Okay, we're going to start. Good afternoon, everybody. Thank you all for coming to our final session of a series we've done over the last four years of case presentations around musculoskeletal care. And what we've done the last four years, and this is the fourth one, is we've talked about different topics in musculoskeletal care, and I have the pleasure of introducing our four attendees this year who are going to be really the speakers and kind of give you some insight to it. My name is Joel Press. For those of you who are online, I'm going to give you a minute to adjust to my jacket. I know your color palette. This is bought in New Orleans actually years ago. I just haven't had a whole lot of opportunities to wear it, and I thought today was probably as good as any. So the first year, I think we talked about tendon injuries. The next year was about joints. Last year was the game of bones. I think you talked about bone injuries. And this year, our final installation of this series is Knives Out, and let me introduce our panel here. First is Dr. Pete Moley, who's one of my colleagues at the Hospital for Special Surgery, a physiatrist who specializes particularly in hip and lumbar issues, and it's a pleasure to have Pete back. He's one of our four-time contestants for this. This is a competition, by the way. I want to make sure everybody knows that. There are prizes, and we're going to do this in the kind of format of around the horn for those of you who watch ESPN, where I'm the moderator. I get the final say on everything. I get to determine who wins, and they just have to try to impress me, suck up to me, whatever it takes to win. So that's how it's going to go. So Pete's our first contestant. Our second contestant is Joanne Borgstein, who you all know from Spaulding and from Boston. She was, I think, the winner of our first year, and she is back again today. And Pete and Joanne are both kind of four-time, four years in a row contestants, so we appreciate them for coming back every year and sharing their wisdom with us. Next to them is Heidi Prather. Heidi is another one of my colleagues at the Hospital for Special Surgery, and I just want to make sure everybody knows that I don't play any favorites here, but Heidi has been a very close friend for many years. Heidi is one of the smartest people I ever know, maybe the best person I've ever hired in my life, and a very close friend, and my mentor. So do you need anything? Can I get you a towel, cold water, or anything? But there's not going to be any bias in her, just so you all know that. And she actually stepped in last year when I wasn't here and actually led this, so now she's on the other side this year. And last but not least is Scott Laker, who's come to us from Denver. He's kind of the newbie of the group here, but he's going to bring a lot of clinical expertise to the practice today, too, and to kind of fill us all in. So that's our group, and we're going to be talking knives out. So this year, the topic is really to operate or not to operate. A lot of the problems that we see in musculoskeletal medicine are really problems that the orthopedic surgeon sees, too, and they may say, we should operate this, and people want a non-operative opinion. People, you know, I tell people all the time, my job is to come up with ways not to operate, if that's appropriate, right? And so you're going to hear today from four experts on four different cases that we're going to present. We're going to move quickly through it, but their perspective on how do they address these things, and how do they address it if there's really a surgical option in here, too, and when do you need surgery, when do you not need surgery, what's the outcome going to be, how does it compare? So those are the types of questions that I'm going to be asking them, and they're going to be giving us input into. So the other stuff I wasn't able to bring today with me is I did have my knife with me when we were in Petra visiting, and I didn't bring it because they weren't going to let me bring it on the plane, but that was just to drive home the point that this is kind of the opposite of the surgical decision making, or really what's the non-surgical decision making. Okay. Are you guys all ready? Okay. Anybody want to say anything nice to me first? No? All right. Let's start. The first patient is a 60-year-old recreational tennis player who's got chronic shoulder pain, and they come in to see you. And I think what we'll do is we're going to start with Dr. Borgstein, since she's like one of the reigning champions here, and she gets to go first to tell us kind of what do you see. And again, the x-rays and the MRIs and stuff we're showing, it's not to show you any nuance or anything. It's kind of, I think these are straightforward cases that we want to discuss, but are the things about the imaging that you see right away that are, you know, important to you? Obviously, a cuff tear here, but tell us what you think and kind of how you would approach this. The surgeon said, well, I think they should have surgery. Anyway, thank you. Got two minutes. This is our wonderful leader, smart, brilliant clinician for inviting me. Anyway, just in this one coronal view, it looks like certainly there's a rotator cuff tear, probably with some retraction. Also looks like, it's hard to tell, but it looks like there's probably some mild to moderate OA there. From the view we have, there's pretty good muscle mass that the person still has, just based on that view. And I think our questions are going to be here, certainly, what has this, why is this person coming to you now? What have they had done for their shoulder in the past? How is their strength? Is it well preserved? How's their function? And what's their functional goals? So generally, if I see somebody like this, I'll probably on the first visit, especially if they want to continue to be a competitive recreational, if they're a competitive recreational tennis player. I will be having that discussion with them about surgery pros and cons versus non-surgical management going forward. And we would certainly talk about physical therapy, look at their range of motion. Outcomes are certainly a little bit better under the age of 65 and with well-preserved muscle mass. Nitin Jain and some of my colleagues from the Brigham have looked at outcomes for surgical versus non-surgical treatment. And just let them know, non-surgically, he'd probably feel better in the short run. But in the longer run, they published in JBJS in 2020, he'd probably be better served with surgery. That said, if he had a bias towards non-operative care or wanted to try non-operative care, tennis wasn't that important, or he's getting by and he's tried other things, we could talk about injection therapy. What do you want to inject? Oh, I was afraid you might say that. I think at this point, honestly, we'd have to decide on what we were trying to treat. So if the glenohumeral or AC joint were symptomatic, I might start with something simple like a platelet-rich plasma injection. If I wasn't sure where the pain was coming from, I might do a diagnostic injection. Treating that rotator cuff tear with any orthobiologic is not going to heal it, although he may feel a little better. We've reported on some cases that we published on a few years ago for the use of micronized fat in rotator cuff tears, but nothing to this degree with this amount of retraction. I think it would be disingenuous for me to tell someone we could really do something to repair that rotator cuff with orthobiologic. I don't see a lot of bursitis. We could consider a one-time steroid injection if there were an event coming up, but really there would be no long-term value in that. So I think that would be the nature of the discussion. Got it. Thank you. Scott, what do you think about non-operative care? What are you going to do in therapy for this person? Anything in particular you're going to start to focus on? I mean, certainly you want to start working on range of motion. Right here, it's described as kind of chronic shoulder pain. So depending on what the physical examination, you'd start addressing what deficits they currently have. But let's say it's hyperacute. You'd work immediately on pain control, then you'd work on preserving range of motion, and then you'd advance from there. I think some of the other things that weren't mentioned, what is his occupation? Some of that comes up here too. If he's a manual laborer, that's going to have an impact on what we do with him. Also, Joel, it's great to be with you, square-jawed, conquering leader, intellectual powerhouse. All right. You got points for that. Thank you. Thank you. Are there specific kind of questions that you're going to ask that are going to tip you off into which way to go on this, or things specifically on the physical exam that you really want to focus on? By the way, you look really great in that jacket today. I meant to say that too. Yes. I would probably go backwards. I know they've had shoulder pain for a while, but did they have a trauma? Because that, to me, really distinguishes if this was a traumatic tear versus a non-traumatic tear. Their ability to recover may differentiate and kind of put you on the hook for what you want to do therapeutically. I would also look at nighttime pain. Somebody who has nighttime pain, which is really common in shoulders, is a big bugaboo, because when they don't sleep, everything else in their health goes down. Three, their physical