The Achilles Island: “It takes longer for an Achilles tendinopathy to recover and to get past that acute phase because it cannot hide. So it’s an island of itself. Now patellar tendon… it doesn’t have to be great rehab… A lot of times they go off and they kind of respond on their own, but they’re also hiding between two joints, the glute and the soleus/ankle.”
Achilles vs. Patellar: “You cannot hide from the forces being administered to the calf complex, which makes that even more problematic and likely one of the reasons why you see more ruptures to that tendon versus a quad or patellar tendon.”
“I look at the rear foot is the rudder of the foot. So how does that calcaneus look when it takes on ground reaction forces? And a lot of times what I’ve noticed is an everted calcaneal position. So there’s more loading on the medial side. ⁓ It’s not great for the Achilles complex. There’s more traction and loading on that medial side and it similarly kind of unwinds the subtend and twist that it naturally happens. So sometimes when I train the Achilles I will twist it from a medial to lateral orientation either by taping or manual and have them trained to make sure that I have good vector pull happening on the medial gastroc, because we know the medial gastroc is likely the most inhibited portion of the calf. I’m trying to get and twist the tissue to then align better. And I use that strategy a lot with Achilles repairs when you’re really fighting an altered pulley system that doesn’t work the same anymore.”
Achilles ruptures in older athletes: “There’s more false steps, I think, because it’s a strategy to beat the defender at one point in space. And if you, are A) older, or B) if you are not athletically built to have that same ability to produce power, you’re gonna find strategies to create distance and win the strategy. So I find that it is, sometimes a strategy used more for individuals that are not as elastic because they’re not able to generate the same amount of pop with a more highly toned or a stiffer complex.”
Achilles ruptures: “You see these individuals that have a previous calf strain and then it leads to an Achilles tear… There’s a combination of a delayed neural firing to the gastroc and it’s the combination of it not firing as quick as it needs to and then there’s a drop in the calcaneus into more dorsiflexion and then there’s that delayed firing. So it could be a combination of the tendon itself not being able to take that force or the inhibition of the gastroc and firing at a delayed as it’s moving down into a calcaneal drop.”
Achilles rupture: “It’s kind of like if you’re rock climbing and you got a spotter that started to nod off and that person dropped and then they woke up and pulled the rope to save the person, that dropping of the person and then the quick pull from the guy up top spotting is when it snaps.”
“In the patella femoral joint, specifically at 10 to 30 degrees, that’s not a great range. And the reason is, it is a low surface area, high concentration of stress to the distal patella. And also it’s not sitting in the cup of the trochlea very well. So it can have a tendency to tilt in that range.”
“I’ve looked at enough MRIs with NBA players and their trochlea doesn’t look great but the lateral portion of the trochlea is the thing that shows more wear which tells me that lateral side is just dropping into more compression and that is a combination of hip adduction and internal rotation which causes more pressure to the lateral facet of the patella.”
“In basketball, I call it the wears of necessity, which is with time, the trochlea will wear, the patella cartilage will wear. It’s not a bad thing. It’s just the outcome of thousands and thousands and thousands of jump shots and deceleration points within basketball.”
Patellofemoral pain: “It’s a physics problem. And that is you got this bone, it’s a sesamoid bone, it’s a floating bone in a groove. And what is its value? It’s one of the most important bones in your body because it creates a change in your moment arm for your quad. And it’s stronger and it can generate more force through a longer arc of movement. So as much as it can produce force through that bone when it’s injured or with time of degradation, it also leads to pain. As much as it’s a proponent of function, also can be dropped into more of a dysfunctional pattern or a dysfunctional issue.”
“The knee is special because it glides with arc of movement, which means that joint is engaged through the whole range of motion. You can’t hide. Just like the Achilles on Achilles Island, you cannot hide load through the patella femoral joint. You can with the tendons in some ways, but the engagement and the compression that happens to that bone is always on.”
