Oh, Hi, hey, Hi, it's the lady at the COVID swapping clinic who always has the best scrubs with like holiday lamas on them, Alley Ward. And actually I'm not her, because that lady actually does exist at the Bourbon COVID clinic drive through, and I love her every time I see her. Okay, let's talk about your shitty niece. Let's talk about Jarrett, your pod mom's shitty knies. So in late August, he was vaccinated. He was in a small
pod of jiu jitsu folks starting to train again. He has a brown belt, two stripes so close to his black belt, was so excited to get back into the sport he loves. He was grappling, took a wonky fall, heard a pop, and here we are, folks. Terrible pain swelling. MRIs busted ACL surgery, physical therapy, and now he's two
months out. He's still healing. Luckily, a friend of his family happens to be this world celebrated surgeon who has pioneered knee reconstructions and gotten a bunch of patents and fixes everyone from pro athletes to actors to actual ballerinas. This surgeon is also in Bay area and very out of network, but he understands how to get athletes back
on their feet. So we packed our bags. We stayed with Jared's wonderful mob Christine, for a two week blur of general anesthesia and thailanol and ice and pain and crutches and rehab. But amid all that fun, why not record an episode? I feel like most people I know have kind of an on off relationship with their joints. And I found myself looking at these knee diagrams wondering
what was going on in there. And luckily, Jared's surgeon, who is this athletic, soft spoken and deeply knowledgeable knee celebrity if you will, was down to sit on a porch this October afternoon in his neighborhood in the Redwoods, just north of San Francisco. So he studied internal medicine and orthopedic surgery at Harvard University and then went to this place called Stanford University to study general surgery. And he's written books and done ted talks and educated people
all the world on this stuff. People who call him Doc include the Marin Ballet, the US ski team, dance companies, rugby teams, pentathletes, and of course my husband. So I was like, hey, Hi, can you explain knees? And I'm pretty sure he was like, okay, yeah, you make a podcast. Sure, okay, that's fun. But little did he know that I would lob one million all of our knee questions right at his face, but before I ask him your questions. Patrons, thank you for supporting the show like a beloved crutch
since before the beginning. Anyone can join that club for a dollar a month. You can also send this episode to a friend, or rate, or subscribe, or even review, because yes I do read them and weep happily. And this week's fresh reviews from Mary Mama Sunshine, who wrote, I started listening when pregnant with my fourth little guy, especially on my trips to and from doctor's appointments, and your podcast helped mellow me out to get me through
a post miscarriage pregnancy. Now fast forward and come to find out that apparently ology is the magic that mellows out my pandemic baby who hates car rights. So Mary or Mama, I'm super sorry your first child sentence is going to be about butts or have the aff word. But you're welcome. Also Smology's episodes. They're released every two weeks, their classroom and kid Safe.
Okay.
Genicular traumatology, so genicular means of the knee, and the root in Latin means having knots or bent, and traumatology comes from the Greek for to twist or to rub, and Surett was like, I mean pretty spot on the study of twisting and rubbing knee injuries. Boom.
So we talk about.
Joints, tendons versus ligaments, robot doctors, cartilage donuts, physical therapy, self surgery, joint juices, sporty injections, donor tissues, pig legs, if weight has any effect on knee health, types of arthritis, how to make exercise like play, and then how to play Forever, which is the title of his new book, Bionic Body Part Biologic Ones. The Best Exercises for healthy knees creaking, popping, locking, bending, biking, walking, and if knees
are the worst. Also, some of these asides go off on some stories that maybe you'll remember forever, but I couldn't help it include them. This episode is It's a wild ride. You never knew your knees, but you will right now. So pull up a seat or go for a walk and get ready for an episode that we all need so much with orthopedic surgeon and researcher doctor Kevin Stone. Doctor Stone, can I get you a water or a tea or anything? Yeah, okay, we got that.
We got that in spades. It's fine if.
You hear us and you want to chime in on anything. As a patient, the people who.
Are excited to figure out their knees work.
And how mostly their knees don't work.
So it's Kevin Stone, it's he and him cool.
And doctor Kevin Stone. Do people call you doc a lot?
They do?
Yeah? Hey, Doc? Do you think that that's like an informal thing because they see you a lot? They know you're not just like a surgeon who works on them while they're in twilight sleep, but you're you see them, you know, follow up and stuff.
Yes. And the structure of our clinic is that our rehab team is rate next all on one floor, So I'm floating around seeing them when they're rehabbing, when they're on the bike, when they're working with the therapists, and so it's a very familiar environment. Yeah.
I know when Jared had surgery, you called him to check on him, like every day for after surgery. He was like, oh, thanks for I'm doing well. You called me just to let me know how he was doing. So do you feel like that's important to have that kind of relationship, like to just check on people, make sure that you're not just kind of them open and sam ba by, Yeah.
The fun of what we do is to try to convince people to become athletes for life. And so if I can convince them to use their injury as an excuse to become fitter, faster, stronger, which is the phrase we like to use, than they've ever been, then it's a fun relationship for a lifetime because number one, yes, I get to know them immediately after surgery and check in on them and make sure that they're doing okay.
But then number two, I get to see them as they come back for their what we call stone fit tests, which occur at one month, three months, six months, one year, and then every year or thereafter, because we want to figure out how do we help somebody become better than they've been before.
So better than when they first.
Yeah, and so using that injury as an excuse to become better we've got a whole rehab team. We're going to take a moment of your life where you're going to be really focused on your knee or shoulder or ankle, whatever we fixed. And so we can use that moment to engage you fully in your fitness program and your diet and your mental attitude. And so in order to do that, you need to have trust that I'm on board with you, not just during surgery, but immediately afterward
and then forever. And the fun of what we get to do is that when we fix things and then watch people go back and do, whether it's an Olympic sport and win a gold medal or whether it's just be able to go to the grocery store. Yeah, but we get the feedback when they come back for their sport fit tests and show how they're doing and see
where they are in life. And so, yes, to answer your question with a long winded answer, that immediate phone call, post up the next few days and bonding with them during that little window of time when it's kind of scary is a really important time.
Yeah, it definitely works. Now, obviously, you were not born an orthopedic surgeon. You became one. How did you decide that cutting open and fixing knees being a knee and a joint mechanic, How did that even come about?
So probably two big events. One as I went to college as a government major oh okay, and was playing soccer and tore my knee while playing soccer as a
freshman at Harvard, Oh God. And in the training room after the brutal surgery at that time, I watched the orthopedic surgeon rome amongst the different athletes and check on them the way I get to do now, And I so admired that environment and that ability to be around athletes who are trying to come back, the ability to help somebody who's broken something where you can fix it and they can get better was just clearly I knew that that looked mighty attractive. So that was a first
major thing. The second major thing was, unfortunately, that surgeon took out a key structure in my knee called the meniscus cartilage. And I'm sure we'll get a chance to talk about that some more later, but that structure is critical to how the knee functions. And so years later I was out for run with my mentor at the time and he looked at my bow legs and said, you know, Kevin, if you could ever figure out how to replace the meniscus, you'd make a big contribution to orthopedics.
And in my typical Harvard arrogant way at the time, I said, great, I'll do it. You pay for it. And that started off my entire research career around replacing tissues in people's bodies.
Oh cut Banks, Texture Crush, ask someone for millions of dollars to learn how to replace parts of bodies. That's apparently how the world works. But how do knees work. Let's get into it. Let's talk about what a meniscus is. I tried to study this before you got here so that I would not be a total adult, but I understand that there are three bones involved in the knee. I'm going to let you. I'm going to let you start. What are we even looking at it?
Okay, Well, first of all, you've had some other folks on your show who talked about the heart or the kidneys or other things, and let me just prioritize the only purpose of the heart is to provide blood flow to the knee. So you need to understand our sense of priorities. Let's just get that straight up.
Front, spoken like a true knee search exactly.
That's number one. Number two. In normal walking, you take one to three million steps per year, add up to five times your body weight depending on the height of the step, because you're coming down on one leg, and if you're coming down from a height, it can be five times your body weight. And so for your knee joint to be able to take that many cycles and that many repetitions and not wear out, it needs to
have some pretty unique structures inside it. And so the key structures that will probably get a chance to talk about, and I'm sure your listeners like to know about, are number one. The two types of cartilage. First, there's the articular cartilage, the shiny white surface on the end of bones. When you crack open your chicken wing, that white, chiny surface that's articular cartilage. And when you get arthritis, it's wearing away of that white, shiny surface down to the bone.
Okay, quick visual, So there's cartilage coating the foremoral condolites aka the nards of your femur, as well as the top of the tibia and fibula shin bones, and between them lie two c shaped cartilage wafers, kind of like airplane neck pillows.
