I wouldn't do it because there's certain circumstances that I would, I would give hyaluronic acid in the hip. Also, although it's not FDA approved, it can be used off label for that application. There's some studies to suggest that the gel can help. We're still trying to find out, figure out a better way. But we also know that if you give an injection right before a hip replacement, there's an increased risk of infection. So we know that there's something about this that we need to be cautious about.

Anything else about the hip before we move down to the knee?

No, because I think even in the knee, we're going to be talking a little bit about the hip too.

So let's talk about the knee again. I think most people listening to this can at least relate briefly to some bout of knee pain. So walk us through the anatomy of the knee.

Sure. So the knee is a bit different than the hip joint. It is different, more unstable than the hip joint. The hip joint is a true ball and socket joint. And the knee joint is inherently more unstable. So when we look at a knee, what are we looking at? If you look at the front of your knee, you often see that rounded area in the front. That's your kneecap or patella. The quadricep tendon attaches to the top of the patella right here. And then that tendon continues on as the patellar tendon and attaches to the bone here at the tibia. If we were to fold that over, what we're looking at is the under surface of the kneecap. And this is the patella. And this is the cartilage on the patella. And all joints like we spoke about, have cartilage. All joints are made up of cartilage. So the end of all of the bones allow that to glide smoothly on the surface. So we're always interested in maintaining the cartilage because once that disappears, we have trouble. So if we were to flex the knee a little further, what we can see are ligaments in the knee. I don't know if you could see that well, but here's the anterior cruciate ligament, posterior cruciate ligament. They're called cruciate ligaments because they cross. And then we have on the side the collateral ligaments. So this is the medial collateral ligament, this is a right knee, and this is the lateral collateral ligament ligament. And then if we were to fold it over and you were to look directly there, you would see two semicircular structures that are called the menisci. And you have two menisci, medial and lateral menisci. If I move the model away and we look at the picture here, you can see those cruciate Ligaments a little better. This is the anterior cruciate ligament, posterior cruciate ligament, and we see the collaterals. This picture is without the kneecap there you could also see the menisci or meniscus. And the main role of the meniscus is to distribute force across that knee. And they're imperative to maintain the surface of the joint, the cartilage, from wearing down. And the ligaments provide stability to the joint. And the anterior cruciate ligament is a commonly torn ligament.

And just again, to orient people, here you are looking at the right leg. Correct. So the fibula is that little small bone on the outside, and that's where we see both its attachment to the tibia, which is the platform on which the knee sits, and also you have the lateral collateral ligament attaching there. Yes, Correct. So the menisci collectively make up the bulk of the cartilage surface of the tibial plateau.

Then the function of it is to distribute stress, and it distributes about 30% of the load of the knee through the joint. So without that meniscus there, you end up having point load or edge loading. And it will cause degeneration of the cartilage pretty rapidly if it's removed.

I always hear people talk about how running and walking, they amplify forces at the knee. So I've heard people say, when you're running, you're experiencing eight times the force of your body weight at the knee.

A.

Am I remembering people say that correctly? And if so, why is that the case?

So it depends which joint you're talking about. So if we're talking about the kneecap, the amount of load that the kneecap sees with activities like squatting and lunging, if you do not even a deep squat, just a regular squat, the pressure behind the kneecap is about seven times.

Greater than the weight on your back.

That's right. The cartilage has an incredible responsibility here. One of the most important conversations that I have with patients, because I get the similar questions often, which is things like, is running bad for me? Is this activity good for my knee or bad for my knee? Because you'll read a different report in the news all the time. Running's good, Running's bad. The truth is, we kind of know the answer to this. In general, that is, no activity is horrible for cartilage. If I put your leg in a cast and we then look at your cartilage, in a couple weeks, the content of that matrix is going to be significantly depressed.

Nothing's worse for you than inactivity Right.

But it's an inverted U shaped curve.

But it's not symmetric. It's like that where more and more and more activity, probably better and better and better, but then you can go too far and it falls off. It's not a perfect you where it's pure Goldilocks, where you want to be right in the middle of doing nothing and doing a lot, because we'll never.

Know because it's dependent on a particular individual and so many factors. So we know that chondrocytes respond to activity. They feel the stress and they make more matrix. They make all of the proteins within cartilage. So a chondrocyte that's being pressured is happy. A chondrocyte that's not being pressured isn't going to do anything. And eventually it's going to break down.

And biomechanics have to matter here.

They do.

In other words, you watch an Ethiopian runner, you know, you watch Kipchoge running a marathon, and you realize, okay, clearly there's a lot of force there, based on his velocity, for him to have the stride length that he has, he is hitting that ground so hard and that ground is hitting him back so hard, and that's what's allowing him to stay in the air long enough to travel the distance he travels. And sure, he's not the heaviest guy in the world. He probably weighs a buck 20 soaking wet. But again, if he's feeling eight times that, we're close to £1,000 every time. But his mechanics are perfect.

I think it's all mechanics. I mean, that's exaggeration, but it's mostly mechanics. If you have good mechanical alignment, we call it, that is if we draw a line from the center of your hip to the center of your ankle, and we do this regularly and it goes right through the center of the knee, there's a good chance you're going to be okay.

Center of hip, meaning where the femoral head meets the acetabulum.

Right. The center of the ball.

Center of the ball. You should be able to drop a plumb line that cuts the patellar tendon and the patellar bone in half.

Correct.

And should land where? On the foot. Where in the ankle.

You draw the line from the center and you connect the center of the.

Ankle to the center of the ankle.

And then you see where it goes through the knee. If you go dead center, there's a good chance you're going to be okay sometimes, even if you have other problems, if you are off to one side or another, and that's where we have people who have knock knee or bow legged knees. There is an increased amount of force through one of those compartments of the knee and you are at high risk for degeneration. And then if you get a meniscus tear on top of that and you lose that surface area of forced diffusion, that chondrocyte is no longer going to be happy. So once the knee is unstable, just focusing on the knee, let's say you have an ACL tear and then you measure the compressive force of that cartilage before and after an ACL tear. So like a normal knee and then your contralateral knee, the amount that the cartilage gets compressed in an ACL deficient knee is substantially greater than an ACL intact knee. If you reconstruct that ligament, it still doesn't come back to normal. There's something that happens once the knee is injured where the loads through that joint change and sometimes permanently.

So is that why if you have an ACL injury, you do increase your risk of arthritis later in life?

You do.

Is that partly why? Because you never fully get the chondrocytes back?

Correct. I think there are a couple issues here that obviously we don't fully understand. But the first thing I'll say is that a lot of it is baked in the cake at that injury and any injury where there's sheer stress on an acl. And I think we should talk about the biomechanics of the ACL injury. But when you have that event on any joint, the stats are that in about 15 to 20 years, half of the people who have an ACL tear, whether it's reconstructed or not, have signs of arthritis.

No difference if you reconstruct or not.

It's debatable. There are some studies that show that if you've had your ACL reconstructed, you have a greater chance of arthritis.

Those are the literature I'm sort of familiar with.

And that's because you're active, so you are now able to do things.

Very good point.

Because you're knee stable.

So there haven't been any RCTs that have said randomize to repair, no repair and let's see what happens.