Leg extensions: “From 30 to zero, it is a very hot spot. So think of stilettos, it’s a very pinpoint pressure to the inferior pole and the inferior part of the patella. As you go into mid-range, so 40 to 60, it’s gonna get better congruency and it’s gonna drop into the trochlea and the cartilage behind the kneecap’s gonna be better to take on force. So think of more of a snowshoe. So you’re spreading that force through a longer period of time. And then as you get back to 90, you have a really nice positioning of the patella, but the problem is there’s so much force at that point in that range of motion. So if I’m looking at angles that can be problematic to the specific cartilage or the trochlea, it’s likely deeper positions at 90 and up, and also early stages or early shallower ranges.”
“For people that have patellofemoral pain, if you do a TKE from 30 to 0, they respond pretty well but I also know people that don’t do well in a split stance position with the leg being in the back position and that’s because you’re at about that 30 degrees of flexion, but the thing is, is the relation of the hip. Now you have the hip in either neutral or an extension, and now the length-pension ratio of that quad is tighter, and now there’s gonna lead to more compression behind the kneecap. So a lot of times I have to modify that position into more a Bulgarian with more knee flexion to do different exercises, but the split stance position will be tough.”
Going deeper than 90 degrees: “It [pressure] starts to narrow a bit again as you go deeper, but instead of it being hit kind of in the distal part of the patella, it’s putting more load on the superior or the proximal part. So if you go into more flexion, you’re going to be loading the upper portion of the patella and the quad tendon, which is why you see the quad and patellar tendon ratios change with movement.”
Lesions: “Central lateral to the patella and lateral portion of the trochlea is common. The cartilage has about six millimeters of cartilage. It has the most cartilage out of any part of your body. So there’s a really good bed of cartilage behind the patella and the trochlea is a very thin layer, so only about two millimeters. So there’s a variation in difference between those two. But when you look at lot of MRIs from NBA players, you’re going to see that central to lateral, and then I would say inferior portion of the patella.”
“Let the sleeping beast sleep. Which is the chondral defect. How do we make sure that it stays like this is the wears of a necessity? It has changed and altered the joints so the rules have changed, but how can we make sure that it doesn’t wake up and that’s in itself is really focused in on workload, how much spike acuity-wise are they taking on to that knee that could wake it up.”
“There are times where you probably would never be able to return an athlete to sport if you asked it [the patellofemoral joint] to do in isolation things that it would just take too long for it to look good or they may never look good. And by doing that, you’re basically honoring kinematics at that point and not kinetics and honoring that dysfunction.”
“I think we can kind of put our hat on and say, we want to make this perfect return to play scenario with proper KPIs. But when you’re dealing with something notably like a cartilage lesion, those rules are different. And sometimes it’s just graded exposure on the court and if they’re still responding well, it may never look good with a pure isolated knee extension isometric or a isokinetic test. It may take two years for it to actually generate enough force that would make them clear.”
“If you have a central lateral lesion or sensitivity, you’re not going to do well with a lateral lunge. They likely will inherit more of kind of a stiff knee and it just kind of like a hitch where it just doesn’t look like clean knee flexion. And that’s one movement that I do if I just have about 20 minutes of time to screen how you look.”
“I’ve seen Hall of Hall of Famers with knees that would make you cringe and they’re still putting up 20 points a night but they can’t do very very basic things in the weight room. So it’s just one of those things that if you haven’t been in the trenches of pro sports and looking at how true athleticism is and how they find success and I think, out of any athlete, the NBA athlete finds compensation the easiest. Because most of what they do is they jump from their ankles, not their knees.”
“In season, you manage it by loading it. You are microdosing, you’re finding ways to slowly climb that sensitivity or at least drop the sensitivity to actually load it.”
“Cartilage doesn’t have any nerves at all. What they feel pain is the bone itself. And with time, there will be continual microcracks… and with time, those micro cracks will stimulate localized healing and fibroblasts will come in and say, well, we’re going to do something about this [create a callus].”
“Hyaline cartilage is the supermodel of all human tissue. It’s beautiful. It cannot be recreated, but it’s dumb. And it doesn’t know what it’s doing.”