The second type of cartilage in the knee is a fibrous tissue called the meniscus cartilage, and there's a medial one and a lateral one, and those things distribute the force inside the knee. So when you walk that one to three million steps per year at up to five times body weight, that force gets distributed by the menesky. So there's not one area that wears out. So unfortunately, when you tear one or somebody takes one out, it becomes dysfunct, and you concentrate the force and start the
wear process. And then the other last key structures that everybody wants to know about, of course, are the ligaments inside the knee. And you often hear about the ACL or the PCL, and you hear about the medial clouteral ligament in the lateral clauteralligment. So these ligaments you can think of as guide wires. So you think about the marionette and the guidewires that make the marionette work well.
If one of those strings is broken, they are and the marionette doesn't floppy right and doesn't work so well. And that's true inside your knee. And so if you tear that ligament, any of those ligaments, the knee doesn't flex and rotate in the normal pattern. And just like a car tire that's out of line, the tire wears down quickly down to the steel rim. So your knee wears down quickly to the steel rim when either the ligaments are torn or dysfunctional, or the meniscus has been
removed or is torn. And that wear and tear is what we call post traumatic arthritis. It's the most common kind of arthritis that people get, and it's what really wears out the knees and so much of my career and many things we'll talk about today, or how do you prevent that from happening.
So the two most common kinds of knee arthritis. You got your osteoarthritis, which is a breakdown of that slippery cartilage from wear and tear or injury or infection. And then there's rheumatoid arthritis, where the lining of the capsule that holds all your knee parts gets broken down by your own sneaky, jerky immune system. So thanks, Dick, I was using that. You want to scream at your immune system and I understand. So, yes, you have your femur,
your tibia, and your fibulous shin bones. There's that patella kneecap. You got your LCL on the outside of your knee that connects the shin bone to the femur bone, and it hurts like a goblin when you foam roller that, but it's also kind of so good. And you have a medial collateral ligament MC on the inside of your knee, and then your PCL ligament is on the backside, and then your ACL, the anterior cruciate ligament running inside diagonally,
which is why we are up here recording this. It is a ligament that is not fun when it snaps. Is it a ligament? I guess yes, ACL, yes, And what about a ligament in attendon. What's the difference there.
Yeah, So the ligaments connect the bones and the tendons connect the muscles to the bone. So you have a pateeller tenon in the front of your knee, and you have an ACL in the middle of the knee, which is the ligament connecting the bones.
And you have to work on all of them.
Right.
When someone injures her knee and they hear a pop and they know that they're screwed. That happened to Jarrett. What are they hearing? Are they hearing popping? Tearing? Like when there's an injury like that when you tore yours in soccer? What was that experience?
Like? Awful? Yeah, there's an intrinsic knuck useating feeling when it happens. And so when a patient sits down and says, hey, Doc, I twisted my knee. I heard a pop. My knee swelled, they have a ninety percent chance of having torn one of the key structures in the knee, either ligaments of the meniscus or damage the articular cartilage. And that tearing, it leads to swelling, leads to that gnos feeling, leads to that instability, leads this swelling leads to all the problems that occur.
What about your meniscus? Did you ever get one back? Did you ever say, hey, I figured it out, let's put a little meniski back in there.
So, yes, I figured it out, but no, I wasn't able to do it to myself. So at the end of the day, my knee wore out and I had to have a partial knee replacement, which is what we do for people when they're down to bone on bone. So it turns out that if you wear out your knee so that the bone on the femur and the bone on the tibia are now rubbing against each other, that's what we call severe arthritis. And about eighty percent of people who are told they have severe arthritis and
need to have a total knee replacement actually don't. Oh no, they've worn down, usually one part of the knee, not the entire knee. And depending on how much they wear it determines whether we can do a biologic knee replacement that we can talk about some more, we replace all these tissues, or whether or not we can do a partial replacement or resurfacing.
So in a partial they'll go in and say, okay, this part of the femoral condolit the femur nerds needs a new surface, So doctor Stone will do a bunch of imaging, make a computerized three D model, and then perform the surgery outpatient using a frickin' robot. And then on the new surface, they smack some metal or plastic over the worn down area, but they keep the healthy stuff as it is. It's kind of like having a
tooth capped with crowns. But if things are not looking good, if things are more like ooh, then it might be a denture situation. Up in there.
We just put a cap over the worn out part and a tray on the tibia, just on the worn out part, not touch any of the rest of the knee. It's an outpatient procedure under a robotic control, and it's much easier for patients than a totally replacement. If they have totally worn out their knee down to bone on bone or in multiple spots, then we do a total new replacement. But even that's completely changed from what your parent's totally replacement was. So now when we do that,
it's an outpatient procedure. We use a robot in order to do it extremely precisely. We don't need to use cement anymore. So the body can grow into the implant, and the implant can become part of the patient, and therefore we let our patients go back to running and climbing and skiing and doing all the sports that they want to do that previously they were told not to do. After they have a partial or total new replacement.
And is that like terminator metal? Is that titanium or what kind of materials are you seeing put into knees to get them back in shape?
Sure? So two big groups, the biologic replacement or the bionic replacements. Okay. If they're in the bionic replacement, that is metal and plastic, it's usually cobalt chrome on the thermeral side and titanium on the tibial side, with a high molecular rate polyethylene tray in between, which acts as
the new meniscus. If it's a biologic knee replacement, what's something we called a bio knee, then I'm putting back in a new meniscus, regrowing their articular kerdil It's using a combination of growth factors and stem cell recruitment and all the cool things we're doing these days, rebuilding their ligaments and creating a new biologic knee joint. The big discussion of animal tissue versus human tissue. So right now we're only using human tissue, okay, and so it will
come back. The use of animal tissue to replace ligaments in meniscus was work that we spell fifteen years doing and develop the new, first, new successful pig ligament for people, and I have people still skiing on those ligaments today.
Pig legs is they're called big legs.
Yep. We ran a successful clinical trial in Europe, but for right now, it's all human tissue.
Okay, So to recap there are knee replacements that resurface using metal or a high molecular weight polyethylene. And then there's biologic, which doctor Stone says can include stem cells injected into animal tissue or human cadamor tissue which is beautiful and spooky and relies on really generous donations from folks who are no longer with us. So why do
they use only that if it's harder to come by. Well, it turns out that it's one thing to be a brilliant surgeon and compassionate doctor and author and innovative biotechnician, but when running animal trials there's a whole other bag of worms about needing to raise funding for research, whole business thing that's all a real pain in the meniscus. Now, you have some patents in this field, is that true?
Yeah?
What can you tell me? Can you give me a quick rundout of some of the patents you have, and what was that like applying for a patent and being like, dang, I really did do a lot of innovation in this field.
Well, the first ones that I wrote were around a collagen scaffold for regrowing the meniscus. Remember at that time, back in the late eighties, when we tear them, they were taken out, and my feeling at the time the challenge from my mentor was to figure out how to replace it. And so at that time I thought, well, if I don't have the right materials to replace it with, maybe I can stimulate the body to regrow it. And so I designed a collagen scaffold which could be sewn
into the meniscus and other tissues. Then you could tweak the tissues with growth factors and other things and stimulate the meniscus to regrow. Oh wow, And that that actually was a successful approach came on the market. Eventually, it's not currently on the market, as we're going to build a new, better one now of a stronger, better collagen.
Now, when you have knee surgery, do you this is a question for my dad, Larry Ward, wants to know if you're like, can you just numb me up locally and I or put me in some kind of twilight where you have one eye open, because as one of the best orthopedic surgeons on the planet, do you want to be able to work on your own knee or you just like, put me out let me know how it goes.
Yeah, So we did that for quite a while where patients would stay awake and comment on their surgery while we were doing their surgery, and it turned out to be more of a distraction and not a big benefit.
What's happened in anesesia's The drugs have gotten so good and so short acting now, and the procedures are pretty quick, and so most people go off and take a nap for twenty minutes or a half an hour an hour and then and don't have the old hangover effects that we all used to have from anesesia in the past.
And talk to me a little bit about the evolution of human needs. Obviously we started off as crawling critters and evolutionary wise, are we still pretty new to walking upright? Are our knees still evolving to be a little bit more robust or do you think this is like evolution has found the final perfect mechanism.