It's too hard to do. There was a fate study I think, in the 90s where they look at the fate of doing ACL surgery, not doing ACL surgery, but you can't randomize it. That's where that data comes from, where that you may end up having more arthritis if you have it reconstructed. I'm not necessarily saying that you shouldn't reconstruct it by any means. Why do we do ACL surgery? We do ACL surgery because we want to protect the meniscus. Because if your knee is flopping around, your meniscus is going to tear. If your knee is flopping around, you're not going to be able to play the sports you enjoy doing. So by all means, it's worth the risk of arthritis. The other thing is it's not everybody has an ACL tear.

Yeah, one in five.

Not everyone. Who has eight.

Right.

But to that point, I mean, I'll just use my own example. When I was hit by a car when I was 14 years old, I had an ACL tear and a meniscus tear. This is the 80s. I had knee surgery that week. But nobody did anything. You just went in and looked and I came out and said, what do.

You mean they went in and looked?

I had an arthroscopic surgery and only later they're like, what did we do? They said, oh, nothing. They just said they're going to treat.

It non operatively after the operation. Yeah, they didn't have MRI that was high enough resolution.

Well, I don't know, you know, I was 14, so it was like I just did what I was supposed to do. And they said after. The doctor was. It's funny because he's the reason I wanted to be a doctor too. You know, he came in, he's talking to his dictaphone, he says, you know, 14 year old male injuries knee. I was like, that's cool. That's what I wanted to do.

Yeah, he gets addictive. Exactly. Who doesn't want to have one of those?

Exactly. So I didn't have the surgery. They said we're going to rehab it from the age of 15 basically to 30. I did not have an ACL. I had a bucket handle tear of the meniscus, which is a very severe meniscus tear. And only at age 30 did I have the surgery done after my fellowship was over and I recently took X rays of my knee because I was curious. I did standing alignment, center of the head to the ankle. I have no arthritis in my knee, but my line is straight through the center. I don't think that would have happened if I had some mechanical alignment issue. So half people get arthritis, half don't. There's probably.

Oh, I thought it was 20%, 50%. Oh, 50. I'm sorry, I misheard that.

50%.

Oh, it's within 15 to 20 years that you said, that's right.

And we also know, and I know this from my own practice, cause I do a lot of ACL reconstructions is that some people recover fairly well after the surgery. And there's a small group of people who stay inflamed. We're identifying this cohort of patients. We call them an inflamma type. That is if you take out their fluid and you look, analyze that fluid, they have elevated Illinois 1, Illinois 6 inflammatory markers that are not coming back down to baseline.

It says in the synovial fluid.

You mean in the synovial fluid. A lot of people recover and then some people go on to have sort of low burn, chronic inflammation. And I don't think this is just with acl. I think this is with a lot of problems. And this is also where biologics may come in at some point to push someone from the catabolic state back to the anabolic state.

Let's talk a little bit about how the injury happens. And then I want to understand kind of how it's repaired.

In general, there's ACL contact ACL injury and non contact ACL injuries. And the majority are non contact impact. Some are also indirect contact. We also categorize them that way. And women have a higher risk. Females have a higher risk of ACL tear than men. And there's a lot of factors, just the strength difference. That's one of the reasons it's a neuromuscular control. So early in puberty, boys tend to, during the spurt tend to have testosterone. And that affects muscle growth in females. That's delayed. And if you look at sort of the neuromuscular control factor, specifically, we have patients will, you know, you jump off. This is pre injury. Just so we evaluate why are they greater risk. You have them jump off a box and see how they land. And in general, at that age, females are more likely to land with a valgus knee with an adducted hip, right? The leg goes in. That is you have weak gluteus medius imbalance with the adductors. So they land with their knees and valgus, oftentimes with a very straight extended leg, slightly flexed and a little bit pronated. So one of the programs we're trying to implement, which is incredibly difficult to do, are injury prevention programs where we could take individuals and see risk, stratify them based on risk to see, you know, we do landing error score scoring system and see how people. And we mark them and say, okay, you need special neuromuscular training.

What percent I know that this answer can't be known. But just to speculate, what percent of ACL tears do you think could have been prevented if the individual was maximally strong, had the highest amount of their genetic potential for neuromuscular control going into it? So even though virtually all ACL injuries, I assume, are acute injuries, how many of them do you think are on top of a chronic weakness?

The only thing I can get close to sort of answering that question is there have been studies that looked at injury prevention programs and then followed those people. And the number that has come out of the literature is that you need to treat 90 people to save one ACL. So the number needed to treat. But I think that also probably speaks.

To how hard it is to treat, how hard it is to prevent, but.

It'S potentially also decreasing risks of other injuries too. So it's not just ACLs when you strengthen the glutes and you. So let me show you sort of the mechanism. I'm going to move the kneecap out of the way. So this is a right knee. So this is the outside of a right knee. What happens when you land in a valgus position is like this. So you land with the leg a little bit like this. What this does, we call this condylar liftoff. So that's why you often see MCL tears, because this gets stretched, the condyle lifts off of the surface. And that surface on the inside of the knee, this is called the medial part of the knee, is very congruent. It's the most congruent part of the knee. The lateral side, the surface of the tibia is convex. It's very unstable in general. So now you're only bearing weight basically on the unstable non congruent part of the knee. When your foot lands in pronation by nature, the tibia internally rotates slightly. At the same time that happens, the quadricep pulls and then it shifts out of place. The only thing that typically will help that is that the hamstring on the back has the opposing force. So if you land with a flexed knee, it can help stabilize the knee. Did that make sense?

Yeah. Unfortunately, this is going to be something where people listening to us on audio will have no idea what we're talking about. You really have to see the model in 3D and the way you just described it, you could experience that if you fell, for example. Correct. Is that also what's happening in a ski injury? I just seem to see more people tearing their ACLs skiing than I can shake a stick at.

And it's hard to know because even when we have video analysis of skiing injuries or even basketball injuries, sometimes it's hard to get exactly that. It's probably a similar mechanism, but hyperextension of the knee will also have the same problem. The other problem is if your trunk is leaning over to one side at the same time, that's an extra amount of force pushing the knee that way. So we see football players get it all the time. As soon as they plant, if they're hit on their hip, their body weight goes over that side, their foot struck, there's a lot of contact force, the quadricep contracts, the tibia internally rotates, it shifts out of place and it's ruptured.

So what is the typical cool down period you want on an ACL when a person is injured? And are there various considerations as to how long you might wait versus operating right away?

I prefer to wait until the knee is quiet. I'd like the initial inflammation to come down my practice. I feel that if you go into the surgery with a quiet knee to the point where you almost feel like I don't even think anything's wrong, I think that's a good time to do surgery. But there are plenty of studies that show that you can do it right away. There's no adverse effect down the line. But I also like people to sort of prepare themselves and just sort of think about what's happening and get some prehab before the ACL reconstruction so that, you know, we're all on the same page about what this means long term and how to prevent the other side and all the issues regarding recovery from the initial injury because they also re tear. So we're doing a lot of revision ACL reconstruction.

What are you typically using to repair the acl?

We have different categories, Right. So autograft versus allograft. So the main autograft tendons that I use are patellar tendon and hamstring, although quadricep is being used a little bit more.

So what part of the patellar tendon are you using there?

