Common Knee Pain Diagnosis

Could you be at risk to end your running career because of a knee injury? To find out, read on…

Female Runners: does this describe your experience running?

1. Marathon participation
2. Weekly running distance (30-39 miles)
3. Running on a concrete surface
4. History of previous injury
5. 4 to 6 months of running experience

Male Runners: does this describe you?

1. Marathon participation
2. Weekly running distance (20-29 miles)
3. History of previous injury
4. Recent return to running
5. Running experience of 0-2 years

If these describe your running experience, then you had better read this article. These gender-specific high-risk running profiles were not developed from thin air. Over 400 research articles written in recent years contributed data to describe what you’ve just read. Let’s not ignore what science has shown to be true.

Hi, I’m Dr. Sebastian Gonzales. I own a rehab clinic in Huntington Beach, CA where we specialize in reduction of running overuse injuries.

I’ve run many races from 5k’s to 1/2 Irons. I’ve experienced knee issues as a runner, just as you have, yet I’ve been fortunate to have a sports medicine educational background to trouble-shoot “what works and what doesn’t work” to heal many conditions like runner’s knee, patellar tendonitis, and meniscal irritation.

How long does it take to recover? Everyone is a little different but if f I had to estimate:

• 1/3 of the people I see feel 50% better within a matter of 30 minutes and are able to keep milage up, with slight suggestions.
• 1/3 take roughly a month to get back into their desired milage, with a more focal warm-up/ cool down.
• The last 1/3 are more complex cases and can take months.

Don’t get me wrong, the complicated ones aren’t broken. I still have them train in some way, shape or form within the first week. Typically, I start them with resistance training.

If you want these same results, I’m here to guide you. Take a look through the article below to get a feel of what I can offer.

Some of you may get benefit from the tips within this article, but if you’re not don’t fret. You probably just need a little one on one direction is all.

There’s no substitution for one on one help.

I could write an article telling you how to fix your care, or I could just come over and show you how!

On that note, if you’re in the Southern CA area, book a time with me. The proof is in the pudding and it’s faster to make pudding when you can use your hands.

People recover from knee pain from running everyday. All you need to do is duplicate what works.

If you need my help just book an appointment with me HERE.

Before we start getting into the article, let me ask you… Do you want a downloadable list of the top knee rehab exercises I use in practice?

If so, here it is. I created this guide/ cheat sheet for those of you who would like to skip all the reading and just get the “magic list” of exercises.  Buy downloading this pdf, you’ll save yourself 20 minutes of reading and get access to the best videos on the most effective exercises I’ve used in clinical practice for reducing knee pain while running within a matter of weeks.

Within this article, we will go into some of the most common reasons for knee pain in runners just like you. Does this mean you’re destined to get knee pain? No, but it means you should take precautions to prevent a knee injury that could potentially end your running career. If you’d like to know more, I’ve created an online course on knee health for runners that you can access HERE.

I’ll still give away a ton of free content within this article, but if you are serious about running, then you should check out the manual. It’s not for someone just adding running as a “side hobby” because one of their friends told them it was cool or if you’ve started dating someone who enjoys running. It is a course for people who are passionate about making running a lifestyle.

“Overuse” knee injuries total more than half of all aches and pains sustained by runners. Don’t let this preventable type of injury end your running career before you get past year two.

Here’s a video of three of my favorite exercises for a very common running knee injury, a medial meniscus tear. Enjoy, and if you like what you see, please take a look at my online course.

Here’s a video I titled “Top 3 Knee Rehab Exercise for Medial Meniscus”

Rehab and prevention programs can look more different than you think, so start your plan with an open-mind. Leave your bias of what you think a program should look like. Effective prevention of knee pain requires us to take our bodies through a series of progressive, loaded movements, but only after we’ve laid the proper foundation.
In the course, you’ll learn all about the foundations of:

1. Position/Pressure
2. Pattern
3. Speed

The injuries you will learn about are:

1. IT Band Syndrome
2. Runner’s Knee (Chondromalacia Patella)
3. Plica Syndrome
4. Patellar Tendonitis
5. ACL injury
6. Medial Meniscus Tear

Now, on to the Top 8 most common knee pain diagnoses in runners. By the way, if you want to get my take on your achy knee, just book a time (if you’re in Southern CA) or set up a call.

 IT BAND SYNDROME (ILIOTIBIAL BAND SYNDROME)

• Stinging pain on the outside of your knee?
• Does your knee click?
• Does the pain come back as you stop and start again?
• Knee pain while running?

Watch this video before going on.

I go into almost everything you’ll need for ITBS. I cover anatomy, rehab, treatments and theory. I know it’s a long one but if you want to get better, you need to watch the entire thing.

Sit alone during your lunch break and spend the time.

For your convenience, I created some page jumps since IT Band Syndrome is a big section.

– What creates the pain associated with IT Band Syndrome?
– What causes the friction of the IT band on the bone?
– ITBS correlation with the Ankle
– ITBS correlation with the Hip
– 2 Bonus ITBS Exercises
– IT Band Syndrome Video Mini-Guide

I actually had IT Band Syndrome one time in my life for about a month.

It was unbearable.

I remember was training for a ½ marathon. On one of my runs around Back Bay in Newport Beach, I reached the section where you come to the neighborhoods on the north side where there are some traffic lights.

Red light.

Green light…this is where the stabbing pain began. There was pain with every step, or every landing to be more exact. It slowly dissipated over the next 50 yards.

I saw another light coming up and of course, hit another red light again.

Green light…the stabbing pain began all over again.

I began to walk and realized this was not normal.

Iliotibial Band Syndrome (ITBS or IT Band Syndrome) is an injury that can keep you down for months if you let it. I beat it and you can too. Let’s start by learning something about it.

What creates IT Band Syndrome?

The IT Band is a dense, fibrous band of tissue that runs from the outer hip down to the side of the knee. It sits right on top of the lateral quad muscle, and when it gets to the knee, it runs over a bursa. This bursa is normally located there to decrease friction between the IT band and the bone of the knee that lays deep to it.

Pain develops as the IT band is compressed into the bony area (lateral condyle) of the knee. It is commonly called a friction syndrome.

What Causes IT Band Friction?

The most common answer you’ll find on the web is “tightness of the IT band.”

But what is the truth?

It’s a combination of strength, coordination and endurance deficiencies of the core, hip and ankle. Some call the knee the “red-headed stepchild of the leg”. It’s never its fault, but it always gets blamed.

What’s the real story?

Not buying it yet?

Look at what the research says about IT Band Syndrome.

In 2010, an article from The Journal of Orthopedic & Sports Physical Therapy looked at the differences between the biomechanics of runners plagued by IT Band Syndrome and those who weren’t (so called non-injured/healthy runners).
In the study, they looked at and compared three things between the two groups:

• Hip biomechanics
• Knee biomechanics
• Ankle biomechanics

In the past, researchers have theorized that IT Band Syndrome comes from any of the following: (Ferber 2010)

• Excessive rearfoot eversion
• Greater internal rotation of the tibia (where the band attaches)
• Weakness of the hip adductors (on the sides) creating more adduction in running gait (crossing the leg past midline when looking head on)

Technical, I know, but hang in there. (I said we were going in-depth, didn’t I?)

First off, it’s important to know the IT Band does not stretch…maybe a tiny bit, but really not much at all. It is a structure of support just like the ACL. One of its functions is to provide lateral support to the hip and knee…so why would we even attempt to stretch it anyway?

I don’t know of any runner who spends their mornings trying to stretch their other joint-stabilizing structures like the ACL, PCL, and stiff ankle ligaments, which can often be sprained/torn.

Let’s start with the ankle

In this study, they found no correlation with IT Band Syndrome and rearfoot eversion (in laymen’s terms, some might call that “flat feet”). In fact, the IT Band syndrome group actually had less eversion (“pronation or flat feet”) than the non-injured group.

“How could that be?” you might ask.

They found that the IT Band group actually had higher activation of the opposing muscles of the ankle, which do the opposite motion, called inversion. Inversion would be like running on the outer parts of your feet.

Perhaps, this is a compensation mechanism…we don’t know for sure.

Even if ankle eversion was a significant finding in IT Band Syndrome cases, there is a lot of variability in how much eversion is too much. There is not a direct, one-to-one relationship in degrees of motion between rearfoot eversion and tibial rotation.

So if you’re wearing orthotics and you are still having IT band pain, perhaps we should look into the hip and then the knee itself.

Does the hip have a correlation with IT Band Syndrome?

Ferber’s study points to poor biomechanics of the hip as a reason for IT Band Syndrome due to significant increases in hip adduction or crossing the midline. Correction of this problem via strengthening of the hip abductors over a six-week course showed improvement in 22 out of 24 runners with IT Band Syndrome and knee pain while running (Fredicson 2000).

So, getting stronger hips is the answer?

Just six weeks of hip strength training resulted in pain-free running in 92% of runners.

For those of you interested in this study there is a reference in our resources.

If you have been studying causes of IT Band Syndrome then you have a run across the topic of internal tibial rotation.

Does internal tibial rotation cause IT Band Syndrome?

Studies have been indicating that it is not as big of an issue as we originally thought.

So am I saying there is no internal tibial rotation with IT Band Syndrome?

Not at all.

Internal rotation of the tibia is not something that just happens, but according to this research, ankle biomechanics is NOT the main cause in IT Band Syndrome. What is causing it to rotate is a different process altogether.

Why is all of this information important to you?

If the hip and ankle are factors in IT Band Syndrome, then it is more than a knee problem, correct?

So, there is more to it than just foam rolling till we are black and blue?

Definitely! The great thing about ITBS is that it’s really not hard to resolve. There just seems to be a lot of mis-information about how to resolve symptoms and return to running. Because of this, I put together my mini-guide to resolving IT Band Syndrome. You can get it here if you want to skip all the reading and just start “doing.” I call it An Introduction Into The 9 Best Corrective Exercises For Unhappy IT Bands.

Catchy and hip I know. Take a look at it. If you aren’t impressed just return it for a full refund.

A rehab program for IT Band Syndrome encompasses core exercise, squats, lunges, hip band work, and ankle proprioception drills to name a few. I know it sounds complicated, but it really isn’t.

Here are a few exercises I start people on if they have knee pain while running:

There’s a few videos in this block. I would take the time to watch them all if you’re serious about your knee. The last one is provided by an awesome Jason FitzGerald at Strength Running.

IT Band Stretches

The sad reality is stretching the IT Band is old news. Study upon study over the past 10 years has shown when we improve core and hip function, majority of IT Band cases get better without stretching.

So is there a need for IT Band stretches at all?

Sure… they can assist with decreasing pain but that’s not the most important part of injury recovery. The most important part is FUNCTION. How do you function today? It really don’t matter a ton how you feel.

What will keep you running longer is improved function. Pain comes and goes but when it’s present it’s the best motivation factor you could ever ask for. Be thankful for it and allow it to improve your function for a longer running career.

IT Band Treatment Options

Here’s some other treatments and/or factors that can assist you in recovering from IT Band Syndrome and decrease knee pain while running:

• Active Release Technique
• Deep Tissue Massage
• Progressive hip loading and core endurance under supervision (most effective option)
• Anti-inflammatory Injections
• Prolotherapy
• Chiropractic Adjustments or mobilizations
• Strength training/rehab
• PRICE therapy
• Running gait training
• New shoes
• Better roads

Stop just foam rolling your IT Band and taking excessive time off. You can be moving towards your running goals during your downtime from running; but stretching and wishing you could run is not the best plan of attack.

Have someone assess what your problem is, get on a training plan, and get back to running within a few weeks. This will just be a hiccup on your path to becoming a healthier runner.

References:
Ferber, R. Noehren, B., Hamill, J., Davis, I. 2010, “ Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics”, Journal of Orthopaedic & Sports Physical Therapy, Vol. 40, pp. 52-58.

Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000;10:169-175.

PATELLAR TENDONITIS

• Pain just under the kneecap…on the tendon?
• Painful and tight when you’re just standing up?
• Scared of pain associated with stepping off of a curb?
• Knee pain while running?

This does not have to be the injury that takes you out of running. This will not be your last race.

In this section of the article, you will learn the ins and outs of Patellar Tendonitis. More detailed and easier to understand then the last page you read…which was probably WebMD, huh?

Before we start into the text you NEED to watch this video… yes it’s another long one but it’s very comprehensive. I cover just about everything you need to know about patellar tendonitis in one video.

Don’t cheat you’re self. Find 30 minutes out of your day to watch the entire thing.

What is Patellar Tendonitis?

Patellar Tendonitis can feel like pain just below (inferior to) the kneecap at the inferior pole down to the tibia, but it can also be present at the top of the kneecap and run into the superior portion as well.

Looking at the anatomy of the patella, it is not hard to see it is a unique bone because it is encased in a tendon. It is called a sesamoid bone.

Its purpose is to create mechanical advantage as a tendon crosses a certain joint, in this case, the knee joint.

What Causes Patellar Tendonitis?

• Overuse
• Compensation of old issue on other lower limb (most common)
• High intensity and frequent physical activity
• Muscular/skeletal instability
• Malignancy of bone
• Tightness of the muscles surrounding the area
• Obesity
• Patella alta

How Patellar Tendonitis Starts

The patellar tendon is just like any other soft tissue structure of the body. If you demand too much from it, eventually it will fail.

This is exactly what happens. The tendon is exposed to too many miles, too much concrete, or too much improper running mechanics.

The tendon becomes irritated and starts to yell at you.

“Hey! You’re hurting me. Stop!”

Do most people stop?

No.

Typical treatment is an anti-inflammatory remedy such as pills or ice. Remember, inflammation is a natural process. Your body is telling you something.

What is your body telling you?

Change something because what you’re doing isn’t working.

Does this mean you have to stop running forever? Not at all, but you may have to decrease your mileage a bit to “cool the knee down” while you rehab.

Research has shown Patellar Tendonitis can be treated with rehab of the core, hip, thigh and ankle. Imbalances of the muscles of the pelvis and thigh would be my first guess as to what causes most cases of Patellar Tendonitis in the first place.

Usually, if we work from this assumption and move our way towards gait analysis later in the program, it goes fairly well. With Patellar Tendonitis, if you look at gait too, soon there will be false positives.

I know all of this information is cool, but you just want to know what can decrease the pain, right?

Isolated treatment of pain in the tendon is important though.

Patellar Tendonitis Treatment Options

Treatment of the area of pain is critical in decreasing knee pain while running and rehabbing the area. All of these are great options:

• Rest the area (72 hour max)
• Stretching
• Some good old progressive strength in the hips and core endurance (most effective option)
• Ice treatment
• Non-steroidal anti-inflammatory medications
• Chopat straps/braces
• Active Release Technique®
• Surgery
• Corticosteroid injection
• Massage
• Platelet rich plasma

Here’s one of the ball mobilization exercises that really seems to free things up. Rolling out the quad group will decrease the amount of tension on the kneecap and the patellar tendon that’s attached to it.

Also in this collection is one of the rehab circuits I like to do with my runners as we advance. Everything can be scaled back, and the hardest part will be squatting. I know there is squatting in this circuit, and if done more in a box squat pattern, it will decrease the pain. Increasing height will assist as well.

What testing/ exam can “rule in” the need for Patellar Tendonitis treatment?

• X-ray’s will rule out if there is a problem in the bone
• Definitive answer is an MRI
• Diagnostic Ultrasound
• Physical exam by a medical professional

The examinw is the best way to start. In the through examination (not a dismissive 5 minute exam), a skilled clinician can decide the best route of care without using advanced imaging. I know it’s nice to have an MRI, but to start treatment/ rehab you do not often need it.