“The cartilage has two roles. It has compression to take on ground reaction forces and gravity, and to create the most frictionless environment between two joint surfaces. So one is shearing, and one is basically taking on load. And it’s a internal pressurization system of hydrostatic pressure.”
Viscoelasticity of cartilage: “if you have high force or high strain, the water content can’t get squeezed out from the sponge, so it takes all that pressure from the internal structure of the matrix and absorbs force. And if it’s a slower, application so it’s very similar to a tendon. A slower application of load is removal of fluid through the matrix. It pushes out into the joint and then that spikes hydrostatic pressure. So a lot of the load is being taken on from this really stiff water balloon of fluid and not so much the interfaces of the cartilage itself.”
“Synovial fluid is a different type of fluid because it has viscosity and it changes with stress. It’s just like paint. If I take a paintbrush and it’s thick, that viscosity is high. The moment I start to spread it with speed on the wall, it thins. And that’s what happens with that interchange of fluid within the knee. When you sit for a long time, it becomes very cushioned and thick. And that requires you to get the knee moving and create heat and shearing, which then will thin it out and it spreads between the inner faces of the joint.”
“There is an inverse relationship of pressure and velocity. So if you have a higher amount of pressure, you have less velocity for the fluid to glide through the joint and vice versa. If the pressure drops, there’s more fluid. So if you go and ask somebody to just start doing isometrics, either overcoming or yielding without good preparation, you’re asking it to do a high pressurization movement when knowing that you have a pathology of the knee, it needs to have additional work to coat and get it prepared to do it, to create that frictionless environment.”
Bernoulli prep:
- “doing velocity-based movements first to get that fluid to kind of coat the whole complex. And then with graded exposure, you start with high velocity, low pressure, and every stage you get more pressure to the knee. So you start out either on the bike or if you do knee extensions with very low weight and just speed and just kind of get this fluid to kind of move through the knee, maybe some banded TKEs for speed with light load, that’s your first stage.”
- “The second stage I like to share the load between the glute and the knee itself. So I find almost a coupling sharing movement, maybe even more glute dominant, but you’re starting to sneak in some loading through the knee so that’d like a high step up on a box where it’s more of a glute derived movement or maybe I have them do some form of you know a goblet squat or an Front leg elevated split stance where it’s glute and knee working together.”
- “Then I transition into pressurization which is I’m going to do some form of isometric loading, whatever feels appropriate for that person.”
- “And then after the isometric loading, I go into some form of eccentric loading.”
- “And then I end it with plyometrics to basically prepare that joint to take on rate.”
“A lot of times when you have a cartilage problem, you have more fluid. You have kind of like resting residual effusion. And then when you have resting effusion, it increases the hydrostatic pressure of the knee. When you have more pressure, you have less velocity.”
“A dry knee is what we call it when there’s no fluid. That’s what we try to strive for.”
“When you have an engorged tendon, it’s gonna be more painful and you wanna squeeze that fluid out. I think for the cartilage, it’s the fluid outside of the matrix. And if that is high, then you don’t have a good sponge. We call it cartilage breathing, which is when you compress, it squeezes out. And then when you unload, it draws back in and that’s how the cartilage breathes and it creates micronutrient movement. But if you already have a high amount of fluid externally to the cartilage, that interchange of micronutrients is reduced. So, your case, the hydrostatic pressure is higher in the tendon, the cartilage, it’s probably more outside of the cartilage and it’s not allowing that nice fluid exchange.”
“It’s critical to get the knee with no effusion and that’s going to allow that quad to fire better.”
“When we’re talking about that subchondral and bone interface, it’s not a cartilage issue, it’s something beneath that. It’s a desensitization, it’s a graded exposure, and how much are you gonna dial and pull the levers to say I’m gonna load that and at what magnitude?”
