BoneChat #137 - Physical Therapy Is Broken: The Real Reason Patients Regret Knee Surgery

Hey Sheila, how are you?

Oh, I am doing well. And actually, I'm also a cash-based business, no insurance, no nothing, and diving deep into concierge because— yeah.

Oh wow. Well, we'll see you Kinematic will be on in August at some point, so you should definitely join for that.

Yeah.

Um, today is open discussion, and I have no idea if you have something to talk about, Sheila, you can certainly talk about it. So you run a, you run a PT company in knees?

I am a PT, but my company is like e-commerce online cash pay. I just created a— I patented a product that I have built a fully like pre-op, post-op recovery program that the patient does at home. So I just like, I shipped one to Canada today. I shipped a couple to California and Pennsylvania yesterday. It's all automated videos. They play it at home and it's for knee replacements.

Oh, I love it. Yeah. Kyle and me and a bunch of other people used to design total knees. So we know the device side really well. We don't know the patient side as well.

I would say that—

Oh, the x-ray looks good. Every— everybody's fine, right?

Yes.

Hey, Colleen.

Hi, Bob.

It's been a while.

Good to see you.

Yeah.

How are you?

Good. This is open discussion, so, okay. Anybody can throw out a topic and we can dive into it. I know Copeland's going to be a little late, but anybody— man, I had two just bizarre reach-outs yesterday. I had two friends from 40 years ago that one reached out. I used to play tennis with this guy, and now he's the CEO of Move Medical, and they manage, they manage orthopedic inventory for the big, the big orthos. I mean, they're doing— they're like DePew and Stryker, and they manage Trey Logistics. They're, they're, they're doing $40 to $50 million this year in sales.

Wow, incredible.

Anyway, I had no idea my old tennis buddy was the CEO. And then you, you're gonna— Eric, you're gonna be amazed at this one. Ronnie Pickard called me yesterday.

Wow, I know that name too. I'm trying to think of why do I know that name.

Well, he was the guy probably responsible for building Danek Softmore more than anybody else. Uh, Eric was there.

I probably met him somewhere, I don't know.

Yeah, he, he built more— he probably built more value in orthopedics than almost anybody on the planet. Um, but he's, he's an old school guy. He's like 78. You know, he's got a new women's health startup that he wants me to do recruiting for. But man, I did not expect a Ronnie Pickard call out of the blue. It's a small world. Well, anybody have a topic? Otherwise, I'll— I'm gonna ask Sheila just to tell us more about her business because We all know about total knees. Colleen used to be a CEO of a total knee company and total hips too in California.

I love that.

I was just going to make one comment, and maybe this is kind of related to what you're doing, Shella, is I'm starting to see on all kinds of social media a lot of what I view as probably scams targeted at individuals that are probably in need of a total knee and trying to convince them not to get one, to go try all these other things. I was just curious if others are seeing that.

I mean, it's a new thing.

I haven't seen it before.

Yeah.

I mean, it's a huge, it's a huge market, right? I mean, everybody's targeting people with knee pain. I mean, whether it's knee devices or therapy programs or apps or, you know, injections. I mean, I feel like I was on a call recently with surgeons who were complaining about the reimbursement cuts for knee replacements. Well, like I said, the whole— anyways, I feel like I'm on the patient-facing side of it. So yes, PT treated patients. Yes, I heard the surgeons talk about how great the X-rays looked. And then the patient's like, I still can't go down the stairs. My walking's still off. I regret having this surgery, right? So, um, but anyways, um, yeah, so that's it. That all I did was I created a program. I, I believe the home exercise program is the key to a successful recovery. I think surgeons think they're the surgeon, they're the key to the success, but surgeons are really good. Hip and knee surgeons are really good at what they do. Implants are all really good, you know, they've all kind of leveled up the playing field. Um, I think PTs think they're really good, um, and I think that surgeons rely too heavily on going to outpatient PT 2 to 3 times a week. And I think that what the patient does at home, you know, all day long, 7 days a week, is what's going to be the key to the success. And as a PT with 26 years of experience, like, the home exercise program has not changed in 26 years. And as you guys have talked about, you've designed implants— I mean, everything has changed in knee replacements. The implant design, the materials, the anesthesia, you know, the outpatient procedures, the robotics, the navigations, like the kinematic— like, all the things have changed. But PT, the only thing that's gotten better in PT is in-clinic treatment, meaning my hands-on, which I'm not going to bore people, but if you had surgery and your leg is swollen and hot and painful, the last thing you want is my face popping in going, hey, let me grab your knee and let me do something with it. Um, your brain immediately resists, restricts, inhibits, and is fearful. So that's what I did. I created a program that they could do at home. I built a very simple-looking device. So if anyone looks it up, yes, I get it, it looks ridiculous. It weighs 4 pounds, but it mimics my hands. It moves and allows the patient to do advanced exercises at home, which I think if you do that every day, multiple times per day, and you're in control of your pain, your recovery will be smoother. And that's exactly the results that I see. It's a cash-based product. That wasn't intentional, just because the research came out at the end of 2019. And we all know what happened in 2020. So I couldn't do in-person marketing, I couldn't go to trade shows, and so I decided to go direct to the consumer because of COVID and I have not looked back.

Good for you. So her company is called Go Knee, so the— and the website is thegoknee.com for anybody. Sheila, just write this down. We had Pletthy on Bone Chat a few weeks ago, and you, you, what you're doing and what Pleti's doing is very similar and you should learn. They have, they have a, it's basically a cell phone. You just, when you do your exercises at home, you put your phone down and it kind of, it's an AI that coaches you. And yeah, you should, you should watch the Pleti episode with Ravi and the CEO.

Yeah.

Okay. I will.

Thank you.

Just Google Tiger Buford and Pletthy, P-L-E-T-H-Y. You'll find it.

Okay.

Cool. And the other person you need to talk to is Mark Maloney's not on right now, but he's doing a, he's an entrepreneur in this space and he's doing a roll-up of all of the joint preservation techniques. He's trying to create one company that gives healthcare providers access to everything but cutting bone. So injections, PT, braces, whatever.

What's his last name?

Mark Maloney. He, he may pop in here.

Okay, I really appreciate that. Thanks.