activity. Do they primarily play tennis? That's what keeps them sane. I have a sister. We all voted for her to have an operative treatment of something when she went down with something in middle age. I think I would want to know, is tennis something that they do regularly? Is it a mainstay of their physical activity? Then you definitely got to know what they do for a living, for sure, because that will have an impact on it. Is it their dominant side or not dominant side? All of those would be things I would take into consideration before going right into the immediate discussion on surgical or non-surgical. Got it. Pete, I noticed the other morning, Thursday morning at 6 o'clock in the morning, I was on a Zoom conference call with our sports medicine institute. We had a visiting professor, Dr. Joe Iannotti, who's in the Cleveland Clinic. He's a big shoulder guy. He gave an incredibly good talk. I noticed that you happened to be on the same talk. He had talked about why we're still doing rotator cuff surgery and what's the problem with failure. If we're looking at this from a surgical standpoint, did you learn anything from him the other day about why they don't work sometimes? We hear the story about the rotator cuff surgery, maybe 25, 30% of the time, it just doesn't work well enough. Yes, Joel, and you look great. I think it was a good talk, and it was timely for this lecture. When you look at why to operate or not operate, you should actually understand the strengths and weaknesses of the operation. What he did is he looked at, can you put the tendon back to its normal location? The anatomic location of the tendon, where does it end up? There's studies from zero to 94% failure for rotator cuff repair, and he put in markers within the tendon. The average length of retraction of that tendon was 22 centimeters. That's average. That's in everybody. There's failure. There's non-failure. They're going to stretch out about two centimeters. The reason, looking at this, is you're healing through scar. You're not putting back, not getting the tendon back to its normal location. That scar probably, over time, when you start to load it ... The initial study, the Yamaguchi studies where they were looking at it afterwards, they weren't bracing those patients. Now they're bracing them for three months. Once you start to load that tendon, the failure starts, or the stretch in that scar. Think of a scar ball that stretches out. It's kind of interesting. I think, just looking at MRIs and understanding that, there's a couple of chronic things here. One, you see this large bony at the greater tuberosity. Number two, in that study, just looking at where's the muscle tendon junction. Typically in a functioning muscle, it should be at or distal to the AC joint. Here we can see the muscle tendon junction is retracted. Once the function, once the blitz curve for that muscle, it now even functions, it's going to go down. I think, finally, it doesn't cut me off for time. Also, when you look at rotator cuff outcomes, this kind of 85% success, that's pretty good, but not when you start to do overhead activities. There's very little success in major league pitchers or professional tennis players getting back to their sport after a rotator cuff repair. Keep in mind that when you're speaking to a tennis player and you're talking about surgery, what's the success going to be? It's going to be pretty low if they're going to continue to play tennis. Keep that in mind. If they're going to be underhand, or they're a rower, or they're doing something else, probably feel a little bit better, a little bit of rest, but if you're looking to go back to tennis and play at a high level, particularly the serve, probably not going to get back at the level that you expect it to. We have to ask the question of everybody, do you PRP this person or not? Let's start down there with Scott. Any role? I've got to get a yes or no from everybody on this. I would start with the corticosteroid injection first, given the situation. That's typically my practice pattern before moving on to PRP. Same. Maybe. Plus, minus, if you do ACP or corticosteroid, I'd probably be addressing more of the joint degeneration than the actual, doesn't look like there's a lot of versatility. We're actually giving everybody else, if you have questions, you want to send them in if you're online. Please go ahead and send them in. Okay. We have just a couple minutes left, and what I wanted to do is at the end of each section is give everybody the last maybe 30 seconds if they have any one last pearl, either diagnostically, therapeutically, or anything about a chronic shoulder pain, full thickness cuff tear without significant retraction. Anything else you want to tell us or say? Pete, then we'll go back this way. From the same talk with us in two, he described like how you look at a functional limitation versus a disability. So if you're not a tennis player and you can't throw a ball or you can't serve after rotator cuff surgery, that's a functional limitation. You don't care. But if you can't serve and that's what you had the surgery for, that's more of a disability. So your functional limitation stops you from doing what you want to do. Your outcomes are worse and your frustration is higher. So really investigate what your patient wants to do going after the surgery if you're doing that or if you're going to do non-operative. Talk to them about what you're going to do and what they want to get back to and where are at this point. Joanne? Good point. All I was going to add is that shoulders can maintain their range of motion even with a fair amount of glenohumeral arthritis. So I think really carefully examining this person and seeing where we think the pain is coming from, where we think the functional limitations are coming from, it might not actually even be from the rotator cuff. So to that end, we just need to really correlate the different joints and see how that shakes out. My friend and colleague, Heidi. Oh, thank you, Joel. I was going to go back to if you do get into the differential and rotator cuff seems to be the leading source or in this situation for pain, think about two things. One, Lisa Gallat's study, you were mentioning Ken Yamaguchi's studies. Her article where she showed that people do re-tear after rotator cuff tears. When she had mouse models and I was her EMG-er in the mice models, when she created a tear in a mouse, it denervated the cuff. So that neuromotor control post whatever intervention that is, whether it's going down a conservative math or going down the surgical path is really important. Number two, just remember too, if you see retraction, look for fatty infiltration. Fatty infiltration equals no, surgery's not going to do well. Scott? Point of clarification. Does she get points for doing EMGs on mice or? She gets points for being here. Okay. I guess two points. One would be I would probably be apt to put this person through non-operative care first. I would be aware that there's a possibility that that tear propagates and then you move from a couple centimeters to a five centimeter and that changes things quite considerably. The other one, which would be the pearls, if you do decide to do a corticosteroid injection, you do have to advise the patient to be aware that they probably should not go forward with surgery because of the increased risk for infection that happens in that window. Got it. You know, we have one minute and 20 seconds. So if somebody has a question from here, if not, we're just going to go on to the next case. But you got to stand up fast and ask it. Okay. Quick. No, no. No x-rays. Okay. What are x-rays? Next case. We move on. This is a 35-year-old female with hip pain for one year. And because I want to take care of my colleagues, I'm going to start with Dr. Moley because he's the hip guy. Tell me what you see. Tell me what you think. Tell me what you want to do. So I like x-rays. So I'm going to talk a little bit about the x-ray, then we'll get into how to approach this. I mean, this is a good x-ray. And you can, the important features in this x-ray, just understanding it, is that the coverage is good, joint space is very good. And when you look at the lateral with the anterior portion, you can see that this is more in line with a type of pincer impingement. The source hill angle is probably less than two degrees. It almost looks like they've had an osteochondroplasty. So when you look at this design, you have to say to yourself, like, what's going on? So it's a 35-year-old with hip pain. And so this, if you were to, in your mind, think what's the damage going on, this is going to be more blunting of the labrum with preserved cartilage. So something is different for this patient. So when you look at this, this is a patient group where you see around this time, you know, they've gone from college to school and they've been sitting for a long time. And these, the injury pattern starts to become painful. So when I see this patient, I want to understand, when did it start to hurt? Was there a change in activity? And then the important features of what's your range of motion? How much, how does this hip move? Is it retroverted? Is it normal version? What's the arc of motion that's reduced? And what do they want to get back to? You know, what are you going to do with this hip? Because I'm looking at this hip thinking, is this going to have well-preserved cartilage? It's going to have a blunted labrum. Something's lasted 35 years. It's probably not