We take the central third of the patellar tendon. So the width of the patellar tendon from medial to lateral is about 30 millimeters. And so the central third, 1 centimeter, we take 1 centimeter or 10 millimeters of the central third of the patellar tendon with a little bit of bone from the kneecap and bone from the tibial tuberosity and that becomes your new graft.

So that you're doing bone to bone attachment.

Bone to bone attachment, Exactly.

Has it always been that way for patellar tendon.

Yes.

And if you did cadaveric acl, is that done anymore?

Yes.

And you're still going bone to bone.

You can ask for different types of allograft so you can get a bt, we call it btb, Bone tendon, bone allograft. Or you could do soft tissue allograft. Bone to bone healing tends to be more predictable. Allograft is really not a great idea in the younger cohort. There was a recent study that showed that you're safe with allograft after the age of 34. That is before 34, the risk of a re rupture is unnecessarily high if you use allograft, because allograft tissue is somebody else's tissue and it takes longer for that tissue to mature and to get strong.

And typically, how old are the cadavers from which you're getting that?

Hopefully a young person.

Do you get a say in this?

Well, you do you ask for, I won't take it unless they're under this age. And there are ways to make sure that you only are provided.

Super tendon is the main incentive to do allograft to avoid the patellar injury.

There are a number of reasons why people want it. Number one, it's an easier surgery to recover from upfront. So people are busy, they work. They may not be skiers or play basketball. They may just do some recreational stuff occasionally like hiking. And they're in their 40s. And it's perfectly reasonable to use allograft. The rates are higher of re rupture, but it's not as if, I mean, it's still being done because it's still a reasonable option. So that's why people are doing it. But if someone participates in high risk activities, high risk sports, level one sports, then it's not a great idea.

The patella is that much better.

It's that much better. Yeah. And sometimes we compare. So the big question is, what's better? The hamstring, the patellar tendon, the quad tendon and the quad tendon. There's not enough research to say definitively that it's not in the game yet. As far as.

And which hamstring tendon are you taking?

It depends. Some people take the semitendinosus along with the gracilis. Some people just take the semitendinos. And again, you can access that from the front because the tendons attach right here in the front of the medial tibia and you make an incision in the front, and you find the tendon and take it.

So what happens to the rest of the hamstring?

Great question. Tends to scar in. But that is one of the reasons why people don't necessarily want to do hamstring, because you do have weaker hamstrings after. Now you have the biceps femoris on the other side, and you have the semimembranosus that's not affected, which are the other components of the hamstring. But your hamstrings will be weaker. And the hamstring is there also to protect you from an ACL injury, because as the tibia moves forward, the hamstrings are pulling you back too.

So it sounds to me like if you can handle the additional recovery and the pain of having your patellar tendon cranked open, that's the better operation.

Right. The gold standard, I think, still is the patellar tendon. And the downside of that is it's a little harder recovery early on. And people do complain of kneeling pain because of the bone removed from the kneecap, the incision on the front of the knee. So people truly do complain about that. So if I have an individual who.

So if you're Catholic.

Correct. Or if you're active, you garden all the time, or you love yoga, I'm gonna say, listen, let's do the hamstring tendon instead. So you can sort of tailor it to what seems to be more appropriate.

So 50% of people who get an ACL repair or frankly, just tear their ACL, it seems like there's no difference. 50% of those people within 15 to 20 years are gonna need a total knee replacement. No, no, they're just gonna have arthritis.

Right. And it doesn't even mean it's symptomatic.

I see. Okay, again, X ray tells a big story here. I've seen my knee on X ray. I've got unfortunate. I don't have arthritis, so I've got a big, clear space between the femoral condyle and the tibial plateau. How narrow does that need to be before you would make the diagnosis of arthritis? And how correlated is the reduction in that space with symptoms?

It's not correlated well. And even when I say arthritis, it's hard to define. The way I think about it is there's arthritis and then there's symptomatic arthritis. So you can have cartilage loss, and we consider that quote, unquote arthritis, but it very often isn't symptomatic. And so when we really think about arthritis It's a whole joint disease. The cartilage starts to break down, an inflammatory reaction happens. The synovium, which is on the inside of the knee, also gets inflamed. The bone under the cartilage goes through changes. So the arthritis that you're worried about, that I'm worried about, is that whole joint arthritis. Not so worried about narrowing of the cartilage. In isolation.

It's the, it's much more systemic to the knee as a system.

It's like a biologic process we're really trying to avoid. And I see them come in. They were perfectly normal. I see people with horrible looking knees who come into my office. They say, my knee started hurting last week. I've never had a knee problem before. I get an X ray and there is no cartilage left. They won't believe me. They said, but I don't have arthritis. I say, I know you didn't know you have arthritis, but now you do.

So what tipped that person over? Because clearly if you took that X ray a year ago, it would look almost as bad if not the same. What flipped the switch?

It's usually a traumatic event. It's usually a stumble. It's usually nothing. It's like I lifted something heavy and twisted. Funny. I felt a little something. Maybe the meniscus tears a little more. It's a very slow process. The chondrocytes have been not doing their thing. The cartilage has worn away, but it's been such a low burn that it hasn't tipped the scale into a very painful process. And then it goes overboard. And it's hard to bring it back at that point because there's not really any healthy cartilage left. That's very difficult. It's a very difficult problem. And those people get knee replacements.

Before we go to knee replacements, let's talk about the meniscal tear. This is such a controversial area. I assume there have been sham surgery studies that have been done. What do we know about meniscal isolated meniscal tears?

The principle is if you have a meniscus tear and you don't have arthritis, you need to strongly consider fixing that meniscus because that's what's keeping us from getting arthritis.

And the meniscal tear means separation from the tibial plateau. Is that what the tear means or is it a tear across the surface?

Let me get a picture out. So here we have a cross section of the knee. This is the lateral meniscus here and this is the medial meniscus here. So if we were to look at the model, that's what we would be looking at. So there are different types of meniscus tears. There are tears that are at the periphery where there's very good blood flow. And in those types of tears, you can sew it back together and should. There are tears that go all the way across and then this piece can flip. That's called a bucket handle tear, and that often will lock the knee.

The inner piece or the outer piece?

The inner piece. The outer piece is connected to the capsule. There are tears that we call radial tears that go through here. Occasionally, if it's close enough to the rim, you could put sutures there. But sometimes you just need to trim it where you take out the torn piece of meniscus and you just leave what remains. So that's the difference between a meniscus repair and a meniscectomy. So when we talk about in the.

Bucket handle, you repair primarily.

Yes. You put it back to where it is and you sew it back together.

So all the controversy around meniscal surgery, that is no better than sham surgery, is it based on a particular one of those, or is it based on the fact that these studies didn't stratify for those.

So it's a specific type of tear. In general, we want to save the meniscus when we can. So if you're young and you have a meniscus tear and you heard that sham surgery is no better than. That's not you. You need to have your meniscus fixed. If it can be fixed. If you have degeneration of the knee already, if you have arthritis, let's say you have advanced arthritis of the knee and your doctor gets you.

And again, sorry to interrupt. I want to come back to this point. The diagnosis is made how of arthritis, because it's clearly no longer just a radiographic diagnosis.

Well, if it is even with a radiographic diagnosis, because that's what the studies use to say, say this isn't effective.