Yeah, yeah. But I, what I've seen is the stem cell thing is just out of control, and everybody you know, it's like black magic. And, and the state of Florida, I believe anybody can go to Florida and get stem cell injections now. And I think that's the only state where you could do that. Used to have to go to, you know, Brazil or Europe or something.

But they'll do it here in California.

Oh, well, you can do anything in California. I'd think about that.

Yeah.

Forget about that.

Yeah.

I think there are surgeons doing injections and they're not calling it stem cell, FYI, meaning because they're using— um, oh, I just met a surgeon's office that's doing— well, no, no, they're beyond PRP, but based on my discussion with them, it sounded like they were doing stem cell. But when I asked that question, they're like, no, we can't do stem cell, but they're doing something that it looks like it's very adjacent to. Um, anyways, I'm seeing that come up a lot because people are wanting to use my program as part of their post-procedure protocol, which is nice.

So yeah, I mean, here, PRP you can usually get done for $1,000 to $1,200 for one knee, and then stem cells is more like $2,500.

Okay, got it.

Sheila, Sheila, I have a question for you since you've kind of lived in the other side of surgery compared to some of us that are working on the device side. If you go back a decade or two, you know, all the rave reviews about how great devices we're doing were based on, okay, it's got 97% survivorship at 20 years, and, you know, knees are amazing because they have this great survivorship. Well, a few years later, you started realizing that, you know, like 20% of patients reported they regret their knee or that they, you know, aren't pleased with their surgery. And This is purely anecdotal. I think that number is low. I think if you are displeased with the performance of a joint, you simply stop seeing that doctor.

Yeah.

Or you go to a different doctor. Or you just deal with the fact that you got surgery and your knee hurts just as bad as it did beforehand. And we have no mechanism to capture those people because there's no kind of guaranteed registry. Now, I say that's anecdotal because I have family members that have had nothing but terrible experience with knee replacements and I've never worked specifically in knee design. I've worked on shoulders and hips and foot and ankle stuff, but I've been around it enough to know that I expected a lot more than every knee surgery I've been around has gone poorly. Do you think that you— because you said that the, like, the post-operative PT protocol hasn't really changed, I guess. Maybe is your sense that the problem is is there, has been there all along, and people just aren't necessarily looking for it. And that now we're starting to address it, that we're not looking for what— the fact that a much higher percentage of patients are actually displeased with their surgery compared to the survivorship numbers that we think make it look good.

And I will also tell you, the research out there that talks about the dissatisfaction rates, like, don't even go into detail asking the consumer, like, really why they're dissatisfied. I think there's a disconnect, meaning the surgeon says it's a successful procedure, if they live, there's no infection, you know, if the alignment looks good, which, you know, check, check, check, for the most part they do that. And then you have the PT who has different success rates. And then really the patient just cares, can they go up and down their stairs? Can they go on their walking program? Can they walk on the beach? Can they resume hiking?

Blah, blah, blah.

But yes, so I will tell you right now, the dissatisfaction rate anecdotally, like you said, I speak to thousands of people probably every month. I mean, all over the country, different surgical techniques, different implant designs, different all the things, um, and they're not happy. But I will tell you, I think the problem is— and I've added this into my program— is setting realistic expectations beforehand. You know, you meet with the surgeon after years of waiting because your knee's hurting, right? You meet with the surgeon because you're like at ends wit, and the surgeon's like, oh my God, that's the worst knee I've ever seen. I don't even know how you're walking on it. So they just planted the seed that your knee is terrible, right? They want you to have surgery, and they lead you to believe the surgery is the dream that that's going to solve all your problems, and that is not true. Now, it has worked for hips because you sit on a hip. A hip moves through normal range of motion through daily activities, but a knee doesn't have to. So I think some of the dissatisfaction rate is directly related to unrealistic expectations set for the patient. So I, you know, part of my program, like 3 months before surgery, 2 months before surgery, I start telling them, you understand, like, the recovery is on you. Like, the surgeon's going to do his part, PT is going to tell you what to do, but really, ultimately, it's up to you. And I think that Setting realistic expectations of what the pain is going to be like, what the swelling is going to be like. There's a whole neurological pain neuroscience component that no one talks about in knee replacement. I think that education needs to be done. And then I think the workload that the patient has to do needs to be explained to them. Um, and I feel like all of that would actually increase satisfaction rates. But I think dissatisfaction is way higher than you said, in the 1 in 5. Um, but I think it's also because Patients have been misguided to believe this is the dream outcome. The marketing efforts by these large ortho companies are unbelievable.

That's really well said. One of my favorite quotes, and I don't know who said it, was joint replacement is one of the most successful procedures in modern medicine until the patient walks out of the OR. I love that.

That is brilliant. I will tell you that. Yeah. And again, remember, I only talk to patients. I only talk to the individual waiting to have surgery, who's already had surgery, or is, you know, suffering. Um, and it's— yeah, they're not happy. And the surgeon's response is, look at the X-ray, it looks great. And then either have two types of surgeons: one that's like, you know, I hate the PT, the PT is being overly aggressive, they're undoing my great work, you know. Or they say, my PT is awesome, so it must be the patient that's the problem. Like, that's That's literally the flowchart, you know, either the PT is great and then the patient's a problem, or the PT is the problem and so poor patients suffered, you know. I think it's on the radar now because reimbursement is changing and is being based on outcomes and patient satisfaction and patient-reported outcomes. So, you know, naturally surgeons are freaking out because of the satisfaction— the dissatisfaction.

So, um, I got a question.

The—

some surgeons, uh, advocate PT before surgery. So, when you have a lot of arthritis, your knee hurts, you can barely move it, but they, they get them to go to the clinic. Does that help, or is there any evidence that that helps?

Okay, I'm going to be candid. I don't know if there's PTs here. I'm going to try not to ruffle feathers.

We're all the nice people.