PATELLOFEMORAL PAIN SYNDROME (RUNNER’S KNEE)

• Does your knee sound like a rusty door hinge?
• Does it swell after a run?
• Inner knee pain?
• Thinking you’re just “getting old”?
• Knee pain while running?
• Pain on inside of knee (medial knee pain)?

This does not have to be the end. You don’t have to start cycling or swimming just yet.
You can run again with the right rehab.

Before you go to far, you should find 30 minutes to watch this video all about Runner’s Knee. I included many corrective exercises, assessments and treatments. It will answer many of your questions and you won’t even have to read the whole section.

In this section of the article, you will learn about the most common knee injuries experienced while running. You will learn about common treatments and rehab exercises.

But most of all, I want you to know you are not alone. Many runners have gone through this before and have come out fine. But with an injury like Runner’s Knee, you must understand one thing:

It is not a major injury in the beginning, but it can and will be the injury that stops you from running permanently if you don’t address the underlying causes.

I have had Runner’s Knee just like you. It was around five years ago.

I was in my prime. 31 years old and the fittest I’ve ever been.

It was a slow progression. I began noticing my symptoms for about a week before I realized and then considered the consequences of my neglect.

What is Runner’s Knee?

Pain felt deep in the knee can be a symptom of Chondromalacia Patella, also known as Patellofemoral Pain Syndrome (PFPS). The meaning of chondromalacia can be broken down to chondro, meaning cartilage and malacia, which means weakening.

Runners Knee and Patellofemoral Pain Syndrome are the same condition. I know it’s confusing since the names are different, but think of one as the athletic term and the other as a medical term.

In the past, the term “Runners Knee,” was used to describe pain around the patella or kneecap. Currently, most doctors recognize it as a “catch all, garbage term,” used to describe pain around the kneecap. The term is used so loosely it no longer has value and lacks description of the underlying reason for knee pain around the cap.

Runner’s Knee is clinically known as Patellofemoral Pain Syndrome or Chondromalacia Patella

Patellofemoral Pain Syndrome is a little bit more descriptive because it indicated the region or location of the irritation. However, it still doesn’t account for the mechanisms causing Patellofemoral pain. We will go into that later…

Let’s start with describing why it’s medically called “Patellofemoral Pain Syndrome.” The region of the knee in question is called the Patellofemoral complex, which is made of the kneecap (aka the patella) and the femur (aka the thigh bone). This region also has ligaments, cartilage, nerves, blood vessels, and tendons. It’s a complex joint when we look into the small parts but by no means is it as complex as the ankle.

The underlying fact that this is a cartilage injury is what makes it the kind of injury that could ultimately keep you from running. Cartilage does not heal as well as bones and muscles do.

Cartilage doesn’t have a direct blood flow supply (excluding the outer 1/3 of the meniscus) like other tissues of the body. It gets its nutrients through intermittent compression, pushing out the waste and sucking in the good stuff. Cartilage is just like the rest of your body in that respect.

You eat food and then get rid of the waste. This is no different except think of the cartilage is constipated. It sometimes needs to be squeezed. Constant squeezing however won’t allow for nutrients to come in. This eventually leads to slow cartilage degrade, resulting in Runners Knee.

Once you lose it, you lose it. Although with some experimental techniques, regeneration of cartilage is looking more and more possible in the future.

Do you need your cartilage?

Yes, you do. It provides a slick surface for bones to glide on one another. That grinding feeling you have is from the cartilage not being there or it being too soft to do its job.

If you suffer from this condition, you are not alone. In fact, it is the most common reason any athlete will report to a sports injury clinic. It affects up to 30% of all athletes.

Runner’s Knee Symptoms

• Pain that is generally dull and constant
• Clicking/popping of the knee upon motion
• Swelling of the calf
• Bruising of the muscle
• Restricted motion
• Dull achy pain around the knee cap
• Pain walking downstairs
• Pain running downhill
• “Movie theater sign” (Pain after having the knee flexed for a period of time)

The “Movie theater sign” or the bent knee position is an interesting one since it confusing many patients. The belief “rest will make it better” seems to not work in this bent knee position.

PFPS is a condition where two surfaces (the femur and the underside of the kneecap) are being irritated against each other and in this bent knee position they will rub more. Let’s look at some pictures.

What causes Runner’s Knee?

I hear “overuse” a lot.

I’m not going say that is 100% wrong, but I like to point out the obvious.

“Why does it only affect one of your knees, then?” you ask. “Don’t you run the same amount of steps with both legs?”

I am like everyone else. I too would like to think that I crushed so many miles this week, I just overused my body, but that is not the case.

Often after testing flexibility, core strength, hip strength, single leg balance and movement patterns like squatting and hip hinging, we find there are asymmetries.

Studies in the past blamed a weak vastus medialis or inner quad muscle, but recently we have learned there is more to it than just that.

You may be thinking it’s from a laterally tracking kneecap. Yes, that has been a theory as well, and yes, it can cause rubbing on the outer aspect of the femur bone, which creates damage, but the reason why it is “tracking laterally” is not the fault of the quad group.

It is the core and hip’s fault.

It’s true! You knee injury is from the core and hip once again!

Dynamic “motion” MRIs of patellofemoral pain syndrome patients have found that the main reason the kneecap rides laterally is because the femur bone spins itself into contact. The spinning starts at the hip.

If the core and hip muscles are not doing their jobs, the femur bone rotates medially (inward) and contacts the kneecap leading to patellofemoral pain syndrome.

Am I saying the theory of the quad being the issue is not possible?

I’m not saying that at all. It’s just not as probable. Common practice in movement therapy is to stabilize regions proximal (closer to the midline) when we have a distal injury (further from midline). When we have a knee injury we check the core, breathing patterns, pelvis and hip function before we narrow our focus to the knee.

If we conclude the knee itself is the contributing factor the following are the first places we look:

• Active Stabilizers: The Quad group
• Passive Stabilizers: The ligaments and fascia around the knee complex
• Static Stabilizers: The bony contours and surfaces

Any of these three groups could be the reason for knee pain. But again, we always have to assess above and below the knee first.

Here are a few things you can try to assess your midline stabilization. If these tests are positive then we have a need for core, pelvis, and hip rehab before we even waste time on the knee. When we correct these, often times the knee will unload the cartilage and allow healing.

1. Trendelenburg Test (10 sec hold)
2. Dynamic Trendelenburg Test (quality of motion assessment)
3. Side Planks (1 min hold)

If you’re not rock solid on each of these then you have some work to do. I have some Runners Knee exercises I use in my office in the video at the top of this section… better watch the whole thing this time.

Runner’s Knee Rehab

If you have Runners Knee the first thing you should do is the exact thing you didn’t want to hear. Stop the mileage.

This doesn’t mean you can’t run ever again but you need to stop the mechanism of injury for the medial knee pain. You have to stop the compression remember. If all goes well in rehab you maybe able to build up again in a few weeks. With proper guidance, most people can keep a fraction of their mileage as a “base.”

Take this time to find your cardio through swimming, cycling (clipped in only), and high intensity weight training. All three of these activities independently can assist in your recovery by pumping nutrients into the cartilage and as a bonus they can all make you faster!! More on this later…

When you do start running again, you should consider beginning on flats with dirt. The harder the surface the more impact into the knee. This won’t yield the quickest speeds ever but you’ll be on hard surfaces in no time.

Just like all of the other knee conditions, we need to focus on the core, hip and thigh. I know this article is getting redundant, but it is true.

Here’s a circuit I use with my runners rehabbing Runner’s Knee. Remember, this is all scalable. More importantly, keep in mind I prescribe this circuit to a person whom I’ve tested and deemed it’s safe for them to use. If you like this video, I have more exercises I guide you through in my Runner’s Knee Video Guide.

Most people should be able to reintegrate running via “sprint drills” within about 10 days of onset with the proper strength and conditioning recommendations. Building strength within the “first aid” phase of recovery from Runner’s Knee is really simple and will dramatically improve your chances of recovery.

Not sure where to start? Take a look at the Guide.

Other rehab exercises we often use are:

• Proprioception exercises for the knee
• Deadlifts
• Multiplanar core stabilization
• Pallof press variations

I strongly believe one of the worst things you can do when injured is to 100% rest the area… the knee is no different. There are ways to keep function and strength on the hips, core, knees and complex motions of the leg when injured.

Here’s a video on the concept of lifting around Runner’s Knee so you can recover and start running again sooner.

Runner’s Knee Treatment Options

These are all great treatment options for decreasing knee pain while running. Without a drop in pain it is hard to rehab the area and use exercises.

• Rest and ice
• Specific strength and conditioning after a legit examination (most effective option)
• Addressing the scar tissue formation with soft tissue manipulation
• Active Release Technique and Graston
• Rehabilitative strengthening exercises
• Taping or bracing the knee
• Anti-inflammatory pain medications
• Surgery options of arthroscopy or realignment of osseous structures

To be clear, I do not agree with all of these, but they are used nonetheless.

Some image options that can assist in confirming (but not required) the diagnosis are:

• X-rays – rules out bone injury
• MRI – way better image
• Diagnostic Ultrasound – can see the soft tissue of the knee
• Physical exam by a medical professional

Works Cited

Staff, Mayo Clinic. “Definition.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 05 Feb. 2013. Web. 06 June 2013. http://www.mayoclinic.com/health/chondromalacia-patella/DS00777

Endo, Yoshimi, Beth E. Shubin Stein, and Hollis G. Potter. “Abstract.” National Center for Biotechnology Information. U.S. National Library of Medicine, 30 Aug. 0005. Web. 06 June 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445133/

PES ANSERINUS TENDONITIS

• Pain about an inch below the knee?
• On the front but inside?
• Pain climbing stairs?

This could be an injury to the Pes Anserine tendons or bursa.

Just like the other sections, please watch the following video for extremely comprehensive and actionable steps you can take if you have a confirmed diagnosis of Pes Anserinus.

What is Pes Anserine Bursitis?

The Pes Anserine is the attachment point for three muscles and in the area of a bursa located about an inch below the inner part of the knee. It is on the tibia bone.

The three muscles that attach here are:

• Gracilis
• Sartorius
• Semitendinosus (medial hamstring)

Pes Anserine pain is normally due to inflammation of the bursa at the location, but it can also be from the tendons…making it a tendonitis.

A bursa is a naturally occurring fluid filled sac designed to limit friction as soft tissue structures pass by an area.

Who gets Pes Anserine Bursitis?

Pes Anserine Bursitis is one of the less common running injuries, but it can happen. The more common injuries you will encounter are runner’s knee, meniscal injuries and tendonosis.

Pes Anserine Bursitis can be present in athletes such as runners, cyclists and triathletes. On the flip side, I have seen many normal sedentary people who have it as well.

What Causes Pes Anserine Bursitis?

It is no mystery there is a connection to the hip and core. All three of the muscles attaching to the Pes Anserine come from the hip.

Hip strength and endurance are directly connected to how well the core functions.

The core is the trunk as a whole…not just the six pack muscles.

Just like any other muscle/tendon injury, if you over stretch it, it goes beyond its optimal range. Think of a spring.

It has a length that it functions at best. Muscle and tendons are the same. When they are outside of these ranges, they are less effective at their job…so they become damaged.

Why is this important?

If the tendons become damaged, they also become inflamed. Inflammation creates a local chemical process, which then irritates the local bursa and leads to pain.

Pes Anserine Bursitis Treatment Options

• Self massage of quads and hamstrings
• Specific strength & endurance exercises after a through examination (most effective)
• Active Release Techniques
• Graston or other tool assisted tissue work
• Stretching of the hip, thigh and ankle
• Deep tissue massage
• NSAID
• PRP
• Prolotherapy
• Rehab exercises for the core, hip, knee and ankle

When can you start running again?

It really depends on when you want to risk it.

In a perfect world, I would not have anyone run more than 5 miles at a time until they have successfully passed a battery of core and hip testing.

A decrease in pain has no correlation with if you can pass these tests or not. It just means that the area has calmed down. Simply resting it will calm it down, but that doesn’t mean your core, hips and knee are any more stable.

Pain can decrease within a matter of weeks, but building strength and endurance will take months to achieve.

PLICA SYNDROME

• Clicking on the inside of the kneecap?
• Small swelling in the area?
• Pain with running?

Plica Syndrome is a less common cause of knee pain in runners, but it is always on the list of possibilities.

It’s kind of funny this small tissue can create pain since it is not really a functioning part of our anatomy.
Just like the other sections, please watch the following video for extremely comprehensive and actionable steps you can take if you have a confirmed diagnosis of Plica Syndrome.

For your convenience, I created some page jumps for the Plica Syndrome section.

– What is the Plica?
– What is painful in Plica Syndrome?
– What does Plica Syndrome feel like?
– What else is Plica Syndrome misdiagnosed as?
– How can you treat Plica Syndrome?
– How to rehab Plica Syndrome

What Is Plica Syndrome?

Plica is remnant tissue from our development. The main function of the plica is to provide glide for the knee joint.

Anatomically, the plica is thin layer of vascular synovial tissue found within the joint line of the knee. The plica is remnant tissue from fetal development that is diminished in size; it also known as a synovial fold.

What is painful in Plica Syndrome?

The plica itself is inflamed and irritated. It can become caught during motion of the knee due to poor running gait or in certain movement patterns such as squatting. The plica can be more prominent in some than in others, which increases the likelihood of it becoming irritated more easily.

Remember, it is a remnant of our development. It should have gone away just like our tails did.

What does Plica Syndrome feel like?

• Dull and achy pain in at the inner (medial) knee joint that increases with activity
• Catching or clicking of the knee upon flexion and extension
• Swelling of the knee joint
• Restricted motion
• Pain going up and down stairs
• Pain with squatting, bending, or getting up from a chair

What else is Plica Syndrome misdiagnosed as?

• Meniscal tear
• Patellar tendinitis
• Stress fracture of the tibia

Plica Syndrome Treatment Options

• RICE (rest, ice, compress, elevate)
• Progressive hip, core and foot loading exercise after a through examination (fastest results)
• Surgery based on the severity of the inflammation of the plica tissue
• Lidocaine injections
• Addressing the scar tissue formation
• Stretching
• Rehabilitative strengthening exercises
• Active Release Technique

Plica Syndrome Rehab

Rehab exercise is one of our focal points with Plica Syndrome treatment.
Normally, we focus on strengthening the entire kinetics chain, which includes:

• Core
• Spine
• Hips
• Thigh
• Knee
• Ankle
• Foot

Sounds like everything in the leg, right? It is!

Leg and knee injuries are issues with the entire leg and core. Therefore, in rehab we can leave no stone unturned.

Works Cited

Griffith, Chad J., and Robert F. LaPrade. “Abstract.” National Center for Biotechnology Information. U.S. National Library of Medicine, 27 Nov. 2007. Web. 25 June 2013. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684145/>.

Cluett, Jonathen, MD. “Plica Syndrome.” About.com Orthopedics. About.com, 21 July 2008. Web. 25 June 2013. <http://orthopedics.about.com/cs/otherinformation1/a/plica.htm>.

“Synovial Plica Syndrome.” Synovial Plica Syndrome. N.p., 2011. Web. 25 June 2013. <http://www.osmsportsmed.com/OSM/Synovial_Plica_Syndrome.html>.

Nottage, Wesley M., MD, Norman F. Sprague, MD, Burt J. Auerbach, MD, and Hesmet Shahriaree, MD. “Plica Syndrome.” Plica Syndrome. The American Journal of Sports Medicine, 01 Sept. 1990. Web. 25 June 2013. <http://members.optushome.com.au/physio/plica.html>.