going to fail. How do we get it back on track? What's happened? So typically, asking those questions is very important. So if they've got your classic impingement, let's just say, where are you going to start the rehab on this person? Before the surgeon said, well, you need to get the shave down, but you're going to say, well, what's my non-operative options here? So looking at this, you know, I think the important features is one, I want to address their activities. What are they doing? Am I going to stop activities that are causing them pain and try to move them to activities that are not going to? Number two, I'm going to assess the motion by assessing arc of motion. So where's the arc of motion? If it's reduced internal rotation bilaterally, might have retroversion of their femur. They have a 70 degree arc of motion. So where's it gone? Have you lost on one side? So I want to normalize motion on both sides. Three, I want to look at their, I usually get a standing lateral too, so I want to understand how they're standing, how they use their pelvis, what's their pelvic instance and how to approach that. And then I want to work on kind of a core and neuromuscular timing and training so that they have less impingement during activities. And I'm going to talk to them about more passive things, sitting at work with their chair a little higher, decrease the angle, don't sit low. All these things we kind of saw during COVID where people are sitting at home at desk and at their dinner table and started to impinge. It wasn't unusual to see this group come in around COVID times. So work from home a lot of times, they're not getting up as much, they're sitting down, they're at low chairs. And so assess all those things from what they're doing at home to how they're injured, what they want to do, and then look at the joint, the function and structure. Always look above at the spine mobility and how they can manage that. Look below at the alignment of the lower limb. I think foot mechanics are also kind of important to look at in some of these people. Okay, one of the advantages I have every Wednesday morning at seven o'clock is we have a hip conference and I get to spend that with Pete and with Heidi. So I want to hear Heidi's side of it too because sometimes the perspective's a little different. What are you looking at, what are you thinking about with the 35-year-old with impingement? Well, again, it's such an honor to be with you, Joel. And Pete, I'm way simpler than you, so thanks for the great explanation. I'd start off with where's your hip? When you say hip pain, where is that? Because I want to make sure when somebody walks in and says my hip's hurting that I understand is it groin, is it groin, lateral hip, is it buttock, is it all of the above and do you have back pain associated with it? Right, because that has a lot to do with where we're going to go from there. Number two, I'd want to know what you can and can't do now because of the pain. Those would all right away start making me decide about how to approach this. How long you've ever had it, again, go back to the sleep thing. People that don't sleep with hip pain I find have a lot more severe, multiple things involved than just usually interarticular hip pain. And then differentiating and explaining and going through intra versus extraticular pain and how they converge. So in addition to the wonderful things Dr. Moley just said, those would be the first things I would go through. Oh, gait. Please walk your patient, right? Walking really helps. One, you look at are they limping? Number two, you look at how much is their pelvic girdle moving? Is their spine responding to what the pelvic girdle's doing? And really just simple things. Is there a Trendelenberg? You don't have to have gait analysis there but that really tells a picture about differentiating for me. And any pearls on the rehab part for this patient too that we need to keep in mind? Pearls on the rehab part. So in the exam and in the history, I'm gonna hopefully get those to match with what's the movement impairment that I need to address. I find particularly using tests like an active straight leg raise really tells me about neuromotor control across the pelvis. I look at the plane of which the femoral head moves within the acetabulum, whether that's in supine, whether that's in prone lying. I look at the motion. Is the motion between the hip and the pelvic girdle independent and prone? Because those will drive what we do, how I write my rehab protocol. If somebody's had hip pain for a while or even heaven forbid, Peter and I have to see patients after surgery and they have a stiff posterior capsule, a lot of times that's one of the first places to go is to mobilize that so then you can then engage the muscles and balance between the front and the back. Scott, you wanna talk to us, is there any role for injections here both preoperatively or diagnostically that help you or that help along in your rehab process? Yes, I go back one step on this. I mean the prevalence of these impingement anatomies on x-ray is really high. So right now you have hip pain and you have that x-ray. You've gotta combine the rest of this differential on it and depending what you have, one of the first steps that I would have is is this truly intra-articular or is it not truly intra-articular? Unless the physical examination really hammers it home. So doing a diagnostic injection, though not perfect, is more perfect than what you have because once you start moving down the road of MRI, you've got a really high sensitivity for labral injury but you've also got so many variants and there's so many people that are roaming around with asymptomatic labral tears that it may lead you on a rat-a-chase that you don't want. I speak for everyone. We feel illuminated by your moderation, Joel. I do wanna say you've been trained very well by Dr. Akithota who we trained very well. So that's good. Joanne, thoughts on things? Humbled by the fact that I am in between two hip scholars of all time and their wonderful boss. No, quite honestly, I certainly would echo everything that's been said, especially by Heidi. To my observation also, there might be a little sclerosis in the acetabulum, there might be a little bit in the inferior SI joint on the left and although this is supine, it does look like there may be a little bit of a shift of the spine. I know it's hard to tell from this view. So I'd really wanna dig down. Some folks are stiff, some of our young folks are hypermobile and there may be a component of that that we need to consider and factor in as well. And then the other thing is, depending on the exam and the history and all those things in the office, I would probably, if I have any question about extra articular component, I'd probably pop on the ultrasound and take a look and see if I could make some correlative or soft tissue diagnoses that make sense, that might be contributing to this as well. And then after that, up in Boston, our sort of go-to hip arthroscopy surgeons, very conservative and very drills down that basically the articular cartilage needs to be near perfect. So if I got to the point that we were thinking of anything surgical, I would go ahead and probably just get a 3T MRI of the hip as well. Okay, that's a perfect lead-in to my section. I wanted to make sure we talk about, we're talking about knives out, so these are people that have seen surgeons and then see us and we go back and forth and we do what we can do. So who are the really good candidates? And I think you were starting to allude to that. And who are the ones that you just do not want having surgery because you know that they're gonna end up post-op back in your office and it's not gonna work. So Joanne, you can kind of go on from there if there's anything else you wanted to add and then we'll get to the rest. Yeah, I think there are a lot of things to unpack there. Number one, I think you kind of alluded to it. There is a psychosocial profile that we need to think about in terms of chronic hip pain and sleep and dysfunction and impairment and how that might influence outcome. Number two, I certainly generously will consider a diagnostic intra-articular hip injection. And I would want that to be quite clearly positive before I would be happy with surgery as an option for my patients. What does that mean? What percent do you mean? In other words, that both, they would immediately reduce their pain. We do something provocative right before the injection, put some local anesthetic in there, and then see if the pain essentially goes away, that they're coming in with their index pain. And number three, I would certainly get an MRI for the reasons that we mentioned. Be very, very cautiously advising people not to consider surgery if they're articular or chondral wear or other chondral defects. That would imply potentially a poor outcome. And that's where, you know, kind of go by Scott Martin's work and what he published in OJSM and lectures a lot about in terms of his selection criteria for hip arthroscopy, resurfacing, et cetera, osteotomy. Great. Heidi, what do you think? Yes. And did I mention how cute your grand boys are, John? Thank you. That's very cute. You won. Okay. Where was I going with that? I was so worried about that answer. To cut or not to cut on the hip. Oh, there's this really old, really Passor Award paper with the first author, Daviani Hunt, where we looked at this. We looked at this. This is the messiest data in the world, but it's still