Perfect. So, here's my thing. All PTs are not created equal. Just like you wouldn't have a general surgeon do your knee replacement anymore, right? There's hip and knee specialists. There are no knee replacement specialty therapists. So the therapist that's treating your knee is also treating an 18-year-old ACL. They might be treating a 25-year-old patellar tendon rupture, and they think that knee rehab is all the same, and it's just not. A knee replacement patient typically has had pain for years, usually decades. And so that is a way different patient than someone who suffered an injury this past weekend, right? So I think that sending patients to pre, uh, to therapy before surgery is a checkbox and it's what they're supposed to do. But I also think it, it— most PTs that I've talked to, I'm disappointed. They're going to have them doing lunges and squats and step-ups. They just can't do it. They just cannot do those exercises because it causes pain. And so, um, and I'm not here to promote my thing. I did all these mistakes. I mean, I, I did all the things. I cranked on the knees and I told them to do things they couldn't do. Um, now I've created a program. They're sitting. There's no weight-bearing. They're doing isometrics, which means no motion is happening at the joint, right? I'm teaching them Joint M.O.B.E.S., which is clinically proven over 30 years of how effective they are in pain management, lubricating a joint, loosening up tissue. So to me, I've created exercises that they realistically can do. And I don't know if anyone on this call has knee pain. I've had 3 knee surgeries. I play competitive pickleball. I mean, there are— there was a time where squats were not an option for me because it hurt so bad, or lunges hurt so bad. So for someone to tell you that, it discounts To me, the patient's expectations of what therapy is going to do goes downhill if the prehab part of it is not good. So full disclosure, I have yet to meet really great PT pre-knee replacement surgery programs. They're not great. They, they put them in the same bucket as every other knee patient, and they— the patient can't do it. Again, pain neuroscience, I'm not going to bore you with it, but your nervous system is overprotective. Everything you do with your knee is gonna hurt, and these PTs just tell them to push through it.

Yep.

Interesting.

That, you know, that may be, and I haven't been in hips and knees since the '90s, so I've been in spine since '99, so I don't know the LCDs and the medical necessity requirements of private payers. For knee replacements, but for SI joint, which our company, Corner Lock, you know, specializes in SI joint fusion. And the medical necessity requirements to work the patient up to a fusion requires a certain amount of PT, et cetera. And so I'm wondering if it is a payer requirement that they have to send them to PT. And really what it is is a payer delay tactic. You know, you, You know, yeah, we, we can see you have bad knees on the x-ray, but you know, did you do your 6 months of, of PT? You know, it's a way to push them down the road. And so, you know, the doctor may not even feel that it's clinically beneficial, but they've got to do it. And I don't know if that's the case or not. I don't know, you know, I know SI joint LCDs and payer requirements much more so, but that might be something to look at. And, you know, try to understand that part of it, you know.

Well, you are correct, and I feel like that's a different question than what Tiger just said about prehab, meaning in specifically the surgery's been scheduled, you're going to PT before the surgery. I think that what you just said, Bob, is that— but yes, a conservative measure that has to fail before being approved for knee replacement through insurance is physical therapy. I put them in two separate boxes, meaning they'll do conservative therapy to try to see if they can get the knee pain under control. And then once that fails, they go to the orthopedic, the surgery is scheduled, and then it's, I'm not even gonna say 50/50, 20% of the time the surgeon might say, "Go do some prehab before the surgery date," which is in 6 weeks. Sometimes the surgeon's like, "You'll just go to PT afterwards." But there's to me 2 separate PT interventions happening there. Conservative, non-surgical that has to be done, in order to get the surgery. And then sometimes, I mean, joint camps and prehab used to be the standard when it was reimbursed. When it kind of got thrown away, most people just threw it away too. And again, I'm not saying prehab is great right now the way it is.

So. Interesting. This is fascinating. I'm going to change the topic here. So does anybody know about— does anybody know what price DePew paid for expanding Innovations? Or is there any guesses?

I can find out. Hold on, give me one second. Wow.

Yeah, I thought I saw a mention of it somewhere.

I can't find it.

J&J.

On LinkedIn post.

Yeah, I was an investor in Expanding Innovation, so I think I might have the— give me one second. And while Dennis is looking that up, it's, uh, let me, uh, let me talk to, uh, Ron Satcher. Um, right now it says this is confidential.

Sure, sure.

Sorry, I, I would— if I had a confidentiality agreement with you guys, I wouldn't.

Right, right.

But do you know what, what were the revenues of expanding?

Uh, about $50 million.

Okay.

They spent 6 or 7 years building it up. I got, you know, I introduced them— not that they didn't know, but introduced them to a lot of their spine surgeons that ended up using it, helped them get through some, uh, you know, approval processes.

Excellent. So a 5x would be $250, a 10x would be $500 on that $50 million run rate.

I, I will find out because I have a call with them next week.

Got it. And then I saw Tiber Health just pulled in $30 million this week for their soft tissue gel. I don't know much about that, called B3 gel for soft tissue. I guess it's for tendons and ligaments. That's pretty amazing. I, I get the feeling that the, uh, the capital is going to start loosening up here. I think the AI uh, stuff has run its course a little bit. We'll see.

Yeah, I just spoke at a meeting. Oh, I'm sorry.

I would agree with you, Tiger. We're, we're, uh, working with a couple clients that actually happen to be in Europe, but, uh, but we're seeing, um, investors writing checks. I mean, even for biotech, which is Even more challenging than devices.

Class 3 kind of stuff.

Yeah.

Yeah. Yeah.

Wow.

That's incredible. Go ahead, Dennis.

I, I was just saying, I just spoke at a couple investor meetings and I, I completely agree with you. It's, I don't think it's because the AI thing has run out. I think it's, there's a lot of AI out there. And, you know, there's a lot of investment that's already been made in it. So now they're going to more traditional devices and new technologies. That's what I saw at the conferences. I mean, there was a lot of interest in those areas, whereas before, you know, it was very difficult to even get somebody to talk to you.

So implants, traditional implants. Um, or I don't know if it was—

I don't know if it was traditional implants. I think technologies that were additive or would make an implant work better or be able to measure it better. Uh, I'm seeing a lot of that. Um, I'm seeing a lot on the joint preservation side. Um, I, I know you were talking about Mark Maloney, and I literally today We're on finishing up the business plan for that. Um, we've already got, uh, an acquisition plan. There'll be an announcement here any day and a couple of other ones right behind it. So, um, Sheila, if you want to talk to somebody, feel— I'm on here, just email me. And I was actually in quite a few clinics, uh, about that, Sheila, um, this week. So just a question on the prehab side for that, and one for, can I steal this one, Tiger? 'Cause at this point—

Yeah, no, it's all you, this is open, it's open.