So it's an interesting comment because what's beating us first, evolution or our own advances in sports and activities. So everyone wants to play sports more harder and faster and live longer and do them, and so could evolution ever catch up to the rate in which we're advancing our
sports and our desires. I have a book coming out this December called Play Forever Nice, and it addresses some of these issues about how do we adjust our sports and our desires to our bodies and adapt our bodies to be able to hopefully drop dead at one hundred playing the sport you love. Since evolution won't go so fast enough to help all of us who are here now, it's our job on the science side to number one, improve the techniques, number two to improve the materials, and
number three to accelerate the healing. So for instances you know personally, now you know, why does it take a year for an ACL injury to be operated on the tissue replaced in the patient to come back. Why does it take so long for the body to recover, Why is there so much stiffness, Why does the tissue take so long to remodel? And what can we do to accelerate that process? So while It won't be evolution that
does it. It will be our addition of growth factors, stem cell recruitment factors, because your body has billions of stem cells, and there's no reason why we can't figure out, which is what we're doing in our research lab now, why we can't figure out how to add just the right factors to migrate all of your body stem cells to that side of injury and accelerate the healing.
Ah, so say hey, we need you over here rebuild this once. It's kind of like calling the landlord when you're like, we got to drip here, get a contractor over What about what is a growth factor exactly?
So when you have an injury your body, you have bleeding in the blood usually contains a host of proteins, and those proteins are commonly both growth factors. That are factors that stimulate the cells to turn over and lay down new collagen. And there are factors that are anti fibroduct to stop scarring. There are factors that are antimicrobial
to prevent an infection. And so what we want to do is use these factors, which we call growth factors, to stimulate the healing, to turn on the cells to have them lay down new collagen to have you heal without scar as fast as possible.
If you're like, what.
Is a stem cell? Well, they're really whatever you need them to be kind of. Stem cells can turn into more stem cells, very meta, or they can differentiate into blood cells and brain cells, bone muscle. It's kind of like if you were in a game of Uno. A stem cell is like a wild card. Whow just what a treasure common in clutch.
There are other factors called cytokinds, which are again proteins usually that help recruit your body's own stem cell derived self repair cells, which is what we're calling them with a very complicated name. I guess we've learned that the stem cells aren't really the cells that come and do the work. It's their progeny, and so we can stimulate stem cells to create more progeny, to migrate those cells
to the side of injury and accelerate healing. So now with almost every injury that I see in my office now, and almost every surgery that we do, we add stimulating factors to the injury, to the side of injury, or to the tissue that we're transplanting in order to accelerate that healing process.
So does that cause more targeted inflammation to sort of recruit better healing? Like does that kind of blow up in mee a little bit more?
It's actually interesting question, you know, I wouldn't growth factors turn on more swelling, right? Yeah, So it turns out that some of them are more anti inflammatory or what we call immunomodulatory. They shut down inflammation, and others stimulate cells to produce more of the hyaluronic acid, the natural lubric can pivot the joint, and so the body knows
how to titrate that. If you have just the right combination, as I call the right chicken soup, all the components are in there together and the chicken soup tastes great, but if you're missing salt, didn't taste so good. So you need to have that right combination to not produce inflammation, but to stimulate healing.
I always think of joint issues like arthritis as a rheumatological issue and an inflammation issue. How much of the knee injuries and pain that we're having, how much of that is inflammation versus traumatic injury from soccer or jiu jitsu for example?
So when we hear the word arthritis. Ninety seven percent of arthritis is either osteoarthritis genetic from your family, possibly thanks Grandma, or post traumatic arthritis you had an injury, you damage the cartilage and it started to wear out. Three percent of all of arthritis is what we think of as inflammatory arthritis or rheumatoid arthritis, all of those inflammation diseases that are fortunately these days being treated. They're very potent drugs, but it's not the section that I
deal with. Ideal that ninety seven percent of post injury arthritis.
And you have a lot of athletes on your roster too. What happens when there's an athlete who was paid to run and jump and go laterally and use their knees and they blow something out? How I mean, there's so much at stake their whole career. How do you even go about treating that? Like I imagine mentally, it's got to be really difficult.
So I'll tell you a fun story about that one. And because the person is deceased, I can use his name now, Otherwise I wouldn't. So one day I get a phone call from a very famous movie director and he said, Kevin Robin Williams has just twisted and injured his knee. It's costing me four hundred and fifty thousand dollars a day for every day that he's off the set. How fast can you fix it? How long is he going to be out?
The director Francis Ford Coppola also on the way to and from taking Jarrett to physical therapy for weeks after the surgery in the city, we would pass through a bridge in Marine County. Its upper arch has this faded rainbow, and there's a freeway sign next to it, noting that it is the Robin Williams Tunnel, which honestly kind of hurt every time. But back to it, knees should not hurt too much. Her millions of years of evolution.
Right, so, knees are designed beautifully. I'll give you a fun example from what we know from the animal Kingdom. Elephant fifteen pounds or more, can run up to thirty forty sometimes fifty miles an hour, lives for sixty years, almost never develops arthritis. Their cartilage is unique. It's a little bit thicker than ours, but it's still wonderful material
and similar to ourrow and cartilage. Your ankle joint almost never develops arthritis, even though it's a tiny little joint that your entire body is on, unless you fracture your ankle or tear your ligaments and it's unstable. So the joints, the cartilage in the joint is a brilliantly designed material. It's five times as slick as ice on ice. If it is not injured. On the running side, run forever, as long as you use good mechanics, short stride, great sneakers,
prefer soft surfaces. All the good thoughts about good running mechanics are very important to know. Optimizing your weight is pretty critical and the reason, as I mention before, you're going to take one to three million steps per year at up to five times your body weight, and so a ten pound weight loss can be up to fifty pounds one to three million steps per year. That's a lot of force. So optimizing your weight is one of the critical ways you can keep exercising and not damaging.
Picking multiple sports so that you don't become a one sport athlete. So if you're going to be a runner, for sure, mix in biking and pool and weightlifting. Try to mix up your sports as much as possible. We know that resistance sports are the only way, especially for women, to counteract the osteoporosis that occurs with aging. And so you've got to hike the stairs, don't take the elevator. You need to do resistance exercise. Weightlifting is particularly the
best way. Hill climbing, hiking, do whatever you can to really load the muscles and the bones. And that's true even if you've had a joint replacement.
And just a quick circle back that, yes, there is so much research on biomechanics and physics and the effects of body composition and muscle mass on the development and the prognosis for osteoarthritis. I was literally up until four in the morning last night reading meta analyzes on it and summation. There's just so much research to support that.
But I also wanted to acknowledge that weight optimization can be a challenge if you're in pain to begin with, or you've experienced factors like trauma or lack of access or care which exacerbated or pardon the punt here, kicked off a weight struggle to begin with. And it's also worth noting that not everyone who would call themselves fat, which is an acceptable term in the body positivity community
struggles with their weight. Many are just fine the shape and size they are, and their knees are fine, and they struggle with maybe a knee jerk diagnosis and the stigmas sometimes faced in healthcare. Also, metrics used to assess health are not one size fits all either. BMI is a really loose gauge for determining body composition. It was actually invented by an Austrian scientist who wasn't actually a medical doctor, but even a legit modern MD can tell
you that. Of course, BMI does not tell the whole story. Ask any bodybuilder or me the day after I eat soy sauce, I'm a talking sponge with hair. But knowing that some blanket medical guidelines might be less breezy to take in stride and I asked on Twitter the middle of the night last night. I was like, any folks have thoughts about size and knees? I heard all kinds of responses from Lord of Goats said six foot one, been over three hundred pounds with a better part of
my adult life. Yes, weight is killing my knees and is getting worse with age. It's more tolerable with good low impact exercise like road biking and anti inflammatories and water helps to and Nancy, who's a scientist, said personal anecdote, my knees hurt more when I'm heavier. Currently at a moderate weight for me b. Twenty seven, and they're mostly happy, but occasionally grite me, they say. And Jay has be chimed into say overweight and forty two year desk career.
Losing weight and moderate activity both helped. I played a lot of basketball younger. Best exercise for me now was a bike, and someone named Mixed Meridian said, from my personal experience, the right exercise is also important. This begins with learning to stand and move safely, and there's taischi and yoga if you have an instructor who understands anatomy
and challenges and can teach you modifications. Ditto for strength and balance, and Graham shared, I've had knee problems most of my adult life, and it's been fascinating to watch how I was treated as an athletic eighteen.
Year old versus a fat thirty two year old.