out there because we compared the people, their baselines, and where they went, whether they went on to surgery or didn't have surgery and continued with conservative care was about 50 people. Messy data. It's still out there published. But the thing that really determined where the person went, whether they had surgery or not surgery, was their activity level. So people with a higher activity level opted into surgery. So if you ask me about where the patient goes next, I want to do my best that they don't need to go to an OR. But ultimately, we've got to follow what's patient's choice. And so educating them about the pluses and minuses around what can, and we've seen it, what can and can't happen around arthroscopy is super, super important. So that if they do go in that direction because their activity level is high and they want to go back to being at a very high level rotational sport, they're fully aware of the risks and benefits of that procedure. And even though we're not the surgeons, we can at least start talking around some of those parameters because it's not just a one size fits all and certainly not everyone does well. As most of us on here and probably in this room have had to see. So I think that would be my number one thing. Scott, who are the red light flashing, don't do surgery, if you can avoid it under any circumstance, even if it looks like they may have something the surgeon wants to take down. I mean, some of the, like the pray their pentagram of psychosocial things not to take people to the operating room for, but beyond that. I mean, cartilage damage is a really bad predictor and it's not significant arthritis. I mean, you're getting like tonus level two. I mean, it's not severe OA that causes problems here. It's every little bit of cartilage loss. And one of the pearls may be that MRI tends to underestimate some of the cartilage delamination. So we've gotten really good at looking at like labrum under MRI, but we forget that that may not be a great way to look at cartilage. Pete. So getting to like this is what's a good surgical candidate. So the Warwick paper was very good. It's not perfect, but you have to have some focal loss of internal rotation. Be careful when someone impinges and they have 30 degrees of internal rotation because they are what we saw as failures. Make sure you understand the x-rays, be cautious of your dysplastics. They are now what we're seeing for failures is to see a decrease in osteochondro, the osteochondroplasty was done incorrectly. Now we're seeing a lot of dysplasia coming in. So know what you're looking at, an x-ray here, a little deeper. There's really no osteochondroplasty to be done. The labrum's gonna be somewhat blunted, maybe barely there. There are labral reconstructions. I think we feel our hospital stuff by White and Wolf isn't going to prove to be long-term beneficial, but does denervate the labrum, they feel a little bit better. I think when you're looking at a surgical candidate, make sure that there's a decrease of internal rotation on that side, that's gonna be kind of your winner. Younger patients, cartilage is very important. There's a study from Siebenrock, it's been put out just looking at the surgery itself and doing degenerative studies and seeing a significant decrease in the cartilage health just after not touching the cartilage, just doing an osteochondroplasty and labral repair. So the surgery itself has a negative impact on cartilage. Also in your more arthritic patients, more motion sometimes is bad. So I want them to see that this patient has been through good conservative care. When the surgeon says they failed conservative care, drill down on what was a failure. Did they get light therapy or did they get, did they actually do a good, thoughtful program to restore that hip motion, strength, stability, and get them back to their activities? Or did they just go somewhere and they got stretched? So be careful with that one, we hear it a lot. So I want to see a loss of internal rotation, I want to see excellent cartilage. I want to have a good discussion with the patient what they want to achieve and how they can achieve that. And then I think that's, if you're looking at a surgical win, it's gonna be probably someone younger than this, high-level athlete, a lot of motion loss, and I think that's the person who's gonna see the best results. Okay, 30 seconds, any last final thoughts? Let's start down there, Scott, and we'll come this way. I would consider talking to the orthopedic surgeons that you work most closely with and come up with kind of a standard set of x-rays, you know, AP, false profile, done is what we're typically doing. That way you can save your patients from going in and getting your protocol and then going in and getting their protocol. I like that, talking to others, really good. Because the better that there's a continuity of care, the more the patient feels like this team is handing off from one to another is super, super, super important. If you are really stuck about where is this coming from, I'll echo again what my illustrious and beautiful colleague next to me said, which is a diagnostic injection. It's like 100% sensitive and specific for differentiating a spine disorder from a hip disorder. And it will help you differentiate intra versus extra-articular pain. So I would, I highly recommend that. I use four CCs, we did a little study saying when you blow up the capsule more, people actually feel worse, and then what the heck do you do? So I would advocate for that. Excellent points all. I would also just emphasize the functional goals and the length of the recovery from a surgery so that patients have the right expectations. All good points. I really do think, you know, we're saying this is a hip impingement case, but always look around. What is the hip, where's the pain? There are pain pattern guides, and anterior pain is very persistent in someone who's got impingement. So they're lateral, only lateral, only back. Just make sure you're looking around. We have a quick anecdote on these. Just make sure your physical exam really makes a difference. And so when you're speaking to your therapist, make sure you're also speaking to them, not just sending them a prescription, and look at the hip. And so we kind of developed like a matrix where, you know, if you're kind of stiff and weak, then you need to be stretched and do some strengthening. If you're very stiff but strong, maybe you just need more strengthening, more mobility. If you're mobile and weak, like you're high Baton score or you're dysplastic, don't stretch them. They may say they need to be stretched, but the reality is they need more stability. And you know, some people actually are quite mobile and quite strong. Try to look at what they're doing differently. Did they take up running? Are they doing boot camp? Or did something change to them? Why is this hip that looks like it should function not functioning? And then definitely look around. Is it in front of the spine? Is it lower limb? Is it something outside the joint? But those, kind of look at that exam and then apply it and talk to your therapist. Make sure you have a good communication system going because we're seeing much better results now by reaching out, by educating each other. Well, you all get points for congeniality. I'll give you that. All right. One time for quick question. Anybody? We have a minute. We're staying on schedule. Everybody's very good. Quick. What is the role that they do in terms of their sexual health history? I've actually made a difference. Role for a sexual health history on these patients with impingement. Anybody want to take it? You mean specifically pain? Yeah, so pretty important, right? I recently had this conversation with one of our hip arthroscopists. He says, well, can you see this patient? She had pelvic floor pain after surgery. And I'm like, well, did you ask about it beforehand? But I didn't say that. And he says, okay. I said, well, yeah, I'm happy to see her. She goes, well, in the meantime, I'll just send her to our pelvic floor therapist. I was like, you don't have one and that's kind of crazy because you're a hip preservation service, right? Opterator internus is one of the major causes of pelvic floor pain and it operates the hip. So if we don't ask the question, we won't know the answer. And we don't want to say it's something that happened after surgery, although it can happen after surgery, but I think we need to be very aware of it prior to surgery. Okay, we're gonna move on. Good question. Next, we have a 42-year-old physiatrist with back and leg pain for three weeks. I couldn't get my MRI from 25 years ago, so I just made this up and I found somebody else with a big herniated disc. Let's start this one with Scott. All right, you've got an axial and sagittal T2 cut. You've got an L4-5 disc herniation. Disc is going, looks a little left paracentral and getting the traversing L5 root is what it looks like. If you look closely, you will find that there's almost no PRP in any of those discs. And that's gonna be a clear problem as we move on. So three weeks of leg pain. Joel, you want me to start with treatment? How would you like me to be? Yeah, yeah, because the surgeon's seen this person already and said you have a big disc and you have to have surgery. They come in to see you, now what? Well, I mean the joke is that these are surgical emergencies that if you don't fix them quick enough, they'll get better on their own. So really the goal