So on the investment side, I am seeing some uptake on the concept of prehab or rehab for outcomes. I think there's some investment there. And Bob, do you see that in the concept of prehab for spine?

You asking me?

I have—

or anybody?

I haven't really seen that first, and I haven't been in regular spine for about 7 years or 8 years now.

Oh, okay. I thought you were—

since I started Corner Lock, but we just focus on SI. But there was I think when I was doing spine a lot more, and I used to work with Ron Satcher, by the way, I used to work for the P-Spine in the early days.

Yeah, I know, I know exactly who you are. That's why I asked you.

Yeah, he and I go way back. He's a very good guy.

But he worked his butt off.

Oh yeah. He's, he's, he's worked very hard. Very, very smart guy. So I've got nothing but good to say about Ron. You know, I think there's mixed feelings about prehab and actually people like deciding, you know, to maybe work out, get, you know, get their muscles bulked up and stuff before spine surgery. You know, so I think there was some thought that that might be a good idea in the early 2000s, but I don't think it is necessarily a good idea according to a lot of physicians that I've talked to over the years. So I don't know that there's much benefit to it.

Can I, can I chime in from the rehab side of it?

Yeah, that's what I'm setting you back up for because this is actually a pretty important topic.

Yes. And let me tell you that again, like there's spine surgeons, there's knee surgeons, there's hips. PTs notoriously are generalists. Okay? So to me, if your prehab program is sending them to generalist PTs, your outcomes are not going to be that great and the prehab program is going to be ineffective, could actually be counterproductive. So again, I think that there's not intentionality of like, "Hey, I'm going to find the PT clinic or the PTs that specialize in spines." Those are very different than, you know, extremity joints, are very different than concussion management, very different than, you know, inner ear issues. Like, we have specialties that broaden the entire body, and you have to find— so it's like doing a general diet for someone who's a diabetic. That's not going to work. So to me, prehab for spines with people that are spine specialists, have extra certifications, the specialty certification, the manual techniques to really— I, I can treat a spine good enough but not great. So to me, I feel like maybe before discounting the benefit of prehab programs for spines, maybe look at the quality of the prehab programs that they were sent to. That would be my suggestion, because I would— like, as you were talking, um, Dennis, I was thinking like, okay, I'm thinking of PTs that I would send those people to. You know, they're McKenzie certified or Maitland certified, or they're manual technique certified. I want them to be certified in different modalities that you don't see for, say, you know, knee replacements. And so, um, again, speak specialties in dry needling and massage techniques, you know, taping techniques. And I think the whole pain neuroscience thing is huge in spine. And again, it's huge. And I feel like if therapists aren't seeing those types of patients— and again, an athlete with an injury this weekend is very different than a spine patient who's been dealing with pain for years, but we treat them the same. We're like, oh, go strengthen your core. You know, oh, go do some leg strengthening. Oh, let's go stretch your back. Well, again, you're— you have a hypersensitive nervous system and your body doesn't respond to those typical exercises. So then the PT says it wasn't effective. And then what do we do? We send them into surgery thinking that, okay, that's going to be the solution, when in essence we just teed them up, I think, to fail. I think it absolutely affects outcomes, um, patients' expectations. Can be deterred by ineffective therapy.

Yeah. One other, one other modality that, that has been very popular in the interventional specialties, interventional pain, et cetera. And I don't know if neuro and ortho spine guys are using it much, but Mainstay's product called Reactivate is an activity dysfunction treatment. That uses a muscle stim type of thing to, to build back your multifidus. And I think that does have some, some good success to it. And I know that they're— I'm not caught up on their data, but I know they were doing, uh, studies and, and whatnot and having some really good results with that. So I do think that if you have multifidus dysfunction, uh, that that could be helpful, uh, for, for low back pain. But, uh, I, I gotta, I gotta catch up on the research on that to understand more about it.

That's a great point. Oh, go ahead, Jill.

I was just gonna say, but my argument to that is there's not a lot of treating therapists that are going to identify that the multifidus was even the problem, right? You have therapists that maybe see a high volume of runners or something, and they're like, oh, it's always weak glutes, or it's always weak hamstrings. Like, I just think that people underestimate estimate our knowledge base is only based on what we see every day. So I'm a geriatric specialist, okay? You give me an 18-year-old knee, I'm going to be okay. But I am a— I understand comorbidities, I understand medications, I understand polypharmacy, I understand psychology. That's my specialty, which is why I, I, I'm— again, I'm great with knee replacements, better than an ACL, like, injury that's 18, even though they're both the knees. So as an outsider, you guys might be like, but a knee is a knee. It doesn't matter what the injury is. It absolutely does. It, you know, anyways, I don't want to go on the soapbox of specialties. I tell my patients to go to hip and knee replacement surgeons for a reason, but then the surgeon sends them to a generalist PT, and then when the outcome is not great, nobody knows why. It applies to spines.

I love how passionate you are. What do you think, guys? Does she really believe what she's talking about or what?

I— oh yeah, yeah, I love it.

Started— well, she started a company based on her passion, so, and she's doing it.

And if you don't have passion, it's a long, long road.

Forget it. Um, so still, yeah, if you want to connect with, uh, Mark Maloney and I, we're doing a whole thing on joint preservation. Multiple technologies companies. I just met with Reactivate, Bob. They're great guys, known some of them for many years. But I just have a question about like whether it's pre or post-hab, pre, you know, pre-hab or post. And I'd like— I'm actually asking you, Shiloh, so I'm gonna— I think your point about— I'm I've done a lot on the pain management side in pre and post-hab, post-rehabilitation, right? 'Cause that's it, you're 100% right. Your brain is directly tied, that most people don't understand the neuroscience, they don't understand the active mechanisms. One of the complaints I hear all the time is, you know, if you got somebody who's 68 years old and you're rehabbing their knee and you're treating them like you're an NFL quarterback, just because they want to get— they have a thing to get the range of motion to a certain, you know, level, and they want to hit that no matter what, right? That's what— that's determined success, not that the person is like screaming in pain. I hear that all the time, all the time, right? Um, what would you consider— so I, when I talk about pre or post-op, I talk about it with the type of nutrition they're taking, uh, the type of pain management they are on to be able— I don't, uh, the— a lot of the prehab that I talk about is where they're treating the pain, okay, whether they're using, you know, some type of cryoneurolysis, a drug, whatever it might be, um, so the person can get flexion. Or most that I see is to strengthen the areas around that they're like, you know, they're, you know, if they've got a bad knee, their back and hip are out of alignment, right? You know, where they can start taking care of those problems. So when they come out, they can focus on their knee. I'd like to get your opinion on the other things that add to a good prehab program or rehab program that may not be directly related to the therapist.