Most recently, I tore my meniscus and the first doctor I saw didn't even do an exam, just told me to lose weight and quit soccer. So someone on Twitter, Marina suggested that doctors take a more compassion approach, something along the lines of studies do show that weight plays a role in this, but don't focus on that as the cause. Causation does not always mean correlation. It's important to treat potentially weight correlated issues as medical conditions first,
bringing up weight as one of many possibilities. And ultimately I was pointed in the direction of a biomedical researcher and engineer, doctor Dina aka It's broken Me on Twitter, who wrote, Hi, did my PhD evaluating osteoarthritis related knee pain, bone body mass and distribution, and bone mechanics. Simply put, it's complicated. It's a lot going on in that joint related to osteoarthritis, and you can't just attribute pain to mass and activity. She went on to say that pain
is biopsychosocial, meaning there's a lot to factor in. Take home regarding mass and knee health. Be as active as you can for as long as you can and as much as you are able to pain wise, but don't over do it. And after I saw that tweet, I tag doctor Rachel's oftness from the Dolerology episode in this thread, as you can imagine, a Twitter friendship was born. And also worth noting that a lot of conditions can cause acute or chronic me pain and the right diagnosis is important.
As these good footwear. A few people said that getting the right shoes or seeing a podiatrist too helped them a lot and got them on the road if you will, to a more active and happier lifestyle. And myself, I used to love to run four or five times a week because you can turn up music and you can pound the pavement like boxing with your feet, and I loved it. But true story, when I launched ologies in twenty seventeen, I stopped running like I used to. I
just couldn't fit it in my day. And I also have gained an appreciation for homemade sour dough during the pandemic. And sure my pants are a little tight, but whatever. When we think about body composition, a lot of the times it's really sexualized. How big is my butt? Can you see my apps? Does this look ot? And that's all appearance and that shit does not matter and it's nobody's business. But I have to say that this conversation
and working on this episode. Looking at my body as kind of a biomechanical marvel and move as play and maintenance for it, as opposed to a sentence that I was served for neglecting my sneakers has gotten me really jazz to take better care of it in a way that feels good to me both mind and body, better
than anything else I've read or heard for years. So I hope, no matter what you're feeling, less pain, more happiness, and whether from an injury or wear and tear, that you do not need a knee replacement, but back to exercise, even after having a little work done in there.
So in the old days, doctors told patients after a joint replacement, go home and rest your knee. Huh, I did two terrible things. Number one, their muscles got weak, and number two, of their bones became osteoproduct. And so we, after we do a partial or total knee replacement these days, explain to our patients that the more they exercise, the better they are going to do, the stronger their bones will be either better the muscles, the more they'll protect
their joints. And we've never seen a joint worn out from exercise. And so all those years of doctor's telling patients to you know, rest a knee and protect it, we don't think is the right advice today.
Yeah, I was going to say, Jarrett went into your clinic like the next day to start physical therapy, during which he cried that it was the hardest exercise he's ever done, just lifting his leg straight. And this is a guy who is powerlifted and you know, grappled until he's choked to death. So why is it so important to do PT And when do you know if it's just something that you have to do physical therapy on versus get in there with a knife and noodle around.
So let me give you an example. So from my ballet dancers, if they suffer a knee injury, a an ACL injury, or a meniscus injury, immediately in their recovery room, I have them extend their leg and see their line. Just want to be perfect. It's so important for their brain to see their line, to know that they're going to be able to come back to that beautiful extension that they're so good at doing, both men and women. And so the reason that patients are in our clinic
the next day after surgery. Is that they know immediately that they shouldn't treat themselves as an injured wounded animal and hide in bed, get moving right away mentally knowing that they can do it. Having the therapist do manual therapy to push the fluids out of the swollen joint, to get them contracting their muscles right away, to get
them moving through a range of motion. All of that can start right away, and we don't let them get stiff and sore, which is natural after any injury or surgery, which will occur, but we want to have it occur in the least amount possible.
Right So it's not like when I got my tonsils out and I went home after surgery and ate gallons of ice cream every day.
I wish I had ice cream for the knee. And that's what we have for these cold machines now, these cold depression machines PS.
Now there are these electronic contraptions that involve a hose and a cooler full of ice and water. Are they magic a little bit?
They're like ice cream for the need? Now?
Are those pretty new on the scene.
They've actually been around for the last ten years. They weren't as good as they are now, so immediately after surgery used the ice compression machines that intermittently provide compression pumping the fluid out icing, which we do for twenty minutes each hour while they're awake.
Yeah, Jarret was like, I don't think I need one of those, and literally, like the next day he was like, yeah, I going, so he's got one rented. I think it's a cuff. It's like a blood pressure cuff that has cold water going through it so you don't have to keep holding soggy ice packs. I realized that the bags of frozen peas I got him were not necessary after all that he'd need them. Can I ask you listener questions? Sure, Oh, we have so many good ones. Also, we donate to
a charity every episode in your name. Is there a related charity or foundation or your own that you would want the genation going to.
Yeah. So the Stone Research Foundation is a public nonprofit five to one c three dedicated to the science of accelerating, healing and reducing, treating, preventing arthritis. And so we're driven on the research side and it's all for that public research foundation and you can find it at Stoneresearch dot org.
Great, We're going to do a donation to them. So yes, a donation is going to Stoneresearch dot org and their mission is to pioneer new orthopedic treatments that accelerate healing and enable people to stay active through research, development, innovation, and education. And they are an independent five oh one c three nonprofit. So a donation went to Stoneresearch dot org. Thanks to sponsors on the show, who you will hear
about now? Okay? This first patron submitted question was asked by Alex opp as well as a few others okay questions. Mike Monokowski, Denise and Abraham Livingston all wanted to know. Mike said, do supplements like glucosamine or boron actually do anything? Are they expensive placebos? Denise wants to know does drinking college and effect that joints or do you just pee it out? And Abraham same question. Anything you can eat like you mentioned chicken soup. Does eating a lot of
collagen and bone broth? Does that actually affect our joints at all?
So let me answer that two ways. Of all the supplements, we think that the best science is around glucosamine. It's been around a long time. There are plenty of good studies that show that it does get into the joints and into the tissues. It's a precursor for building cartilage. The most common thing we hear from patients over the last twenty years of giving them glucosamine is that patients
say they feel less stiff after they take glucosamine. So it's objective proof that the glucosamine is getting into the bloodstream and doing something. Collagen, on the other hand, when you eat it is a steak, it's digested quite completely in by the stomach acid, and so taking additional oral
collagen does not produce a benefit. Eating protein, which is collagen in proteins amino acids is important part of your diet, and so we generally advise patients to be on a high protein, low carb, low fat diet, so lean protein. That's probably the healthiest way to optimize your weight when you add least eight classes of water to it each day. So the water part of is you think of supplements, We think water is the primary beverage that most people
should drink. If you can lift the glass of water before you lift the fork, most people will find they feel little full, and it's good portion control. If you're an athlete, if you can use both water and protein as your primary food sources, you generally build muscle and stay healthy.
And doctor Stone has written on this most recently in his book Play Forever that was released literally yesterday, and he writes, here's what you need to know. Complete our quality protein is protein that has all the essential amino acids required for health. Lean protein sources such as skinless chicken or turkey ninety percent or leaner ground beef, low fat or non fat dairy, seafood, soy products, porkloin, and
eggs are ideal and incomplete. Proteins such as beans, oatmeal, barley, corn, nuts, and seeds are missing some of the essential amino acids and must be combined with other foods and for good health maintenance. He recommends point eight to one point five grams per kilogram of body weight. So do some beepop beepop, and you figure out how many grams are protein a day.