here is to get pain control. It's to understand where the neurologic exam is and then it's to intervene based on the severity of how the patient's feeling. There's no one right answer on how to approach this pain control, it's really based on how bad this is. To Heidi's point earlier, is this keeping them up from sleep, that's one of the reasons that we'll really intervene more aggressively on oral medications and a few days of opioids to try to get things under control to start putting things back on more of a virtuous cycle. We also obviously are gonna really look at a neurologic exam, again one of the pearls may be when you're seeing these people in a hyper acute phase, they may not have had a chance to get weak yet. So you're examining in the early phase, they're four out of five and they come back four days later and now they're three out of five. Are you really seeing a neurological decline or have you just not seen kind of neuropraxia get to its nadir yet? I'm gonna ask everybody this, but does the degree of weakness that you see day one change anything you do in the management of that patient? Like one over five, three over five or maybe four plus over five? It does not change how I think about it. We talk through the patient pretty considerably about this of you know, I think the estimation is unless you get surgery within six hours of the onset of that disc herniation, it's already a done deal. So after that, then it's what's their level of comfort? You know, can they sleep at night with having this weakness? Because as we all know, as you age, you're gonna lose some axon, you're gonna lose some myocyte. And are you damning them to a life of a drop foot because you're not dealing with it now? We know that not to be true, but can the patient live with being really patient with a really severe drop foot? So I would say that I am comfortable managing it, but sometimes the patients are not comfortable being managed non-operatively and will go more more acutely to surgery. And I think that's, I think to Joanne's point, they have a vote in this too. And just in terms of epidural, is there anything with your timing on it? You're gonna wait a little bit? You're gonna say, wow, you've already had pain for a few weeks, is it time to do it now? I would give this, if I can get it under control orally, I would prefer not to do the steroid. If we were able to start some medication on this person and it did not help in the first few visits of physical therapy, let's say they just do not tolerate it, then I would move more aggressively to epidural steroid injection. And that's somewhat to limit some of the medicine burden, but also to get pain under control so that they can make some decisions in a more comfortable manner. Okay, Joanne. Agree with you, all good points. I'll just take off from there. Couple of things, if there's a one over five, even if the patient is a little anxious, you know, we work literally next door to or right with our surgeons. I might just pick the right surgeon and have them say hello and say, hey, I'm here for you if you need me, if this can get better, if we can't manage the pain so that it just allays their fears a little bit. You mean you make sure they have lunch before they see the surgeon, so they can pick him, yeah? Second management aspect would be sort of what to do here and how to educate our patients. So, a little hard to be certain, but it looks like this is somewhere from extruded to sequestered. And certainly, there have been studies looking to, in 2014, sort of published on what the natural history of sequestered disc herniations are, and the vast majority of them will get better, as will the extruded that will, you know, shrink, et cetera. So just sort of educating the patient that even though it might look bad, and if we can manage the pain, this is the type of disc that is likely to get better with conservative care. The third thing would be which medications to choose and kind of what's the evidence to support them. And there have definitely been mixed studies on the use of oral steroids. So if I could manage it with nonsteroidals, I would. Otherwise, I would feel comfortable with at least one study by Goldberg looking at first couple of weeks management with oral steroids, and a recent paper that came out, a meta-analysis on gabapentin for short-term use for relief for the first couple of weeks for nerve pain. And then, you know, just close follow-up. Tell me about the therapy that you'd recommend for this person. Anything in particular you'd tell them, ask them? The first thing I would try to do is just see if I could find some bias or some direction in which they're most comfortable. And if I could, I would just educate them on that here, you know, in the office. Depends on the degree of pain that they're in. If they're in too much pain, we may have to take a little weight and manage their pain a little better and then have them engage with PT. And I would certainly have them up and walking or Nordic walking or doing what they could right out of the gate. Got it. Anything on the physical exam or on the history that you're taking from them that starts to move you towards the surgeon pretty quick? Obviously, bowel and bladder problems, but are there other things that are kind of thinking like, this is not gonna get better, I'm a little more concerned about it, I want your pearls and wisdom? You know, this is really interesting because there's studies that we quote from sort of years ago that I haven't seen anything better of looking at what sort of neutralizes their pain so that if I can get it better in extension, I'm usually a little bit more optimistic. If I can manage the pain within the first six weeks and get that leg pain feeling at least 50% better, I'll be more optimistic. Again, based on some older outcome studies. And if I can't get them comfortable at all, no matter what I'm doing, even though they may get better on their own, I'm much more likely to consider a surgical consultation. Same question, Heidi. You've seen a lot of backs in your day and you've seen a lot of these type of patients. What are the things that just kind of get you like, I got a bad feel on this one? Yeah. Did I mention I can't wait to buy you dinner next week? Yeah. Yeah. Okay. I have to think about that so hard that I forget what I want to say. The things that I think about that make me pause-pause is a diabetic person or somebody with peripheral neuropathy sitting in front of me with a large disc herniation. I'm like, oh, jeez, is this one going to come back? Because they're already predisposed to not recovering as my really, really smart partner sitting next to me was talking about with neuropraxia in the beginning. So that one worries me. Somebody, not this particular case, but somebody who has micromotion or even gaps with a spondy at the same level. I'm always like, ooh, is this one gonna get through or not? Not because they're gonna become unstable, but because I find it harder to manage their pain. Parkinson's, especially young Parkinson's patients. I have a really hard time, or anybody with active seizures that suddenly has onset of a really hard radiculopathy. I've just always found those other disorders they have making it harder to manage. Okay. Pete, what do you think? So, again, with imaging, the extrusion, so we're looking at the study of Bowdoin and all that, people, it's very common to have these. But when you mentally chew and start to look at it, these extrusions tend to be more symptomatic. So that's one factor. But the other factor is that extrusions tend to reabsorb faster. So I always look at it kind of like a race. I want this case, because I think this is gonna reabsorb. Canal size a little smaller than average. Those are things that kind of worry me a bit. But I also, the surgeon wants it, because this is like a home run for them. They go in and pluck this out. And so we all look, think we're like superstars. But the reality is these are gonna reabsorb. And if I can make them comfortable and functional during that time, there's a recent study out of Australia that showed in the first three months, a third of these will reabsorb. And the next nine months, the rest of them will reabsorb. So these are gonna reabsorb. When you go back to your sport trial, everything else, at two years, we're all gonna be in the same place. Can I get them there comfortably? So what I wanted, you know, it's a lot of sitting down with patients that are standing there, psychological feeling about it. Do they have weakness? How do they manage that? This is a physician. So that kind of shared decision making. What are you gonna do? So my goal is to try to get them back to some basic activities as soon as possible. Because disability gets people stressed out. So I gotta manage their discomfort. Typically I'm gonna use mainly NSAIDs if anything. And then if necessary, I can get them PT faster with an epidural. I'll probably intervene with an epidural. It's all about getting them to PT. The reabsorption study actually compared acupuncture to no NSAIDs because they wanna see how fast it would move people. And the patients did well in both arms. So it's about getting this, you let the body do what it needs to do. How do I get them there? Well, what do they need to do? What do they need to do? They need to walk or they need to get a bed. So a lot of the first part of therapy is gonna be mechanics. How do you get up? How do you move? How do you lift? So I wanna try to get them doing that and try to