Okay. Well, again, I include all of that into mine because I never know what a patient's getting, right? Like, I see people all over.

All over the world.

So part of my education is like, hey, I always have a disclaimer, talk to your surgeon. But I agree with the nutritional component. Like, I cannot believe it's not a standard of practice to do a complete lab panel and check out their protein levels and their nourishment and everything before they ever have surgery, because there's a, a correlation to successful outcomes based on nutritional status. So I do talk to them about anti-inflammatory diets. I mean, your diet will directly influence swelling and inflammation in the body, which will influence pain and stiffness. And so So I do talk about that. I prep them about sleep. I prep them about their stool patterns. I talk to them about hydration. I talk to them about weight loss. I feel like, you know, I want to be a one-stop shop for knee replacement. So we can't tiptoe, right? This is an elective procedure. These guys are like going in eyes wide open. And so I'm kind of like, you want to set this up for success? Here's everything you need to know. But I will tell you, the huge part of my training is the neurological component. Because they don't understand it. The surgeons are doing an orthopedic surgery, the therapists are doing an orthopedic recovery, when it's to me a neurological recovery.

If—

and, and let me give you my prime example. What is a manipulation under anesthesia, right? They shut the brain off, they, they bend the leg to like 120 degrees and straighten it out. Even after surgery, the surgeon has bent and straightened that knee in surgery before he ever, you know, stitches them up. And he comes out and immediately the leg balloons up and the person has like barely 80 degrees of flexion, right? The brain's number one job is to protect your body. It has been protecting that knee for years. Just because you went under anesthesia, got a new implant, it doesn't wake up and forget the trauma. Maybe your knee buckled, maybe it locked up, maybe, you know, all the— it hurts every time you take a step, uh, uh, uh, going upstairs. None of that goes away with the beautiful implanted, you know, surgery that the surgeon did. So to me, to not educate and start the education process to the patient that your brain is going to have to calm down and not send the fire alarms that my pain is an 8 the minute I touch, you know, do anything. I feel like if you don't address that, then you're missing the entire boat. I just had a guy on Monday had a manipulation, and the doctor got him to 120, and he said that. He goes, I got to 120 at 9 AM, took him 6 minutes. I'm like, perfect. Then he went to therapy, who was told to be aggressive. Not me. Went to a therapist who cranked on that leg, and I literally sent his wife a message saying, you might want to reinvent, you know, reuse the ice tonight. And she was like, no, he says it feels great. I mean, that leg ballooned up the next day, couldn't do any of his exercises. And then he's supposed to go back on Wednesday, and they rinse and repeat. So got him to 120 under anesthesia, and now he's back to about 70 degrees of flexion. You think he's going to be one of our satisfied patients, right? And this is 6 weeks. I mean, I think they did the manipulation at 7 weeks post-knee replacement. So again, you have a surgeon who's like, okay, he needs a manipulation. He sends him to his PT that now is being aggressive. They've increased the frequency and nobody— and the patient has been told to be aggressive and push through pain, and his, his outcome is going to be subpar. And yet the 3 people involved are doing what they're supposed to be doing. This is why I'm passionate, because it bothers me that Rick is not going to get the outcome he wants because the system is flawed. And how am I supposed to, as an e-commerce cash pay business, supposed to say, hey, can you just stop your PT for a couple weeks? I, I will prove to you that we can get the outcome you want without aggressive PT. I can't do it. I can't tell the surgeon that, which is funny. The surgeon told him to get Goni. He knew it works, but he also sends people to Goni after they've been struggling for a minimum of 6 to 8 weeks, which means the neurological part is even worse than it was even before they had surgery. So I have to undo that. So when you asked about what's the key things with prehab— yes, nutrition, yes, sleep, yes, diet, yes, stress, yes, weight loss, all the things— but if you don't explain to the knee replacement patient that their brain is hypersensitive, the alarms are going off even if there's no tissue damage, If you don't explain that analogy that pain does not equal tissue damage, the outcomes are never as good and the patient never pushes as hard as they should.

Thank you.

Well said.

Thank you.

She's an expert, obviously. So let me, let me, let me get, catch Mark Maloney up. So, hey, so we've sort of been mostly talking about the joint preservation roll-up that you guys are doing.. And we have Sheila Rooney on today who's, she's an expert. She's an ex-PT, I guess, but she's got a company called Go Knee. It's in the chat. And so it's a great time. You want to know anything in the world about physical therapy, now's the time. So that's—

And I'd like to say, I'd like to say something that people don't say, especially PTs. I don't believe the knee replacement patient needs PT immediately after surgery. They just need the right program. So I'm just here to say Goni users that don't have outpatient PT for at least the first 4 weeks have the best outcomes because we've calmed their nervous system, we've gotten their range of motion, we've got their quadricep firing, and then you go to PT and you do functional stuff. Let's work on stairs and let's work on other things. But I find going to PT early is the, um, it's the standard of practice but it's also perpetuating the negative outcomes. That's what I think, which is—

I would—

I don't know that I would say that. Well, this is probably being recorded, so I guess, I guess it's now out there. But yeah, that's what I think is— I think that's the biggest problem.

So Sheila, nothing private, we deal in reality.

Go ahead, Kyle.

I wonder if part of the, the core of this and— It seems like to a certain degree what you're arguing against is across different parts of the body and across different surgical procedures, a lot of the rehab programs have been just passed along and shared. And it really shouldn't function that way at all. And you're talking about honing in on for a postoperative total knee for a certain age demographic with other considerations in mind. This is, this is what their program should look like, and it should have nothing to do with necessarily anything about you want people standing the same day on their hips, or this is what an Achilles rupture repair looks like and what they have. It should be completely not only unique to that surgery but also perhaps even unique to that patient.