And he also says that for sick or injured people trying to build muscle, the recommendation increases to two grams per kilogram a day, but he warns other health issues must be taken into account before introducing any dramatic increases in protein intake. Always consult your own physician before making
any changes. And he's also written via some blog posts on a website which is just like a treasure trove of orthopedic articles he's written, and he writes fats and carbohydrates and sugars are also essential parts of diets, yet most everyone gets an excess of both, and it takes effort to get protein, but if it's consumed in the morning, protein carries most people through the days activities longer than other choices. And it's protein that builds muscle and provides
the longest lasting energy supply. It helps the immune system resist infection. Good to know during these times, and it also allows bones to build mass and it helps your tissues repair. So he tends to recommend using carbohydrates and fattier foods as kind of a garnish to compliment protein dishes and vegetables. So washing down a chicken breast with
a two liter of mountain dew is not good. Now, it's not good, And gird your bladders because one of doctor Stone's posts is about to get you so horny for water. He writes, water is the ideal beverage, no calories, no sugar, pure taste, and an optimal source of hydration. There are millions of people who, if they drank water
more often, would save untold dollars while improving their performance. Damn, this guy just managed to single handedly be a water influencer, and working on this episode is the most hydrated I've ever been in years. I'm not getting I peede so much. I'm not mad about it. And if you're wanting to up your glucosamine, but like doctor Stone's patience, you don't want to kick back six big pills a day. That joint juice, which he no longer owns, can still do
the trick. It has fifteen hundred milligrams of glucosamine and two hundred milligrams of chondroyten per serving. And I wasn't going to mention all that because it sounds like we must have just gotten free knee surgery out of it, and trust me, oh boy, if we did not, this was very out of network and lots of money, but
worth it. But I dug around into studies and there was this one twenty eighteen paper in the Clinical Rheumatology, a journal entitled Effects of Glucosamine in Patients with Osteoarthritis of the knee a systematic review and meta analysis and found that sixty seven percent of published studies showed that glucosamine was effective in reducing pain and osteoarthritic symptoms compared with a placebo also joint juice not to be confused with a juice joint, which is prohibition era language for
the clerb Okay. Speaking of laud, so many of you patrons, including Larinda, Desiree Minetti, Hulton, Tony Vessels, Aubrey Nelson, Lena Zika's Ruby, Eric Azolk, Careless Kitty, Meghan Stingle and agusman Adele Masa nouve Ed Nogg, Danielle Rosa, Sylvia t Christy Kazakhov all had questions about our crunchy, creaky, poppy squeaky parts, or, as Michelle Chick called them, my favorite joint to hate the Niece, Let's get to noises Aubrey Nelson, Otter Apocalypse,
Jennifer wy Sakowski all wanted to know Truther flin Flamm that popping or cracking your knees can cause problems later, and Otto Apocalypse said why do my knees crackle like popcorn on the way upstairs? But there's not a sound. One descending Jennifer said, I get a soft, crunchy sound on my knees when I go downstairs, So what is that? When I do squats they crunch and it's terrifying what is going on in there?
So two major groups of noises in the knee snap, crackling pop for the knee. Yeah, so occasional pops and cracks of your joints are pretty normal and almost everybody has them, and as long as they're harmonious and not cacophonus, we generally don't pay too much attention.
By the way, this noise has a name. It's called crepitis, and it comes from the Latin word for rattle, and it happens when you get air bubbles in your tissues or when ligaments those straps that secure bones to bones, or tendons which attach muscles to bone snap over your knee bones. It's usually pretty harmless and painless.
Usually the grinding in the front of your knee, though going up or downstairs is usually your knee cap loading on the femur, and that sometimes can be a sign of rough cartilage there or tissue getting caught. Generally we ignore it as long as it's not producing pain or swelling. If you come into the office say hey, i've got some noise there and we feel your knee, there's a little bit of grinding, but no pain or swelling with it, will generally ignore it or provide a lubrication injection if
it's bolished them in any way. If there's grinding associated with pain or swelling, then that's damaging the cartilage, and there we want to address it, and we can address it either with injections or surgery to smooth it down or regrow the cartilage, depending on how bad it is.
Okay, So that lubrication injection is called Visco supplementation, and it's usually a gel form of hyaluronic acid, which if you listen to the Glycobiology episode from twenty eighteen you'll know. Is it carbohydrate that your body already makes and it binds to water up to one thousand times its volume, and they inject about two milliliters of it right into
the joint capsule around your knee. If they have any leftover, maybe they can jam it in your face because if hyaluronic acid injections sound familiar, think Jupiter and restalin and other dermal fillers.
PS.
They won't actually do that, but trend wise medically, cortisone injections are passe, and what surgeons like doctor Stone recommend is getting things all juicy with anib therapy or stimulating
the tissues. And he says that instead of injecting stem cells directly, since we already have billions of them, but injected ones can die off quickly, docs like him use cidokines, which is what cells used to direct as he calls it a symphony of healing and patron Ryan Martin wrote in said longtime listener first time question asker wanted to know what role are plasma rich platelet injections or PRPs
playing in today's procedures. He wanted to know if the good doctor and his patients had any thoughts on that. Ryan has had three of them, so I looked this up. So PRP platelet rich plasma injections, that's when they take your blood. They concentrate the platelets, which are tiny cell fragments that help clotting. They look for damage tissue to repair, and you can also call platelets thrombocytes for short, and these things are just choc a block with growth factors
and cidokines. So they do kind of one of those wolf whistles at stem cells and they say.
Hey, get trasses. O here, we got some tissue to fix.
But what about cartilage makeovers? So patron Shannon Patterson asked, when can we grow new cartilage in humans? Asking for a me, and Samantha Ray's shades niece asked straight up, why are they so injury prone? Mara Rosenbloom said that they tore their meniscus and didn't need surgery. But Beverly Soberman wants to know, in their words, about snipping off all the jaggedy bits of cartilage like a shredded meniscus,
their's having been thrice torn. Ouch ouch ouch, how does that cartilage get shreddy like that?
Yeah? So remember that smooth surface that's five times as slick as ice on ice and can go one to three million steps per year. Well, that only works when it's white and shiny like the chicken wing. The crack open as soon as you damage it, either by hitting it directly or by losing the meniscus, and therefore there's more force concentration or by tearing the ligaments and now there's abnormal rotations and pivoting in the joint. Any of those mechanisms will cau that smooth surface to now become
rough if you damage it. We want to repair that surface right away. And we've got very good techniques for stimulating the cartilage to regrow. Now. One of them that we invented back in nineteen ninety one was called articular cartilage paste grafting. It's like grouding a hole in the wall. And so if you have a hole in your cartilage, we want to fill that before it becomes too big a hole in the cartilage. So back to your grinding question.
If there are no symptoms, would generally ignore it. If they're causing pain or swelling, we want to pay attention.
Is it kind of like dentistry, like if you've got a knee injury, is it better to get it looked at earlier so that it doesn't cause you, like the equivalent of a root canal later.
Yes? Okay, So the best example of that is if you have a meniscus tear, you want the surgeon to repair it. If they have to take it out. You want them to replace it right away before you develop the arthritis that will certainly occur from losing the.
Meniscus, Like what happened to you a little bit?
Yeah?
Yeah, And now your wife is also a patient.
Oh, she's been a patient a number of times, unfortunately, from ski injuries and other things. It's always challenging you.
Do you operate on her?
I do?
Is she like all right? A lot on the line here, yes.
But fortunately there's no one else she trusts more, I imagine, and she knows that I would do anything possible to make it come out right. But it is stressful. And there are lots of folks who think that you shouldn't take on the liability and responsibility of repairing a family member, and I think that that has validity as well. So
there has to be only certain circumstances. When you, you or somebody feels like you're the best in the world of doing that particular procedure, then it seems like it may be the right thing to do.
Yeah, I would trust you, But would you trust you? You know? My dad Elward asked earlier off doctor Stone, as ever attempted to operate on himself, and obvious as your grandpad. He's being cheeky. But this did not stop me from spending way too long reading old medical documentation of autosurgery. So please grab my creepy, bony hand and to send for a quick diversion on surgeons who read their own YELLP reviews and were like, yeah, this is
the doctor for me. Okay, so really quickly. In the nineteen twenties, there was a German medical student who was like, yo, what if instead of cracking open a chest, we just jammed a tube through some veins to reach the heart. And other doctors were like the fuck, dude no. And he told a nurse about it, who was like, I'm down to clown. She's like, that's a great idea, dude, try it on me. So he sedated her, numbed her up, and then he was like, psych too dangerous. I'm shoving
this thing up my own elbow vein. And another doctor saw what was happening was like your trip and dude no, and then a dramatic tussle ensued. But this doctor, Werner Theodore auto Forceman made it, jammed the two foot long catheter all the way to his heart, and then calmly walked himself to the X ray department to get a gander at this handiwork. What kind of penalty did he get for this recklessness? Well, the Nobel Prize, happy ending,
not really he was also a Nazi. But you know who wasn't Inez Ramirez Perez, who was a woman living in a remote region of Wojaca, Mexico. She was in labor this is in the year two thousand with her ninth child, and realized this kid isn't taking the open door option. She's gonna have to make him a window. She sat herself on a stool, she took three shots of hard liquor, got to work using kitchen knife and some skills she learned butchering animals. And that is enough detail.
But she and the baby survived. And later she was like, yeah, don't recommend that. But every March fifth, I think we should all celebrate her son, Orlando Ramirez's birthday. I hope he gives her at least a cart every year. Also, there was a nineteen sixty autosurgery by a Russian doctor on an Antarctic expedition who realized he had no choice but to break up with his bitch of an appendix, and he was the only person available on this icy continent to remove it. And he described the pain that
led him to operate on himself. He wrote, it hurts like the devil, a snowstorm whipping through my soul, wailing like a hundred jackals. God, I wish this guy had a blog. But the autosurgery, honestly, that sticks with me, the most last one, I promise. Pennsylvania surgeon doctor Evan O'Neil kane, who was not only the owner of Caine Hospital,
but he was also a client. He too had an appendix needing ousting, and he really just put the patient in impatient because in peak passive aggression or like the worst episode of Under the Cover's Boss, he decided, you know what, we're gonna do it live.