reengage some of these muscles they can't engage because of the pain. But that's what we look at. If I get that time, I'll win. If the surgeon gets them, they'll win. I mean, it's just like if we can avoid a surgery, it's beneficial. I think in this case, he definitely could. Well, I'm so glad you brought up the physical therapy because I've been waiting to ask this question to you for six months, knowing your thoughts on McKenzie approach because I wanna get your thoughts on that. But just to give everybody a preempt, in March, Dr. Molli and I are gonna have a debate on our grand rounds on a Tuesday morning. We'll send you all the link for it about does McKenzie work or not and what that actually is. But just mechanically, and we're gonna talk about mechanical assessment, does that play a role in here in terms of how they move? And you're talking about getting them to a point where they move better. So I think you're talking about directional preference. Yes. Which is fine. Maybe not McKenzie. We don't wanna be dogmatic about what we're doing. But I'd be absurd to believe that doing a press up would make this reabsorb. But I do think that you could find positions of comfort and how do you build them in that so that they can stabilize and move forward. So I do think it's important. I wouldn't call it one specific thing, but I still like you very much. And I can't wait for our debate. But I think it does. I think you wanna understand where are they comfortable? You're seeing them in the office. How do they move? Are they standing when you walk in the room? There's a lot of clues from these people. But you have to spend some time. You have to educate them. You have to show that there are x-rays, MRIs. You know, there wasn't the greatest study in the world, but they showed that the degree of sacral slope makes a difference. And I do think that they did it on an MRI. But I do think seeing someone standing in a lateral, do they live in a little bit of flexion all the time? Do they posterior pelvic tilt? How does it affect the spine? Maybe that's what McKenzie does anyway. Just tries to get people to have a little bit less, increase their sacral slope, but not living in flexion all the time. So those little things are gonna be important. We're gonna sit down with the patient. We're gonna go through x-rays, MRIs. Educate the patient. This is a physiatrist, but anybody can be taught, understood, and they really need that. And now that they're on board, you're working together. And I think you just have to be clear to them. Let's make a decision together. I think Joanne's point is great. I have a lot of surgeons I know. I'll swing them by there. Make sure we're all working together and that the patient is the focus, not what I think is best, what the surgeon thinks is best. How do we get that patient better? The more people involved, the better. That leads me to the next thing. Just number one, be ready, because I'm coming hard in March. But really more important, from the rest of you, are there certain things you say to the patient? Let's get down to that we were just talking about, which I think is really important, is you've got somebody who comes in and they have a little bit of weakness, let's just say. They're not floridly weak, or maybe they're even moderately weak. And they're scared. So are there certain things you say? I mean, because this is really important, that therapeutic milieu and what you do with it. So let's go, Joanne, back this way. Is there something you add in there that will help you along the way here? This is where I try to take advantage of maturity. And I just kind of sit back and go over the pictures with them and reassure them that one way or another, they're not gonna live their life in pain, that we have options for this. And then we go through the options and kind of explain to them what to sort of think about this, what the natural history is, what the time it will take. But most importantly, when I can find sort of a positive energy, you know, hey, you've been in really good shape, you eat well, you sleep well, whatever I can find that will A, be true, and then B, give them sort of the coverage and resilience to get through this. And my confidence that I'll stick with them no matter what it takes to get them to the finish line. Great. Heidi? Yeah, I'll start early on, you know, the pain and the intensity of pain, validating it and then going right into, it doesn't mean you're damaging your back further. There's not a direct correlation between the intensity of your pain and the structural thing I'm pointing to on the MRI. So hang with me. And then I try to get in, I do exactly what you do, Joanne, get in the motivational part of like, what is positive about interaction. And then three would be, give them some, find something in the room that actually makes them feel better in the moment. And we're already starting the process of them being able to be an active participant in making this better. Two things. I think you should all remember when you're talking to your patients to remind them that Joel Press is an American treasure. That'll definitely work on these patients, I'm sure. The way I frame this with patients is to say, you're going to get better and you get to help decide how you're going to do that. The fastest way out of this problem is a quick trip to the operating room and have the surgeon pull this thing out. That will make you feel better. However, if we can get through this and I talk about kind of what the expectations are, this is going to be medications, it's going to be weeks, not days, it's gonna be maybe months. You're likely to need somewhere between two and three injections. There's lots of different options to make you feel good and we'll make sure to bring you back frequently enough that will keep you safe. But if at any point you decide you want to exit stage left and go to the operating room, that is not the boogeyman here. This is a good, reliable surgery that has good outcomes. And I think that decompresses the patient so they don't feel a bias from a non-operative provider. I think you just summarized the sports study there in terms of people will kind of figure out where they want to go on it. 20, 30 seconds, anybody have anything else you want to add? Anyone? Or did you cover all the pearls? First of all, I would never debate you openly in public about anything that my other colleague down the table is. I think another take home about directional bias is whether it's McKinsey, whether it's for instance, therapeutic out, whether it's movement impairment systems, whether it's Deloitte stuff, whatever one you use, use something because it standardizes you on an exam so you're consistent in performing that kind of methodologically because we're the ones that disengage the black box of back pain. We're probably the only specialty that disengages the black box of back pain because most people, most other specialties don't know those specifics. So finding whatever type of method of assessing directional preference or standardized exam is really important. Two other little pearls that I would add. Prioritize sleep and pain management and enough so that people will get sleep. And number two, not to forget that in the throes of this, there may be a very, very substantial myofascial reactive component. So sometimes I might just do some trigger points or dry needling or something right there on the spot to get them a little comfort, even though we know it's gonna come back, at least it breaks the cycle and we just don't wanna forget about that. I'll give a quote from Voltaire. The art of medicine consists in amusing the patient while nature cures the disease. I think in the spine, that's by far the most relevant portion of it is how do we get them along through all these techniques and whatever you use, be consistent, but you need to become a partner with them and keep them going. And sometimes they're down, set up phone calls. So sometimes I'll say, listen, you look pretty grim today. We're gonna get you and I'll find a therapist that will mix with them pretty well. And then I'll give them some things. I'll give them some to do at home. And I got a therapist who works with me and she'll spend some time. And then I'll say, let's talk next week. And then we'll talk every week. Whatever you have to do, just make sure that they know you're on board. Once they feel like they're kind of left out there in the wild, they'll get stressed. And so the more frequently you touch them, the more you get a good group. The therapist is calling if there's problems. Just make sure you don't let them get kind of lost out there because they'll get frustrated and they'll get scared. And it needs to get better. It was my back. I had this almost a deck disc. I did fine. It just took time. Any questions from the audience? We've got a couple minutes here. We're still staying on schedule, remarkably. Dr. Akathoda. No, I was 42. That's why, this was, I mean, I couldn't find the films because they're so old and they're like, you know, on that plastic stuff. Most of you don't even know what that is. You know, we used to have them. But, Joel, you look 42. Yeah, I thought it was a typo. I thought it said 24. That was the setup. I got it. I'm sorry? No, actually, I mean, I'm kind of the typical large herniated disc that, as everybody here, I think, has said, if you kind of wait them out. But I was set up for an epidural, but it kind of got better before that. And my leg is numb every now and then if I walk