Wear of necessity
“Things will wear down because you’ve done repeated things all the time. In baseball we call them tears of necessity. When you get an MRI of the shoulder of an overhead athlete, the label will be torn in some capacity, because you cannot achieve a ninety-eight mile an hour fastball without altering the joint.”
“The analogy I give is opening up the hood of the car. You can see all the stuff, but the car isn’t running. The car running is you looking at functional movement. You can see the belts, you can see if something’s smoking — but you will not know that unless you turn the car on. A still shot image is just opening up the hood and trying to figure out the problem.”
“More information, more power, more understanding.”
Look at the tree before the forest
“We as a profession do a great job of making things so complicated. A lot of PTs look at the forest. Look at the tree line, look at all the stuff. The diagnosis, the pathoanatomy, the force profiling — that is the tree you should be looking at. Once you understand that, then let’s look at the forest.”
“The bridge between rehab and performance, in my opinion, is pathomechanics. Because that’s the thing that alters function.”
“Understand what pathomechanics means, and more importantly, how do you progress and how do you regress. That is the power of what a rehab specialist should know. It’s not bastardizing your own profession and spreading out into others.”
Kinematics, kinetics, and compensation
“Kinetics is force output, ground reaction force, joint angles. Kinematics is the relation of the whole chain and how it takes on force. One is in isolation and output driven, and the other is the strategy — how do you accomplish these movements?”
“Right now we live in an idealistic world of rehab: objectify, get your measurements, see the true force. It’s very honed to kinetics, but we don’t really honor kinematics, or the compensation of kinematics that lets someone keep doing the activities they want to do.”
“If your brake pad isn’t great behind your kneecap, you’re going to find brakes in other locations. The soleus, the Achilles, the hip, a change in the inclination angle of your trunk. Or multiple steps — you’re just extending out the impulse demand by catching up with time.”
“You might be able to accomplish the task, just not as efficiently. So your athleticism changes.”
“There might be athletes that don’t need workload management because they’re really efficient and smart with how they move. There are others that probably don’t manage momentum as well. The workload is completely unique to the person.”
The soleus is the airbag
“The patellofemoral joint is the brake pad. The soleus is the airbag.”
“The soleus can fire much quicker than the quad based on pennation angles and the architecture of the muscle, and it’s closer to the ground.”
“If you land in a more plantarflexed position, you have all this room where the tibia can travel, so the soleus has more time to do its job. When you land on your midfoot, that cuts it in half. Now big brother, the quad, has to respond quicker — and it’s not meant to fire as fast as the soleus. That’s where you start to see bad injuries.”
“The soleus is a type two lever. It is by far the mechanically strongest muscle in your body because of the lever system. It also has the highest type one fiber content, which makes it fool’s gold to think aerobic, let’s just do endurance.”
“It doesn’t matter how many type one fibers it has, it is strong as hell and you have to load it accordingly.”
“Never. We talked about anterior tibs before we talked about calves.”
Valgus is usually a quad problem
“Back in the early 2000s there was a lot of directed research on glute medius training, to fix the boogeyman, which is dynamic valgus.”
“If you see a collapse like that, yes, there’s likely something proximally. But more importantly, it’s likely a weak quad driving that adduction moment at the femur. It’s not absorbing at the local capacity of the quad, so the chain has to find another way to absorb the force.”
“Maybe they have strong quads, but they don’t have the rate. That’s a whole different ball game.”
Tendon or cartilage — usually both
“They’re the same structure. It’s the joint, the cartilage, the undersurface, the synovium, versus the tendon. When you start talking about chronicity of anterior knee pain, it’s likely both. What came first, I don’t know.”
“The fat pad is the barometer of a chronically irritated, recurrent issue. There are a lot of nerve endings there, and that’s where you start to get more of your pain.”
“There’s a ninety-six month longitudinal study showing that if you had a hypoechoic or hyperechoic finding of the fat pad, you’re likely going down the road of some kind of cartilage pathology. Where there’s smoke, there’s fire.”