“Pepé Le Pew is just like the cartoon. He’s kissing the gal and he’s doing small pecs. So it’s high frequency, low to moderate intensity, and low duration. So your isometric load would be 30 to 50 % your one rep max or tolerance, and you’re doing it for five to 10 seconds maximum, and you’re doing it frequently throughout the day. Within maybe a six hour frame, you’re hitting it multiple times in the day, but you’re just trying to hit the callus. You’re just trying to engage that area to desensitize it to create that interchange of fluid to get some of that cellular activity to start building again that fibrocartilage that’s not perfect but it’s something and that’s much different. You’re gonna smoke a lot of your patients with patellofemoral pain by doing the opposite which is the tendon is like you’re making out with someone like it’s high intensity, high duration and you don’t do it very often. So that’s the opposite.”
“With the Pepé Le Pew, I’m not going to do this strategy if this joint is hot and it’s irritable. I’m just offloading, getting them on a bike, I’m having them wear a compression sleeve.”
“The patellofemoral pain, it may take some time, but then we forget about it and you just move on with your life and then you piss it off again. Because you do need a seated knee extension and you weren’t really focused and it’s now awake. And it may take two weeks, but that’s the other issue about this whole thing is sometimes it’s very easily forgotten because it just kind of gets better on its own.”
“With a cartilage issue, probably start with more durational changes than magnitude. And I think that would be different with tendons. So you may stay with the intensity of contraction, but hold it longer. So that would be the first thing that I would start to adjust once the knee is responding well.”
“I think you have to have a discussion with your client or patient that it’s gonna take longer than a tendinopathy because we’re dealing with the supermodel of tissues. They’re the divas or the divos. They’re the ones that it takes longer and it’s because there’s so much stress and pressure that happens behind the patellofemoral joint. It is a dynamic pulley where it’s engaged through full range. It cannot hide.”
“I look at biking as a functional range of motion and kind of this compression offloading through range to pump. It’s more of a pumping mechanism.”
“Old guys, when their knee hurts, what do they do? They go grab a heat pack and they throw it on their knee and miraculously it starts feeling little bit better. If you put it on for 15, 20 minutes, it starts to wake up the cellular activity to kind of clean up some of the debris and some of the kind of the metabolites that are just kind of stagnant. So heat is helpful. You just got to look at what your dad does.”
“If you look at the accel decel ratio, if you have a low ratio, that means there’s a higher amount of decels. That’s one of the first things I look at, players that have a high risk or they may start to show some reactive effusion.”
“When you’re looking at the hydrostatic pressure and the fluid, when you’re having a struggling knee, the body senses that it’s struggling. So what fluid’s in the knee is called synovial fluid. And the main ingredient to synovial fluid is hyaluronic acid (HA). And that is the mechanism or ingredient that helps with thixotrophy, which is a changing of thickness of the fluid to do its coating. But the issue is, is as you start to have a failing interface or inner surface of the joint, the body knows that and it’ll start to dump more interstitial fluid to help. But the issue is it doesn’t have hyaluronic acid. So you’re diluting the concentration of HA. So you’re just putting more fluid and it’s increasing pressure, but it doesn’t have any of the good stuff that helps with coating.”
“Iff somebody has a cartilage issue, ideally getting them on two to three times a year with a HA injection might be good for them.”
Swelling: “You need to track it. That’s one thing I teach my patients. Like every morning, your audits are you look at if you have any bogginess or any kind of puffiness in the knee.”
“If you’re gonna do patellar taping, I probably would try to offload the lateral facet to pulling it more central, because we know, again, 30 degrees is not great, and that’s also a position, almost a loose pack position where the kneecap can shift. And again, if you have fluid behind the knee, that can shift even more. So gliding it more medial to get it more centralized is good.”
Using a hip strategy to offload the patellofemoral joint: “If you have a longer impulse, you have a longer time to accomplish that strategy. But when you cut that strategy time in half, you can’t inherit that. So you either injure yourself, you fall over, or you take four more steps.”
“You got to look at the glute strength. You got to look at soleus. If you have a ⁓ deconditioned soleus, it is the airbag to the knee. It takes on force first. And if you can dissipate enough force from the ankle, then the knee’s doing great. They got a roommate that’s paying rent on time. They’re not that shitty, I’m gonna get you in two months, and now the knee is paying for rent because the soleus isn’t doing the job.”
