Welcome, everybody, to this year at the Academy meeting, and this is the course that we're presenting for you. It's called Understanding Joint Structure and Function to Improve Patient Outcomes. I'm Joel Press. I'm the moderator and kind of arbitrator here today, and I have a great group of panelists here who we're going to discuss kind of in the fashion of ESPN around the horn. We're going to kind of look at the musculoskeletal version of that, and what we're going to do today as we try to understand the joint structure and function, particularly looking at some cases of the knee and the hip, is we want to present some cases to you, and I'm going to give each one of our speakers today here about 90 seconds to kind of go over that case and what are some of the really important facts and things that they think about when they're treating the patient, and then we're going to kind of open it up to each other, and I'm going to be keeping score here because I want to know how good information they're providing to you guys, and then we're going to have a winner at the end of this just like they do around the horn. I'm going to just take one second to introduce everybody. From University of Washington in Seattle is Brian Krabeck. From Boston and the Harvard system is Joanne Borgstein. From Atlanta is Ken Motner at Emory University, and from the Hospital for Special Surgery in New York is Pete Moley. So welcome, everybody. I'm so glad to have you all here, and we're going to kind of get right into this because we want to really spend the time talking about these cases. You know, you guys have really been selected to be the panelists for this because you're all really musculoskeletal physiatrists extraordinaire. This is what you guys do all day long, and these are kind of the typical patients that are going to walk in your office, walk in my office, and walk in a lot of the members of our academy. And I think to have the opportunity to kind of pick four people's brains at once in a really kind of rapid-fire way is going to be a great way to kind of just get those pearls. And I'm going to be taking notes, and I'm going to be kind of giving credit when somebody makes really good points, and I think we'll have a great time here with this. So let's go to our first case. Dr. Motner, I'm going to start with you, and I'm going to give you 90 seconds to talk about this patient, JF. Let me go to the first slide. And as you can see, JF, there's a 23-year-old professional hockey forward. He's had some mid-season pain, stiffness, and inability to play in consecutive games. Now his contract is up at the end of the year. Now you can't see all this because some of the images are, you know, so-so, depends how big your screen is, but his center edge angle is 28 degrees. The tonus angle is around 2. His tone is great, is 1, and his alpha angle is 75. So we're going to give you 90 seconds to start, and what are your thoughts kind of about these x-rays and kind of some of the options that might be available for this patient? You're on. Thanks, Joel. Well, my first question would be, why is a hockey player coming to see me in Atlanta? But let's assume he's still a hockey player, which we did at one point, and I'm going to assume also that his exam is consistent with his x-ray, meaning he has groin pain, works with kind of scouring and hip motion. And so I don't want to spend a lot of time on that. But what you described sounds like he's having femoracetabular impingement. His cam deformity, as measured by the alpha angle, is 75 degrees. His center edge angle, which is more looking for the pincer type deformity, was not significant. It was under 40. It was 28 degrees. So this is primarily a cam type impingement. Looks like, according to images, he probably has some early arthritis as well going on on his x-rays. So where you described during the time of the season plays a big role. And so we're going to have a conversation about what his best options are. I'm not opposed to doing a one corticosteroid injection into a player like this in the middle of a season, give them three to four days off afterwards, and then allow them to quickly get back into play to try to calm this down and get him through his season. Obviously when you're dealing with professional athletes and contracts and agents, there's a lot of dynamics that come into play that we'd have to discuss. If you ask me best long-term management or possible other in-season management, since my time is running out, I would also discuss things like A2M, IRAP, or a leukocyte-poor platelet-rich plasma injection to try to get him through the rest of his season. Okay, I'm going to give you 15 more seconds and tell me what you think about how would you modify his activity if you did a steroid injection or any other injection? How would you kind of get him game to game? Yeah, so for a corticosteroid injection, I have a 48-hour