“You have both. So how do you load it? They’re different structures with different sensitivities. I usually go after loading the more challenging issue. With the tendon you can kind of get away with it. With the patellofemoral joint, the surgical options become fewer and fewer. So you fashion your loading to the joint.”
The trochlea is the silent killer
“There’s only about two millimeters of cartilage width at the trochlea. The patellar cartilage is the thickest cartilage bed in the body, four to six millimeters. So that thin interface is buffering against a nicer, fluffier pillow.”
“It’s the silent killer because you don’t know about it until later down the road, because it’s been supported by the adjacent joint.”
“The trochlea is engaged through full range of motion. With a condylar lesion you can kind of get away with it — most are in the back of the knee, and that just tells you you can’t go deep into knee flexion. The trochlea is always engaged, so it takes longer for it to settle down.”
The stiletto and the snowshoe
“The inferior portion of the kneecap is more engaged from zero to thirty or forty degrees, so there are more concentrated compressive forces to that area. That’s the stiletto. It’s like having somebody walk on your back in stilettos.”
“As you bend further into flexion at ninety, it fits into all of those patellar facets and sits into the trochlear cup the way it’s meant to. There’s more congruency and it can dissipate. That’s the snowshoe. It’s the highest absolute compression at that angle, but it’s anatomically built to take on higher loads there.”
“In a lunge, the hip is in an extended position, so the anterior chain is in more of a stretch. There are more compressive forces pushing the kneecap into the trochlear cup. And at thirty or forty degrees, look at that torque curve — it doesn’t generate much. So there’s compression, and it’s a weak angle.”
“I don’t mind open kinetic chain knee extension. But if I know somebody has an active issue at the patellofemoral joint, I might just cut that last bit.”
“Train partial arcs in the most effective way the quad can be trained. Or go through full range at a lighter weight and use graded exposure, and tack the heavier work onto the partials.”
Patella alta and baja
“Alta sits tall in the saddle. That kneecap lives a little higher, so when you unbuckle the knee it takes longer for the patella to drop into the trochlea. We call that delayed engagement. And if it’s not as engaged, it can move more than just going through the groove.”
“Baja is compressed. That kneecap is already sitting further down in the femur, so it naturally falls into the cup. There are higher compression forces throughout the range, but especially early on.”
“In PT school I was confused about why there were Spanish terms in this one case, and I never used it until ten years later in the NBA, when doctors would say we’re going to put a flag on this person because they have patella alta.”
“I’m not going to measure their kneecaps and tell them they have patella baja. But if a radiographic finding tells me that, I already know I want that complex to move as much as it can relative to the other side.”
Cartilage is the supermodel tissue
“The surgeons will say your cartilage was pristine. There’s no other tissue in the body you hear described that way.”
“I call it the supermodel because genetically it can only be made when you’re born. It can’t be reproduced. And it’s dumb, because it’s just a transfer of synovial fluid and proteoglycans. It’s a sponge. And it doesn’t have any nerve endings, so it doesn’t feel pain.”
“The body doesn’t know how to create hyaline cartilage. So it substitutes a tissue that is fibrocartilage, which is not as perfect.”
“Hyaline cartilage is a sponge because it breathes. When you push the foot into the ground it squeezes the fluid out, and when you alleviate it, it sucks it back in. That’s how the system moves nutrients. That’s Darcy’s law.”
Synovial fluid and Bernoulli’s prep
“There’s a dynamic relationship between two things: articular cartilage and synovial fluid. The cartilage breathes and takes on ground reaction force to protect the bone. The synovial fluid bathes the cartilage so it can be in the most frictionless environment possible.”
“When cartilage breaks down, Darcy’s law is influenced differently. Now you need the synovial fluid to do its job even more. That’s where the problem is.”
“Synovial fluid is a non-Newtonian fluid. It thins or thickens with speed or force. If I put a paintbrush in paint, it’s thick. When I spread it with speed, it thins and I cover the whole wall.”
