Combine a couple of talks, I'm gonna give you two stats while he's pulling this up. 40 to 70% of ACL injuries have a meniscus tear. 80 to 90% of ACL tears have a bone bruise. So I think, I wanna put that in context. I think Dr. did a great job outlining all the mechanics of the knee and why saving the meniscus matters. So I think what I wanna kind of walk through is a little bit on the rehab standpoint of how I think about protecting. And it gives me great joy. And somewhere Dr. Steadman is super happy that everybody's talking about the fat pad because that was his, one of his, just really key things and key to health. I don't have any disclosures. So one of the things I think is important, this is Willis McGahee in the Fiesta Bowl, I think, tore his ACL. Went back, went on, had a great career. Adrian Peterson, Jamal Lewis, et cetera, et cetera. That's what our athletes and patients think about. However, this is actually more consistent what actually happens. So Marcus Lattimore was at South Carolina, similar type college running back, tore his ACL, was a little more than that, but never really made it back. And the point being is that I think we all remember the successes, but we kind of try to push the failures back. So I think Dr. Frank hit it. It's not a home run. And so when I think about the importance of the meniscus that Dr. Wuerst laid out, when we think about what it takes, we have to understand these hoop stresses and what it takes to protect the knee. And at the end of the day for me, that's all this is about. And so it's really about getting out of the gate in a good way. So we know that standing in extension seems to be okay. And it's actually the shearing of the flexion. He did such a good job describing the pivot. We think about it, it's like a hinge. It's not a hinge, not a hinge at all. It's actually that rotation and pivoting at end range of flexion and loading, in particular between 30 to 45 degrees. If you don't control it, you're not helping the meniscus. So then when we think about it, I think about when we let people weight bear and walk and what we're really responsible for in that early period, and maybe why there's a lack of alignment, is knee excursion is decreased because knee moment's controlled. But when you take the quad out, what happens? You have no control at zero to 30 degrees and you lose that control. And then now what happens to the meniscus as you get into that 30 to 45 degree range where it's most at risk? Well, it shears. Like, okay, so nice mechanics lesson. But I think when we look at the differences in outcomes, there's not really any difference in the literature between weight bearing and not. And so if you think about it, it's a, I'm gonna try to repeat the term you said, a macro-micro environment. Is that right? Close? Micro-molecular. Micro-molecular. Because I think the meniscus is a living organism. It needs stress to remodel. And so I think my concern is when you go completely no weight bearing, you've taken all the stress away. So really our job is how do we give appropriate stress in the rehab? So you've really gotta get maxed expectations of surgery and rehab. And so I think if we think about the discussions and really the really great description of the knee surgeries, here's all the things we gotta know. Surgeon's gonna direct based on what they see. What happens? Our job, we don't have any way to look inside the knee, at least not yet. Hey, I'll do that soon, I guess. But we gotta look at pain and swelling, change in motion and change in quad function. Those are my indicators or my dashboard of how the knee's doing. And ultimately that allows me to match the expectations with it. Now this is actually, can you click that please? It's actually my knee. I wish I'd had you in 2000, well, long time ago. But when I had a big ACL tear and double bundle was all the rage. And if you don't tension, like Dr. Frank said, it doesn't heal right and you get a cyclops, it's really bad and then you get a total knee when you're 45, no big deal. But being able to understand what happens with a surgery. So I think one of the things I appreciate about the opportunity for us to be here and build on this is understanding that allows us to understand the weight bearing status for the surgeon, patient and rehab team to be on the same page. For us to understand our early expected knee range or motion and then what are the other concerns? There's other things going on with most patients in regard to their pain control postoperatively and how they manage that we need to be able to deal with. So we have criterion and we've got time. And those are the two things that we used and I think of it like an accordion to either expand out or to compress. ACL repair, young healthy athlete, not a lot of other comorbidities and injuries, maybe not super high level pivoting, cutting, maybe I can pull it down. Pivoting, cutting, joint damage, other things going on, now it gets much longer. And I think that's sometimes we put these absolutes out there and think, oh, NX, I'll do Y and that's not really how it works. The most important thing is to get out of the gate first and if you lose the first six weeks with any knee, you're done, you can forget it. Whatever goals you have, you can just put them in the trash can because it's completely unpredictable if you lose the first six weeks. And so in this world of insurance and things where we're at, if you have to choose where you're gonna spend your time, don't lose out of the gate because if you lose out of the gate, you're done. And so when I think about it, we've got to control pain and swell and we know that pain and swelling limits quad function. If you don't have quad function, you can't control the knee. So there's lots of things out there. That's where the modalities matter. And I realized there's all the don't need modalities. Oh yeah, you do. Because that's how you went in the first two to three weeks. So you've got to get out of the gate. Do you brace? I think it helps as much as anything. It puts some reins. I grew up on a horse farm. So it puts a bit in the mouth of your patient and slows them down. Now, I hope if I could make a brace go away, it would be the big blue behemoth because if you see this come into your office, you better get ready. The knee's going to be stiff and it's going