ACL INJURIES

• Have you every twisted your knee?
• Did it “pop”?
• Did it swell immediately?

You could have had an ACL injury in your past.

Why does the past matter?

An ACL injury is a huge predictor of future knee injuries for one reason… Your knee is probably still “loose.”

The knee is intended to bend a lot in two motions: flexion and extension. It is not intended to rotate and bend laterally.

How does the knee stop itself from rotating and laterally bending?

Bony architecture, ligaments, muscles and tendons help to keep the knee stable. One of the larger contributors is the ACL.

What Is The ACL?

The ACL, also known as the Anterior Cruciate Ligament, is one of four ligaments that allow your knee to function properly. It forms an “X” shape with another ligament in between the tibia and the femur. The ACL is the ligament that prevents forward movement of the tibia from underneath the femur.

Who gets ACL injuries?

Females are are at a higher risk of ACL knee injuries.

How much more?

About ten times more! Pretty unfair, huh?

You can prevent ACL injury and even rehab one if you do the right exercises. The American College of Sports Medicine claims significant improvements in knee control can be seen after just eight weeks of proper training.

ACL Prevention & Rehab

ACL injury prevention programs must contain a few aspects:

• Core training
• Hip Strengthening (squatting and deadlifting)
• Hip Stretching
• Proprioception exercise for the hip and knee
• Single leg training (lunges, ½ one leg squats etc.)
• Landing plyometric training
• Acceleration, deceleration, change of direction training
• Knee rotational and lateral bend stabilization exercises

I know it sounds like a lot, but it’s not. If programmed properly, it can all be done in less than 30 minutes a day.

How many days a week should ACL prevention training be done?

I like three as the magic number, but here is the thing: once you stop, you will once again be at high risk of injury within about a month or so.

It’s not a scam; it’s the truth.

If you don’t use it, you lose it.

What if I already have an ACL tear…what can I do now?

If you have a tear and it has not been repaired, you will need to do a lot of the same work as someone who’s preventing an ACL injury, BUT you need to understand your knee is inherently unstable and very susceptible to swelling and injury.

I always suggest athletes with past ACL injuries have one on one instruction with a strength coach or a sports therapist.

Will you have to spend money?

Yes, but it is very much worth the cost!

CYSTS OF THE KNEE

This section is only video currently. This video topic was in response to a Youtube questions I received. There are four major types of cysts you will hear about in the knee region. There are more but these are the strong majority.

These types of knee cysts are often incidental findings and don’t need direct treatment. They are often a sign of other injuries to the knee… such as the ones above this section.

MEDIAL MENISCUS INJURY

• Pain on the inside of the knee?
• Minor clicking in the knee?
• Minor knee swelling after running?

Medial Meniscus tears are extremely common and very manageable when people get early care. If not managed early in the injury process, it can lead to a surgical correction down the road.

Here’s a video that will greatly assist you in understanding your medial meniscus tear. It’s a long video but very comprehensive. Sit down, get some popcorn for this one… it’s worth it!

What Is A Medial Meniscus Tear?

The medial meniscus is a type of cartilage in the knee. This cartilage can become frayed, torn or caught at times. There are many different grades of medial meniscus tears, yet not all of them produce knee pain.

The medial meniscus is composed of fibrocartilage, which is different than the articular cartilage on the bones of the knee joint. One unique aspect of the meniscus is the outer third is the only vascular cartilage in the body, this means it has the potential of healing at a faster rate than most cartilage injuries such as Runner’s Knee.

Medial Meniscus Tear Symptoms

• Clicking
• Popping
• Catching
• Swelling
• Pain with twisting
• Pain with partial squatting
• Pain with running

Interestingly, not all meniscus tears are painful.

I’ll give you an example… I had a patient about a year ago who came in with the chief complaint of medial knee pain (inner knee pain) after running. I conducted a series of tests to see if the medial meniscus was torn.

These tests included but we’re not limited to:

• Thessaly’s Test
• Apley Compression Test
• Medial joint line tenderness

These were all positive tests so we worked off the diagnosis of a medial meniscus tear, of a minor grade.

After a few weeks of rehab, she asked if we can confirm if her pain source was from a new meniscus tear or not. So I said “sure let’s take a look.”

We utilized a diagnostic ultrasound to visualize the medial joint space on the symptomatic knee and we found there in fact some meniscus changes.

But here’s the interesting part… we took a comparative study on the other knee, which was not painful and it too had very similar changes as a painful knee. What does this mean?

This brings to light the possibility that her knee pain was not solely from changes within the medial meniscus. Perhaps the medial meniscus findings were incidental and the real root cause of knee pain was something else… such as how she moved her body on top of her knee, her gait mechanics, or the way she walked, squatted or perform daily activities.

We call this method of finding the main trigger “Root Cause Analysis,” if I can steal the term from a colleague Dr. Scott Mills.

The takeaway is this… although you have positive meniscal imaging and test, it’s always important to find the root cause of your pain before starting a treatment plan.

Medial Meniscus Tear Causes

In textbooks, meniscus tears are created with knee cave (valgus force) and twisting of the knee. While in stance phase of running, knee caves and twisting occurs from the hip in the form of internal femoral rotation. Internal femoral rotation comes often comes from an athlete’s poor ability to keep the hips level when running. This hip drop comes from poor function of the stance leg gluteus medius and the swing side quadratus lumborum. A simple exercise that can assist in preventing hip drop is a fatigued state Farmer’s Carry.

We can say there’s deficiencies in a “functional core” or the midline of the body doesn’t have the ability to keep optimal position when running. Keeping form when under exhaustion is way harder than when fresh by the way.

Medial Meniscus Tear Rehab

I like to start by showing patients their knee pain can be dramatically affected by avoiding their pain triggers. Pain triggers can be extremely simple to point out (twisting) or it can a little bit more investigation and history taking. For this reason you may want to see a professional who can spend more than 10 minutes in your initial exam. Each case is unique and it’s impossible to suggest care if you haven’t been examined thoroughly.

If we can identify the patient’s pain triggers, we can also correct the person’s movement so the medial knee pain no longer is sensitive. I’ll say that another way… we need to decrease the motions creating pain so the knee become desensitized in the region of injury.

In some cases, there could be something structurally wrong with the knee. In these cases, specific manual therapy applied directly to the region can provide some immediate relief and often times results in better quality corrective exercise.

Over the years some of the treatment of choice that I’ve use are:

• Active release
• Cross friction massage
• Deep tissue work
• Joint Mobilization

I know I probably sound extremely vague in describing how to rehab the knee but honestly each case is extremely unique in its own way and we need to first evaluate to find with the person’s deficiencies are before we recommend a correction.

Some of the most common deficiencies that I often find with runners with a medial meniscus tear are:

• Hip drop
• Low core endurance
• Neuromuscular fatigue during training

Medial Meniscus Tear Treatment Options

Here are some other treatments and/or factors that can assist you in recovering from a Medial Meniscus Tear and decrease knee pain when running:

• Active Release Technique
• Deep Tissue Massage
• Anti-inflammatory Injections
• Prolotherapy
• Chiropractic Adjustments or mobilizations
• Strength training/rehab
• Core Stabilization/ Endurance
• PRICE therapy
• Running gait training
• New shoes
• Better roads

INTERVIEW WITH A PHYSICAL THERAPIST

0:00:29 Dr. Sebastian Gonzales: This is session number 33 of the Performance Place Sports Care Podcast. I think my voice is getting deeper.

0:00:35 Speaker 2: Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis and how to understand the doctor lingo you didn’t understand at your appointment. And now, your host, Dr. Sebastian Gonzales.

0:00:53 Dr. Gonzales: Hey, everyone. It’s Dr. Sebastian Gonzales with Performance Place Sports Care Podcast again. And today, we have a really great guest who is going to be our expert on knee conditions, mainly with… We’re gonna be talking a little bit about runner’s knee, as well as meniscus tears.

His name is Dr. Davis Koh, and he is someone I met actually probably about… Gosh, I wanna say it’s probably about six, seven years ago, but actually it was interesting when I started looking up other providers in the area ’cause I’d seen other people who think the same way, and he was one of the only PTs, I think, who had some of the same credentials as me, and I was like, “Who is this guy? And why does he have so many different degrees after his name?” So [chuckle] I’ll let him speak in a second but he’s gonna go over some of the things that you might ask a physical therapist about rehab on a knee. So, this is Davis Koh. Dr. Koh, say hi.

0:01:48 Dr. Davis Koh: Hello.

0:01:49 Dr. Gonzales: Hey. Okay. So, tell us a little bit about yourself and then we’ll jump right in to the topics.

0:01:55 Dr. Davis Koh DPT: Okay. Well, I’m a primarily a sports and orthopedic physical therapist. Been practicing over 18 years. My background also includes working in the cardiac and neuro rehabilitation sections of UCLA Hospital and also in other aspects of my career in the beginning. And then, the sports and orthopedic side came as a second half of my career, and it gave me a chance to see a broad spectrum of injuries from all different age groups, all different causes, all different backgrounds and to see the similarities and the differences unique to their situation.

0:02:41 Dr. Gonzales: How many years were you in cardiac, again?

0:02:44 Dr. Davis Koh DPT: I was a bit, in there about six, seven years and saw a variety of different patients, and again, even from heart transplants, to brain injury, to working even in the psych ward where we’re dealing with people with schizophrenia and working around their conditions while at the hospital, as well as the pediatrics and even as young as neonatal. So there is…

0:03:12 Dr. Gonzales: Oh, really? [chuckle]

0:03:12 Dr. Davis Koh DPT: Neonatal physical therapy, if you could believe that.

0:03:14 Dr. Gonzales: I couldn’t even imagine, other than if they had like, spina bifida or some type of…

[laughter]

0:03:19 Dr. Gonzales: Geez, I have no idea what you can even do with ’em. Then why did you get into sports injuries and other stuff? ‘Cause I know that… Isn’t like for physical therapy, majority of physical therapists, they’re not in sports injuries, right? I mean, a lot of them are in… Is it home health and…

0:03:37 Dr. Davis Koh DPT: Correct, yeah. A lot them have opportunities in hospitals, neuro rehabilitation centers, skilled nursing facilities and so a lot of them start that way; they can start that way. I did that on purpose because when I was in physical therapy school, I did wanna do sports and orthopedic. And then, my sports and orthopedic professor said, “Well, if you wanna do that, go to the in-patient hospital.” And I said, “Why is that?” “‘Cause you’ll get a nice foundational base, you’ll appreciate different issues that they may have outside of the injury itself.” The importance of where certain medications can affect them out in the… When they are out of the hospital, what they’re taking, what type of surgeries they did, appreciating the development or the after-effects of the surgeries from beginning to end. And it didn’t have to be orthopedic surgeries; it could be liver transplants, it could be other types of… Heart transplants, open heart surgery.

0:04:36 Dr. Davis Koh DPT: And they wanted me to have that type of foundation where you can see all age groups at the same time, so that when you do see ’em in the orthopedic or a setting out in a out-patient clinic, you can appreciate what their backgrounds of Hep C, or diabetes, or they’re taking a certain anticoagulant medication or this type, and the side effects that may occur, and to have a better well-rounded understanding of the patient that’s coming in with a knee pain or a shoulder pain.

0:05:13 Dr. Gonzales: Geez, you’d think there’s a little less to it.

[laughter]

0:05:19 Dr. Gonzales: Yeah, it’s funny, ’cause actually, in chiropractor school, we didn’t… We went through things like blood panels and we learned about systemic or organ types of pathology or injury but we didn’t really focus on that much. And even now, if you show me a blood panel without the normal ranges, I don’t think I would… Yeah, I’d just refer that right out.

[laughter]

0:05:41 Dr. Gonzales: So, good. Dr. Koh has a large background. When we go into the topic here, I was thinking of focusing on… Obviously, there’s lots of different people who have knee pain, but let’s just say, we’re gonna focus on the runner population since it is pretty prevalent and their injuries are a little different than say, a geriatric or a 70, 80 year old with knee pain, right?

0:06:07 Dr. Davis Koh DPT: Mm-hmm.

0:06:11 Dr. Gonzales: Tell me about runner’s knee, what is it? How often do you see it? What type of person usually comes in with it?

0:06:18 Dr. Davis Koh DPT: When I dove full force into the orthopedic and sports world, the athletes I normally saw were from my time with USA Volleyball, which I currently still work with, or with a different sports like USA Weightlifting, or the pro athletes that have come in through the clinic. And what I notice about the runner’s knee is it can happen to a non-runner, so it’s one thing that people need to understand that when they say it’s runner’s knee, it doesn’t just happen to runners, it’s commonly in runners, it got that name from that. But the runner’s knee can be in a cyclist, and it can be in someone that does repetitive training or repetitive work related to the knee, and it’s become more of a generalized… More like a generalized symptom or a…

0:07:24 Dr. Gonzales: Like a catch-all term.

0:07:25 Dr. Davis Koh DPT: Catch-all term, garbage term for a lot of different causes. So I tell patients, when they come in with certain diagnoses like a plantar fasciitis or whatever, there’s about five, six, seven different reasons for that particular heel pain that can be contributing or be the actual cause outside of an actual plantar fascia inflammation. Likewise with runner’s knee, there’s a lot of different causes and a lot of different backgrounds of the person getting that type of pain, so that’s been one thing that I definitely notice that you can get runner’s knee even if you’re a volleyball player doing off-season training. You can get runner’s knee if… And it doesn’t have to be the marathon runner per se.

0:08:09 Dr. Gonzales: Yeah, I totally agree. And I know we have different AKAs for it as well which might confuse people, the patellofemoral pain, is chondromalacia patellae, would be the same thing?

0:08:21 Dr. Davis Koh DPT: Yeah, chondromalacia patellae, patellofemoral syndrome. Yes, they all have and they’ll all be grouped as that common term runner’s knee.

0:08:29 Dr. Gonzales: Yeah, why do we do that? I don’t understand why… [chuckle] Why we have so many AKAs. It just don’t make any sense.

0:08:36 Dr. Davis Koh DPT: Yeah. [laughter] I guess, it just makes it easy for people to hear it versus chondromalacia patellae and they just go, “Oh, it’s a runner’s knee.” And it’s common and someone branded it and just took off with it.

0:08:48 Dr. Gonzales: Wouldn’t it be cool if there was the runner’s knee trademark term?

[laughter]

0:08:51 Dr. Davis Koh DPT: I’ll have to look into that. [chuckle] Might have taken it or it’s too common right now.

0:08:56 Dr. Gonzales: Well, explain then with a, quote unquote, “runner’s knee” or that type of symptom pattern, what do you usually see? How do these people come in? How would someone that’s listening to this podcast know if they are experiencing or they should be tuning in right now and thinking about, “Oh, I should be listening ’cause this actually is more so what I have.”