“Bernoulli looked at fluid dynamics in a pipe. When you increase pressure it reduces velocity, and when you decrease pressure it increases velocity. It’s like being eight years old in Wisconsin drinking from a hose, and you see your brother coming around the corner, so you cinch it. Increased pressure, zero velocity. Then he runs around the corner and you open it up.”
“There’s another guy named Hagen-Poiseuille who had a similar law about viscosity. But Bernoulli’s prep sounds better than Hagen-Poiseuille’s prep.”
“If you do the same technique but add some preparation to warm the knee up and it feels better, then that’s the relationship we have to work on — synovial fluid management to create a frictionless environment between the joints.”
“Chronic inflammation changes the environment of the synovial fluid. The system looks at it like you need more help, so it puts more fluid in the knee, and in doing so it dilutes the hyaluronic acid.”
“Long term the research on visco injections isn’t great. But PRP isn’t great either, and it’s a catabolic event — it creates inflammation. Hyaluronic acid might give you some residual soreness from the effusion, but it’s not going to do harm.”
Moviegoer’s knee
“You’re in a sustained position, and not just a sustained position — a sustained position without weight bearing. You’re sitting in a position of comfort. The moment you get up, you start to limp.”
“If I sat and watched an hour show with my arm hanging straight down holding the remote, and then bent my elbow, I’d say, God, my elbow hurts. But in that situation you don’t have concern. Of course it would be sore. It was straight against gravity.”
“We have to avoid apprehension — my knee is going to be like this, I can’t run with my kids, I’m slowly losing all my function. You might walk with a limp because it was there for a while and now you just have to loosen up the joint.”
“Morning pain is something we track with both tendon care and patellofemoral dysfunction. How did you feel on waking? How did you feel the first few steps? That tells you if you did too much the day before.”
Let sleeping beasts sleep
“Let sleeping beasts sleep. Your job is to put the beast to bed. The beast isn’t leaving, it’s there. How do we progressively manage an athlete or a patient so that it never wakes up?”
“Biking warms the tissue up, it repetitively glides the patella through the trochlear cup, and it’s non-threatening. That’s everything you want for neuromodulation — non-threatening, repetitive movement.”
“Running is another benchmark I care about, because jogging is also a repetitive cyclical movement. If it’s at a state the knee can tolerate, it becomes non-threatening.”
“It’s a game of pain. It’s a game of sensitivity. You see how much you can adjust that through loading and neuromodulation, to really see the true envelope of function and how much they can load that joint. Then you get a realistic measure, and from there you decide what needs to be changed in their movement.”
The tide mark
“We call it the tide mark. It’s the last defense, the last brink before — just like medieval times — it’s been breached. Now you’re screwed. You’re protecting the castle.”
“Bone marrow edema is basically fluid, and like any other fluid it goes to the point of least resistance. You get pain from venous congestion and fluid building up in the trabecular bone.”
“A bone cyst is like a bullseye. It’s telling you this area is being excessively loaded, and it’s not a good sign. The body’s doing its best, but there’s a cyst underneath it.”
“We don’t know if bone marrow edema actually causes pain. But just like the fat pad, where there’s smoke there’s fire.”
“With chronic microcracking and steady linear progression, your body is naturally doing a microfracture — which is what you’d go down the street to the hospital to get.”
Taping, orthotics, ice, and heat
“If you take some tape and it offloads it in some mechanism and it feels better, then do it. I’m not going to sit and recite every journal article to justify the finding. It changed. That patient felt better. Put some tape on it. Just don’t overpromise — don’t say this is the magic tape you got from a course. And let’s try to wean away from it in a week.”
“Everything starts from the foot when it comes to taking on ground reaction forces. If you support the medial longitudinal arch, maybe you have less tendency for a hip adduction moment, which maybe leads to less valgus, which maybe alleviates some of that lateral compression.”