too far. And I know, I'm afraid to even look at what an MR. I was gonna do, get a new MR, but I'm really afraid what it's gonna look like. So, don't wanna know. So, so far, so good. We'll see how that goes. All right, any other questions? Yes? What are your thoughts on the role of osteopathic and manipulative medicine? Great question. What are the thoughts on the role of osteopathic manipulation in this condition? Yes, I think the biggest thing for me is the intensity of the radicular pain and their ability to tolerate that. I think, you know, to me, manipulation in this group, if they were weak, I might stay away from it in the beginning, but definitely if they weren't weak or had other attributes that really pulled me towards there's a very big myofascial component, because that's what I believe manual medicine can really help with, is the myofascial component of pain. I think it could be useful, but if they have a really strong neural tension sign, I don't want the 2 a.m. phone call, because I've really flared it up, and so maybe it's out of self-preservation that I say that. Anybody else? Yeah? So, this was an older patient, and you felt that you got their radicular component of their pain better enough, 2 or 3, but they have a bad hip, it's a lateral hip replacement, and now you think the hip is the main driver of the pain. I see varying practices between, some surgeons will say, definitely don't do the hip until your back is perfect, and then some people will, just because of a complication of injury to the nerve, when they get their hip done. It's a whole other conversation, but we'll ask them, no, no, we'll ask them to answer very quickly the concept of, you've got a hip problem and you've got a back problem, and you're thinking that they may need surgery on both. Is there one you do before the other? I'll take a crack at it. Hip replacements now are reliable, they're safe, they're rapid, they give good, consistent results. I would err on the, let's deal with the hip. Back surgeries for back pain and degenerative spines are very unreliable and extremely variable in the case that you presented. Yeah, I think you may, there's a study, I'm not sure if that's the one you're referring to, where it showed that people who had severe spinal stenosis and then had a hip operation, they actually did worse, and so, okay, but those are both extremes of ends, means, my guess is they didn't know how bad they were neurologically, is a guess I had when I read the paper. If they have weight-bearing pain, go for the weight-bearing pain. The nerve pain, eh, it's gonna go up and down. Weight-bearing pain, persistent, get rid of the weight-bearing pain, I would do the hip first. All right, let's go to our last case. 42-year-old knee pain after a fall skiing. This was years ago, but they come in now with this feeling of, just doesn't feel quite right, it hurts every now and then. So, this one we're gonna start with Heidi, we've got her ACL injury here, and tell me what you think. This is a 42-year-old and they wanna know, am I gonna be able to get back to doing everything I wanna do? Or, the surgeon I saw already said, you know, we should probably do surgery on this. Yes, I think for me, with an ACL tear, and somebody who's middle-aged, it is completely dependent on what they wanna do. Because in the end, they're probably gonna get to the same place, which is early arthritis in their knee. And it's how they wanna spend the years in the coming between that and the onset of that OA. So, for me, it's very dependent on the patient's goals on how to advise. Because they can go either way, and they can ski, even if they don't have it replaced. It is not an ICU moment when your ACL is torn. Especially in the middle-aged folks. Hypermobility, probably maybe a consideration in there. If this is a hypermobile person, you might think differently. But in general, for me, it's really about what they wanna do, and what's really important What do you say to them when they say, this surgeon said, if we don't fix this, it's torn. You can see it's torn. What do you want? How are they gonna un-tear that with any rehab? So you're not gonna un-tear it. That would be the first thing. Number two, it's gonna be, how do you, you know, you're gonna protect your knee and get your knee more functional by improving stability of the knee through co-contraction, and for neuromotor education, and proprioception around the knee. Once we've gone through kind of a rehab protocol related to that, then we go into sport or activity-specific things you like to do. I would even go into functional task assessment recommendations. I pick up a kid every five days, or every three hours, or whatever. Can we practice picking up that kid that's mechanically appropriate? And there's, you know, evidence shows that, again, at the end, depending on what they do, you end up kind of in the same place. So it's really about how you want to spend that time. So if they are into, I'll give up my all, I want to stay away from surgery, you champion that and go for it. So outcomes, you're saying they're gonna be the same pretty much either way? They're gonna get to where they want to get to? They're gonna get to where they want to get to. They may get there, they may be able to return to a high-level rotational or a skiing sport or that type of thing quicker with an ACL repair, but in the end, they all end up in the same place. They're gonna be in the same place at about five years. So it's really about how you want to spend your time. Okay. Scott, 42-year-old, chronic ACL tear. Well, to Heidi's point, no one in Colorado thinks they're just doing a side-to-side sport. It's exclusively elite athletes that are doing, cutting well into their 80s and 90s. So everybody gets ACL repairs there. You know, I agree with all that. Joanne moderated a great discussion on post-traumatic knee arthritis, and they get post-traumatic knee arthritis regardless of what you do. So really, some of it beyond what Heidi had mentioned is, are there other concomitants in injuries? You know, how does the meniscus look? Is there significant bone bruising? Is there already some significant degenerative joint disease? Because that may push you a little more towards doing knee replacement. I think one of the things, this is more anecdotal than anything else, really in our population, they want to talk to a surgeon regardless of how well you know what's going on with ACLs, and that's been a barrier to really getting patients to really buy into non-operative care of ACLs, at my institution at least. Okay. Joanne? This is a little bit of a tricky one, because the patient's 42 and had a presumed injury years ago. I don't know if that means when he was a teen, or are they, you know, 20 years ago playing basketball? You know, so if the person had this really a long time ago and has been sort of what used to be called a coper, or had been rehabilitated, has functionally and on exam a stable knee, then probably there is little to no role for ACL reconstruction at this delayed point in time. We certainly know that it's not going to reduce the post-PTOA risk. It might even enhance it. There's a recent meta-analysis suggesting that by Ferrero et al in 23. The other thing is, again, we're just getting one view here, but it does look like there's some articular, especially femoral-sided cartilage thinning. So perhaps the, you know, why are they there now? Probably because there's some early arthritis that's contributing to their symptoms. So unless there was something new, relatively new, that happened with dysfunction because of instability, and they hadn't done well with rehab, I don't really see any indication for surgical intervention at this point. And I did forget to acknowledge that congratulations on the Distinguished Clinician Award. Thank you. Congratulations. Thank you. Okay, Pete, anything else you want to add here that you would do different in the rehab, in the treatment, in the thought process? So I think Joanne's point is, when did this occur? It was years ago. They functioned for a while. So what else is going on? What's happening? I do think you should look above, plug for the hip. You know, a lot of times I would get these three-time ACLs in, and you look, and they have no internal rotation. So what's going on? They're at 42. Are they starting to get a little bit of stiffness above? Is it starting to stress that cartilage? You know, what's the role of the ACL? I do believe a physical exam is really important. You should check these knees, do a Lachman, do a drawer test. If you can do a pivot shift, it's kind of fun. It's rare that you're going to get someone in the office who's going to pivot on you, but you've done an OR. It's kind of interesting when someone's asleep. But is this a stable knee? Is it not a stable knee? It seemed to have worked. It's interesting because, you know, look at skiing. There's Bob Marks that published a study of HSS showing a pretty high rate of reconstitution of the ACLs. These low-energy tears might reconstitute and become functional again. There's a recent Australian study that actually showed about a third of the tears did reconstitute. And if it did reconstitute, they had better outcomes. So don't believe that every ACL is going to fail forever. So I think, you know, it goes to Heidi's point. What do they want to do? This is someone who wants to play basketball, you know, three times a week. I'm going to be talking about doing, you know, having that replaced. If it's someone who