Yes, I think that, and it doesn't have to be as varied as I'm making it sound. I think that most of the people fall into about a 90% bucket, whether they're a 45-year-old knee replacement or an 80-year-old knee replacement. And then outside of that are a few deviations. What is their goals? What do they want to get back to? What was their, you know, pre-surgery range? And, you know, all these other things. But I think the bulk of it is knee replacements are very, very unique. Um, you know, just like you would treat a stroke different than I would a Parkinson's patient, or a, you know, all the different neurological diagnosis. And same with backs, you know, if it's a strain versus a rupture versus a surgery versus They're all different, but PTs treat them as if that knee just needs short arc quads, long arc quads, isometric. That is not true. That is not true. And so, yes, I think it should be so much more individualized and there should be so much more. And again, I cranked on, cranked on knees in my early days. I felt like if I didn't lay hands on a knee replacement patient, then I wasn't doing my job. So PTs think they have to do it. But if you have a super anxious patient who's super fearful and their knee is super inflamed, the last thing you should do is touch that knee, right? Like, but we feel like if we don't do that, then we're not being productive, or we can't bill insurance, or we can't— that is not true. But I feel like PTs have gotten more highly educated, and I feel like the common sense has gotten less. And again, I'm sorry to my profession, but that's what I feel like. I feel like we're now doctorate levels, and so— but it's almost like we've lost those soft skills of listening to a patient, hearing— some can be aggressive, some love PT, some hate PT, but we don't even know it because we're not even talking to them because we see a knee and we automatically know we need an extension goal or a flexion goal, we need a quad goal. Like, we've already funneled them into the, the, the, the software system that says knee replacement category and tells them exactly what to ask. I think that's the problem.

So is there something inherent— let's kind of back up to earlier in the process. Is there, because you mentioned, uh, it's a hip, you sit on it, it's, you made some, you know, allusion to just it being easier to rehab a hip or whatever, which is probably very fair. But is there something inherently about a knee replacement procedure that makes it more traumatic that you think feeds into some special considerations here? Like, you know, there's so many bone cuts or you're removing mm from each side or whatever it is. I wonder if there's, there's maybe a different category of trauma that makes the front end of it worthy of considerations on the back end.

I think there's definitely truth in that. I think there's definitely truth. It's a very complicated, um, it's a complicated joint. I— and my, my, my comment about the hip was, again, back in the day I would never have thought that a hip replacement wouldn't need therapy, but now that, that, that is the pathway for a lot of you know, hip joints is like, just send them home and they'll be okay because you have to walk and you have to sit so you get the range of motion. But with the knee, you don't have to. Like, you can put that leg out in front of you, you can limit the motion. You're not going to put the knee through a full range of motion in everyday activities unless forced to. So I feel like, um, but I think you're absolutely right. I've watched a lot of knee replacements in the last 5, 6 years. I have not watched a lot of hips in the last 5, 6 years. I did before then. But I mean, it's traumatic. It's traumatic what they're doing, the shaving and the this and the hammering and the taking out and the moving. And, you know, so it's a very painful recovery. It's a painful recovery orthopedically. Okay. But I think that the neurological component for the patient to understand, don't measure your success every day. Don't measure it based on just a range of motion number. Like, I think that they feel disappointed. They feel depressed. I think that discouragement starts Literally in the first 3 days after surgery, as soon as the initial pain starts wearing off and the therapy starts getting more aggressive, I think it starts immediately, the dissatisfaction. And I think that wouldn't happen if you kind of knew about it. You know, it's kind of like I've had 3 kids and I'm so glad someone said to me, hey, it took you 9, you know, 9 months to gain the weight, give yourself time to lose the weight. I'm like, oh, thank you. Like, thank you for setting that expectation so I don't feel bad about myself every single day. And I think that's what the Go Knee users say is that I'm constantly reminding them One bad day does not equal a bad outcome. It's just one bad day. It means you might have overdone it, or maybe you didn't do enough yesterday, but now you know. Let's use that information and move it forward. But over a 3 to 4 day span, you will see improvements, and they just need to know that. It's psychological. I mean, I, I know we are all implant designers and all, but knee replacement recovery is psychological. And if you— I have improved patients simply by when I sent them my device. I haven't even they haven't even gotten it yet or started my program, but I just send them a video about pain neuroscience, and I explain in 20 minutes about how you're— it's like your house is on fire, um, versus the toaster has some burnt toast. And I explain it in this analogy, and I've had people call me the next day and say, my knee felt looser the next day. They haven't even gotten my product. Or my swelling was reduced after watching your video. Like, literally, they'll wake up with— so you can't tell me there's not a neurological you know, slash psychological component when I've had patients report they've had improvements before ever starting my program. It's information that their brain is taking in and applying it.

I think another big factor that, that, uh, I don't think we've, we've talked about here today, but what I remember from my Total Joint days, um, there was a big disparity between physicians. And I guess part of the art of a total knee is ligamentous balancing. And, you know, you gotta be very careful with your, you know, and now that there's even ACL sparing, but there was PCL sparing back in at that time. And then you had to worry about the, you know, the lateral collateral ligaments and the medial collateral ligaments and everything. And then once you get your implants in, you've got to make sure that those ligaments are balanced, that you don't, you know, that this side's not too tight. So there is some release of ligaments that can be done. And some guys are great at it. Some guys get super aggressive and maybe do too much. Some guys don't do enough. So your knee is too tight or imbalanced. So I think that's a huge part of the art. And I think that really changes the, you know, the outcome and the PT and the rehab for the patient at the, you know, after the fact.

Agreed.

Yeah. What, what I always go back to, I been in lots of total knee surgeries and you, you see somebody that's 5 degrees, varus. Okay. They've been walking like that for years and their muscles, their ligaments, the, their neurological system is all used to that 5 degrees of varus. And then all of a sudden they're back to neutral, but the nothing else has changed. You know, it's, Yeah, it's— you can't remodel, you can't remodel a straight leg, you know, overnight.