I got this.
He did what anyone would do. He spent half an hour injecting himself with adrenaline and cocaine, did a little cutcut, snippy, snippy appendectomy. Maybe some of his guts fell out and he had to stop them back in to the horror of all of the other medical personnel, but he gave him self five stars. In fact, becomes a repeat patient of himself he operates on his own hernia a few
years later. But that's not all he's known for. I found out he also helped invent music therapy and operating rooms, bringing in a record player with some chill jams to help his patients relax. He also invented asbestos band ads and clear peekaboo windows for your skull.
You know what, not.
Every idea is a good idea, and that's okay, let's get back to nice. You're screaming at your windshield while I google fruitlessly for the nineteen seventeen paper sheet mica plate for brain covering, which I never found anyway. People want to know about the pain factor, So patron Ashley Oki cut surgically right to the chase, asking very important,
why do my knees hurt all the time? And this was echoed in various degrees by patrons Lana Schuster, Jesse Hurlbert, Pam Lynn Hodnett, Elise, Alana, Rickman Olga and Ali Barg who asked again, why do they hurt so much? Seems like a design flaw? How painful is that? Surgery?
Is a knee surgery, so pain is very individual? Okay, Number one, we don't think there's any benefit to having pain, So we want to do all the little tricks we can to help your husband and others, you know, not suffer from pain, because pain causes you to freeze up and stop moving and to be depressed and all the things that we don't like. We want you to feel great about it and be moving and be active. We like to avoid narcotics whenever we can, because of all
their downsides and their inhibition of muscle function. But we have better long acting injections, we have better patches, We have exercise right away and soft tissue and ice and all those things we have boosting up your attitude about your healing, which definitely decreases pain. So we find that people very widely in their pain response to a procedure, and we respect their responses in our jobs to figure out what's going to work for that individual patient.
That's good to know. I think a lot of people figure like, oh, you get knee surgery, you're going to be on vic it in for six months, which is like, really not everyone wants that. For more on what is pain, why do things hurt? What's acute immediate pain versus longer chronic pain, and how can outside factors reduce how we feel pain aka the biopsychosocial pain model. Check out that Dolerology episode with doctor Rachel's Softness.
Herself a sufferer of.
Chronic pain from an injury, and she also has a workbook to help you understand your own pain and how social and psychological factors come into play when it comes to disability. And the TLDR is it's not all in your head or imaginary or made up or your fault,
and not all doctors get that. And I was actually really impressed after Jareded's pre surgery appointment when he left doctor Stone's office with a pamphlet written by Kevin himself which explained that the surgery happens, all goes well, you begin your rehab, but a couple of weeks later you hit the skits. You've had it. You're sick of the soreness, the dressings, the ice machines, the knee braces, the PT appointments. You just want your life back, he writes. For this malaise,
he continues, you have officially acquired ACL depression syndrome. And a recent study documented that forty percent of people who undergo ACL surgery experience clinically diagnosable depression. So yes, of course, our bodies affect our minds. Our minds affect our bodies, and a good doctor knows that pain is real and that the bigger picture will get you feeling better faster, and that psychology of a physical condition is not just for the birds.
Which was the worst.
Segue I've ever done to read one patron question from Sarah Meaden who said, do you know why some animals have knees in reverse? And Jacob Elsbury who asked, why do chickens and birds have backward bending knees? And we don't which is better from an evolutionary standpoint. I'm still not convinced people are better than chickens, Jacob brights, which might be true. And another patron, Maria, responded to Jacob
and said, they don't. What we see as a backwards knee is actually their ankles and their knees are further up, hidden under the feather. So thank you Maria for answering that question. But you know what my favorite animal part ever is. It's the apn femoro tibial joints. Those are the bees nies. Now this is my show. I do what I want, I'm leaving it in. Okay, what else is weird? Your babies? Let's talk babies and how weird they are. A lot of people, including Jesse Hurlbert, wanted
to know why are babies born without a kneecap? Are they? Someone told me this once? Is this true? Do babies do not have knee caps?
Not that I know of. I think they all have kneecaps. They're just small.
Okay, so they're not born without them, not that I know of. Okay, that is a big that's some big flim flam that we've just debunked, because for a second I was like, where do they get them? Later?
So let me explain. The kneecap is what we call a sesamoid bone. So it's a very small ossification within the tendon. So you have them underneath your great toe, you have one at the front of the knee, and so at birth they're very very small that ossification center. And what happens is they grow that center ossifies and becomes a real kneecap. So yes is not truly what you think of as your normal kneecap, but it is an ossification center and it becomes that sesamoid bone.
But it's teeny tiny. Katy Noble had a good question, why do we have kneecaps and why don't our elbows have elbow caps?
Super good question, Katie. So if you look at the long lever arm of your leg, in order for your quadriceps muscle to lift your shin, it would have to be much larger if it didn't have the lever arm of the patella the kneecap rate in between. So by firing the muscle of your quad loading that kneecap on the center, you can lift through the pedellar ten and you can lift your shin. That's why in your arm
you don't have such a long leave arm. It's doesn't need as powerful a muscle to extend your elbow, and you also can use gravity.
Is the patella kind of like a fulk crumb in that great example? Ah physical indeed Archimedes right away. Good to know. Physical and physics both come from a root word meaning nature. In case you have like a zoom trivia night you need to win. Now, tall folks, let's talk ready. Violent badger wants to know is there an actual correlation between being tall and having bad knees? How can I stop my knees from killing me in the future?
They write, and Grace Robis Show and Leanna Schuster's thirteen year old daughter Sammy both want to know about growing pains, leg length and knees. So yes, physical physics, I ale Vanmuherbeek says, does the ratio of lower length leg length to upper leg length affect your likelihood to having knee pain and certain activities? And also, if you have more muscle on your upper leg versus your lower leg, does that affect your knee health at all?
Not really, except just say that muscle balance is always helpful. Okay, So folks who are doing one type of exercise exclusively, you know, we really try to focus them on more than one exercise and becoming a fit all around and having a balanced musculature.
I like the idea that if you are exercising and you are more fit, you'll save money on knee surgeries later because they're not cheap.
True.
I guess I guess I'll go for a walk because I'd rather buy a boat than knee surgery. Okay, great question here. Mark Ship wants to know do allographs bone tendon bone graphs particularly remain the standard of treatment for torn acls are their new technologies on the forefront. Also, so many people have fml acls or loved ones who have snapped theirs, including question askers Mofo, Margaret Shephard, Jennifer Green, Malia Holland, Dream Tree, Calli Girl, Nolan Childerhose, Pam Carry, Constantino,
and Keenan Day. So they all wanted to know about ACL surgery. Many folks asked about donor tissue aka allographs versus autographs, like Patron Kelly Olsen who has a donor tendon, and Aaron Sandfold. So yes, grafting human tissue was a big question. And Anna Rubino wants to note does the body reject cadaver tendons and if no, why not? And
if yes, are there anti rejection meds needed? Because if you get a transplant of anything else, you'd have to worry about your body saying get out of here, right.
So that's a great series of questions. Okay, So let's start with the first principle Number one, donor tissue. The person's asking about allographs and bone put teller tendon bone allographs. So when you tear your ACL, we have a choice of which tissues to replace it with. We can use your own tissues, your own petiller tendon which is called a bone, putillar tendon, bone, your quadriceps tendon, or your hamstring tendons. Each of those tendons that requires a second surgery.
So we're robbing Peter to pay Paul. We're producing a second injury to repair the first injury. And intuitively, I think that's a terrible idea. I did it for the first half of my career because that's all we had. But then what happened about fifteen years ago is that tissue banks got very very good at providing donor tissues. So unfortunate's usually a donor cycle. Somebody has fallen off their motorcycle at a young age and has donated their tissues.
So then once we have tissues that have been tested so we know they're not contaminated and that they've not been irradiated, so have just fresh frozen tissues, and we can then use them instead of taking the tissues from the patient's own body. And these days we can add growth factors and sided kinds to stimulate stem cell derived cells to migrate into them and accelerate the healing. So now,
when we rebuild knees, our preference is to use donor tissue. However, there is some data to say that their rerupture rate of donor tissue is higher than the rerupture rate of normal tissue of the patient's own tissue, and the reason for that probably is the wide variety of donor tissues that are there. There is no rejection and the reason for that is that since the tissue is dead, there are no live cells to stimulate, another part of the
rejection phenomenon. When you get a heart transplant or a kidney transplant, we have to keep that tissue alive. Therefore you have all those live cells and therefore you need anti rejection drugs. In orthopedics, we have the luxury of having dead tissue which we then want to recreate to be live. But we want it to be live with your own cells, so we don't have a rejection phenomenon.