0:09:18 Dr. Davis Koh DPT: Okay, for a runner’s knee or knee pain in general, one of the things that, when they look up… Things that I see is, one of the things is they look up a certain diagnosis they heard from another friend. They Google it and doctor internet mimics… It has the symptoms that they’ll label and they go, “Oh, that is my pain. That’s runner’s knee. I’ve got runner’s knee.” And one thing I want the… I tell my patients and the public to know, that just to keep your mind open. So, yes, you may truly have what they’re calling it and it may truly be a classic example but there may be other reasons behind it. And so when they have a pain underneath their kneecap or in front of their kneecap or the top of their kneecap, and it’s related to movements or certain activities, particularly stair climbing, running hills, descending hills, or what have you, and it acts up to… Yes, there is a pain in that knee and one structure may be involved, a patellar tendon, the tendon, or the cartilage underneath the kneecap, or the meniscus itself. They can all be the victims but they may not always be the causes. So people also come in and they say they have runner’s knee and they say it’s…

0:10:37 Dr. Davis Koh DPT: And my doctor or my friend said it’s because I have weak, or my trainer says it’s because I have weak quads and I have an imbalance and tight hamstrings or I have some other condition or it’s just ’cause I do it too much, I’ve been running too much. And then what I try to also tell them is that a lot of times the predictor of future injury is your medical background. What happened in the past. And so sometimes when the knee is not necessarily the cause of your pain, it may be the victim of your pain, meaning that something else, your gimpy hip or a stiff ankle from chronic ankle sprains or an Achilles tendon surgery on that same leg may actually have been the cause and that is resulting in a knee pain so the example I’ll give is… And I try to explain things as simple as possible because I remember there’s a quote by Albert Einstein that says, “You don’t really know something unless you can explain it to your grandmother.” [chuckle] So I try to say it just in simple terms where… Not simple but just in easy terms where that pain in the knee, imagine if someone is bleeding, the problem isn’t that they’re bleeding, is who shot them? And so sometimes I tell them the sniper’s actually your ankle, and it’s shooting at your knee and your knee is suffering.

0:12:05 Dr. Davis Koh DPT: So you’re seeing the bleed and you do have to stop the bleed. You do have to control the bleed, but you also have to find out who’s shooting the knee. And so a lot of times, the knee is a culprit because it’s in-between your ankle, foot, and it’s also in-between your hip, pelvis, low back. So it can be the victim of these other two parties, or three parties, or whatever the issue is, even your great toe, that can cause your knee to keep recurring. The other thing I would say when people say, “Oh, it’s because I’ve been training for my marathon and that’s why my left knee is hurting. And that’s why I have runner’s knee.” And I say, “Well, why is it only in your left knee? If you’re running, are you only running on your left foot and you’re hopping? Or are you actually running… So why is your right knee seem to hold on okay, but your left knee seems to always hurt?” So, I…

0:12:56 Dr. Gonzales: It’s the camber on the road.

[laughter]

0:12:58 Dr. Davis Koh DPT: Exactly.

0:13:00 Dr. Gonzales: They like that one a lot.

[laughter]

0:13:01 Dr. Davis Koh DPT: I’m running on the beach and it’s at an angle. But I try to tell them that there is a reason. And when there doesn’t seem to be a rhyme or reason, there’s always a rhyme, there’s always a reason, and it’s about private investigating. And so part of what I believe Dr. Gonzales and I do, is we try to find those clues to find out what is really the problem and what is the source of the problem. Just like CSI looks at blood splatter patterns, or this piece of hair, or that little piece of metal, or this bullet shell, and they piece it all together to make sense. Even the most minute details make sense and it comes together more cleanly, and that’s part of our job. And for the patients, look back at your history. Did you always have a left ankle sprain that just didn’t heal right? It’s a little stiff. Did you have a prior… Do you always have your left calf cramp up for years or months, prior to starting to have your knee pain? Things of that nature. That really helps give the practitioner clues and even for yourself, appreciation and understanding that those things really do make a difference in trying to problem solve what’s exactly going on with your knee. Not only what is being affected, your tendon is inflamed, okay. But what is actually also causing that to keep coming back or as we try to treat it, to also treat the sniper as well.

0:14:36 Dr. Gonzales: I see you’re finally striking into your own here with the… You were a little concerned about your first podcast and interview.

[laughter]

0:14:44 Dr. Davis Koh DPT: Yeah, I’m starting to hit my groove.

0:14:45 Dr. Gonzales: Yeah, you’re starting to hit it now. Well, you present a lot anyway so, it’s like you’re, really talking in front of one person right now, and you know me well enough.

[chuckle]

0:14:54 Dr. Gonzales: Yeah, I totally agree. I think on the podcast, I said that the knee is the redheaded stepchild of the leg, it’s never its fault, but everyone blames it. But you always need to look around it, look at the hip, and the ankle, and the foot, and the big toe. They’re so far and extreme. And I remember I had a patient just about… It was about a month or so ago, and she just could not see… The first time, and I’m sure you do the same thing, you spend the time explaining to make sure that they are on board with what your ideas of rehab are.

0:15:24 Dr. Davis Koh DPT: Right.

0:15:25 Dr. Gonzales: So, her outlier was some hip and trunk stuff, it looked really, really sloppy. So, the next time we went into some basic trunk stabilization and I could tell she wasn’t paying attention. And finally I looked at her, I’m like, “Is everything… Are you understanding?” She’s like, “What does this have to do with my knees again?” So I’m like, “Okay, okay. We’re gonna spend the whole time here talking. This time again, let’s… ” But they need to understand it to really grasp the treatment plan.

0:15:52 Dr. Davis Koh DPT: Exactly. And usually what I’ll also… It reminded me of a story, there was a professional fencer. And if you know fencing, they have huge legs because they’re always lunging. The lunging motion, they’re diving in, lunging, lunging, lunging. And so, this guy had patellofemoral knee pain. And so, he was working out hard and he could leg curl or leg extend over 300 pounds, and he’s just going and he’s still getting that knee pain when he’s doing that lunging, when he’s doing this. And then what happened was, looked at how low he could sit without plopping onto the chair. And he could not… At a certain point, he would just plop into the chair. And so the cause was, that he had a very weak core. And so, they could see that ’cause he could not do that and he’s super strong, built like an ox, he had quads out the wazoo. And then he worked on his core, and so when as he lunged, and only his core, and as he lunged again, his knee pain went away. So, I think there’s some buy-in where I will also palpate, feel, look at the medical history, and then see any associated factors that might be underlying.

0:17:15 Dr. Davis Koh DPT: Once they feel how tender it is and let’s just say that they’ve had a history of a sciatica or something, or shooting pains in their butt, and now they’re having the knee pain in the same leg or what have you, I’ll show them different areas and I’ll palpate. And if they find an exquisite tenderness in between their hamstrings, where the sciatic nerve also passes through, and say that this is still not resolved. It may have calmed down, but it didn’t really… Either it didn’t heal all the way or it’s calmed down enough ’til you don’t even notice it as much anymore, but it can be still part of the problem. So once they feel the difference, and I’ll go to the other side and go, “How’s that feel?”, and they go, “I don’t feel anything. That helps with the buy in and then, also as a practitioner, the responsibility of actually explaining it clean enough to where they can understand, connect the dots, and see that for themselves.

0:18:16 Dr. Gonzales: And, say it to their grandma?

0:18:17 Dr. Davis Koh DPT: Yeah, and be able to tell it to grandma so that grandma can explain to grandpa what their doctor said about why they’re having knee pain. And I think that helps them a lot to see that, but if they can’t see that connection, then you’re right. They won’t believe in it and they won’t buy into it. The other extreme is you don’t want them to, I’ve heard that where they go, “Oh, there’s this kinetic chain.” Again, they either from a friend, or from a colleague, or they look up Google research. Which I don’t mind, I like them to have as much information on their situation, condition, whether it be a certain diagnosis, or a treatment plan. I have no problems with that, but sometimes the other extreme is they’ll go, “Oh, I have foot pain and I know it’s from my kinetic chain of going to my right low back quadrant.” They’ll just kind of put the dots for you and it’s also again, sometimes you have to… It may simply just be something in the foot. [chuckle]

0:19:20 Dr. Gonzales: Yeah, I totally agree. People coming in with a preconceived notion of what they’re wanting to get is a little bit of an issue. I think it takes a little bit of the power out of your hands and I know that there’s been times where people come in thinking they’re gonna get one thing. And, I’ll play the game a little bit in the beginning where I’m like, “Okay, I’ll let ’em think that’s what we’re gonna do.” Not deceivingly, but kinda like you gotta build a little bit of trust. And then, you gotta turn a U-turn if you think that’s what their care needs. Because, they’re just gonna go somewhere else trying to get the wrong thing as well, not do them any help.

0:19:56 Dr. Davis Koh DPT: Right, yeah. You don’t want to discount what their belief or what they’re coming in with, or discount where they got that advice from, from someone that they may have trusted and yes, I will also respect that and treat that. And then, if it plateaus or if it’s not getting better, then they tend to be more open with the other possibilities. And then, going into treating a different muscle in your glutes, or in your low back. And, if that creates a change in the pain, then their eyes start opening. I remember a friend of mine from Cirque du Soleil, is a Cirque du Soleil pt full time out in Vegas. And, the athletes come from all over the world. One of them had a severe sprain in their left ankle I believe. “You have to put ice,” and she said, “No, no, no. You put an onion on that thing.”

[laughter]

0:20:57 Dr. Davis Koh DPT: He didn’t know what the… “No, the onion will reduce the swelling. You have to wrap an onion on it.” He did not want to I guess again, get into a fight and also talk about other… But, what he did was he said, “Okay, let’s wrap the onion. And then afterwards, we’ll wrap the ice.”

0:21:17 Dr. Gonzales: We’ll do both.

0:21:17 Dr. Davis Koh DPT: We’ll do both and she was okay with that. Even though that was… It was totally foreign to him, but he respected what she had seen, maybe what they had done back in her home country. I think it was Romania actually, but and then at the same time be able to have her buy into doing other types of modalities including ice to help with the ankle sprain. I try to… Kind of like you, where we try to respect that and try to hit certain areas, and then at the same time, to see if when things plateau, or if it’s not really changing the symptoms, to reassess and then to try other places and see if that makes changes for them.

0:22:03 Dr. Gonzales: Yeah, one time I actually had to do… There was a guy that I was trying to con into doing goblet squats. The only way he would do it is if I would have let him bench-press.

[laughter]

0:22:13 Dr. Gonzales: I said, “Okay, we’ll play this today.”

[laughter]

0:22:15 Dr. Davis Koh DPT: He walked in the next week and he’s like, “Can I bench-press again?” I’m like, “You want to goblet squat again?” He’s like, “No, I don’t wanna do either.” I’m like, “Okay, fine.”

[laughter]

0:22:24 Dr. Gonzales: Okay, well let’s jump into the meniscus. And just for everybody that doesn’t know what the meniscus is, there should be a podcast right before this. I’m trying to line these things up so that I go over anatomy and some of the basic foundational education stuff before we go into theory. But, the meniscus is some of the cartilage in the knee which sometimes gets torn or frayed, and that is a common diagnosis. Dr. Koh, tell us about meniscus tears and what your experience is anyways.

0:22:55 Dr. Davis Koh DPT: Okay, there’s growing research and studies about meniscus tears in general and the treatment options. The typical is you have the knee pain, you have an MRI, they show a meniscus tear, you have surgery. And, then they’ll come in and they’ll clean out the meniscus, they’ll take out any loose bodies and then, you go to physical therapy, or rehab. And, that is the way to go. One thing that people also need to be aware of is after, I believe, the age of 40, over 40, 50% of people will have asymptomatic meniscus tears. It’s just part of the process, just like many people if they did an MRI. When they do studies of people with asymptomatic, no back pain, well a lot of them will have two millimeter, three millimeter dis-bulges, herniations, but they’re still playing golf, they’re still running, they’re still playing, and they’ve never had a history of back pain.

0:24:03 Dr. Gonzales: So non-painful meniscus tears.

0:24:06 Dr. Davis Koh DPT: Non-painful meniscus tears. And so that being said, when we talk about, like I said, there is many different causes of your knee pain. And some of it is osteo or arthritis. Some of it is a certain tendinitis. Some of it is a past history causing you to move or run in a certain way that is causing pain or undue strain on certain structures in your knee. And those are all true. So when you see the pain and then you go right to the MRI that it’s not always… But I don’t wanna undermine those facts that… It’s okay to go. If you choose to have surgery that it’s totally fine. And there is nothing to say otherwise because you did have an MRI, they did go in, and there was a definite tear, but it’s for those people that don’t necessarily feel better after the fact. And they go, “It’s still there. I just had meniscus surgery. I’m not sure, it’s been two months. I’m not… It’s still hurting the same way.”

0:25:10 Dr. Davis Koh DPT: And so it’s not that necessarily the surgeon did a bad surgery. It’s not any of that at all. Or the PT did a bad rehab, it’s just that there may be other underlying factors. And so I think there was a study in Finland. They’ve done a couple of ’em, it’s difficult with… For surgically, but they did two things. One of ’em was that they did sham surgery on the knee and then actual meniscus surgery. And the sham surgery, they just did an incision. They didn’t do anything and they sowed it back up. What they found a year later was that the overall performance and pain reduction was similar. There’s no statistical significant difference between the two groups but there were more side effects from people that actually had meniscus surgery. The other thing… What they also… Again, it is difficult to make those type of studies. It’s expensive and risky but they… What they’re trying to show is that… And they also did another where they had one group just do the physical therapy and the other group had the physical therapy and the surgery. And one-year follow-ups and two-year follow-ups found no significant differences in the recovery, overall performance, range of motion, pain levels, so on and so forth, between the two.

0:26:30 Dr. Davis Koh DPT: And so there are options where people who do want to avoid surgery. It’s not a bad idea to what I call, “earn your surgery.” Where you try the physical therapy, or you try a chiropractor, you try someone that you trust, a medical professional that you trust in conservative care and see where that goes. If nothing comes of it, then yes. You can… Then you’ve kind of earned your surgery ’cause you tried everything else. And even if you go that route, it wasn’t a waste of time ’cause I tell people, what is also very popular now is prehab. So what you’re doing is you’re pre-habing your surgery so the recovery is much faster. And so when I had a patient with a total hip replacement, he fought it for years. And we were able to get him to a certain point, but eventually he needed surgery. He was scheduled. We worked on him for six to eight weeks prior to. And he had his hip replacement. It was successful. And then when he did his follow ups, his surgeon told him, he told me just offhandedly, ’cause his surgeon offhandedly just said, “You know what, in 20 years you’re the fastest person I’ve ever seen recover from the surgery.”

0:27:46 Dr. Davis Koh DPT: I think part of it is him being diligent with his home program and him being diligent with going to rehab but at the same time, the prehab, cleaning out all the collateral damage that’s happening because of his severely arthritic hip, getting all that cleaned out, ready to go, so that when he does do surgery it’s a lot less complications from the other surrounding tissues that were damaged leading up to the surgery. That enabled him to recover and get to the exercises and strengthen much faster, I believe than normal.

0:28:27 Dr. Gonzales: Yeah. Yeah. They show that people who are… Who move better and are stronger will recover quicker. Yeah. I don’t think there’s anything wrong with earning your surgery with the rehab. I like the saying. And I know there’s probably a lot of people who think that well… So you said there was that study who… Where that showed that surgery and rehab was kind of the same outcome, why not just do the surgery? Like what is, just to play devil’s advocate, why would someone want to, if they’re not opposed to surgery, they’re like, “I don’t mind getting cut into. Let’s just do this thing.”

0:29:03 Dr. Davis Koh DPT: Okay. So that’s a good question. So why not just make sure. One of the thing about surgery is that, again, it’s surgery so there’s complications. There’s risk of infections which we’ve both seen. There’s… If they have cut too much, if the onset of arthritis is much higher for someone that’s had surgery. And even for someone who has had back surgery, the statistics show that it’s… There’s a 10 times higher onset of a second surgery for those who have had back surgery prior, for the first time versus someone that’s never had back surgery. And number two, the onset of arthritis, becoming arthritic is much sooner and faster on average. So now you’re putting yourself up… And then also the other thing is, surgery, there’s only so many tickets you’re afford so if you’ve already had your first knee surgery, then do you really wanna be… Five years later the knee pain comes back… Do you wanna be a two time offender and get second knee surgery and then another 10 years later, it comes back, you want a third knee surgery?