to have a flexion contracture. So I just get ready. So just if you take a sock and put it inside the big blue and put them in hyperextension, you can fight with it because there's still surgeons that that's what they want to do. But if you can, you want to be in one of the braces allows you to put them in about five degrees of hyperextension and actually have them live there. Make your life easier. These are the core things that I tell every patient. This is what you owe me every day, twice a day. There's nothing hard. There's nothing complicated, but if they can do this, you'll win all day long. There's lots of other cool things that Mike puts on Instagram and you can be like Mike. I'm just kidding, Mike. But I think he and I were talking like, those are all great, but you got to do this and you don't miss this. At the center, the reason I have at the center is the patella and tendon mobilization. If you get that right and they understand to separate the fat pad from the tendon, from the patella, no problem. The emotion comes back easy peasy. If they don't do it, you're screwed. We know that motion loss exists. There's abundant literature that shows when you have motion loss, bad things happen. And those two things go together. And so then our job is how do we keep that together to prevent the long-term degenerative changes? For me, it's simply a hilt. Every time a knee patient comes in, you're on the plinth, knees off the end, where are you at? And we're not starting until you're equal. And so it allows me to set the expectation of the patient. This is how you have to look before we go. Now, what's changed for me is probably 20 years ago, that's what I would do. I'd put you in whatever extension device and I would crank and I would hammer. And what I learned is actually by mobilizing the fat pad, you're actually able to change knee extension. I don't completely understand it all. Maybe if I understood mechanics as well as you do in anatomy, I'd get it. But because the fat pad gets sucked into the knee, you can't get extension. So actually what you're doing is try to get the fat pad out of the knee and to separate the tendon and the fat pad. And so really it's grasping. As you can see there, I've kind of pinched the fat pad underneath and back and forth. Becomes really important in particular, depending on where your portals are. So one of the reasons that going at, several of the surgeons have offered to come and see, is seeing where those portals are, in particular the medial portal, if they get into the fat pad, no bueno. So you get patients that are super sore on the inside, it's just because they nicked the fat pad a little bit. And so when you have that, you've got to be able to understand how are you going to calm that down and get it. So I think that allows us then to get along. These are two really good papers that have shown really pain induction and really tie together where the portals are and the relationship to the fat pads if you're interested in digging in. So when I get extension now, it's a much more dynamic. I can do that, I can do some easy mobilizations on a plant and get back and extension comes back. And it's much less aggressive than I was probably in my early days. So once I do that, now I can get muscle performance. And we know that at the end of the day, quads are king. It's amazing to me. I've been, well, a really long time, like 27 years now, and we still can't manage to get quads consistently strong. And I think it's because we miss the basics. And so really it starts with not allowing, that's not an acceptable straight leg raise. And so I work for ATI, big clinic. I go all over the country and it's amazing when I walk in, I'm like, really, this is really what we're doing today. And it's all of us, because you get busy, the patient's not on it. So I think really making sure that this is not acceptable, right? You got to have equal heels and you got to have good straight leg raise. If that's not there, we're not getting off the plant. You want to get off the plant and do fun stuff? We can, you got to give me that. So I think it's really this gating or what did you call it earlier, Julie? Earning gravity, right? You got to earn the right to get off the plant. And so there's lots of ways to do that really progressively coming in. And I think ultimately clearly defining with your patient what a good straight leg raise is and what good quad function looks like. I will say there's a few things that have come along that I'm like, oh, this shiny object actually has got something to it. And so this has been both personally and professionally with blood flow. It's not overly complicated. I'm not going to go into the depths of it. You can gauge what the right one, we've kind of landed in the middle. You know, $5,000 is a lot per clinic, but I think there's good solutions in the middle. And what's amazing is, is in this non-operative limited weight bearing, you can get similar response. So there's several really good randomized control trials and some very complicated knee patients that are showing just almost unbelievable results. So I think it just really has changed the ability to strengthen the quad and get it back. So having this right early weight bearing pan, because remember we said bone bruises are there, whether we do anything with them or we pay attention to them, they're there. So how do we manage that? And I think clinically, this is completely anecdotal. I don't know of any evidence that says this. I feel like these patients, that's when the quad shuts down. Bigger bone bruise, those patients seem to struggle with pain and swelling to get it back. So we have to make sure that we're getting that back and getting patients in a good spot because ultimately the ACL is the watchdog of the meniscus and the meniscus is the protector of the articular cartilage. So you've got to have A and B and C. So having that trifecta there allows for a healthy knee. And if we look at the changes that happen in gait, if I have good motion, I've got good quad control, I think sometimes we underappreciate just simple gait stuff. And it's not anything hard, it's just really simple exercises allowing people to learn how to walk again. They lose that, they've been on crutches, they've had injury. How are you going to retrain gait and get folks back? Then