So you don't need inflammatory synovial fluid to make this diagnosis.

No, but they are inflamed because that's why they came to see you. The problem is, we don't know is there pain from the arthritis or is there pain from that new meniscus tear that they had. So I have a patient comes in who has radiographic arthritis, evidence of arthritis, and they have pain, and I get an mri. I mean, often try not to get an MRI because I really just want to treat the arthritis. But let's say they Come in with an MRI and they say, look, I have a meniscus tear. If they don't have normal cartilage and they have a meniscus tear, I want to do nothing. And really, that's the population of patient where those studies really help us to say to our patients, listen, we do nothing, you're going to be just as fine as if we do surgery. And here's a study to show that. But those are just studies. And the truth is, it's easier for me to make a decision about a particular patient than to base it on some randomized controlled trial. It's a nice starting point to say, let's try. But I have untold numbers of patients who've had some arthritis. They have a new injury, a meniscus tear, try conservative treatment, not getting better, do the surgery later, and they do okay.

Regardless of which of those tears they.

Have, it depends on what kind of tear they have. There are certain types of tears where.

You would always repair a bucket handle.

It depends. If the person is 60 years old, they don't usually get bucket handle tears. It's more of a complete complex degenerative. Just like the tendon and the cartilage, the meniscus also goes through these changes with senescent cells and matrix. That is unhealthy. And so those you can't repair, you put stitches in. It's not repairing. So in those cases, you trim the piece.

So the young person, the runner who comes in, they're 40 years old, they're having knee pain. It's new onset. They don't have radiographic arthritis. The MRI shows a meniscal tear. Any of those versions you would fix?

I would try to, yes. This is assuming that their pain is from the meniscus. And that's where this gets a little bit more like art than science, because you can have some tiny tears that I'm not that worried about. And their pain may be from patellofemoral syndrome, anterior knee pains. It depends where their pain is. If their pain correlates to the tear and it's significant, it's a good idea to try to address that. Assuming that tear is a type of pain.

So what are the things you need to rule out? How do you rule out the patellofemoral syndrome? How do you rule out the MCL sprain which might not show up, or other injuries?

Those things usually happen with an injury. You know, you're not going to tear your MCL running unless you slipped and fall. But a lot of my patients have patellofemoral pain, which is basically overloading of the patellofemoral joint.

Right.

So we talked about how if you squat at seven times body weight. Well, running is a similar type of problem with the force at the kneecap. And if you increase your duration of running, your mileage, and the amount of times you've done it, in a week, you're going to overload the cartilage in the kneecap and you're going to generate pain. But that has a very particular feel to it. On examination, you can tell the difference between patellar pain. In fact, on examination, patellofemoral pain, I can't find anything. I can't load it enough to generate the pain. I can bend your knee every which way. If you have a meniscus tear and.

I put some torsion into it, you're.

Going to feel it. It's a different presentation with regards to injury. Also meniscus tears. If there's no history of injury, I want to know, why would this happen? And so if something twists and then they have meniscus tear, the pain happened after an accident. Then I'm like, okay, I have to.

What is the treatment for patellofemoral syndrome?

If they haven't been doing anything, if they haven't been very active, I send them to pt. You need to strengthen your quad.

Yeah. So it's quad strengthening, but it also.

Is difficult because I'm asking them to do an activity that increases the load on the kneecap as a quadricep strengthening for a problem that is causing pain.

And the cause of their pain exactly.

Is what we don't always know in one particular situation. So this is a knee from the. This is a sagittal or a view from the side. And what we see here is this is the thigh bone or the femur, and this is the leg bone or the tibia. And the kneecap is in the front on this image. So this is looking at the side of your knee. You see the quadriceps tendon, and then you see the kneecap with its corner cartilage and the cartilage on the femur and the tibia. And you also see the meniscus there as well. When you overload this part of the knee, your pain can be coming from the patellar tendon, the quad tendon, the cartilage, the bone, the fat pad. There's fat inside the knee, and that sometimes gets pinched and inflamed when you're running. And that will generate symptoms. So we don't always necessarily know what we do know that strengthening the Quadricep helps the kneecap to potentially glide better and can reduce symptoms. But I've had numbers of patients who go to PT and they have worse pain. We need to be creative and they.

May have bad mechanics. It seems to me that the recurring theme here is inactivity or poor mechanics is the root cause of most of these injuries.

So this is where it's important. When I send in a pt, I may say, listen, I don't want you to do any quad strengthening this week. I want you to do hip strengthening. I want you to focus on the gluteus medius. Because if your leg is adducting, you're pulling the kneecap outside, increasing the force on that area. And so I want to create correct that without doing anything to this. And I'll also sometimes use, if I really need to work on the quad, I'll do blood flow restriction in those circumstances because it's lower loads and provides a very similar amount of injury to the muscle as high load training would do.

How long after ACL repair do you let patients do bfr?

I send them to a place that does it a lot. And I as long as the swelling is down and they can tolerate it, I don't mind starting relatively quickly because you can titrate how much you're doing, what percentage of blood flow you're decreasing. And I think it's a great way to start that process early before letting more atrophy set in.

So what are the indications then for the total knee replacement?

So if someone comes in and they have advanced arthritis, that is all compartments of their knee, the medial compartment, the lateral compartment, the patellofemoral compartment, or really too severely degenerative compartments, and they've failed conservative treatment. It's a conversation to have what is failed conservative treatment. Have we tried pt? Have we tried injections? Have we tried a steroid, hyaluronic acid, potentially prp, if they're interested. Bracing and their quality of life is so poor that they want to have something done. We talk about knee replacement.

Do you have a sense of how often body weight is a driver of this arthritis, in other words? I don't know what the numbers are today, but it's roughly a third of the country would have a BMI over 30. Many of those people don't have a BMI over 30 because they're overly muscled. Although I'm not sure that the knee cares how much that weight is muscle versus fat. So just in terms of excess weight, how often is that driving the problem?

It's driving it A lot. Which is why I show them the chart of this is four times body weight when you do this. This is seven times body weight when you do this. Just walking up the stairs or down the stairs.

Down the stairs is even worse. Right?

And I say if you lose five pounds, let's start small. This is how much weight you're taking off your knee. If you multiply that, if you can lose this amount of weight, you may not want a knee replacement and you may not need one. And so I never tell someone when it's time for them to have a knee replacement. They're gonna tell me, listen, I can't do this anymore. I want something. And as long as they're healthy enough to have the surgery, it's reasonable. But obviously, the satisfaction rate after knee replacement is different than hip replacement. And it's just an inherently less stable joint. And so it's harder to feel like it's a normal knee. People feel like it's a normal hip, but they don't feel like it's a normal knee when it's replaced.

So this is probably a decent diagram to show the anatomy of the knee replacement, huh?

I have a good model.

You have an even better one. Okay, perfect.

So this is a model of a replaced knee. I'm going to take off this portion, flex the knee. And what we see here is fake knee replacement, but basically has three components. Before we put those components on, we make cuts in the surface of the distal femur. We make a cut on the surface of the proximal tibia, and that matches an implant that fits right on that surface. And same with the tibial surface. And that is made of the high molecular weight polyethylene. And then also, occasionally, we also will replace the surface of the kneecap with a plastic button. And that's your new knee.