Is it vascularized at all?
Not at first? We have to stimulate the blood supply to grow into it, which is part of those growth factors inside of kinds.
And how old usually is that tissue? Is it usually a recent donation or are you able to flash freeze it and keep it until it's appropriate for a certain patient.
Yes, the tissues are fresh frozen. We only use tissues from people under forty years of age and healthy. But there's always a shortage of good tissues for orthopedic donation, and so everybody, if they can, should check off that little box and their driver's license saying they're willing to be a donor if they unfortunately have an accident. But for orthopedic tissues, we only use them from people under forty.
And it seems like there's it's really appreciated by the donor's family to hear from someone who has gotten a tissue and to say thank you for this donation, thanks for facilitating it. This allows me to do to get back to my activities and things like that.
It's a real gift. And I wish in our country we had what's called an opt in or opt out, where right now you have to opt in to become a donor, and it would be so much better if you had to opt out. And the reason is people would not do it and they would forget to do it, and then everybody would basically be a donor unless they chose not to be, and that would solve the tissue supply problem in the United States.
Also, how cool would it be if you're dead but then you're also winning Olympic medals. There you go, You're like, might need and did that? So Doctor Stone told me that so many lives are changed and saved by tissue and organ donation, and that motorcyclists are one of the more common causes of fatalities for the donors, so much
so that some people call really fast motorcycles donorcycles. And I have never heard that term, and I certainly understand why many people would have a harsh reaction to it. And I asked Jarrett, who both has a donor ligament and has ridden motorcycles for years, and he said that acknowledging the risks that come with riding and the potential anguish that can follow those risks is a reality kind of deserves to be acknowledged. Riding is scary and risky,
and I went to go look into this. I was reading a comment thread on Reddit in a motorcycle group about the term donor cycles, and one writer wrote, in the UK, bikes makeup one percent of road traffic but are involved in twenty percent of incidents where someone is killed or seriously injured. No one buys a bye to be safe, they wrote, Although there are some economic benefits parking, my point is if you can opt in the rest of us to save a life.
Do it.
And thank you to any family who's facilitated tissue an organ donation from a family whose lives were changed by it. Seriously, and patron and philosopher Ali Rosser asked, why use cadaver ligaments when we could be making super jumpers or runners by using cheetah or kangaroo ligaments instead, And that's a good question. Sure they're working on animal transplants and Ali Rosser, you're not going to swoop in and steal a gold medal with any kangaroo upgrade just yet.
So just take a seat.
And if you're Michael Schwartz, take a seat too, because you deserve a break.
Oh yeah.
Michael Schwartz had a great question, what can workers that stanned all day do to protect their knees? Michael has inserts which seems to help, but they want to know more so if you have an occupational kind of hazard, how can you make your knees happier?
Super good question. So number one shoewear. Of course, having good shock absorbing shoewear is important. If you're using orthotics, try to avoid this hard, stiff, carbon fiber orthotox because basically Nike and everybody else spent tens of millions of dollars designing these very cool shock absorbing souls, and then you go and put the street on top of it.
When you put apart arthotic, I didn't think.
Avoid those hard orthotics. That's number two. Number three moving and exercising, so don't stand still. Really see if you can move around all the time. Number four, we do recommend people use glucosemine because they feel less stiff. Number five Exercising in the morning before you go to work, getting the blood float going. It really does seem to help a lot of people. And trying to get on a bike, spinning, doing whatever you can to get motion going.
So these are the key things optimizing your weight, of course, building your strength. These are how you protect your knees.
How do you feel about treadmill desks?
I think anything that induces people to move is helpful. Sitting is the cigarettes of the twenty first century. True.
How do you feel aout high heels?
I love high heels.
Like do they make you a lot of patience?
They actually don't.
Okay.
The foot doctors, you know, see the bunions which I don't see, but we don't really see knee injuries or ankle injuries from my heels.
Okay. A few people had questions about Pateller instability. Hope wants to know why does your patella float like that. They used to be a ballerina and something that happened not infrequently with someone would grab their kneecap instead of legs and it would just like move. My niece also has pateeller instability and had to get some surgery and is still like still dislodges. Gaelic Pearl wants to know why knee caps dislodge. What's happening there?
So that's a really big question because a kneecap can dislodge from reasons starting at the low back down to the feet, and the angle of your hips, the angle of your bones, the way you stand. All of those things affect the angle of the kneecap in the trochlear or the groove of the femur. Picking your parents back is one of the other ways. So if your parents have given you genes that cause either shallow grooves or
hyper mobility of the collagen call airlos danlos disease. Where people are much more flexible than others, then they'll have more mobile kneecaps. Almost all of my ballet answers fit on some scale of hypermobility, and they all have quite mobile kneecaps, and unless they dislocate them, then they're not a problem. Usually, when the kneecap dislocates, though, that means you've torn the key ligament called the medial pateelephemeral ligament, because you can't get the kneecap out of the groove,
usually without really badly stretching or tearing that ligament. Unfortunately, these days we've got a very good repair technique for that ligament and can put the kneecap back where it belongs. But again, if you've chosen your parents badly and you have very shallow chrochlear grooves, you may dislocate again and so got to get pick and better, Gotta pick them better.
What about in ballet? Do people with hyper mobility tend to be the ones who succeed in ballet? Or does it happen over time.
So I don't think that there's a correlation between hypermobility and ballet success. Ballet success is a magical interaction between artistry and physical ability. Very early on, when I started caring for ballet dancers in the late eighties, they were all smoking and terrible diets and influenced by Balanchine and not particularly cross training at all. Fortunately, the entire sport and art of ballet evolves so that we can now
treat the dancers as athletes, not just artists. And so they can train as athletes, they can do cross training, they can optimize their diet, we got rid of the cigarettes, and by cross training they can jump higher, land better, diminish their injury rate, come back from injuries faster, and so I think those are more important factors than their mobility status and their sense of artistry cos their success as well.
And if you're like, I'm sorry, I grew up watching a lot of Threes Company reruns and not ballet. Who is Balanchine? Well, I googled that for us, and he co founded the New York City Ballet and also married a bunch of his dancers, including one who was sixteen. So I'm guessing kind of weird culture around that scene, not a super healthy or save vibe. But hopefully times have changed. And yes, patrons hope Patricia den Lindsay Mixer who have been ballet answers, I hope that you are
plas taking care of your niece. Please. Okay, this next one is a great question. It was also on the mind of Edgar Barrera and I'm sure a lot of us out there who are like I never want to have knee surgery.
Thank you so much.
I thought this was a great question. Jolin Bloom wants to know what is the best way for an overweight person to protect their knees while exercising to lose weight.
It's a great question, and we have, you know, counts lots of patients over the years on how to get to their optimal status. I think most people, and if they have access to a pool, that it's a great way to train. You don't have to be a swimmer,
just walking pool laps. If you walk side to side in a swimming pool and walk twenty laps, and every day you walk side to side and chest deep water a little bit faster than you did the day before, you'll have a great cardiovascular workout, also doing any of the other exercises, and particularly I think the best single thing to do is to get a trainer. It's just very hard to exercise hard enough to change your intrinsic habits. And yet if there's somebody watching you and pushing you,
you'll go harder than you normally would. They don't have to be superb, they just have to push you and it has to be an appointment that you can't miss. And so if you do that, you'll reduce your weight, to choose water as your primary beverage, diminish the carbs, and really change your diet in life.
And save money on these surgeries. I mean, you're going to stay in business no matter what. And so if paying a personal trainer feels lavish, maybe consider it a health investment that'll pay back so much, including a boost in mental health and endorphins longer life. And I just looked it up and according to lessons dot com, personal trainers start around twenty five to fifty dollars for a half hour session, maybe seventy dollars for an hour session
or more depending on what city you live in. Group classes can be under ten bucks or if you're able to safely join a gym. There are group class schedules. There YouTube has so many free workouts. There are even Twitch streamers who are dedicated to free live group lessons. And need I remind you of how much knee surgery costs in America. At a pocket it costs more than
like four used preuses. And Jarrett, who partly blames his torn acl from being unconditioned from not working out during COVID, says that kettlebell swings are really good for conditioning without putting a lot of strain on your knees. If you're looking to up your muscle mass and sharpen your bio mechanic bod so get those pits, sweaty all your pits. Leah and Natasha bars need to know if there's a
name for the back of the knees. Natasha says, if it's knee or leg pit, I'd rather not know what is the armpit of the knees.