shot clock on all my athletes in a joint where no activity for 48 hours, then we'll slowly start to load and as symptoms reduce, kind of get them back as we can, maybe about four or five days later. If we were to do a biologic injection in him, it would be a longer time out, at least seven or ten days of rest time, followed by a slower progression back in that two to three-week range, and that's with an intra-articular biologic, if we're treating any of the structures outside the joint, which I wouldn't do with such a short time frame, it would be a much different return to play guideline. Got it. Any other pearls? Anybody else who would want to add to this? We'll give you 15 seconds, anybody. Go ahead, Brian. Sure, you know, I think I agree with Ken, you know, spot on, always in rehab we're thinking about the biomechanical component and the strength, so making sure we get some truncal and spine stabilization exercises would definitely be helpful. So we're not, can try and dissipate some of the forces. And I think for activity modification, you know, he's a forward, so we've got to think about, you know, he's in a high-paced game, can you, you know, maybe he doesn't take face-offs, maybe the time he's in the line gets adjusted as well. Obviously that will be up with the coach, but that's an option to modify his activity so he can still play. Maybe he's restings every other game, and that might allow him to make through the seasons and hopefully through the playoffs. Release the Kraken. Seattle Kraken, NHL's player, the hockey. Okay, nice for the hockey team, we appreciate that. Ken lost a point because he was already bad-mouthing hockey. Pete, anything you want to add to this? Yeah, I think it's true that professional sport has become a big ticket item, and I think that's kind of like the days off and how much skating is doing. So Brian's point is well taken. It's interesting in dealing with a professional athlete and the contracts and how they're very motivated to play, and if you take them out for a week, you know, the team's kind of looking at some of this. There's a lot of factors when you're dealing with these athletes, and I think it adds a level of pressure, but the other level is they're very responsive to treatment. A professional athlete can manage almost anything. It's unbelievable how well they'll do with something that my average human really suffers with. So he's got a relatively congruent joint, he's got the big cam and some cartilage wear, but it's surprising how well they'll do with this, whereas I think my 50-year-old with a similar x-ray is suffering much more in strength, mobility, everything else. It's a different level. Last point, anybody, do you think this guy's going to need surgery at the end of the season? Go ahead, Joanne. I was just going to add to my esteemed colleagues, let's not forget about the soft tissues. There may be other things that we can do to help his joint mobility, and take your pick of those different techniques. And if I were to do anything intra-articular other than steroid, I would, I probably would not, but if I did, I'd probably use prolotherapy to keep the person at play. Same question, how long would you have him off if you did the prolo? 24 hours at most, until they're done being sore from whatever local needle effect there was. Got it. Any comments? Anybody else? Or we'll move on to the next case. We've got a few seconds left. Go ahead, Ken. Yeah, I would just, I don't know the hockey rules, so I wouldn't know what to modify, but I will comment that, you know, we've looked at both NFL and NBA players coming into the league, and the incidence of CAM impingement is at least 75% in mostly asymptomatic athletes coming into professional sports. And so, so like Pete said, seeing something like this is really not unusual for our athletes at all. And kind of letting the patients understand that this is kind of normal for their sport might also allow them to kind of come to grips with what they're dealing with. Brian, you've got 15 seconds. Yeah, just to follow up with that as well. There is some data that suggests that more than 50% of NHL and collegiate hockey players experience hip pain throughout their career. So it's not surprising that he's having this. Go ahead, Pete. Around the horn, maybe, what's your go-to? I think Ken's point on the steroids is something that we did a lot of. I would say we've morphed a bit into it and some of its player desire and things, but I think if you, this player comes in today, we do ACP and Nuclexa is our current treatment for these players. And it's not a small number of players we're doing it on. Again, they respond better than I, I don't think it's a good study. When you look at outcomes of professional athletes and things, they tend to have a very high return to play, but they're incentivized to do it and they'll play on much more disease than most people. But