0:30:09 Dr. Davis Koh DPT: That’s just a lot of surgery on the knee. Unless you’re a professional athlete, and you’re getting paid beaucoup bucks for that. But that is the issue. So you really wanna save the surgery, any surgery in general for… You don’t wanna do it more than once, and once you have it once, you’re at much higher risk of other side effects. Like that study showed that there… One of the study shows that, that there was… The only difference was, that there was more side effects with people who did have the surgery, the actual surgery where they actually did cut in to certain structures. Now with meniscus tears, it’s very complicated. They’re like snowflakes. Everyone’s a little different, so just ’cause someone… One had a meniscus tear, and you have a meniscus tear, where it tore horizontally, vertically or what have you… Or if there was a loose body, where it… The location of some of that debris is, makes a world of difference. And sometimes it’s just physically caught and that’s why they can’t bend their knee to a certain level.

0:31:10 Dr. Davis Koh DPT: Or sometimes, it’s in a benign area. So you do have a tear and again that’s why sometimes people who do have the meniscus surgeries and they don’t have a favorable outcome, maybe that wasn’t the main number one cause. And so, again, I don’t have a problem when… If their surgeon says, “Here’s a meniscus tear, we have an MRI, you match the profile, let’s do this relatively easy surgery and let’s get that cleaned out and have you have rehab.” If you want to go that route, I have no problems with that. I’m not trying to tell you no and that the surgeon doesn’t know what he or she is talking about. I am just telling you that there are certain options and the risk which I would do for anybody. The risk that I’ve seen either in the clinic, but also in the latest research that I’ve seen, that to earn your surgery is what I would recommend to my own family members and to save that surgery if you possibly can avoid it for when you really, absolutely need it. It’s better for the long game, overall in my opinion.

0:32:20 Dr. Gonzales: Well, is there certain types of meniscus… I know there’s many different types of meniscus tears like you mentioned. Is there a type that when you see it on an MRI, you’re like, “Oh, yeah. This is gonna be a surgery right here.” Just ’cause the outcome is really low with rehab?

0:32:34 Dr. Davis Koh DPT: That’s probably one for that I would probably leave for the surgeon that’s seen the MRI, see it been clinically have a body of work if they are a knee surgeon and then they’ll have just… They’ve seen a million MRIs, I haven’t seen a million. I’ve seen some, but I haven’t seen a million. I’ll leave that. And then they have the eye, the keen eye of seeing exactly those tears, that location, and then what their background is. One other thing that you also see with the radiologist versus your orthopedic surgeon is the radiologist may have a report of a tear or say nothing. But then when you go to certain specialists, they’ve seen, like a knee specialist that is respected, they’ve seen a million knee MRIs, more than they’ve seen maybe a hip MRI. They’ll have a, on average a much keener eye for certain little things. They’ll catch a fracture. They’ll catch this, that wasn’t or that they’ll say, “That’s not really a tear. I think it’s actually this.” They’ll have a much keener eye. Sometimes you’ll see that happen when you get your radiology report, you see the paperwork, you see what the radiologist says, who sees all over the body and then they…

0:33:52 Dr. Davis Koh DPT: You go to a specialist who only sees 90% knee MRIs or x-rays. That person will probably, in general, have a keener eye for those things and then can give you another version of events where they say, “It’s not that bad.” Or, “Okay, it is torn but it’s not really that bad.” Or, “No, no, no, no. It’s not that, it’s this.” And so, they will… Just a little FYI from when you see differing opinions, there’s some good reasons for that, and it has nothing to do with one being competent or being incompetent. And that also goes in with a physical therapist when they see that… Or the chiropractor where they see certain tests or palpations or their conservative tests over the skin without a benefit of an image, or an MRI image at least, that they still may have an opinion based on what they’re seeing. But then again, there’s a consensus confirmation.

0:35:00 Dr. Gonzales: The old tangent a little bit here, ’cause I wanted to ask, then… So we got two different types of conditions here. We have runner’s knee and meniscus that we’re talking about. How similar… When we’re doing physical therapy for it, how similar are treatment plans of both? Are they really close? Are they extremely different? ‘Cause I know that a lot of patients, a lot of runners that have these conditions, they probably think, “Well, I gotta have something specific for the runner’s knee, or specific for meniscus is… ” What do you think about all that? I’ll open it up to ya.

0:35:36 Dr. Davis Koh DPT: Okay. In some ways, there’s gonna be some commonalities, but in some ways, there’s gonna be patient specific. That’s why you have to always look at their history. Someone has a history of osteoporosis, someone has a history of high blood pressure. Someone has a… Or are taking certain types of medication. Someone has another condition that limits them from certain exercises, and so on and so forth. So you have to do tailor it according to the situation. Someone is having a bad reaction to the surgery and so their knee is constantly swollen, someone had an infection. So all those things need to be taken into account. There is, yes, there are some common general themes that we wanna accomplish but also there’s also specifics to make them unique, that’s why you never wanna go to a place where they just… You go, “Okay. You had an ACL tear, or you had this meniscus surgery. Here’s your exercise program, go to town, enjoy.” And then they just supervise you and then they do the same thing for every knee patient or every… That hip patient. That’s a red flag in my opinion. There needs to be tailoring, there needs to be some one-on-one, there needs to be some uniqueness to your rehab versus someone else, whether because of age or because of specific needs. You are a high level athlete, you are a high level avid marathon runner and someone else is an 83-year-old patient that just wants to be able to walk 30 minutes a day with their husband, it’s very different.

0:37:14 Dr. Davis Koh DPT: So there’s activity needs, there’s past histories of multiple back surgeries that you have take into account. We try to tailor things, and that should be… If you’re not getting that unique for you type of situation, then you have to have pause. That should not ever be a case where you’re in some… Maybe on occasion but in my opinion, because there is so much individuality and to get the best results for that person in particular, the more individual that you can tailor everything and even modifying the same lunge exercise to strengthen the quad and the glute differently for that patient versus another patient. And I think that would be very helpful. The other thing I would say with the surgeries as a preventive, so the second part would also be as a preventive, to look for those other things outside of just rehabbing the knee ’cause you come in with a diagnosis of, post-surgical knees meniscectomy, PT, go ahead and evaluate and treat. To look into the causes, to really make this… The end goal is not that you had successful surgery, that’s not your goal, the end goal is not to have… That you strengthen your quad. The end goal is that you’ve really eliminated the pain and also eliminated any future causes that may contribute to it coming back again and again and again and again.

0:38:53 Dr. Davis Koh DPT: The more you can do that and have that lapse of it, never coming back or even if it’s gonna come back, it doesn’t come back in two months, it comes back in two years or five years or what have you, the better for you. I think there’s a preventive part that I always try to incorporate to my patients rehab to not just get the full range of motion back in the knee and then there’s no more pain, “Oh, great. Now go ahead and run.” No, no, no. What’s going on underneath that would always help the patient. And I think it’s worth the investment since they’re already getting there anyway. And to look at things. And so patients, if a certain patient, I tell them you gotta look at if there’s any asymmetry beyond a ballpark 15% difference in how flexible you are, left versus right, how much motion you have in your ankle, or your knee, left versus right. How much strength you have, left versus right, balance, left versus right. Muscle tone… If there’s an imbalance over a certain significant where it’s noticeable, that is a big predictor of some type of future injury to occur because of that asymmetry.

0:40:10 Dr. Davis Koh DPT: I would also encourage people to not only as a rehabbing, make sure that there is a symmetry that’s involved even if you’re not injured at all. If you wanna prevent things from happening, look at yourself and see if you’re noticing, “Oh, yeah, my right shoulder’s always a little tighter when I lift it overhead than my left.” Well, you might wanna look at that, ’cause if you can’t do that and you’re doin’ overhead presses a lot, you’re gonna be compensating and twisting things and that can ’cause future problems.

0:40:39 Dr. Gonzales: Do you have a good… I usually ask people for some type of actionable thing someone can do that’s listening to the podcast. What sounds like they can probably measure their asymmetries. Do you have an easy way to do it for one of the joints which might be a predictor for a knee condition? Is there a certain way that they can do it right now listening to the podcast? Hopefully they’re not in a car or an airplane.

0:41:05 Dr. Davis Koh DPT: Yeah, well, there’s some simply… Usually the patients will tell me ’cause they’ve had this history, “Oh, I’ve never been able to reach, after my shoulder dislocated in high school football, I haven’t been able to reach overhead,” or “It still grabs me.” Or if they’re doing a knee, sometimes I just have them do a deep knee bend, just go all the way down to… And then does one feel tighter than the other? And is there a certain pressure? Where? Is there a certain pain or discomfort? More often than not, they’ll just tell me if it’s something obvious like, “I’ve never been able to… ” And then sometimes I have to show them or explain to them the importance of that and then they’ll bring it up ’cause sometimes they won’t… Someone with a shoulder pain, they can’t lift their arm up all the way overhead. And they won’t mention anything, nothing on the medical history or anything they’ve written down in the questionnaire. And then they’ll say at the end of it, “Oh, by the way, yeah, I did have breast cancer, a mastectomy,” or “I did have a breast augmentation, but that has nothing to do with my shoulder.” Well, yes it does! [chuckle]

0:42:12 Dr. Gonzales: Yeah it does.

0:42:13 Dr. Davis Koh DPT: It definitely has something to do with your shoulder, the scar tissue buildup, the surgery itself. So there is a… Just little things like that will help, but if you take any of your shoulder, raise it above your head with your elbow straight, don’t let it bend and see if one is… If feel one is looser, more comfortable then the other, noticeably, that’s fine.

0:42:37 Dr. Gonzales: Oh wait, for the leg? [chuckle]

0:42:39 Dr. Davis Koh DPT: Oh yeah, for the leg. [laughter]

0:42:40 Dr. Gonzales: You got distracted.

0:42:41 Dr. Davis Koh DPT: A deep knee bend. I’ll have them sometimes just straighten out their leg and push on the top, or part of it right above the knee cap. And if there is an over-push in pressure, a little over-pressure, and if there’s any pain or if they notice one stays more bent and it’s harder to straighten out than the other, that might be an easy check.

0:43:06 Dr. Gonzales: It’s a good tip, good tip. So people need to start looking for their asymmetries and report them to their therapist when they go.

0:43:13 Dr. Davis Koh DPT: Oh, the other thing you also wanna do is when you do like even squats or deep squats, turn your feet out, turn your feet in, go straight, just find different angles, lean on one side versus the other side, put your weight on one or the other, and see if there’s a difference that way as well.

0:43:30 Dr. Gonzales: Do you guys use the Trendelenburg test for anything or some type of finding balance for the hip or the ankle or anything like that?

0:43:40 Dr. Davis Koh DPT: Yeah, so we’ll do a quick assessment of just seeing the balance level, so a single leg balance, eyes open, how many seconds, eyes closed. And then take out the vestibular part or the proprioceptive part or the visual part of balance. [chuckle] And just kinda tease out and see what one’s available. And then we also look at the quality of what’s happening as they’re trying to balance on one leg, or what have you. And so we will look into that and then based on what we see on the movement analysis or just the test itself when we go into palpations or ask about any histories of something that may have contributed to help us with the private investigation.

0:44:24 Dr. Gonzales: By the way, I don’t know if everyone knows, so palpation, we’ve said that a couple times. Palpation means touching, so kinda like the way we feel muscles or structures. So, let me ask you, I know that you’re an instructor for Instrument Assisted Soft Tissue Mobilization or IASTM. Gosh it’s hard for me, I think I’m dyslexic. [chuckle] Tell me about that, as well as how you would do, or if there is any certain treatments you do actually in and around the knee to decrease pain, ’cause I know that some people probably tried some of the stuff. What are the top three, four that you like to go to?

0:45:05 Dr. Davis Koh DPT: Okay, so the IASTM instrument is a soft tissue mobilization. For those that haven’t seen it or heard it, it’s using metal instruments with a beveled edge to create, to help break up scar tissue in a tendon, in a ligament, in a muscle, in your connective tissue like fascia, or anything around the nerve. And it’s just another tool that you can use. You can even call a foam roller an instrument assisted soft tissue mobilizer. You can also call some of these massage knobby things, technically an instrument assisted soft tissue mobilizer. You’re mobilizing the soft tissues, and soft tissues are like I said when we mean that the skin, muscle, tendon, ligament, nerves and connective tissue. The one that Sebastian was talking about is a specific set of tools designed to help break up scar tissue. Designed for soft tissue work, specifically. The way I got into it was back over 10 years ago, I heard about from colleagues that I totally respected. One of the colleagues… But these instruments back then, and even now, were about over $3000 so they were quite cost prohibitive. I didn’t know if that was even worth the investment.

0:46:25 Dr. Gonzales: You had to pay that amount just to take their course didn’t you?

0:46:28 Dr. Davis Koh DPT: Oh yeah you have to take a course, so you have to take a level one I think is 750, 600… 750 without the instruments. And then you take another course to be a certified provider, and it’s another about 700, 750. And then, so that’s already about $1500 plus the time of travel and other things. And then you have the right to buy the instruments themselves which are about $3000. So back then that was a big investment for me and so I called up one of my colleagues, the name was Mark File, and if you google him he was the former Athletic Trainer of the Year for the NBA. He was the head trainer for the Chicago Bulls. And when Michael Jordan was playing, during the heyday. And so I called him up and I said, “Hey Marc do you use these tools a lot, I mean these instruments? And he goes, “Oh yeah. All the time.” I go, “Really? Are they really making a difference in your athletes, versus your hands, what we always use?” And he goes, “Let me tell you something, Michael Jordan just called me three weeks ago and he told me that these were the only things that saved his knees throughout his career. So I don’t know what else to tell ya.” And so that kinda, that and a couple other people talking about it, spurred me on to go ahead and make the investment. See if I can bring faster change, better changes, more efficient changes in less time, and in a better way for my patients, outside of what I was already doing.

0:48:00 Dr. Davis Koh DPT: When I went to the Olympic training center in Colorado Springs before the Beijing Olympics, I noticed they had stacks, about 12 stacks of these instruments. And in my experience I have not met, working with Major League Baseball, professional volleyball, NFL, NBA, Division One NCAA, I have yet to have met an athlete in the pro Olympic level who has not… Either has had it done to them or has at least heard about it. There’s not a single person yet that I’ve ever met that said, “What is that? I’ve never heard of that.” It’s not… And if you look, Kobe Bryant’s PT will talk about it, he’s talked about it, Michael Phelps, he’s talked about it, getting it done to him. And so it’s been around for a little over 20 years and it’s growing considerably in popularity, and the thing that I wanna caution people is make sure you go to a certified IASTM provider or practitioner or someone who has taken the courses because there are…

0:49:13 Dr. Davis Koh DPT: These are stainless steel surgical grade, or they should be surgical grade, instruments and they are going to be working on areas of your pain, your tendonitis, your areas of, ideally that have scar tissue and are injured. So you wanna make sure someone is not putting too much pressure, going too long, too hard, too fast, too strong with these instruments ’cause they can cause quite a bit of pain. And in my recent… The last few years… The last seven years I’ve been a contracted expert witness for the US Government and the US Department of Health, testifying in federal court on Medicare and other physical therapy related cases, and I’m also noticing more and more cases of Instrument Assisted Soft Tissue Mobilization practitioners and patients inquiring because they were used by people that weren’t certified. Maybe their boss was certified and they were just using the instruments or they just grabbed some instruments they bought on Amazon and just went to town. And so I’m hearing more and more of these cases as the popularity’s growing within the PT, ATC or athletic trainer, chiropractic community.