Yeah, well, and even patients that get full range, good strength, who still limp, right? Like, that happens all the time in therapy. Again, there's a psychological thing that your brain says if that leg is stiff, it feels safe. It will not buckle, it will not lock up., right? So again, some patients get great range, and so the surgeon sees them in their follow-up, say 6 weeks, and they're like, oh my God, you're at 120 degrees and 0 degrees extension, great job! And then the patient's like, why am I still limping? And the surgeon's kind of like, I don't know, just work on that with PT, right? Like, that's what we do. And then, you know, PT discharges them because they're 120 and 0, and then the patient's still limping, and then they're still dissatisfied. So again, there is a neurological component because the patient had enough range and enough strength to walk without a limp, It requires training and again, a PT who specializes. You don't have to treat an ACL repair how to walk again. An 18-year-old ACL repair, once they're given freedom to do whatever, they know how to walk. The knee replacement patient is different. I cannot stress that enough.

Sheila, hey, yes. Sorry, I'm late, but you completely destroyed every image I ever had of physical therapist. Who seems like most of the ones I've met in my career, and I haven't spent a lot of time in PT, laid-back, low-key, laconic people. In fact, that's part of the reason why I really never enjoyed much that part of the practice, so to speak. You are definitely the opposite of that. I congratulate you. But I've got several questions. What percentage of patients do you think are getting total knee, if any? That don't need them?

Yeah.

Yeah. Uh, secondly, um, what percentage of those same patients that maybe don't need them could be feasibly delayed for at least 5 years? Um, and I guess the third thing is, do most physical therapists need more information, as in like remote patient monitoring or anything like that, from their patients? Doesn't sound like you think that's so, but I was just curious. So those 3 questions, I got more, but those are the big ones.

Okay, let me start with the first one. You said what percentage of patients don't need knee replacements? It is higher than— I don't know the percentage, but it's higher than you think. And by the time they reach out to me, I think it's high. Yeah, well, because marketing is so great. It is so great, and people are being told that this is the solution to their knee pain, which It goes back 3 steps, right? Like, if the PT doesn't know what to do with that knee, then their knee pain doesn't get better. And if they don't do— if they don't figure out what the actual cause is, like, is it a fear avoidance? Is it whatever? If you don't diagnose it correctly, then you can't treat it correctly. And if you don't treat it correctly, then, you know, we are in a world of we want immediate resolution of everything, right? We're in instant gratification. So I think some of these younger knee patients definitely don't need them. They are— and I'm sorry, I mean, I'm 51, but the younger patients are lazy. And entitled, and they want a quick fix, and they think the knee replacement is the quick fix, and it's just not. So they don't do the work afterwards because they're led to believe this is the solution. They choose a surgeon that also works with, you know, elite athletes or, you know, athletes in the area, thinking that's the solution. It just— again, um, I don't know if you missed at the beginning, Mark, but, you know, it's about expectations, realistic expectations being set, the proper education being done, the right treatments being done before you ever do it. And You know, knee replacements is a fantastic surgery when done well. It should not be a first resort, right? It should be closer to the last resort. That's how I— what I believe. Um, so I don't have a percentage, but I do know it's really high. But I can't tell patients that when they've already told me like, hey, my surgery is scheduled for September 2nd. And I'm like, okay, what's your— you know, what, what, what are you having issues with right now? Stiffness, swelling, pain, a range of motion restrictions, what? And they're like, oh, none of that. I'm like, oh, then what are you doing? Oh, my surgeon said I had really severe bone-on-bone arthritis. He showed it to me on an X-ray.

Yeah, I can't believe I'm walking. Yeah, I'm doing a little survey with a lot of people I know, and I've got a 44-year-old female friend, and they just throw the X-ray up on the light box. You're bone-on-bone. You need a total knee. That's the end of the discussion. And they think they need that. They don't give them— there's 10 other things you can do. They don't give them anything.

All right, well, for the spine people on here, they know there's research out there. There's a story I tell people all the time. If you did 100, you know, imaging of 100 people walking downtown right now, you know, I can't remember what the percentage is, but it's high. Let's say 90 of them are going to show some sort of abnormality, abnormality that is asymptomatic, right? So to me, an x-ray alone showing bone on bone— we all know some patients have excruciating pain with minimal changes, and some people have minimal pain with excruciating— I mean, with significant changes. So to me, I do think— I don't know the percentage, Mark, but I do think there's a ton of people getting knee replacements that shouldn't be getting it. But like I said, by the time they reach me, the decision's already been made, and I cannot go against— you know, I'm technically just an e-commerce business, so I'm communicating via email. I can't be like, whoa, you're 42, you're a mom of 5 kids, let's not get a knee replacement right now. You know, I can't do that. That's not my business. Um, the second, the second thing you said was the percentage of people that can be delayed. Almost all of them. Almost all of them. I have an 89-year-old guy right now in California that's been told he needs knee replacement. He's 89. He does 90 minutes of yoga. He walks to his yoga class. I mean, come on, do you think he needs surgery at 89 years old when he's doing 90 minutes of yoga? Like, let's do some behavior modification, some activity modification. We don't need to put him under anesthesia. But his surgeon's like, the the only thing you need, right? I'm like, come on. Um, but yes, I think a lot of surgeries can be postponed, but I'm also not going to live with knee pain. So I'm never going to tell someone who has no other options and doesn't have a good solution for their knee pain— I am not going to make my life smaller. So if the only thing they think is going to make their knee pain better is a surgery, then I understand why they're doing it. But I, I just today had two patients who bought Go Knee with surgery scheduled in August and September that have canceled their surgery. And that is not why I created Goni. I created it 6 years ago to only help after surgery. It evolved into a prehab program, and now it's evolving. I was just talking to my husband about it this morning. I'm like, I'm like, oh my gosh, I'm gonna have to create a whole email automation flow for people who cancel surgery now about how to use Goni. Like, it's gonna be a lot of work for me. Um, but yes, so yes, people can postpone it. Um, does PT need more information, not just on remote therapeutic monitoring? Like, I think we're doing a lot of Band-Aid solutions. Like, someone earlier mentioned about the implants having sensors and tracking more data. We're doing all these great bells and whistles, um, again, like remote therapeutic monitoring. But I, I think the core of it is the patient is not getting the right education, the patient doesn't have the right expectations, nobody is doing that for the patient, which is setting up the entire thing for, um, a lack of success. And I think the home exercise program is an afterthought in PT. They think, come to me, I do amazing things. It doesn't— you know, here's a 3 sheets of paper that have exercises that you should do. The patient kind of is compliant, but kind of is not because it hurts and it's swollen in between sessions. I think that if you have a great home exercise program that the patient is motivated and compliant with, outcomes significantly improve. That's what I think.