Do you sometimes keep the native patella if it's fine?

Yeah, occasionally. Sometimes. You know, there's some people who it's called resurfacing the patella and some people who don't resurface the patella. And the studies show that there's probably not a difference. In Europe, I think they hardly ever resurface the patella. It's more common in the United States, but I know a lot of surgeons who don't, and I do. Sometimes I do most of the time, but sometimes I don't. The reason I do it most of the time is because if there's significant arthritis there and I'm there, I'm too afraid that they're going to have Pain after. Because a lot of people have to. Knee replacements still are. 85% satisfaction means that 15% are dissatisfied. And if I haven't replaced the patella, I'm thinking to myself, maybe I should have replaced the patella too.

How long does this operation take?

It depends. Anywhere from an hour to two hours, depending on the complexity of the surgery.

And how big is the incision? It's straight. It's a midline incision.

It's a midline incision. Anywhere from 10cm. It depends on the knee. It goes from here to here.

And unlike the hip, which we talked about earlier, where the difference between what happens today and 20 years ago is night and day, and these patients are. They just feel amazing. These patients still struggle post operatively.

Yes, less so. We learned a lot during COVID that you can do these outpatient very safely. The technology is improving with total knee replacements too, where the incisions can be a little smaller. I do.

What's the dominant source of pain? Is it the incisional pain? I assume it's much more. The bone pain of what you've had to resurface. Right.

So none of that's changed, but the perioperative management of the pain has changed. We give injections into the capsule during the surgery. There's other nerve blocks that are used. We send them home with pumps to get them through that initial stage.

What is the time to recovery for a motivated patient who has a knee replacement? And what are the limitations? I should have asked the same question, by the way, on the hip replacement. So we can do that after. But when a 50 year old or a 60 year old comes to you at the end of the rope, they have the knee replacement. What are you telling them is this is when you're going to feel normal again, assuming you're in that 85%. And these are the activities I don't want you doing anymore.

I will always tell them all this is going to take you a year of recovery because I don't know who's going to be shorter than that. And there's a number of people who continue to improve up to a year and sometimes even longer. But I don't say more than a year because it's just too painful to even contemplate. A year is pretty long, but people are showing improvements even beyond a year.

And it's nonlinear. I mean, correct. You know, you're probably getting 80% better in six months.

And then how do I know how people are doing? Well, other than the research and reading it. But I see my patients at regular intervals and it's always the same. So I see someone about 10 days after surgery, and then I see them at two months after surgery, and I see them at six months after surgery. And I could tell you that everybody's different. I have people walking in at 10 days who are without a cane, walking up and down the hallway, doing very well. They're not, you know, jumping up and down, but they're like, not as bad as I thought. And then I have patients who are coming in at their six month visit and they're saying, I think something's wrong. My knee still hurts, I'm still having trouble. And I always have to remind them there's a reason why I said it might take a year.

What do you think differentiates those two patients?

I wish we knew. Sometimes it has to do with muscles, right? Their strength of them, their protoplasm before. And then sometimes I think it's sort of the similar inflamma type that I mentioned with the acl. I just think that some people show prolonged inflammation after injury. And I think we're still.

Have you ever looked at sampling synovial fluid as soon as you get in there, seeing how well the inflammatory milieu of that correlates or corresponds to the recovery?

So I know it's been done. I don't know the data on that. It's been done in ACLs too, where you check the cytokine profile. And this is how we know that there are these types of patients. I don't know the details of that, but it is done.

I mean, there's so much to think about as far as immune modulation as well. I mean, to me, if I think about, like, how would you advance this field? That could be one way is what if we utilized immune modulators in a personalized way based on that inflammatory environment at the time of surgery. Given that, that's probably playing a role in this.

So I think that the more information we get from the ACL injury will help figure out the total knee replacement. The reason I say that is nobody wants to put a needle in a knee that had a knee replacement because it just slightly increases the.

Oh, I'm thinking before you. I'm saying when you're doing the incision.

So a lot of them have. We know that IL1, IL6 tumor necrosis factor. It's. We know what those.

And presumably what's there right before surgery is right there after surgery. It's not like you're washing it away. So, yeah, you could sample that before you do the total knee, that's probably been done. So you're at the one year post op appointment, patient says, adam, God, I feel amazing. Anything I can't do.

So I let my patients do the things that they enjoy doing. I have a patient right now who ran a marathon with a total knee replacement. I mean, she's young, so she's young and she knows the risk. It's more likely to.

How young? Age?

50.

What led to the knee replacement in her case?

Alignment, mechanical issues.

Are those mechanical issues fixed now or is she just going to need another knee replacement in 10 years?

It's fixed. When we do a knee replacement, we make the cuts to allow for better alignment, Although not everybody does that. There are different ways to do a knee replacement where people maintain the alignment. It's called the kinematic knee. But the way I do a knee, I align it.

You align it. So you say, this is the hip you got, this is the foot you got. I'm going to drop that plumb line and I'm going to make the cuts in those two surfaces such that the hardware lines up.

And I use computer navigation so I can really titrate the exact amount that I want to make the cut so that the alignment is as precise as I can make it right now. A lot of the newer technology and software allows us to be more precise in our cuts and the angles we want. And sometimes you need to do a little bit of angulation just so it fits properly. But in general, that's the principle.

And going back to the hip just for the sake of completeness, Six months, because these guys heal so much quicker. Six months post total hip replacement. Hey, doc, anything I can't do? What are you saying?

And this is also with the knee. I don't want any contact sports. No contact sports, because you're at high risk of fracture.

Is skiing considered a contact sport?

No. I mean, it is, but it's not part of the sport. I mean, it is sort of, but I let people ski with total knee replacement, Total hip replacements. They are allowed to ski. It's called a stress riser. Right above the metal on the knee is an area where it can break easily. And that is a really devastating injury to have a knee replacement and then have it broken. So I don't want anybody doing any contact sports, but I let them play tennis. It used to be we would say only doubles tennis, but you know, someone's doing really well, I'll let them play. But I tell them, I said, listen, the more you're on this high molecular weight polyethylene, which isn't perfect, it's going to wear out because it's mechanical too.

That was my thesis in engineering was looking at the axis of failure in tibial plateaus. I spent interesting so much time under a microscope looking at failed tibial plateaus, using a discipline of mathematics to map out the planes of failure from polyethylene from exactly that, ultra high molecular weight polyethylene, but just in the tibial plateaus. So we talked a little bit about the success rate of PRP here potentially and a greater appetite for here than in the hip. Any other knee pains that you look at that are quantifiably not surgical, where you say, boy, operating on you would be a mistake.

So, you know, in general it's injury dependent. Often there are some injuries where there is. There's no doubt about it, you have to have surgery. If you rupture, rupture your patellar tendon or your quadriceps tendon, the conservative treatment is to do surgery because your leg will not work unless we reconnect the tendon.

Is the patellar tendon typically ruptured above or below the patella?

So this is the quadriceps tendon and this is.

Oh, the patellar tendon is the below.

So if either one of these is ruptured, the patella will go with the unruptured side. They're not connected anymore. You have to fix that.

Otherwise it's very hard to extend the knee.