wants to ride a bike, do a triathlon, maybe ski once in a while and play some doubles tennis on hard, true courts, they can live with it. They've lived with it for a while. So understand who you're dealing with. There's pretty good papers. The Panther Group, Freddie Fu published it. But Freddie Fu was a giant in ACLs, the double bones and everything else, and he passed away, which is sad. But it really does kind of look at all the literature and say, you know, what do you do? What's the consensus on this? And I think consensus here would be, you know, the cardiologist is okay because, you know, your cardiologist is going to get worse is not true. Everyone said here, the studies did not support it. The question is about the meniscus. And then there's a compare study out of Sweden where they kind of looked at early operative versus late operative. And they looked at the two groups, and actually there was no increased amount of meniscal tears in your late operative patient. So that may not be true. Some of the older, is it Frobart, the study out of in 2010 and New England Journal of Medicine, they had a slightly higher number of meniscal tears. But I'm not sure if that was an index meniscal tear that was found later or even what meniscal tear they're operating on. I can't tell you how many times I see someone being told they have meniscal tear surgery, they need it, when really the meniscus actually is pretty good shape. So that, the two things I think are total is that you're going to get arthritis and you're tearing your meniscus. I don't think either of those are true. But I think a patient who wants to do a lot of cutting sports is going to be very happy with a less stable knee. So kind of figure out where they are, what they want to do, and go from there. Any role for PRP? Have to ask. Inquiring minds want to know. Well, our illustrious absent partner up here just had something published, was it this past week, right? Yeah, this week. Nature Orthopedic saying that one year there wasn't really a difference between, for an intra-articular injection using platelet-rich plasma versus steroids. So I think we have to be really cognizant of knowing what the evidence is showing. But I think my illustrious colleague next to me may be able to give us more insight on that. It's a really good question. Dr. Mountner say, by the way, didn't have PRP in it. It was BMAC and SPS and compared it to steroids and there wasn't a huge difference at the end of the year. But PRP wasn't included with that. I'd say the devil's in the details. So if we really think this is an intra-articular pain generator and it's a stable knee, then potentially in this relatively low grade of osteoarthritis, you have a good chance of improving for any period of time, one year, two years or so with an injection. Do you think it's because it reduces inflammation in the interim that really helps PRP catapult them? Let's pick your brain. It seems to be the most rational explanation we have now. Yeah. Scott, you got a look on your face. I'm thinking about something different. My apologies. No, what I was thinking about is, you know, you started with this athlete that presumably tore this ACL several years ago and tolerated it. So they didn't have to change their activity level. So there's a percentage of patients that do have to change their activity level to tolerate not having an ACL. And maybe you're just seeing that. But I very much agree that the drill here would be get to therapy, start working with somebody to figure out why is there a new problem here? What's the new thing that's been added on? But that's what I was thinking. Have they just gotten to a point where they've aged into an area where they can no longer tolerate skiing? And I was just thinking that that coat looks so good on you, Joey. It's getting down to the end. It's like midnight. Do they make it in grown-up sizes? I'm the best-looking thing left right at the end of the night. I get you guys. Any questions from the audience? We're almost out of time here, but I want to see if anybody has a quick question or two before I let everybody wrap it up here. Anybody online? Let's check real quick. You get a little extra credit. And I do like your coat. It's really difficult when everybody sucks up to you all day long. Any final comments that you guys have just about the cases, about addressing musculoskeletal problems? Words of wisdom before we leave. This is the final installation of four. It's been incredible. I want to thank them. I think particularly Pete and Joanne, who've been here all four years with us, and Scott for coming on, Heidi for doing a couple years, and also to Ken Motner, who's not there. I hope he's watching, and to Brian Krabeck, who have been instrumental in really putting this together. This has been probably the most fun lecture series that I think I've done for the Academy in all these years, because to be able to have people with all this level of experience and just getting the discussion back and forth and just the little details that you pull out of it, I mean, this is like the pearls that I think we all look for all the time. And to be able to have them for an hour, an hour and 15 minutes here over the last few years has been just incredible. I have to go pick a winner in a second. I think the winner is . . . I'm a winner, because I, again, just getting to be able to spend the time with everybody. I think everybody here with the knowledge and stuff that they've been able to share. I don't know if you guys have any last comments. And you don't have to tell me how good my coat looks or anything like that. Just in general, comments for everybody. We'll start down there and come back if you want to do that. Yeah. These cases are great. I think when I was looking at them, the thing that really came out to me is physiatry is in a great position to be able to answer all of these questions. When you distill it down to surgery or no surgery, that kind of boxes you in. But when you open it up to the hip patient that comes in, there's a million things that can cause hip pain. And we're in a really good position to answer all of these questions, to diagnose it, to give surgical opinions. I just really like our ability to engage in these cases. So I appreciate it, Jill. I ditto that. I would say, to add to my illustrious colleague here, that making sure that the patient understands that we got you. Like we've talked, I think, in another room, and Jill's used the word, oh, I'm sucking up again without even meaning to, the glue, right? We're the ones that can know what other people do. We know we need to be able to make sure we communicate effectively. So we end up being the resource for patients in cases like this that there is not exactly one clear answer. And I think that's super, super important in the way our health care system works now. And then I have to give a selfish plug for if the patient is kind of on a path that may be going to osteoarthritis in this case, and they do ask you about what are the other things I can do, talking about sleep, talking about stress, talking about what you eat, all those things can really help decrease the progression of osteoarthritis. I'd love to show it in the post-traumatic group. I agree with everything that's been said. And just on sort of a gratitude and philosophical note, I really love my physiatry family. All of you have been part of our lives and our training of our field and have made tremendous impact over the years. And I can sort of look back and say it's been a great ride. And these four years have been so much fun. We're not going anywhere, I hope. We're just not doing this. This has been just a joyous time in the last four years. I agree with Joanne. It's really fun. It's nice to be up here with you guys. Thank you. I always feel like I've kind of snuck up here. Shout out to Brian and Ken. We've been doing this for a while, and it's really helpful. I'm going to give some props to Ken, too. That study made it into nature. Wow. Let's be honest. That puts us kind of on the playing field with our colleagues who have been publishing all along here. We're quoting all these studies out of the surgeons. And so good job, great job. And it didn't say it didn't work. It's like steroids. So maybe we dropped the cost down and we study it properly. There are probably ways to do that. And we've been doing some stuff looking at ACP and the different cytokines and who does well. And we're seeing some benefits. We're not finding the answers. But study this stuff. Try to understand it. I think there's been a lot of good pearls here. But thank you, everybody, and thanks for having me. Ken, I hope you're watching because that was badass. So very good. Okay. So I guess as we come to a close, this is a competition, and there has to be a winner. And so I do have a prize. This is knives out today. So I have a prize. And this is the knife that goes to the winner. But I just do want to say before I give the knife out to the winner today, we do have some gifts for everybody. I didn't know what to get, so I got snow globes of New Orleans for everybody here. So that is what they have. But I think today, and partly because I have to work with the guy the rest of my career, the winner today is my writing partner and colleague, Dr. Moley. Thank you. You look great.

musculoskeletal care

surgery

non-surgical management

rotator cuff tear

hip pain

conservative approaches

pain management

patient preferences

physical therapy

injection therapies

ACL tear