0:50:34 Dr. Davis Koh DPT: And so I do wanna caution patients to make sure that you do go to someone that’s a certified provider and make sure the instruments are not plastic or made of bone or cheap aluminum metal because the reason why is the bacteria, the porosity of some of those materials can collect bacteria over time. And you can imagine their scraping on dozens and dozens of patients and then they come to you and so you wanna make sure that things of… That it’s surgical grade, it has a mirrored finish, those things were… At least in that, in terms of cross contamination is covered, but then also make sure that the operator, the guy who’s holding the instrument itself is also well qualified and has the instructions to understand how to use it properly to keep you safe and also to prevent him from, causing, or her, causing more problems to ya.

0:51:29 Dr. Gonzales: With some of the instruments just to… They’ll be some… It’s not bruising, then there’s a… Is there bleeding? Is there a little bit of bleeding?

0:51:39 Dr. Davis Koh DPT: There’s mainly the bruising. So what the… Bruising will heal, forewarn the patients that that is a common phenomenon, the way the instruments and the original patent was on the bevel creating a certain friction over areas of scar tissue, in general. So what will happen is if they go over an area, the operator goes over an area and there’s no scar tissue, it’ll just feel like metal sliding on your skin. And there might be a light… Very, very light pink but almost nothing. The other time is when it goes over scar tissue, number one the patient will also feel like a, “Oh my gosh, that’s it,” and even it’s the same pressure, the same… If they’re going over someone’s lats or muscles or their tricep muscles, and they go over a certain area and it’s nothing and in certain areas it’ll just be super sensitive and they’ll feel that. What may also happen is that that area most likely will have an area of scar tissue contributing to their pain or sensitivity. Scar tissue has very weak blood vessels. The blood vessels within scar tissue are very thin walled, the blood vessels in a healthy muscle tissue for example are thicker walled so when someone…

0:52:57 Dr. Davis Koh DPT: So imagine there’s an area of scar tissue on their thigh, or their thigh muscle and the instruments are going over part of the thigh that has no problems, that’s fine. And then they go to an area where there’s some scar tissue, where there may have been damage, a strain or a mild tear and that’s causing their pain in their quads, then the scar tissue over that area will be the one that’s sensitive. The scar tissue, as you’re breaking it up, has a thinner walled blood vessel so they will break easier as it’s being… Having a friction massage through the instruments. And so that will create a phenomena called petechia and that phenomena will look like a bruising, a hickey or what have you, [laughter] Depending on the patient’s skin tone or color. And you just wanna be cognizant of that, tell them it’s not unusual and they’ll be also… Some of the other things that they’ll notice is a tenderness to touch, to the skin. And so you just remind them, if it’s tender to touch in the next few days versus tender, to movement.

0:54:00 Dr. Davis Koh DPT: If it’s just tender to the touch, like, “Oh I put on my slim fit shirt and it’s really sensitive,” or something. Or their skinny fit jeans and it’s rubbing on that thigh that you just worked on, yeah, they’ll have tenderness. But not to worry about the tenderness. It’s like, and I’ll ask patients, “Well are you moving better? Is it less… ” “Yeah, it’s less painful when I move but it’s really tender, where… ” Yeah, tender to touch is no problem. Tender to movement is the problem. So I will tell them to make sure you understand the difference. And eventually, some of these other Olympic athletes are pro-athletes, you do build up a tolerance over time so it’s not as big of a deal, or they know the game and they’re much more aware of that. But again, that does lead to, if you haven’t gone through courses, haven’t done to themselves, the person, the doctor, having it done to themselves, getting feedback, getting the learning and the education and who to avoid doing it and where to avoid doing it. So not every area is ideal for this Instrument Assisted Soft Tissue Mobilization Technique. If they don’t have that understanding or learning, then they can be putting somebody or an area that they shouldn’t be at, at all, at risk.

0:55:13 Dr. Gonzales: So how would we find someone who is certified?

0:55:17 Dr. Davis Koh DPT: Okay. So there’s different… There’s different websites. There’s one… I think there’s called IASTMexpert.com. There’s also… Certain brands will have their own educational component. One is Fibroblaster.com. There are some other ones like Graston.com and so you can look at these other groups. Look at what their learning… The courses entail. Look at they even require courses. The ones that really don’t require courses, they’re just kinda selling it to anyone and anybody regardless of if they’re even a health licensed practitioner, you might wanna shy away from. You also wanna shy away from places that don’t have any educational components ’cause they haven’t vetted that through. So that’s another red flag. You also wanna look at… You can ask, inquire, if you’re looking at certain instruments if you’re a practitioner, but if you’re a patient, what is the materials that they’re using? And there is a different reason why some materials or some instruments are only 50 bucks on Amazon and some of them are $3,000. And there’s reasons why.

0:56:25 Dr. Davis Koh DPT: So the first thing I got certified in was Graston because the Graston technique was the first company to have a patent on this type of technology in using these surgical grade steel instruments for the purpose of soft tissue mobilization treatments. And since their patent expired, about 50 or 60 different companies blew up. It’s international. When I go traveling with the different Olympic teams for world championships, or what have you, they… Team Finland, team Netherlands, team Russia, they all have… Team Great Britain have Instrument Assisted Soft Tissue Mobilization instruments that they use. So it’s not only national but it’s international.

0:57:12 Dr. Davis Koh DPT: So I don’t want people to think it’s just something new that is out there just the last few years. It’s been around for over 20 years. But as one of my friends who’s a professor at University of Miami Physical Therapy School and at U of C said that by the time anything cutting-edge has gone through its full body of work and research and studies, it’s already 30 years too old. So there is an importance of having the research and making sure we understand its place and its effectiveness within the healthcare community. But also, some of these things that you see, you don’t want something that’s only a year or two old. But you do want something that’s proved itself over the test of time. And again, these instruments have been around for about 20 years and it’s only grown in popularity, and that’s why professional athletes who are worth over 100, 200 million dollars are willing to go through those type of treatments which are not always pleasant.

0:58:17 Dr. Gonzales: Yeah I’m sure. [laughter]

0:58:18 Dr. Davis Koh DPT: Yeah. And so, they’re willing to do that. And there’s other… And that may come about. And I’m seeing more and more invitations to speak at different physical therapy schools and chiropractic colleges, actually on Instrument Assisted Soft Tissue Mobilization, and it’s coming into the academia. More, and more, and more, and more research is coming out, so I’m excited to see more about that.

0:58:44 Dr. Gonzales: I thought it was funny when I went through school… Actually, our physiotherapy class, I think we had… We had diathermy’s in there. I’ve never seen a diathermy in real life other than school. So you’re right, the stuff that they seem to teach are… They’re borderline archaic and then, I think, they’re just barely now teaching how movement’s important, and instrument assisted, and so it’s funny they have to get all that education later after they get out of school a lot of times.

0:59:13 Dr. Davis Koh DPT: Right. And again, I don’t wanna poo poo people in academic or poo poo evidence-based research. It’s an important necessity. We wanna know what certain instruments or certain modalities like an ultrasound or a diathermy machine does for the patient and its proper place, and what it’s actually doing. So that’s all very, very important. But you can’t be cutting edge and completely… It just doesn’t work that way and so that’s why you’ll notice a lot of other things like PRP injections, which are now very popular. That was in Europe and Canada, and other places outside of the US because of the FDA and other things. That was already going on and that’s why Kobe Bryant and all of these people would travel to Germany to find these people that have been doing it for a lot longer than some of the people here in the United States. So that’s just an example of something that’s cutting edge that’s trying to gain headway now. It’s in many, many well qualified surgeons in the US and other practitioners, osteopaths or what have you, are performing PRP and stem cell injections.

1:00:26 Dr. Gonzales: Yeah. It takes… I still have a lot of patients now that I’ve kind of like dropped a little bit of, “Hey have you heard of this? Have you heard of that?” and they’re like, “No, never.” I’m like, “Really?” It’s kind of older now. Actually I did a podcast about probably about five to six sessions ago with a stem cell doctor. It was enlightening. Actually I went to his office and saw that, all the procedures and everything. I’d never seen it all in person but it was interesting.

1:00:54 Dr. Davis Koh DPT: Yeah. Yeah, and even that there’s all details about how they collect the growth factors from the platelet rich plasma for the period. So again it’s not about finding the bargain basement price. There are certain issues of how they’re collecting it, who’s been doing it, how long they’ve been doing it. That makes a difference so it’s good to do the research.

1:01:20 Dr. Gonzales: Mm hmm. We’re coming up on I think we’re about 50 minutes. This might be the second-longest podcast yet. Is there anything you would like to finish with? Or I know that we gotta figure out how to reach you in your office, and…

1:01:32 Dr. Davis Koh DPT: Yeah, well, I have two locations in Tustin and Irvine. Irvine is our main location. It’s in the Irvine Spectrum area for people who live in Orange County and…

1:01:46 Dr. Gonzales: California by the way. [chuckle]

1:01:47 Dr. Davis Koh DPT: California. And you can go to the website www.kohpt.com and it also has some information on some of the things that we did talk about and some of the techniques being utilized including IASTM to give you some background information, but again I encourage the research, knowing what you’re getting into, understanding the problems, but also appreciate that there’re many different ways to treat and also getting as many different ways that are tried and true is nice because your hands may not be as good as the instruments for a particular problem for a particular patient and vice versa. But having the option to is nice and then also to be open to hearing some other possibilities beyond what maybe internet search or from what you’ve heard from other people to appreciate the individuality of your own meniscus injury or your knee pain and to appreciate that as well. That every person is gonna be a little bit different with the exact same diagnosis, exact same surgery, or exact same pain will have different unique aspects and causes and to embrace your individuality and make sure the practitioner embraces your individuality and doesn’t put you on some recipe that’s good for anybody.

1:03:15 Dr. Gonzales: And also the recap, look for the sniper not the bullet hole.

1:03:19 Dr. Davis Koh DPT: Yeah. Exactly. Don’t look at the victim. Look at who’s shooting the victim.

1:03:23 Dr. Gonzales: [chuckle] Well, cool. Thanks for coming on. I know that you’re a busy, busy guy, and it’s hard to get you when you’re in town, but thanks for coming on. I’ll close the podcast now.

1:03:32 Dr. Davis Koh DPT: I appreciate it.

1:03:33 Dr. Gonzales: Well, cool, so everybody, again, if you would like to get a hold of Dr. Koh, his website is three “W’s” and K-O-H-P-T dot com. Again, if you want to reach me at all and ask questions or suggest providers that you’d like me to interview and ask the questions that you might not have gotten to at your doctor’s appointment, just go to P2, that’s “P” the letter, “2” the number, sportscare.com and I will answer any questions you have. There is a button right there on the page which is a voice mail button. You don’t need a phone. You don’t need anything, just speak right to your computer. Send it and I will get it and answer the best ones. So again, p2sportscare.com don’t forget to subscribe and share with your friends. It helps me out a ton and please if you would write me a comment on iTunes it would be absolutely amazing, so I will speak with you guys soon and have a good one.

Podcast About Knee Rehab Options

This is Session #32 of Performance Place Sports Care Podcast. Hope you’re ready!

Welcome to the Performance Place Sports Care Podcast where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn’t understand at your appointment, and now your host, Dr. Sebastian Gonzales.

Hey everyone! It’s Dr. Sebastian Gonzales from the Performance Place Sports Care Podcast again. Today, we’re going to get some really boring information sadly. It’s going to be just me on the podcast today and we are going to go over some of the anatomy of the knee.

The reason why it’s so boring is basically I am going to give you a little bit of a terminology lesson and a little bit of biomechanics. Biomechanics, if you don’t know what that is, it’s how the joint really moves when we move or how we use it in real life.

This is a really critical podcast because if you’ve heard some of the other ones where I’ve talked to the experts, I think I really need to do everyone the service and lay a good foundation of terminology, because basically, some of these experts come on, (especially the one with the knee that’s going to come on) might use some terminology you don’t understand. To really get the most out of what they are saying, I think we need to go a little bit into the terminology, so hang in there tight for this one. If you need to listen to it a couple of times to digest it, it’s totally understandable, but this is what it is.

We’ve sat through (people who do sports medicine) classes upon classes of terminology like this, so it is a different language, and I totally understand that. The general public and athletes use another type of language to describe the same thing that we’re trying to describe as well. So I’m going to try and match those things up today. If you have a knee condition, this is a must listen to podcast, as well as the one to follow it because learning how the knee works, as well as the parts will help you understand the reason why you’re doing certain types of rehab. This is foundational. I think I’m going to put together … just call it the foundational podcast, and this is going to be the boring stuff and just me, so hang in there tight and let’s do it.

So the knee, I’m going to break into a few different parts. We are going to first talk about bones, then joints, muscles, cartilage, ligaments, tendons. I’m going to repeat those again, so bones, if you don’t know what a bone is, it’s the hard area of your body. When you basically die, at some point, all of your softer tissues melt away and all there is, is a skeleton, so the skeleton is all the bones. Where the bones come together, they make joints.

Now the areas that you don’t see on the skeleton are the ligaments, the cartilage, the tendons. You might see some of this if the body is really fresh, but the muscles are … If you think about the bicep or the quad; these are muscles. They are the flesh of the animal. They are what you’re going to eat if you eat a cow, pig, most of the time, and even some fat in there too, but for the most part, anything that is red and striated and feels like a steak, it’s going to be muscle.

The ligaments are attached to the muscles. They are extensions of muscles. They are basically the same complex, so we’re not going to go too much into tendons today, but I will name some off, but there are some tendons that are actually tendons of multiple muscles, so it is a little bit of a complex too. Ligaments attach bone to bone to formulate that joint right there.

Cartilage is a unique structure. It is kind of gummy sometimes, and sometimes it’s kind of smooth. There are different types of cartilage, but the cartilages of the knee are really, really important, and the one you’ve probably heard about is the meniscus, but we’ll go into this in a second.

Let’s start with the bones. So the first one, the big one that comes down from your hip, is called the femur. A lot of you will call it the thigh bone, and again, that’s the femur (the thigh bone). The next one, which is below the knee (the big one), the one if you bash your leg or your shin into something and it started to hurt, it’s probably going to be this bone, your shinbone, which is also known as the tibia. Now there’s one more bone down there on that section of the leg, by the way, that’s technically called the leg. Above that where the thigh bone is, is actually called the thigh, you know the thigh bone, that makes complete sense to me. So below that, down there where the tibia or shin bone is at, there is one more on the outer side. If you run your hand along the side of the knee, it’s going to feel like this little bony area popping up. It’s really prominent and that’s part of a long bone called the fibula, and lastly, we have the kneecap on the knee, which is technically called the patella.

As all these parts come together, the joint names (I know the collective joint is called the knee), but they actually have where the femur attaches to the tibia is called one joint, and where the tibia attaches to the fibula, that’s called another joint. So where the bottom part of the leg, or the tibia, or the shin bone, attaches to the thigh bone that is called the tibiofemoral joint. We are basically just blending those two technical words together. Tibio (or tibia) tibiofemoral joint.

So you will see this a lot in literature, and if you guys choose to do some of your research on how to rehab knees or what the injuries are and so on, you’re going to see all these terms everywhere and it will be super confusing, so …

The next joint, which is also called a syndesmosis, so it’s a little different type of joint than the other ones. I won’t go into what a syndesmosis is, but just know that when you read it in literature, it’s a style of a joint, kind of like a ball and socket is a style of a joint as well. Now this one is where the shin bone attaches to the one on the side, which is the fibula. By the way, the fibula, I guess I heard it called the calf bone; I’ve never heard that before at all. This is where the shin bone attaches to the calf bone, and it’s where the tibia attaches to the fibula, so it’s called the tibiofibular joint (tibia-fibula joint).