You can't, you can't do it. I mean, essentially you can't do it. So that has to be fixed. For a lot of problems, you can try conservative management, meniscus tears occasionally. You could try conservative management. There are even people who don't necessarily need an ACL reconstruction. There are people who have ACL tears who cope well without reconstruction. And we talk about that possibility. If someone does not participate in level one sports, they don't do pivoting or rotational types of activities. You can bike without an ACL tear, you can run without an ACL tear.

So even that, potentially with an ACL tear.

With an ACL tear, you can. And there are a lot of people who cope quite well. I did from the age of 15 to 30 and I was fairly active with occasional swelling here and there.

And during those 16 years that you had the ACL tear outside of the acute phase, how many times did you lose stability or did your knee go out?

Dozens.

Were you causing more injury? Were you increasing the risk of arthritis through that activity?

Through the instability, which is amazing that.

I found it's very similar to the sublux shoulder. Right. The more you sublux, the more you increase the risk of arthritis. So you're tearing the labrum, you're creating more instability, and if you wait too long, yeah, you'll get it repaired. But you might actually start to have arthritis at the glenohumeral joint.

The arthritis is not as common in the shoulder as the hip and knee. And if you've had a shoulder dislocation, you're 10 to 20 times more likely to get arthritis of the shoulder than someone in the general population without a shoulder dislocation. So we know it's that traumatic event. And the same thing is true for ankle sprains and fractures around the ankle, because that joint is so congruent that cartilage in the ankle isn't even that thick. It's so congruent that if you don't have an injury to the ankle, that ankle can last you quite a long time. It doesn't have the same incidence as hip and knee arthritis.

And why is that? Despite how thin it is, it's just so engaging because the surface to surface level is so perfect.

Correct.

You don't have articulation in the same way where you have more degree of motion. Right.

Think about the hip we talked about where it's edge loading in the developmental dysplasia. It's not congruent. That's who gets the arthritis. The patient with the bump on the side, the acetabular impingement, they get arthritis. The knee, which is in the middle, that weight could go through the inside or the outside. The ankle, it's right down the center because that's where the plumb line goes. So there's not a lot of play because it's closer to the floor. Does that make sense?

Yep, absolutely.

So that's why we see it less in the ankle. We see it a lot in the knee and the hip. We see it when there's a mechanical problem.

Let's turn our attention now over to the ankle. The foot and ankle are very complicated, and the number of bones here and the number of ligaments is simply staggering. Obviously, we're not going to provide a master's class on this due to the complexity of it, but let's kind of focus on the big picture here, which is what part of the anatomy do we need to understand to really get a sense of where people have pain here?

It depends, obviously, on the population we're talking about. So if we just talk about athletes For a second. People who are very active and, for example, run a lot. We're interested in a number of things. Let's focus on the top picture here. This is the heel bone, and this is where the Achilles tendon attaches to the bone.

And.

And we do see a lot of Achilles tendonitis. That's a very difficult problem because there are not a lot of great treatment options. Surgery doesn't do great with tendinopathy of the Achilles tendon. And only when it's ruptured is there sort of more of a plan on how to address it. Interestingly, I don't think there's an increased incidence of tendon ruptures in the setting of tendinopathy. We don't really see that.

So tendinopathy would just present as pain. There's. But that doesn't necessarily increase the risk of rupture.

My reading of the literature up to date, and I don't do a lot of foot and ankle surgery, that's been my understanding. And I've treated lots of people over the years with Achilles tendonitis, and I don't remember ever a case where they came back, oh, look at that. I ruptured it.

Interesting. While we're on the topic of rupture, how much of a concern are fluoroquinolones? Everybody asked me this question. I don't really know the answer. So ciprofloxacin drugs, Levaquin, these antibiotics, I know that, you know, we're told that they slightly increase the risk of a subsequent rupture. How big is that increase in risk? And for how long does it preside after the antibiotic?

I don't know the length of how long it presides, but I do know that mine is sort of a sampling error because I see it. I see it more than you do, because that's who's coming in. And I've seen it after one dose. I don't know how to guide it.

How long after a dose? Someone has a dose and then they.

Within a week or two, I've seen it. So this is what I tell people. It's not a reason not to take the medication, but if you start to feel anything, you have to stop and rest, because I feel like that is one of those situations.

Are there warning signs to an Achilles rupture?

They start to develop pain, and that's when I stop.

But it's not tendinopathy. So what's the pain?

I don't know what the mechanism is for that. Would. There is some sort of tendon Inflammation that's happening, but I'm not sure.

Okay, that's a little disconcerting. So what are we doing to prevent this? Because this is definitely the middle aged person injury, right?

The, the tendinopathy.

Well, or just the rupture altogether. You know, it's the. I'm going to go run around with my kids and lo and behold, I hear the loudest bang and your calf balls up and you're. Next thing you know you're in a boot for God knows how many weeks.

I think maintaining muscle strength, calf flexibility, making sure your gastrocs and your soleus have good flexibility, both of those separately. I think that overtraining can be an issue in this circumstance. So just to proceed with care, you can't necessarily do everything you wanted to do when you were 20 and 30 because that tendon degeneration is a biologic event that affects all of us. And again, if you're staying healthy throughout your lifetime, it may or may not help you, but it's certainly possible that maintains.

I feel like such an important part of this is jumping. You know, literally just jumping rope, doing the types of activities like my warmup always sort of consists of, of I have a particular jumping routine I always do. And it's not super taxing. I'm not jumping, you know, onto 36 inch blocks or doing plyometric explosive stuff. I do it sometimes, but on a daily basis I'm trying to make sure I'm putting some bounce in there. My belief is that that's a valuable way to maintain elasticity in that part of the body.

I would agree. And I think it's the neuromuscular training, the neural part is just as important because I think that's really what happens is that it's always vulnerable when the tendon degenerates. But there's a mismatch between the firing of the calf musculature and what you're actually doing at that moment. And so having more motor neurons and well developed motor neurons may help prevent that. And just like it prevent ACL injuries, I think it's the same thing. There's no way that that's not helpful for all of lower extremity injuries, is to be able to know where you are in space and to have good training in those dynamic situations, because that's when people are injured. Nobody wanted to trip on the sidewalk. But what happens when you trip? Are you able to recover quickly or do you end up with an injury?

Okay, so let's go over some of the bony structures here. Maybe it's easier to look at that model.

So this is the ankle joint proper, which is. This is the leg bone or the tibia. It joins here with the talus, also along with the fibula. So these three bones make up the ankle joint. And the surface is coated in cartilage, just like all the other joints we talked about. The talus then articulates with the navicular bone here, and then their cuneiforms, cuboid bone on the outside, the metatarsals, the phalanges, if we turn it to the side. This is the inner side of the ankle. This is the medial malleolus. And along this area is where the tendons that help to maintain your arch rest. So if we were to look at the tendons of the ankle, this on the bottom image is the medial aspect of the ankle. And this is the posterior tibialis tendon, which is incredibly important for maintaining your arch. And then we also have the flexor hallucis longus here, which goes to the first toe. And these are the flexors for the digits as well. We look at the ligaments on the medial aspect of the ankle. We see here, this is the medial malleolus. This broad ligament is the deltoid ligament. And then we have this spring ligament here. And this is the plantar fascia as well, which helps to maintain your arch. And these are important structures to examine to make sure that the plantar fascia, which helps to maintain the arch, is competent and that the posterior tibialis tendon is also working. So it's important to go through walking on your toes, walk on your heels, see how the gait progression is managed.