that's kind of what we're doing. And the rest of the panel, any, you see someone like this. Yeah, I would also comment, you know, we were, I was involved in a large industry study looking at viscose supplementation with hip osteoarthritis and we discontinued it because of failure to reach any kind of improvement halfway through. And so the data just hasn't been there. So I don't do, I don't do visco and these sorts of patients. Nor do I. Yeah, I'd have to say I would probably be similar in, yeah, I'd be similar in the fact that I'd probably try a steroid injection, knowing the risks and benefits of that, perhaps to get them through a little bit. I think at the end of the season, they're meeting with our surgeon because there's, there's a lot of structural things there that have to be corrected. And in terms of. All right. Go ahead, Joanne. You get the last word here in the last. Last word is if I were thinking about which injectate, I certainly would do an ultrasound of the hip on the spot and see if there's an effusion and that might influence which biologic. And I agree about the visco in the hip. Not, not doing it. Great point all around, everybody. You know, Ken, you've got, you got down a point there because of bashing hockey a little bit, but we gave you another one back there at the end with the visco condom. Good thought on that. Again, great points from everybody. I think that you're getting the sense of what you have to do. And this is a little different type of athlete and how you want to do things in the middle of the season. You got to be kind of doing some of the things on the run and then you can kind of make some other decisions later on. Excellent job, everybody. We're going to go on to our second case. The second case is D.O. D.O. is a 60-year-old active male, pull up the x-rays. This is for Joanne. Joanne, you're going to start this one for us. But a 60-year-old active male with many years of off and on knee pain. He was treated six years ago with Euflexa, we just talked about, with no results. He's lost 30 pounds and felt better, congratulations. And he comes in with these x-rays, large, tense effusion, unable to walk without pain. The MRI, which we couldn't put up here today, but it does show some mild medial compartment arthritis and moderate patellofemoral arthritis. These are the x-rays that you can see. And so kind of what are your thoughts about this knee and the alignment and, you know, does that effusion kind of change your treatment, what you're thinking about? 90 seconds, you're on. Thanks, Joel. This is a dense case, so I'll try to be very brief. Number one, you've got to look at the physical exam, make sure there's no joint effusions elsewhere. And this is an isolated occurrence. Second of all, the alignment looks reasonably good. The majority of the OA, if there is some, is more in the patellofemoral joint. We usually get weight-bearing views, bent knee views. Sometimes that shows us more arthritis than we anticipate by just looking at these static views. As I would teach it, you know, someone comes in with a big effusion like that, and it's seemingly out of proportion to the x-ray findings, and if there's no history of trauma, I would be inclined to think beyond just the osteoarthritis diagnosis. And before I would go down that treatment pathway, I might do a diagnostic aspiration, and I might get some blood work to rule out other autoimmune. I might do an ultrasound on the spot and look at the cartilage for gout or pseudogout. If he's overweight, he may be a little bit predisposed to have gout in that knee. It's less likely, but it's certainly possible. In addition to all of that, if that kind of leads me back to, well, this is symptomatic osteoarthritis, patellofemoral predominant, and if the sort of the functional limitations and pain, you know, corroborates with that, I would certainly start him with a physical therapy program. I'm not hearing that he has a regular exercise program. And you can go down all sorts of different things in terms of looking at his alignment, his quad and hip strengthening program. Some patella taping in this world can be helpful, and maybe even a positioning brace, being careful with the depth of the squats. And if I got way beyond that one, and we're still talking about symptomatic predominantly patellofemoral OA, that's a tougher one, I think, in general to get a great resolution with orthobiologics, and I would counsel the patient on that. We would probably try it, but I don't think they generally do as well as a more standard medial and lateral compartment osteoarthritis. So I'm out of time, but. Got it. Okay. Time's up. Brian, any other options that you could think of that she didn't cover? She covered it pretty well and got a number of points there. Yeah. You know, I think, again, to emphasize the point with exercise, right, you want to make sure he's meeting the ACSM