Next, we have where the actual thigh bone attaches underneath the kneecap. So if you all don’t remember what the kneecap is called, it’s called the patella. This joint is where the patella (kneecap) contacts the femur (or thigh bone), so it’s called the patellofemoral joint. That’s it for the joints and that’s all for the knees. That was probably the most boring of all the stuff right there, because some of the technical names for the bones people don’t know and especially combining them.

I remember going through ankle anatomy and had all these ligaments that were named after the tarsal bones that it connected to or from, and sometimes it was one bone first, and then you go to another one, and it’s the other bone first; it was really, really odd. I don’t know why they named it like that, but now we’re past that.

Muscles: In reality, the knee is affected by muscles actually that don’t even touch it as well. The reason why I say that is because in this section, I’m going to classify them as muscles that are above the kneecap, they go all the way into the hip, as well as in the direct vicinity of the knee joint, and I’m going to talk about the ones that are below the knee joint, which go into ankle anatomy.

Now, we really can’t separate these at all. Like this is just the way it is. These muscles that go up to the hip and go up to the ankle, they do affect the knee. The ones that are above the kneecap, which go all the way to the hip musculature are … you might know some generically as the quad. The quad muscle is actually the vastus lateralis, vastus medialis, the intermedius, and rectus femoris. By the way, the rectus femoris is the only one that attaches above the hip.

The next ones we have are the hamstrings. There are four in the back. There are only three that pass the hip joint. There is one that stays locally around the knee. These ones are the semimembranosus, the semitendinosus, the biceps femoris long head, and the one that really stays locally around the knee and doesn’t go up into the hip is called the biceps femoris short head.

Now we’re going to the inner part of the thigh, and this is the “adductor group” which you probably know it as. The adductor magnus is one of the large ones. The adductor longus is another one. Then we have gracilis and sartorius. I’m going to name those one more time: adductor magnus, adductor longus, gracilis, and sartorius.

Lastly, I know there are muscles on the side of the thigh into the hip as well. The one you probably think of all the time is going to be the IT band, but realistically, the IT band is not a muscle at all. Muscles attach to it. It does function in some knee stabilization, but it really doesn’t contract. It’s just a hard dense structure. It’s almost like the plantar fascia or some dense structures in the body which really stretch and bend. So, the iliotibial band is right there, but if you’re holding the side of your thigh and you’re thinking, “Yeah, there’s muscle there.” Yeah, there sure is, but that’s actually the vastus lateralis and it’s a section of the quad that just extends so far to the side that if you look on a really strong person and you see their leg and see them flex, it will be part of the quad, so it will make complete sense when you see that.

Muscles into the direct vicinity of the knee, which you already know, one is the popliteus. It is actually important in regards to locking and unlocking the knee, which is called the screw hole mechanism, which we will talk about a little bit later. The other one is called the articularis genu. I don’t hear a lot of references on it. I do know there are some treatment protocols for these muscles. They are not as commonly found in research, as well as Google searches as the other terms would be.

Okay, so just to recap before we go below the knee: There are muscles above the knee; we have the quad group, the hamstring group, the adductors, and the IT band. Then the ones directly locally at the knee in the direct vicinity are the popliteus, the articulars, genu (I’m not sure how we say it as I’ve heard it said many different ways).

Next, we have muscles below the knee and this is going into ankle anatomy again. I will say the one you probably know first, the calf on the back side is actually known as the gastrocnemius lateral and medial head. These are the ones that present like a ball. So when you see someone with really massive calves, like that big ball formation on the back of the calf, that’s the gastrocnemius.

The one deeper to that called the soleus is actually a flatter muscle. It is for different purposes, but both of those blend into the Achilles tendon, which then will go into the ankle anatomy as well.

Then we have one of the accessory “calf” muscles called plantaris. Yes, there are other muscles which are made up of ankle anatomy and there are some on the front side of the shin, but those actually don’t cross the knee, so I’m not going to talk about them in this podcast.

Other muscles you need to be familiar with if you’re going to be talking about knees are some of the hip. I know this is going a little bit further than you probably want to, but it’s too bad, you can fast forward a little bit (about a minute) and I’ll be through it all, but these are the muscles that are important. When you listen to the next podcast, you’re going to realize how important the hip and the trunk are to knee function and actually the ankle as well, so you might as well be super familiar with these as well.

The first one is called the iliopsoas or what you’d call the hip flexor (iliopsoas). Some of you know it as the psoas muscle. Then, the rectus femoris, which is on the front side, and we did talk about that in the quad group. Then, there’s the hamstrings again, part of hip anatomy, as well as knee anatomy. Then we have the gluteal muscles; the glute medius, glute max, all those are super important as well. Those are on the back side; they’re basically the buttocks on people. The tensor fascia lata or the TFL attaches to the IT band on the front side, and the iliotibial band actually starts up at the hip and it is controlled by some of the gluteal muscles as well, but it’s right up there on the side of the hip.

On the back side, deeper than the gluteal muscles: we have some of the rotators, piriformis muscle, the other one is called the gemellus, the obturator, and quadratus femoris. These are ones you probably won’t hear too much about, but I always consider them the rotator cuff of the hip. They do some small stabilizing motions and they do get injured from time to time.

On the front side, we have one kind of similar called the pectineus (it’s a small one up inside the groin). If you put your fingers across your hip, thumb behind and your index finger and middle finger will start to descend toward the groin area, you will be right in and around the area of the pectineus, especially when you’re seated.

Now, we have the adductor group as well; the adductor longus, magnus, and brevis. I think you’re starting to see these terms are seeming to repeat (longus, brevis, and so on). Then, we have the sartorius, the gracilis, and those are also part of the adductor group, which I noted in the other part of the knee description.

Lastly, we are going to go into muscles of the trunk. The reason why I am talking about muscles of the trunk is because trunk stabilization is extremely important. There is different terminology that people use to explain how to properly stabilize and how the trunk functions. Some of it incorporates breathing. Some people call it postural stabilization. Some people call it midline stabilization, core strength, trunk control, I mean it goes on, and on, and on, but for the most part, you have to understand that the trunk controls the pelvis; the pelvis controls the hip; the hip controls the knee, and then this is why we’re talking about this whole thing.

So the muscles you will hear in regards to core stuff (or the internal and external obliques) that are on the sides. They do wrap around more toward the six-pack muscle called the rectus abdominis. Actually a lot of these muscles of the trunk come in layers and they are kind of in the same area. The transverse abdominis or TA, you will see it a lot in research, is below those internal and external obliques. Then we have muscles in the back side, which are also known as core muscles called the QL or quadratus lumborum, the multifidus, the paraspinous, and lumbosacral fascia, which are all on the back side there.

Now other muscles, obviously they are blending into the hip, as well as moving up the chain, but the other ones to know and are extremely important in regards to core stabilization are the latissimus dorsi, which also go to the shoulder, as well as the diaphragm and gluteal muscles. So let’s not forget about all that stuff.

By the way, if you guys do have questions on some of these areas for the core, I have an article on my site called 14 Secrets to Back Pain Your Mother Never Told You, I believe #3 goes into a lot of this in isolation, without considering the knee. So if you want to learn about intra-abdominal pressure, as well as proper breathing patterns and some things you can do to improve on that, if you’re looking to do that already and if you have knee conditions, then this is something you’re going to want to read.

We are going to go into cartilages next, but before I do, I just want to let you know that if you do have a knee condition, you need to go see somebody and the reason why I say this is because when you go into the next podcast, you’re going to hear that doing the right rehab is extremely important. The term that we use, or this expert is going to use, is called “earning your surgery”. Knowing the right rehab and doing it for a period of time is earning your surgery. A lot of times, you’ll come out much better from the surgery after the fact, if you need it in the first place, but you have to put the time and it all starts here.

Now, cartilages of the knee–There are two you have to be familiar with. The meniscus is one. This is the one that is C-shaped and it’s on the inner and outer part of the knee. If you look at the anatomy, and actually I will have as I don’t have it yet, but we’re going to have a whole knee section, knee anatomy, on the website. So click on the knee on one of the people about your injury and you’re going to see that all the stuff is going to show pictures, so you should probably listen to this podcast while you’re looking at that article as well. I should’ve started with that, huh?

Anyway, we have meniscus (lateral and medial) and we have the articular cartilage which is on the femur head, as well as the tibia. The ligaments of the knee are ones that you’ve probably heard about as well, especially the major one called the ACL or the anterior cruciate ligament. Then we have the posterior cruciate ligament, which is kind of the same thing, but going in the opposite direction. We have the lateral collateral ligament and the medial collateral ligament or MCL, LCL. By the way, the ACL was the anterior one and PCL is the posterior one. Those are the major four. There are a bunch more, which include ones that make up the capsule of the knee.

Think of wrapping your knee in an Ace bandage and just wrapping it, wrapping it, wrapping it, and that’s kind of how the capsule of the knee is, but it’s made up of all these different fibers of the Ace bandage in all these different directions to stabilize against different types of motion. So those are the big four. The other ones I wouldn’t get too concerned about because they’re going to get way more complex than you’re ever going to want to know. This is a good starter course.

Knee anatomy does include tendons. Like I said before, tendons are extensions of muscles and it’s basically a complex. Tendons attach the muscle to the bone, which then allows that muscle and tendon complex to move the joint. The quadriceps tendon is an example. There are four muscles, which we noted before, which then combine to form the quad tendon. The quad muscles become the quad tendon. The quad tendon then attaches to the kneecap or the patella. Then there is another tendon which comes off this. By the way, the patella is a sesamoid bone, which is almost like a floating piece in a tendon, it’s a floating bone in a tendon. So, this tendon is almost the same as a quad tendon, but now it goes even further and now it’s called the patellar tendon. I mean crazy, right? Like you have the same type of structure, which is called a couple of different things, but just know that they are extensions of the muscle. So when you have an issue with the tendon, a lot of times, you have an issue with the muscle. When you have an issue with the muscle, you usually have issue with a movement, or there’s been something which occurs which creates that complex to become symptomatic or painful. This goes along with some of the other types of conditions too of cartilage and so on. I will explain the reasons why here when we go into mechanics.

A couple of different terms that we need to be familiar with that you’re going to hear are flexibility, mobility, and stability. I’m not going to spend a ton of time on these things, because I feel like the definitions are changing a little bit, especially over the last four to five years.

Flexibility, for the most part, I would consider how far you can move a joint without the supporting muscles or the muscles around there even being on. Imagine that you’re lying on a track and one of your teammates comes up to you and they ask if you need help stretching your hip? Yeah, sure. So they put your foot in the air. They lock your knee out and they stretch your hamstring beyond belief and it’s further than what you feel like you can do on your own, so that’s passive–that’s someone else doing the work and that range of motion you attain is your flexibility.

Now when we go into mobility. I mean it sounds like a similar thing and to kind of play devil’s advocate with this, since there is so much different terminology flying around now with it, I wanted to see what most of the Google searches are actually pulling up. I found some really extreme ones or large ones. One was by Kelly Starrett of Mobility WOD, which was a really long complex statement (by the way, you can look that one up if you like). I thought it was a good explanation, but then I found some really simple ones, which were basically the range of motion that you have when your muscles and tendons are contracted or when you’re doing it yourself. So I’m not going to say which ones of those I agree with more, but for the most part, I think I have the responsibility to explain a little bit.

I am going to go one step further and tell you, at least, my thought on the range of motion in flexibility or whatever, we’re going to call it from now on is that, for the most part, if you’re going to attain a certain range of motion or “flexibility” you have the responsibility to control it. If you can’t control the motion that you have, then you are prime for an injury … just prime for an injury.

I’m all about keeping people within The Bell Curve, the normal range of motion that you need to accomplish a motion. An example of that is let’s just talk about the shoulder here. If I can reach my arm over my head 180 degrees and I can control it, that’s great, that’s all I need, because all I need to do is get my arm overhead and reach and grab something off the fridge. That is the purpose that we’re using it for in this case. Now, do I need to have my arm being able to dislocate and go beyond 180 degrees and be able to put suntan lotion on obscure portions of my back to then do that same motion, to do that same purpose to reach on top of a fridge? No, I don’t, but if you do have that extreme range of motion, you darn well better be able to control it too. Because if it’s just that motion that someone else can stretch you into like Gumby and like a contortionist they kind of move themselves, but let’s just say someone else is moving you and you’re a contortionist, that’s a little bit of range of motion that’s just a high risk of injury.

My definition of mobility is going to more go around that it has to be controllable range of motion that allows quality motion or patterning to accomplish the movement pattern that we’re trying to do. An example, if we’re talking about lifting, being able to deadlift from the ground or remaining deadlift requires a certain amount of hamstring flexibility. If you can’t do it, then you have to work from a higher starting position such as blocks. Now, you need to make sure if you’re going to go from the ground that you have proper hamstring motion or hip range of motion and flexion, as we call it, because if you don’t, then it will create rounding of the back and that’s not going to be wanted on something like a deadlift. My go-to is that we need to make sure that we have a controllable range of motion that allows for that movement pattern that we’re looking for. That’s my standpoint on mobility, at least at this point, and I’m sure it will change over a couple of years.

Stability is the ability to resist a position or to be able to resist something or someone changing your position. Now, probably a good example of this is if we’re talking about squatting. If with weight, you’re able to do a proper squat (the knees are stacked over the feet, you’re not caving or anything like that) and also we put some weight upon you and we start diving around and caving inward and so on–that’s not good stability. I always think about a drunk test on this.

Ideally, we want to be walking on the line when you’re getting tested. If you fail the test, you would come off the line in some degree or fashion. Now if you think about how far you can walk that line. Let’s just say you took a step off, like a slight step maybe 6 inches, and then I controlled along that path of the line, that would be pretty good stability in my opinion.

Now, if I was following that path and I fell off the line and had to get back up and about a foot off it, and then I went back to the line and I fell off the other way, that undulation of stabilization I think is terrible, absolutely terrible. So it doesn’t matter if I finish at the end of the line or not on the line, it’s how I get there and how far I deviate from the path that’s intended.

Imagine that again. Close your eyes and sit there and think about that drunk test line. How are you going to pass? Are you going to pass by falling all over, hanging onto the cop, getting to the other end and say, “I did it,” or are you going to make sure you only deviate slightly from the line? In that case, if you deviate slightly from the line, you’re less probable of getting injured and that is better stability.

Now we’re going to go into the mechanics of the knee and how it works with a couple of different analogies, but first off, you’re probably wondering how you stop having injuries in the first place or how you limit injuries of the knee. I would say that first off you have to make sure you have high quality of motion. You have to have proper training volumes in intensities. An example of that is let’s just say you’re running. If you usually run and your volume is 30 miles a week, and then all of a sudden, you jump it up to 60 miles a week, that’s double the jump, that’s kind of irresponsible and you’re looking for an injury versus the intensities of some of those training days, let’s say you’d be normally doing, gosh what’s some easy math here … say about 3 days a week, 10 miles a day, and that is your 30-miles-a-week volume. What happens if one day you’re like, “I’m going to be busy the next couple of days, so why don’t I just do 30 miles today all in one spurt?” So that’s a three times jump in intensity or distance and that’s a little irresponsible too. These are things you have to consider as well.

You have to have proper training volumes, as well as jumps in intensity when you’re doing different things and this comes to squatting, as well as golf, baseball, and all these different things.

Lastly, you need to make sure you act your age. The age difference on recovery is pretty significant. I remember being in my early 20s and being able to just go out and do sprints and the next day, you’re a little sore, but like now, being like 35, I kind of pay the price a little bit. Although, I’m pretty active during the week when I play baseball on Sunday, the next Monday, God, I can’t move! You know just like stealing a couple of bases and running after balls, I mean it’s much less activity than what I usually do during the week, but the intensity is different. So the recovery is different too based upon my age.