Yeah, and all of these things we'll show in the exam, of course, on.

The outside of the ankle or the lateral part of the ankle, this is where the fibula is. This is where most ankle sprains happen. This is the main ligament that's injured. It's called the atfl, or anterior talo fibular ligament. And then we have the calcaneo fibular ligament, posterior talofibular ligament, which is not as often sprained. And then we have this ligament up here, which connects the fibula to the tibia. And when people have high ankle sprains, this is often the ligament that's injured. Whenever someone has an ankle sprain, it's conservative treatment, and most people get better, but not everybody.

And is a sprain, what degree of tear to that ligament?

It could be any degree. If you have a sprain, that is, if your ankle twists and you have swelling, you've torn the ligament. The question is, is it a complete rupture of the ligament? And so we arbitrarily say, this is a grade one, grade two, high ankle. They're all tearing of the ligament. The degree to which they're torn or which they heal will dictate the next step. It's very rare to have a severe ankle sprain without any dislocation of a joint that would require surgery, except for some syndesmosis injuries up higher. Those often will require surgery. But for the run of the mill, Twisted my ankle playing basketball. The treatment is conservative. Strengthening strengthen the peroneal muscles. But doesn't necessarily mean everybody's going to recover, because sometimes what happens is the cartilage gets injured. And just like we talked about in the shoulder and the knee and the hip, any mechanical trauma to the joint puts you at increased risk for arthritis of that joint.

And which cartilage in particular, if you took the most common sprain, which would be the atfl. Atfl. Yeah.

So the anterior talofibular ligament connects the fibula to the talus. And when that rotates this way, this does not rotate at all. You will cause injury to the cartilage because it abuts in this area.

Yep. Makes sense.

So you will see what we call osteochondral bone.

And if you did an mri, would you see bone edema there in that patient?

And so if someone is not recovering after an ankle sprain, I get an MRI because I want to see what the cartilage looks like to see if they've injured the bone, if they're injured in their cartilage. And if anything else needs to be done.

And if there's a small fracture there, is it still conservative? Put them in a boot fracture here or fracture here.

If there's a crack in the cartilage there, it depends if that piece is what we call stable or unstable. So you can have a crack in the cartilage and bone unit that is in place in situ, and you could leave that alone. Maybe give a boot. If that piece is detached, that's unstable.

And what about if you have a distal fibula fracture because the sprain is so bad that when their foot went out, it actually broke the bone? Does that ever happen? The talus will break that tip of the fibula.

So sometimes if this, the forefoot is externally rotated, this will hit the fibula and the fibula will break. And that doesn't necessarily need surgery. That can often heal without surgery. But if you've also at the same time, torn the inner ligaments, the deltoid ligaments. Then you now have instability on both sides of the ankle. And then you go in and you fix the fibula and sometimes even the deltoid.

So I'm guessing that the sprained ankle is, hands down, the most common injury to this part of the body.

Yes.

And obviously to your point, I can't imagine there are too many people listening to this who have never experienced a sprained ankle. They don't require surgery. What is the bread and butter of the foot and ankle surgeon? What is the type of surgery that is most commonly being done? Acute or chronic injury?

There are different types of practices. I mean, there's a lot of degenerative problems where you have arthritis of the ankle. I'm not a foot and ankle surgeon. Once the foot collapses, the arch collapses, and the posterior tibialis tendon is attrition to that. That's a very painful condition. And you often have to fuse the small bones of the joint in order to better create a stable platform.

Which bones are you fusing?

So occasionally it's the mid foot, occasionally it's a subtalar joint. And then you can have an arthrodesis, even of the ankle itself. It's called a triple arthrodesis.

And that occurs when the person's arch is so weak that they lose their arch.

There's stages, so there's early stage where you can treat it in a boot. Sometimes we just go in and address the tendon itself. More advanced stages. You start to see changes in the ankle joints. So you would never do.

How is this occurring? I mean, why isn't this a problem that is fixed with foot exercises and pt? And why would we let a person get to the point where their arch completely collapses and the musculature becomes so compromised?

Because some people have anatomy of their foot, they're pronated flat feet. That is not easily correctable even with exercise. It's just mechanically different. And that tendon itself, once it becomes so stretched.

And these aren't people who would benefit. I mean, I'm not a huge fan of orthotic arches, but wouldn't these people benefit from that?

Yes, and they are prescribed that. It doesn't mean the disease process won't progress. A lot of this is mechanical. We've talked about that. And a lot of this is biologic, too. We have decent ways of helping people if they don't have a biologic problem. We have decent ways of helping people with mechanical problems, but it's all of this. All of these factors play into whether someone would benefit from exercise. Right. But so there are things that can be done nonetheless. So you can give people rigid shoes to help with their feet and allow them to exercise other parts just because one area is deficient. You can fuse the ankle so the pain goes away and still get on a plan to maintain the health of the rest of you. But if your foot kills with everything you do, you can't help any of the rest of it.

So when people talk about an ankle fusion, normally they're talking about tibia to talus. That's the normal fusion.

Now, that was traditionally what's used. Now, again, this is not my field. But there's also ankle replacements now, too, which are becoming more popular because, again, the technology is improved. But that's not the same patient, necessarily.

What are the other injuries to the ankle and foot that require surgical intervention?

So this is the fifth metatarsal, and you can have fractures of the proximal fifth metatarsal where there's a tendon attached here called the peroneus tendon, which pulls off that piece, and that rarely requires surgery. And that tends to heal if you fracture it right here, less than a centimeter higher up, that fracture is in an area where the blood supply is pretty deficient. We call it a watershed zone. And that often won't heal. So you break it here. Oh, don't worry about it. You could wear whatever shoes you like, as long as it doesn't hurt. You break it here. Oh, you need to be in a cast or a boot for six weeks now, weight bearing or surgery to put a screw in there. So there are certain types based on the blood supply to the bone, certainly navicular stress fractures are another one of those fractures that are.

Is that typically in a runner?

Yes.

What about the other metatarsals you have?

Stress fractures tend to heal. You know, we see it commonly second and third metatarsal stress fractures.

Do they have watershed zones as well?

No, they heal.

It's just the fifth one.

Yeah, but, you know, a lot of people have. I worry about the stress fractures because oftentimes you'll see somebody, they have foot pain, they're a runner, and then you find out they had three other stress fractures. So this is their third stress fracture. @ the first visit, you have to have a conversation about relative energy.

Deficiency.

Right. Why are you not healing? Do we need you to see an endocrinologist? Vitamin D? Find.

Out. Yeah. You see this a lot in. I've seen this at least anecdotally so much in female runners who are basically being put into eating disorders by, you know, running.

Coaches.

Right. They're way.

Undernourished. We call it the female triad. And it's a risk of osteoporosis, stress fractures, and menstrual.

Abnormalities. So what about bunion surgery? I guess show us what the bunion actually is and what the anatomy is that leads to the.