“Icing is for pain. Maybe you ice and they actually feel a little better, so they load it earlier. That’s a win too. I’m not here to sit on any soapbox.”
“I do know compression is better. If I care about effusion, I’m going with compression. And the research shows static compression beats intermittent — so I’ll have them sleep in it, because that’s eight hours.”
“I like a compression sleeve on the bike, so you’re actively cycling that fluid with an external compressive force. And a sleeve while they use Normatec, so you have static and intermittent at the same time.”
“There’s research on heat shock proteins with tendons — it activates and helps clean up the environment. If an old guy says his knee hurts, but a heat pack for twenty minutes makes it feel pretty good, is that placebo? Research shows there is some mechanistic influence based on cellular activity.”
Draining the knee
“If they’ve got fifteen or twenty cc’s of fluid, draining is going to make the knee feel better. A lot of that is hydrostatic pressure putting irritation on the afferent nerve endings.”
“You don’t have to have a lot of cc’s of fluid for the quad to not work as well.”
“A Baker’s cyst is one of two things. Either it’s derived from intra-articular pathology, the fluid migrates to the back, and it’s a one-way valve — that’s usually a sign the knee can’t manage the effusion and it’s filling different recesses. Or it’s extra-articular, where a hamstring or the popliteus is flicking and creating enough micro-trauma to irritate the area.”
“The nuance with a lateral Baker’s cyst is that the common fibular nerve lives in that area. You can start to get paresthesia down the lateral leg from an undiagnosed lateral Baker’s cyst.”
Post-op gliding
“With post-surgical knees, interfacial bleeding gets bogged down in the suprapatellar pouch, and the kneecap can’t glide up the way it naturally would. It alters the vector of pull of the quad.”
“So I’ll manually pull the kneecap while they do a quad set. Mobilization with movement. I’m just helping the system out. A lot of times they say, I actually feel it in my quad now. Before it just felt like a holding pattern.”
Stim, stretching, and needling
“When we’re exploring force expression, there’s an element of apprehension — I can’t push anymore because I feel like I’m going to hurt it. That adjacent electricity lets you generate more force.”
“The ideal situation is you do both: biofeedback, seeing how far you can generate, with the assist of NMES.”
“With a bad knee, an untrusted quad, and arthrogenic muscle inhibition, the hamstring will be tight. It holds the knee in flexion because it doesn’t trust the quad.”
“The quad isn’t very strong at zero, at ten, at twenty degrees. The hamstring is very strong at thirty. So you’re dealing with a mechanical advantage to the antagonist with a deconditioned quad. That’s a bad combination.”
“I call it neurological warfare — addressing the neurology of the sciatic nerve, of the hamstring, through reciprocal inhibition or some kind of lowering of tone.”
“I look at everything as a neurophysiological effect. If I were to crack your neck and you had better quad activation, I’ve just changed the nervous system.”
“The key with dry needling is finding the motor points. If you drop a needle in the motor point you can get a fasciculation, a muscle tremor. That’s a reset, because it’s a high neural point of the muscle.”
Too many horses in the surgical race
“Step back and ask why we have so many different procedures. It means there are a lot of horses you can bet on. But it also tells you there’s not a real good racehorse that you’d call the favorite.”
“If the medical field starts to condense and say these are the things that are better, that means research is starting to improve. Right now the options are almost nauseating.”
“Microfracture has been there the longest. You’re taking a drill and drilling into that lesion to create significant damage. And what fills that space? Fibrocartilage. It’s not hyaline cartilage.”
Loading cartilage is high maintenance
“The management and loading of cartilage is submaximal, high frequency, short duration.”
“Think of Pepé Le Pew kissing up the girl’s arm. Little pecks, throughout the day, throughout the week, because you’re trying to desensitize that area for it to then say, I can express more force.”
“Tendon, you can be a bit more aggressive. It wants load, it tolerates higher effort. You can go longer duration holds, higher magnitude, but you probably don’t do it every day. Cartilage is dating someone way out of your league.”
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