Amazing. Yeah. So, Dennis, I think we have found our first clinical advisor. Amazing.

Yeah.

Okay, so the percentage is high of those that can be delayed or avoided. Absolutely no doubt. Someone asked me recently, well, what kind of a doctor is gonna treat this when basically this, if he's a surgeon, by delaying this knee, he's gonna kill his own business. I said, well, not that doctor. And I said, the doctor who will be the specialist or the subspecialist in this particular new field of preserving the joint has really yet to be trained. It will be, instead of a training, it'll be more of an evolving. It'll be a doctor that sees an opportunity. The first question anybody always asks, what's in this for me? How do I get famous? And if I were a physician and young and in my career and I saw that there was a niche that had not ever been treated, exploited, helped, whatever phrase you want to use, I would jump on this, and I think this is a whole new field. I mean, it's going to be somewhere—

can I just say, in case you guys haven't figured this out, I can count on one hand how many surgeons endorse my product. So we all agree with that, right? Like, on one hand— actually, probably on my thumbs. On my thumbs, I can count how many surgeons, uh, refer their patients to Goni.

And those two surgery avoidance program, yeah.

Well, and it wasn't intended for that, right? It wasn't intended. But my patients tell their surgeon like, oh my gosh, I bought this product, you should learn about it, I brought a pamphlet in for you, I'm canceling the surgery. I mean, patients don't understand. In essence, they're shooting my business into the ground every time they tell their PT, I'm canceling my next, you know, 5 sessions because my knee feels so great, or I'm canceling my surgeon— my surgery. So I have zero, you know, faith in PTs and surgeons um, in loving my product because, like Mark so eloquently said, I have a hard time figuring what's in it for them because I understand what's in it for the patient. So it's been really hard for me. Um, but yeah, if someone can help me connect that dot, I would love that. But yes, I wish I could find a surgeon who wants to postpone surgeries, only do them when it's right, and I can figure out what's in it for them. Let's figure out a partnership of some sort because I mean, Goni is an expensive product. It's $400. It's not, it's not cheap. It's not $49. So, but yeah, have you looked into—

I missed all that. Sorry.

Have you looked into reimbursement for, for the patient so it's not a cash, cash deal?

They can use their HSA if they want to, but I'll be honest, Bob, like, when I did my research to get it approved by Medicare, like, so expensive, so timely, um, You know, and, and then I'm at the mercy of whatever they decide to piggyback my product as similar to. Um, and there's just— I mean, I know everybody says this and I apologize, but there's just not something out there that does flexion and extension and strengthening and joint mobs. Like, it just— there's not something out there. And so my Medicare specialist I talked to said there's a good chance we're going to say that's reimbursed at $69 and that's it, and everybody else is gonna have to follow suit.

How would you be able to compare it to a, to a CPM machine?

Yeah, CPM only does passive motion. Passive motion does not translate into function.

So, um, and I will also tell you, so it does more than a CPM, right?

Oh my gosh, CPM does the bare minimum.

What does CPM get reimbursed? I don't remember. I used to do CPMs, but, uh, you know, 25 years ago, they, they pay for the rentals of it.

But again, the research has been proven that CPMs, 6 months down the road, if you didn't use a CPM or you used one, it's no different. I do think— I think if I had my knee done, I'd probably use the CPM. But let me also tell you that, um, the, the reason my patients get better is because they have skin in the game. And I'll be honest, patients that get free equipment don't always use it. So I think there's something to say that they, you know, handed over $400, they bought it with the intent to use it. And then, you know, to me, my customer service is once you buy it, I keep you engaged. I mean, I followed them from before surgery to 4 months I mean, I'll show them how to kneel like 4 months out. So, but yeah, I think my compliance rate would go down if it was just handed to them and they didn't have to pay anything.

That is human nature. It's interesting. Yeah, that's how people are.

Well, I know that Dennis and I would love to follow up because with the platform that we're building, you know, another way to call it instead of a platform, you could call it a roll-up. Basically, it's Anything that can preserve the joint, whether it's an injectable, a biological, a gait analysis, insoles, surgical, non-surgical, you know, anything except that final, you know, step of cutting off half your femur and half your tibia.

I have a solution.

Yeah.

Good.

Dennis, go ahead.

I was just gonna say, for any— I'm not, Mark and I just kind of been finishing up the plan, met with the bankers and everything. I, I'm telling you guys, I've done a ton of stuff in the industry like you all have. Um, I, I think, uh, Expanding Innovations is a good example. Tiger, you just brought up— I saw that, you know, I, I believe in Ron Satcher, Bob. That was one of the reasons I, you know, got— did that. This could end up being a really good opportunity for everybody on the phone. I mean, it's worth, it's worth checking out. That's all I would say, right, Mark? Like, I'm not telling anybody to invest or do anything. I'm just saying you should check it out because I do believe that this trend is not a trend. It is where everything is going. And the point I would point out about that is look at the dropping reimbursement on total knee surgery. I mean, it's going to get to the point where, you know, it's— I mean, The numbers are just, they're there, right, Sheila? It's telling, it's driving them, the orthopedic practices to have cash pay practices and bring in all these other modalities. It's driving the behavior already. It's there.

It is. Well, and let me tell you, I didn't choose this industry. It just happened to be I solved a problem for one patient. But like you just said, it's consumer-focused. Patients are doing their own research now. It's home-based, it's patient-reported outcomes, it's value-based care. Aligns with everything. You know, it's saying let's, let's have less healthcare touch points, you know, less hospitalizations, less, you know, cost— anyways, reducing costs for certain.

Yeah, there's another trend where patients don't trust their surgical specialists anymore. I mean, I think that changed. I think that changed during COVID where we stopped trusting doctors, um, and I see that a lot.

Wow.

Sorry, I have to go. I got a hard stop.

This has been a great hour. Hey, Tiger, great meeting.

Yeah, great job, Tiger.

Yeah, so Sheila's got her email there.

You can also go to thegone.com, and I also hit you up on LinkedIn, Sheila. Okay, I'll say my number so Mark can take care of all that. All right, see you guys later.

Great meeting.

Thanks, guys.

Thanks, Dennis.