Procedure. Well, some people develop an abnormality of the first ray where the metatarsal and the metatarsophalangeal joint, this will start to deviate. Where this portion, which we call the bunion, starts to be prominent on the inner aspect of the foot at the same time, that can sometimes affect and crowd out the second toe. And you'll get something called a hammer toe of that second digit. And so if it gets severe enough, as long as you're comfortable in your shoes and it's not painful, it's not necessarily something to do about. But if it starts to crowd out the toe and you start to develop pain, now we have to talk about correction. And osteotomies or cuts in the bone will be made to straighten out that area. And oftentimes you need to correct the hammer toes of the other digits if they're also.

Affected. How do you correct those? Does moving the great toe over do it sufficiently or do you have.

To? No, because after a while, what happens is the tendon length changes. And so you often have to cut the bone and just pin it to a shorter stump so that it no longer.

Painful. And when you repair the great toe, there's a screw that runs along the.

Metatarsal. There's different ways to do it. Some people use plates, some people.

Use screws, and that can be quite a.

Recovery. Yeah, that's hard. This is why we don't recommend it unless you're starting to have.

Pain. How much of that is driven by wearing super tight shoes? You know, being. You hear, oh, I wore dress shoes my whole life. And how much of it is that? How much of it is anatomic.

Variation? It's a combination. I think it's a factor where some people are predisposed to develop it. But there's certainly a lot of cultures wear tight shoes, you're going to have more a higher incidence of this.

Problem. Anything else on the foot and ankle you want to focus on? What about the calcaneus? How often do we see injuries to.

That? Well, we see stress fractures of the calcaneus as well. Also, plantar fasciitis is very common, so it's important to recognize that this area of the foot, heel pain, is its own animal. And sometimes it's attrition of the fascia or the ligament, the plantar fascia that attaches on the inner plantar surface of the bone. You could have stress fractures in this area. You can have insertional tendonitis where the Achilles attaches to. And sometimes you can have heel pain because a nerve is compressed much like you have carpal tunnel syndrome, you can have tarsal tunnel syndrome. And sometimes people get just heel pain because they have a disc herniation that's affecting S1 nerve root only presenting as heel pain. So it's one of those things where you sort of have to really take a close step by step approach to diagnosing that.

Problem. So taking a step back from all of this, if someone watching this is sort of in the process of interacting with the medical community, specifically the orthopedic community, how can they pick a good surgeon? What are some of the tells that you're speaking with? A good orthopedic surgeon versus someone who's a.

Hack? It's a good question. I think you use the same judgment you have when you speak with anybody. Are they sitting down when they walk in the room, are they sitting down? Are they looking at you in the eye? Are they talking to you? Do you feel like you're being rushed? I think that's a big sign. If you feel like you're being rushed, you probably are being rushed. And so just the ability to listen, to have someone that is listening to you. You know, I hear a lot of people come and I've seen people all the time who they had surgery with someone and they're seeing me about three months after their surgery and they say to me, I said, well, you really should ask that question of your surgeon because they know what they did for you. And if they're still in pain, for example, and they say to me, oh, yeah, but he's just a surgeon. He just does the.

Surgery. I said, well, what do you think I.

Am? I'm also just a surgeon. You know, you can ask him these questions. You're entitled to have a conversation with somebody you're not going to know until you meet them. And some people, some people mesh well with people, other people.

Don'T. What are some questions that they can ask specifically to get a better sense of, you know, a person's competence?

Basically? That's a good question. I think just again, the rapport you're having with the person, let's say, for example, they Say, I think you need surgery. Just a simple question. Are there alternatives or what are the alternatives? Or why do you think I need surgery now and I can't do non. Are there any non operative approaches to it? And just the answer, you know, right off the bat, you could get a good sense. If they're defensive in their response, you know, that may not be someone who's right for you. Even if they're right and you do need surgery, doesn't mean you're not allowed to ask the question about alternatives. If someone comes in with a ruptured patellar tendon and I'd say to them, you need surgery, even though that Visit could be 4 seconds, I could say, oh, you ruptured your patellar tendon. I'm scheduling you for surgery next week. I'll see you then. I'll be right in my assessment of what needs to be done. But that doesn't make me a good doctor or a good surgeon. You need to explain why that's the case, what to expect afterwards. So everybody deserves a conversation about these.

Things. When I talk to people about this in general, especially with surgical procedures, I feel like when a surgeon can't give you a clear breakdown of what the complications are and what the probabilities are of those complications, especially in their hands. One thing to quote the literature, but I want to know what is your risk of wound infection? How many times do your patients get wound infections? How many times do your patients require reoperation? How many times do your patients still find themselves in pain a year out? All of those little things. And then the other question is, what will we do if, if I'm still in pain in six months? What does your intuition tell you is going on and how will we work that up? In my experience, people who can't, surgeons who can't go through that thinking aren't very good at their job. And you're playing a little bit with fire when you go under the knife from them, you might get a great outcome and you're fine. But if you don't, they're not going to be the ones to help you.

Troubleshoot. That approach is also important, I've found, even when you're not recommending surgery. For example, if I have someone come in with an ankle sprain and I say, oh, you just need to do PT and I don't explain to them what happened in three weeks, I could just say, follow up with me in a month. If you're not doing well, I need to go through the steps with them. Listen here's the story. Not everybody with an ankle sprain is gonna get better. You're probably gonna get better cause most do, but you might not. So if four or six weeks goes by, you're still having swelling, pain, you don't feel like you're making improvements. I really need to see you because you may have an injury to the cartilage and we have to get an mri. So I always give them the answer to what we are doing next. If what I've just recommended isn't.

Going to work well, Adam, this has been super helpful. I've learned a ton. Again, orthopedics is a little bit of a black box to me. I think it is probably even to a lot of doctors. We don't have enough of an overlap. It's such a subspecialty. There's so much you're learning. This will be very instructive for people, especially when paired with the exam videos that we'll do. So thank you very much for your time and for sharing all these.

Insights. I appreciate the opportunity. Thank.

You. Peter, thank you for listening to this week's episode of the Drive. It's extremely important to me to provide all of this content without relying on paid ads to do this. Our work is made entirely possible by our members and in return we offer exclusive member only content and benefits above and beyond what is available for free. So if you want to take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription. Premium membership includes several benefits. First, comprehensive podcast show notes that detail every topic, paper, person and thing that we discuss in each episode and the word on the street is Nobody's Show Notes Rival Hours Second Monthly Ask Me Anything or AMA episodes. These episodes are comprised of detailed responses to subscriber questions typically focused on on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members. You'll also get access to the Show Notes for these episodes, of course. Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts. This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter. 4 Access to our private podcast feed that provides you with access to every episode, including AMAs sans the spiel you're listening to now and in your regular podcast feed. Fifth the Qualys, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the Drive this is a great way to catch up on previous episodes without having to go back and listen to each one of them. And finally, other benefits that are added along the way. If you want to learn more and access these member only benefits, you can head over to PeterattiMD.com subscribe. You can also find me on YouTube, Instagram and Twitter, all with the handle Peteratti MD. You can also leave us a review on Apple Podcasts or whatever podcast player you use. This podcast is for generous general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis or treatment. Users should not disregard or don't delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take all conflicts of interest very seriously. For all of my disclosures and the companies I invest in or Advise, please visit PeterAttiamD.com about where I keep an up to date and active list of all.

Disclosures.