“The fat pad is the barometer of the knee… If the fat pad shows hyperechoic or hypo, so at least some fibrotic changes or some excessive inflammation to that area, that there will be cartilage pathology in your future. So I call it the barometer because it tells you how healthy your knee is because stuff gets dumped into that area.”
“The fat pad is a way that you manage friction behind the tendon. It is a way to buffer forces. That’s why you have fat pads. They’re like brake pads. And when we look at the patellar tendon, most of the damage is on the posterior band of the patella. Because not only is it dealing with tensile forces, it’s dealing with compressive forces as well. So now you have this bony interface that starts to create damage because it’s the weakest link of the tendon. And now you’re going to this ultra stiff anterior band of the patellar tendon and this degeneration to the posterior band. And it’s the combination of compression and tensile.”
Fat pad, cartilage, tendon changes: “It is a joint that’s losing the battle. So you’re likely having tendinopathic changes. You’re likely having high signaling to the fat pad.”
“If you’re not decelerating with a more plantar flex position, let’s say you’re landing more mid-foot, you’ve just changed the moment arm of the ankle, you’re asking it now to stop the same rate at half the distance. So that’s the issue. Deceleration needs to have torso, back, foot, and plantar flexion, giving it enough time to plant and then let tibia transition forward. The moment you start landing mid-foot, that airbag [soleus] can’t respond as well.”
“When we talk about OCD lesions and what’s the worst of the worst, ⁓ trochlear lesions that don’t respond well to load are the worst ones to deal with and the surgical outcomes are the worst as well versus more of a weight-bearing lesion on the medial femur condyle or lateral femur condyle.”
“We only look at it [the knee] as a hinge joint but it’s a modified hinge joint, which means it has transverse movement capabilities And if you can get the knee to just rotate one millimeter more medially that can help clean up some of the tracking issues or some of the compression issues that you’re dealing.”
PFP being more psycho-social of a pain: “Sometimes when you try to get back into the functional thing after time and it just continues to wake up and you’re just not able to respond that that’s not great mentally You start to lose confidence. You start to gain more fear avoidance behavior. Now you say I can’t you know, I’m 40 I can’t chase my kids anymore because my knee blows up The other thing is it behaves in a way that it reacts and there’s a fusion and that’s not a great feeling either That you wake up one morning and what you thought was not much now you got a swollen knee.”
“Back in the day I would never want to look at MRIs because I was so much a functionalist and now I think we’ve tipped the hat that structure is everything. It changes the way that the body will choose strategies. I hate this term, the bridge between rehab and performance, right? It’s just too much. We’ve said it too many times. But if we traverse through the gap of rehab to performance, the thing that lies in the middle that makes all the rules is pathomechanics and pathology. That is the bridge. Because if you’re healthy, you don’t have to deal with it. Performance and everything is nice, but when structure changes, the rules change.”
“And I think that’s the number one piece about this whole thing is that’s why patellofemoral joint issues are so complicated and frustrating is the rules have completely changed and now you have to behave differently and it takes longer than you would expect and you have to do low intensity low durational holds frequently throughout the day and it takes time and you have to do strategies to get the knee warmed up before you go do things and people don’t want to inherit those strategies. They just want to go do their sport or do their hobby.”
“Cartilage is more dumb than tendon because it doesn’t have any nerve endings. It’s an inert tissue. It doesn’t respond. It just is a sponge. Your true SpongeBob meme is cartilage. It is the loading and unloading, and the only way it can move micronutrients is through that mechanism. The cartilage breathes through the loading, unloading sequence.”
“When you sit for too long, and we call it the movie theater sign, you sit for two hours and you get up and you start walking like an old man, it’s because there’s not been a good transfer of fluid through your cartilage. It wasn’t able to do its cycling like it normally does. So that’s why you start to limp is because of this static position that changes the fluid exchange.”
“I started working with athletes and started to find that velocity work first and then working pressure.”
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