that sets us up for a progression to gradually get back and I think at that point, we get here. We're finally at a spot that we can do fun stuff, but they're also back to life. They're back on their feet at work, they're back on their feet at school and having had 14 knee surgeries, it swells. You get back on your feet and things swell and so I think we have to be really conscientious of being able to, we're loading them, right? You're starting to crank up the load, but how many steps are they getting daily? What else are they doing in the rest of their life as they come back? So I think really helping them document and however it is, most people have some sort of wearable something, right? That they're tracking steps and stuff, so really helping patients do that becomes really important as we progress them back and just you can see here in a couple of these videos, patient has BFR, so it's a really great way for me to increase load in a small amount of time without actually, I get the effects of load without the load. So then as I transition from phase one to phase two, you can see asymmetrical loading. I'll do some of the things that Kevin talked about this morning with different neurocognitive engagement to really pull them along, because ultimately what I'm trying to prepare for is what do they want to do? When can I run? Think sometimes again, we're a little aggressive because guess what's still happening? If you're not checking later on as they get eight, 10, 12 weeks, you're missing extension lag because it shows back up. It's this nasty little thing all the way through that keeps showing its way up and it matters because remember, when you don't have quad control, what happens to knee moment? Knee moment goes up and that's where you get into this cycle of really the knee struggling. So we think about trying to control the ACL and what's there and I think this is really where we have to make sure we've got the quad control and dynamic controls, they start to load because this is where you get a little cyclical load and this is where for me, I'm interested in the bare and the other more accelerated pieces. Can we help the quad keep up for the loading that now the biology theoretically can take? And I think that's really our challenge is to come into. So for us, it's really making sure we use isokinetics to really test strength. It's exactly what Mike was saying. You gotta test, don't guess. George Davies would be proud somewhere and really come back in a systematic way because these knee strength deficits will come back. My goal at 12 weeks is they can start this kind of stuff. They can start to do more athletic things. So once they begin that, now we're ready to really strengthen them. Not until 12 weeks are you really ready to start cranking up the load and now they gotta train and from that three month to whatever spot that you're gonna let them go back to sport is all about muscle building and being an athlete and it's a different type of training that most in particular adolescent athletes have done. So you've really gotta come in and take them from maybe what I'll call more of a rehab focus, managing their symptoms and impairments to shifting them to more of a performance mindset with lots of training. And so the two things that I come back and really ask is how hard are you working on a daily basis? When you get finished, where are you at? You need to be yellow or red every time you work. If you're not yellow or red, you didn't work hard enough they go back and do some more. And then that allows us to gradually progress because guess what, life's happening. They've got other things happening. So not only how hard are you working in rehab, but how are you feeling overall? And just literally put it in your phone, create a note and just write it down every day and let's talk about that. And I think engaging patients in that way allows us then to begin to mimic in more controlled environments and professional environments where there's more staff to look, this very controlled ramp of how do we do that? So whether it's Garmin or Whoop or Apple Watch or Oura Ring or I'm not funded unfortunately by any of those. So it allows you to come along. I really like this progression that Darren Padua from UNC has published. And he says, really, I've got to take back relative to their training load they wanted to do before. So if you think about how hard were you working before you got hurt and now how hard are you working week over week? And I like the way this kind of progresses out and begin to appreciate it is a long road. If we can progress 10 to 15% load over a week to two week period, that starts to make sense why it's such a long journey to take somebody from postoperatively day one all the way back to return to sport. Ultimately from a return to sports process, it's not a single point in time. We want to participate, we're going to play and then you can perform. So you've got to set your expectations, range of motion, strength, movement, quality, endurance and power in that order. And if you miss a level, you got to go back, right? It's just like you've got kids and you play board games, right? Go back to jail. Nope, got to go back and start all over again. And so having that criterion plus the time really matters. What we've shown is similar to what's in the literature. If you go back to sport before seven months, 17 times more likely to re-tear your ACL. I mean, it's astounding. Several people said, that's why Dr. Bonner said, it's pretty much seven plus months period. And I don't know that it's time, it's just hard to ramp back. If you think about getting all the criteria right, it's hard to get there in time. So ultimately we have to have our patients exit with a good long-term health knee strategy that includes all the things we've been working on. At least my personal experience with knees and following patients for a really long time now, that this is a forever thing. Once you got it, you got it. And you've got to be able to manage your knee over time to continue at the high level. So these are just some things, the slides are available and I appreciate it. Look forward to our other presenters.

ACL injuries

meniscus tears

knee mechanics

rehabilitation

recovery outcomes

meniscus tear

rehabilitation techniques

blood flow restriction training