So the mechanics of the knee that we’re going to go into is first we are going to go into the concept of open versus closed chain mechanics. Next, we’re going to go into my analogy (and I tell this to a lot of patients) I actually take two foam rollers and I stack them together and I call it the cylinder stacking analogy. I don’t think this is a technical analogy that a lot of other people use, but it seems like it works very well in understanding how the knee works to me and my patients. Next, is the door hinge analogy and then we have a little bit about the screw hole mechanism and I think that’s all we’re going to go into and then I’ll just talk about the meniscus slightly.

First off, we have open versus closed chain mechanics. Open chain basically means your foot is off the ground. By the way, the chain is the kinetics chain in case you have heard that term before. It’s basically how the linkage of your body, extremity, or leg and trunk, work. I don’t know how they come up with the term “kinetics chain” but for the most part, we can leave the kinetics part out and think “open and closed.”

Open chain–foot is not on the ground so you don’t have the ability to push off the ground for anything. Closed chain is the exact opposite–you have your foot on the ground and you’re able to push off, so it changes the ways things move.

Let me ask you this then, so just think about it. What muscle actually extends the knee when you are performing a seated knee extension machine at the gym? So you’re sitting there, let’s think about this, the knee is floating, the foot is floating, and you’re extending the foot into the air. This is actually the quad group which does this and this is why people do this machine because they want to enhance the size of their quads. There’s nothing wrong with that in my opinion. It’s just a means to an end if you’re looking to increase the size of something then definitely doing a quad machine or joint-specific activity or exercise will do it for you.

But now let’s think about that same joint. Let’s think about that knee. Which muscle group actually extends the knee when you’re running? Probably some of you are thinking this is still the quad group, but it’s actually not. It is actually the movement of hip into extension. This comes from the hip extenders, the glut max, as well as the hamstrings. I know it sounds ridiculous to think that, but if you stand up … if everyone stood up and then put that foot on the ground and they kind of propel themselves slowly over that, they’re going to see that the extension of their hip relatively extends the knee.

When I first learned this, it was mind blowing because it made me think about rehab and how we should rehab a knee realistically to get people back to the activity they want. If they want to only do quad exercises and they want to work on muscle growth, by all means, that’s no problem. Like they may never do closed-chain exercise; they might not run, jump, cleans, squatting, they might not do any of that stuff, which is perfectly fine. It’s not for everybody. But if the job is to get you back to doing what you want to do, then I think we need to rehab it in that way too. We’d probably start with a lighter load and we go from the concept of proximal stabilization to distal motion. Let me explain that for a second.

So stabilization, we talked about that concept before–it’s being able to hold something in the desired position or path that you want it to. Proximal, in relationship to the body, is actually closer to your center. Distal means further away from your center. If we’re talking about a leg, the knee is more proximal than the ankle is. The hip is also more proximal than the ankle is because it’s closer to the center of your body.

Now, like I said, the knee is more proximal than the ankle is, but the knee is more distal than the hip is because the knee is further away. So you want to make sure everything closer to your body, your core, your pelvis, your hips, your knees are stable before you got to that ankle say. The same thing happens with rehabbing knees–we want to make sure that the core in breathing patterns, intra-abdominal pressure, hip, pelvis, muscles of the thigh are all working well before you really get down to the knee too much.

Obviously, there is an art to programming a program for the knee. There are specific things you want to do locally right there to the knee in the beginning to increase range of motion and increase a little bit of function, but we have to consider why this happened in the first place.

The majority of the knee conditions don’t happen from trauma, slip and falls, someone sliding into you. A lot of them happen from just nothing at all it seems like; although, you might say, “Well, a 10-mile run wasn’t nothing at all.” But realistically if you look back, you can probably see this thing happening and starting over time. There was not one specific run (I doubt … there could be, you could prove me wrong) but the majority of the time, it’s not, and you have to look at why this injury happened in the first place.

Remember that concept of proximal stabilization to distal motion. We have to make sure that we stabilize closer to the midline first if we’re going to be responsible at getting that whole leg working.

Now back on the concept of open versus closed chain mechanics. I originally said that the knee is extended open chain with the quad, as well as closed chain with the hamstrings and hip extenders, and just remember that.

When we’re strengthening the knee, we also to have to strengthen the hip, we have to strengthen the core, and I’m being very general with the term “strengthen” by the way, let’s just say improve function, and also the foot and ankle. The knee is right in the center and it takes brunt force of a lot of things there.

The next analogy I want to go through is the cylinder stacking analogy. Usually what I do is I take two cylinders and I put one on top of each other. If you don’t know what the cylinder is, just think of a Coke can, and you can actually take two soda cans and do this probably, and you could do this right now. These cans stack really, really well when they’re in the right position and they’re really strong and you could probably make a coffee table out of soda cans, especially ones that aren’t open and just stack them there–make the legs, make it three or four times as high, and as long as you don’t push it off from the side, it’s going to be fine. You could probably sit on the table I bet. Gosh … just don’t wiggle around too much.

But basically, when these cylinders are in the right position, they’re really, really strong and they could be stacked into position and that’s why I call it the cylinder stacking analogy, but when they’re off, even a little bit … I mean consider sitting on that coffee table if one of your friends is playing a joke and he barely kicks a leg, and all of a sudden, the whole thing comes crumbling down and it degrades really fast. The knee is kind of like this. You need to make sure it is stacking well and in a proper position.

The analogy of the columns originally came from the cylinder bones above and below, and the femur (or thigh bone) is a long cylinder. It obviously has butt ends at both ends of it, as well as they make up different types of joints where they connect with other bones, but the tibia is kind of the same way too. It’s just a cylinder, it’s a long bone. They are really good at controlling or taking downward pressure, and I think that’s why the body was designed this way because these cylinders are great at controlling the force of gravity downward, but it’s our responsibility to keep these cylinders stacked.

Now I know the knee is more complex than that, and just for all the other healthcare providers out there, just realize that I’m trying to make this easy for everyone to understand. Yes, there is a lot more going on and there’s a lot more to that knee joint and the other joints around it that can tear this analogy apart, but for the most part, we’re talking about how to stack properly against gravity there.

Now the next analogy I’ve used a lot is the door hinge analogy. The reason why I started thinking about this in the first place is because the knee is actually (by categorization) is called a hinge joint. It only likes really one direction of motion. It tolerates the other ones a little bit, so it likes to be extended and flexed. It does really well on those motions; it does it really, really well. I mean there’s a ton of range of motion into flexion. You can actually touch your heel to your butt if you have complete range of motion of the knee, but it doesn’t like rotation and lateral bend too much. By the way, I realize there is some rotation in the knee. We’re going to cover that in the next section, which is going to be the screw hole mechanism, but for the most part, too much rotation (by the way, it doesn’t take a lot) … too much rotation in lateral bend, then we’re basically creating those cylinders to break apart.

The reason why I like the door hinge analogy is because let’s just say you took a door and you had to put a new hinge upon it because the old one was really, really rusty and grimey and stuff, so just shut your eyes and imagine this door analogy. We got a brand new door, we got a brand new hinge, brand new frame–everything about it is perfect. The drywall is nice. We have a nice stained finished wood, maybe even some glass inside it so you can see outside, in case the doorbell rang and you want to see who it is, right?

Now imagine this perfect door, perfect hinge, on this old, rotten wood plank. This wood plank can be as wavy as the swells of the ocean (you know like you’re waiting for surf and you get these ups and downs, and undulations). So in this house, where we put this brand new door, hinge, frame, wall, and glass, and everything, we have this really terrible floor, which has been weathered and wavy around. When we shut this door, or actually I should say when you put in on, it has tons of clearance and it doesn’t hit anywhere, it doesn’t hit the ground, but also now, we’re shutting it and it goes donk, donk … it hits the waves here and there.

What happens there is when you press that door shut, the pressure actually goes onto the hinge. I mean the door itself is pretty strong, but it kind of wiggles that hinge and that’s what is going to wear this hinge over time. The knee is a hinge joint.

So this wave analogy or the door hitting the waves is pretty analogous to subjecting the knee to rotation and lateral bend over and over again. For you runners out there, or repetitive motion athletes (cyclists), these are the types of things that are going to get you. So the way you control this wavy floor, in this analogy anyway, there’s a lot of things that can cause it: poor core function, poor hip strength and endurance, poor ankle mobility from maybe an old injury, maybe hip impingement that you’ve had for multiple, multiple years, maybe an old hip surgery, maybe you had an old injury from way back when that’s never really 100% went away, or perhaps you stubbed your toe years ago and couldn’t run on it and had poor running mechanics, poor shoes; I mean the list can go on and on and on. For the most part, it’s our responsibility if we’re going to decrease the possibility of knee injuries, we need to address the reasons why the hinge is going to rot away anyway.

Now, the more technical of the local knee mechanics is called the screw hole mechanism, and I’m really going to try to make this super easy for you guys because it is … I remember when I was in school and I’m like, “Gosh, is this really that important?” But the screw hole mechanism is a great example of how the body mechanics change again versus open and closed chain, so it’s based upon which point is being fixed.

If we’re open chain and the foot is not on the ground, the contact point or the thing which is fixed is going to be the femur. Let’s say as if we’re doing that knee extension machine, the femur or the butt, the entire thigh, is fixated on the machine, the tibia or the foot is free floating. Vice versa happens when you’re actually standing or squatting, then the thigh is the moving part. The same thing happens with running, jumping, and so on.

The major contact points of the knee are between the femur or the thigh bone, and the tibia and the shin. You should know there is some rotation that happens between those. It happens in order to properly lock out the knee joint, so you can actually propel yourself and use it as a driving force when you’re running, or when you’re doing the knee extension machine.

Now I was trying to come up with a good analogy that would be a good visual for you guys on this one, for this little bit of a term, but all I could think of was tent poles or poles onto like an E-Z Up. You’re basically just extending the pole, and then all of a sudden, you have to lock it out or a pin has to hit a certain point to actually fix it. This is actually the same way.

I know that I said rotation is bad for the knees, but it has about 10 degrees of rotation just before it locks out, so you actually use the leg to drive you forward again. So this is why I said the cylinder stacking analogy is not 100% perfect because it doesn’t account for this, but I’m sure I could probably modify those things up a little bit to show that they lock after about 10 degrees of rotation.

So I said the bones actually move upon each other and I know I said that, and this sounds like a terrible thing, and it sounds like they’re rubbing, it sounds like you’re just tearing your joints up, but realistically, the way that the bones are formed also help guide it into the movement that it needs.

For the screw hole mechanism, some of the contour and architecture of the bones guide it that 10 degrees so it locks. Remember I said it guides the joint … these contours don’t move the joint, they guide the joint. The muscles and the tendons are the ones that move the actual joint.

So the screw hole mechanism as an open (again, this is when the foot is not in contact with the ground) and we’re going to cover this first: this is when the tibia actually moves on the femur or the shin bone moves on the thigh. You might wonder, “Why is this?” Again, it’s because that I said when you’re sitting on the knee extension machine at the gym and you want to lock that knee out to make sure you get the last bit of quad contraction that you can get, the thighs are fixed and the shin is kind of free to do whatever it wants to do. So in open chain, we’re looking at the lock of the knee into full extension happens around the last 30 degrees. This is where the shin bone starts to externally rotate to actually lock the knee into extension.

External rotation of the shin and what it’s going to look like kind of similar to like your toes flaring outwards, and this is not 100% a precise analogy again because there’s an ankle in the way, but for the most part, it is that motion where you are flaring away from the center. So remember that again, in open chain, we have the tibia or shin bone moving to create the locking.

Now in closed chain, it’s the other way around, and it’s basically 100% opposite. So in closed chain, we have the last 30 degrees, and the thigh bone begins to rotate, but instead of rotating externally, it rotates internally. Okay, I will say that again. The thigh bone begins to rotate instead of the shin bone because the shin is now fixed into position by the foot being in contact with the ground. In closed chain, the thigh does the rotation to lock the knee into extension, but this time, internal rotation occurs, not external when the tibia does it.

I know I’m being redundant, but this is a concept that I want to drill in a little bit, okay? The femur spirals in about 10 degrees to match that same point we had in open chain. In the end, it’s kind of the same knee locking. It’s just based upon what moves it to get it there. So yeah, the muscles, tendons, and ligaments are all involved into the screw hole mechanism, but to keep this really simple, I’m not going to go into too much because it would probably confuse you guys.

For the most part, just be aware that there is a flaw in the cylinder stacking analogy, and it’s mainly that last 10% of screwing the knee together to lock it out.

Now the meniscus is the last thing I really want to talk about, and I won’t talk about it too much. The meniscus is the cartilage of the knee which helps glide the two bones together: the thigh bone, as well as the shin bone and the tibia. I said before that it almost sounds like the bones are grinding together, but they’re really not.

This meniscus was really designed to create a little bit of a buffer, a shock absorber, but also helps transfer load between the thigh and the shin. The reason why it’s important to realize the meniscus is there is because that to let it do its job is we need to make sure the screw hole mechanism has actually occurred. The meniscus was not designed to take a ton of force. That is the reason why a lot of times, it shreds and tears.

Going back to the other analogy of the hinge, think of this cartilage of the meniscus in that door hinge just getting shredded up because we’re requiring too much ambient motion and different planes of motion in it.

So, this is all I have for you guys in regards to this, and I know it was a boring one and it was a long one, but you held in there, you did a great job. If you listen to the next podcast, you’re going to fully understand the reason why I went into so much detail because we are going to be flying through some terms, and in up and coming podcasts, I’m going to have other experts talking about knee rehab as well, but in different populations. So the person that we’re going to talk with next is going to talk about runners, but also, he eludes to different types of athletes as well.

Now if you guys have not been onto the p2sportscare site again, some of the show notes are going to be on there. They will be cliff note version, but for the most part, if you dig through that site, if you look through most of the content is actually under the About My Injury section. If you click onto some of those hot spots on those athletes, you’re going to see all this information pop up. I do my very best to keep it simple, similar to this podcast. I realize that we’re speaking a different language than general public, and it’s our responsibility to educate you guys about what we’re talking about, or we should make it into easier terms. One way or another, we need to understand each other, but for the most part, those pages I have spent months and months of my life writing–I’m not even lying.

And if you talk to anyone who knows me and has read my stuff that has not been proofread … Oh my God, I actually had to pay an editor for this thing because I’m terrible with that stuff. I’m good at getting content out, and I’m good at digesting this material to make it easy for you guys, but if you find any typos, please let me know, but spend some time on the site.

The podcasts are intended to feed you the content in a different way; if you’re traveling, if you’re driving, if you have friends that do the same, suggest this podcast to them, but really if you’re a visual learner or if you like reading, then it’s going to be on the website. I also do have some YouTube videos and a YouTube channel that if you YouTube “Performance Place Sportscare”, you’ll find a ton of videos that I have for free on there. I have a ton of free content for you guys.

So, I hope this was helpful. Go to p2sportscare.com and you’re going to find a way to subscribe to my YouTube channel in there. Just go through the Book button, go to the page and resources, and you can find how to subscribe to this podcast, as well as some of the YouTube channels and all the free content that you’re going to love about knee conditions.

By all means, suggest this podcast to your friends … please, please, please–It helps me out a ton! Actually our podcast rankings, iTunes don’t tell us how many subscribers we have, and it actually ranks us based upon how many subscribers, as well as reviews that we get, so please, please review it. I would love that. I want to share this information as much as I possibly can, and the best way to get it to people is for you guys to subscribe and review.

So take care. Again, this is Dr. Sebastian Gonzales from the Performance Place podcast. Talk to you guys soon!