Well, in the back of the knee is what we call the posterior capsule, okay, but most people notice it when they injure their knee and they get some swelling. There called a Baker's cyst, and that's fluid that tracks out from the injured part inside the knee has nowhere to go, so it pushes out the back and causes swelling at the back of the knee.
Ooof so posterior capsule internally or pop lideal fossa. But in non doctor terms, and you can throw this out there when a holiday dinner gets awkward and you need there to be words near. The official word for a knee pit is a huff like huff hough like I want to smell sexy. I just dab a little Chanelle number five on my houffs. Okay, mar Rosenblum wants to know, And I don't know if we cover this. I know that I asked, but I'm not sure if I asked
it about this in particular. They say I had a torn meniscus and didn't need surgery, but others I know with similar injury did, So why do some people have to be surgically fixed?
It's a good question. If the meniscus is torn, it no longer is functioning the same way it did before it was torn, so it's not absorbing the force and distributing it the way a normal meniscus is. So people usually get it repaired when it starts catching or producing pain. But the question is should it be repaired even if it's not catching or producing pain. And fundamentally, there's no other key structure in the body that we let become dysfunctional and just ignore and hope that it won't cause
a problem, because they almost always do cause problems. And so what we're learning is that the meniscus is a critical structure. It needs to be repaired or repla placed or the knee is doomed.
So says someone without a meniscus who launched a knee empire. People need to recognize how important meniscus is. Correct good to know. I'll hail the meniscus, As Alina Bittencourt says, what's physically happening when knees lock up? And is there a way I can prevent it? I'm tired of tripping while walking hole.
Yes, So locking is one of the key mechanical signs that we listen to, and we're talking to a patient because most of the time we can make the diagnosis of what's wrong with the patient's knee just by listening to the patient. Amazing doctor listens to patients, right, But it's invariably true. If the patient tells you that their knee is locking, it means that something is getting caught
between the femur and the tibia. Most commonly that something would be a torn meniscus, but it can also be a loose body It can be a chunk of scar tissue. It means something that blocks that knee from flexing and extending normally, and generally we pay attention to that. And so if you're having locking, it's worth doing an MRI, doing a careful physical exam and figuring out exactly what's wrong.
So it's time to see a doctor. I perhaps yes, haha. And patrons Asia Yeger, Jeffrey Bradshaw, and Jeff Swan all have this question. Jess asks, why shouldn't you lock your knees while standing? Number one? Not great if you've got a tissue stuck in there, like beef jerky between molars. But also I looked it up and locking your knees
while standing could invite orthostatic or postural syncope. That's when you cut off circulation and you pool blood in your lower extremities and then boom, timber, we got a piper down. Not fun? Are we talking too much shit on knies. Last listener question, Yoga mel, I want you to address this question and tell me if you agree with it. They say, why do knees suck so bad? Seriously, the engineering sucks, evolution couldn't make them better. Do you agree
that knees suck and the engineering is bad? Or do you think that we just are we living too long? Because I would definitely be dead right now if there weren't for technology and indoor plumbing and heating and medicine.
So I think knees are brilliant inventioned. Again, as I mentioned, if you don't injure them, they can last forever. You know what else is five times as slick as ice and ice? What else can take millions of cycles per year? What else generally doesn't cause a problem unless you injure it. So is it the knees that or is it the people? So the fact is that we are all pushing harder, we're doing more extreme sports, we're playing harder, we're playing more,
We're exposing our body to higher levels of risk. And so if you're going to do that, you have to train for that risk, you have to prepare for it. You have to try to prevent it if you can. The most common cause of an injury to the knee is a mental error. Oh nice, so my skiers, we're just we're not paying attention for the moment, or we're going too fast. Somebody on a soccer field was thinking
about their girlfriend or boyfriend or whatever. It's the mental gap when you make the move that you know you shouldn't have made. And if we can train both our bodies and our minds to be in the moment in the sport, not on your cell phone, and really be there, then you'll dramatically diminish the number of injuries that occur.
So the knees don't suck.
The court finds the defendants not guilty.
What about your work does suck? What's the worst aspect of being one of the top surgeons in the world, or what do you hate the most about knees or recovery or having to have your own knee surgery?
The worst part is scar tissue. So we're driven to figure out how not to let people form scar because after injury, the body lays down disorganized collagen and that's scar. You look at your skin when you cut it, you form scar, and our job is to figure out how to induce the body to lay down collagen along the lines of stress so that the tissues look healthy, the ligaments look healthy, the knee has a full range of motion. So scar tissue and the loss of joint motion is
our number one bugaboo. It's a thing that keeps us up at night. It's the thing I'm trying so hard to solve in our research. And so as we figure out which injections to give to people, a big part of figuring that out is which are the most potent anti fibronic injections, What will induce the least amount of scar, what will diminish the scar, How you help that patient keep their range of motion.
So you want your body to not do a sloppy patch job after an injury. And if you would rather buy a very expensive stay in a bungalow over the turquoise blue sea instead of knee surgery, well treat them right when you got them, use them.
Drink water. Protein is your friend.
Ask yourself not what your knees can do for you, but what you can do for your knees, and if you love it, loupit.
One of the things that's dramatically diminished knee surgery for my patient is that they come in now and get a joint lube. And so once a year, many of my skiers, sometimes twice a year, will come in. They'll have tremendously arthritic knees. On X ray, they look like
they should have a knee replacement. And yet each year I've given them a combination of hyaluronic acid, the natural lubricant of the joint, and growth factors these days from PRP or used to be from birth tissues, but right now the FDA has put a pause on that until further studies are done. So we combine these growth factors with the lubricant, and in many patients they get six months to a year of tremendous relief and they say to me, hey, doc, I'll let you fix my knee
when those injections stop working. And so that is one of the great ways in which we're diminishing the role of knee surgery and permitting just by better lubrication, better growth factors, better recruitment of the body's repair cycle, we can diminish the rate of knee surgery for so many people.
That's got to be rewarding to watch too. What is your favorite thing about what you do?
Oh, seeing somebody go back to the sport they love. Yeah, sure, it's such a thrill. The surgery is fun. I love doing s love repairing things that are broken, but I most love seeing the patient return better than they've ever been.
Well, it seems like your patient's success rate is really high, so that must be something that continues to reward you like that, and you're great at it. I mean we when Jarrett came up to see you, it was like, of course you were the first person he was going to come see. But we came up from LA to see you. And when it came to who is going to do the surgery, it's like, well, we've just got to be up there for a couple of weeks to do pet. There was just like no question about it.
So I'm happy that I could sequester you on a bench and ask you all these questions.
Happy to help you anytime.
Thank you so much for doing this. Thanks for being such.
A great doc.
Doc my pleasure.
So ask smart people creaky, bendy poppy questions, because you'll never bend your knees the same. You'll say, hey, good job. If you want to know more about Kevin Stone. His website is linked in the show notes Zone clinic dot com. Also, you can find us at aliward dot com slash Ologies. There'll be a link to this episode in the show notes as well. We are on Twitter and Instagram at Ologies.
I'm at both at ali Ward with one l. Thank you to Aaron Talbert who admins the Facebook Ologies podcast group. Thank you to Shannon and Bonnie who handle our merch. Transcripts are by Emily White of the Wordery. Bleeping is done by Caleb Patten and those are available for free. The transcripts and the Bleeped episodes at aliward dot com, slash Ologies dash extras linked in the show notes. Thank you to Noel Dilworth for scheduling and Susan Hale also
handles so much Ologies business. Smologies episodes are out every two weeks. They're clean in classroom friendly. Thank you Stephen Ray Morris and Zeke Rodriguez Thomas for working on those. Nick Thorburn wrote and performed the theme music. Thank you to Jared Sleeper, husband pod Mom, Knee Surgery Survivor, and the whole Muse for this entire episode. I'm glad we
all know about nies. If you listen to the end of the episode, I tell you a secret and number one, there's so many long asides in this I went down way too many rabbit holes, and I didn't even include the fact that your elbow pit is called a chi leiden and it's named after a swallow bird. Also, I have been adjusting my brain meds and it has not
been easy. So stay tuned for an episode on ADHD wherein you might learn a little bit something about that and whether or not I have recently been grappling with a diagnosis of that. We'll learn more. But if you're like, hey, why have the last two episodes been up a day or two late? Pops is struggling, but it's gonna get better anyway, Thank you for being here. Episodes will be up on time in the future probably, Okay, bye bye.
I used to be an adventurer like you. Then I took an arrow in the knee.
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