guidelines, right, 150 minutes per week of moderate exercise, as well as strength training, and shape that within regards to his goals, right? We mentioned a little bit about weight loss, which I presume is what he's been trying to do as well. I would have a good conversation with this patient about what their goals and activities are and start out, like Joanne mentioned, with really focusing on the biomechanics, the lifestyle issues in regards to exercise, nutrition, and help him understand one of the best ways we can decrease that pain is by decreasing the force to that knee through the loss of weight. Okay. Ken, biologics, going to help this guy? So I agree a lot with what Joanne said, unfortunately, so I can't get points for disagreeing. The telefemoral joint doesn't do as well with biologics, yet I do think that with intensive fusion, I am also inclined to drain the fluid, send it off to the lab, and look at those results. We've also seen a few biological cases that have maybe gone the other direction where they've kind of flared up with pseudogout or something else inside the joint. So I would probably want to know the answer to that first, and maybe put, you know, we use very small doses of corticosteroids still in—in—at times in clinic. We know they give short-term benefit and not much moderate or long-term benefit, but if I'm gonna drain a knee, I'd probably put a small dose of ototoradol or a little corticosteroid in the joint, and I've said that twice in a row now, and I don't do that very often in my clinical practice, but at times, I do think it can be worthwhile to do. The only other thing that I haven't heard mentioned was to maybe look at, you know, shoe wear and orthotics, and—and, you know, I always talk about correcting the imbalances from above and below, and seeing if there's a way to modify what he's wearing from a shoe point of view. That's good, and you do get a point for being honest there, too, so we do like that. Anything else you would be different? I—I think the answer's been very good. You look at a knee like this, you see relatively maintained joint spaces. Getting to the structure and function, you've got to start taking it out of the box, like why is this knee failing, and Joanne's on par—on spot with like, look around, take the fluid, send it off. Well, there's another thing. They have short-eric arthritis. They have some other disease process. Why is he getting this large effusion? I'm gonna jump on Ken's back, and I—I—I'm not completely against steroids in my life, and sometimes a little bit without effusion, you know, what do you do with a large effusion? You can drain it, but they tend to come back a lot of times, so you go through the whole panel like Joanne did, really well thought out, and then you have to say, if the effusion remains, what do you do about that? I just throw in, I think, and Joanne mentioned it, you've got to look up top of patellofemoral disease. That's a hip-related problem, and proximal rotational control, stairs, getting them into that, and I think his 30-pound weight loss was very helpful in why he was away for six—for six years, but all good answers, everything new. Ryan, you rebut. Oh, no, I just want to—I just will go on—on—on record, especially since Joanne was my mentor, so I think I would totally agree. The number one thing you have to do is figure out why that effusion is happening, like that's a—that's a given from there, but then once we kind of get past that, I think, again, the exercise, the biomechanics comes in, and, you know, every once in a while, these people want surgery, and I think that we should just make it pretty clear that, like, surgery is not in the picture for this person, assuming that it's just mild arthritis. Yeah, good point, but no points for sucking up unless you're sucking up to me, just to make that— Very well. At least I didn't lose any. You didn't lose any. One quick question for the panel. If you're going to drain this person's urine, and you're going to take fluid off, and it's a little cloudy, not really, do you put the steroid in then, or do you wait until you get something back on the fluid before you put the cortisone back in? Joanne, you started it? Yeah. Yeah, I think if I—if I didn't see any crystals, you know, if I didn't see either gout or pseudo-gout layering out, and it looked more like that slight, turbid, non-inflammatory, non-infectious type fluid, low-level inflammatory, I think I would be okay putting some steroid in there. If it looked very turbid, and I was concerned about something—inflammatory, I wouldn't be so worried. It's something infectious, low-level infectious, and that I wouldn't want to put steroid in. Any other comments from the group? I'd say something, but I don't want to look like I'm sucking up. Yeah, I mean, the gout or pseudo-gout. I would only comment that, you know, the gout or the pseudo-gout certainly wouldn't scare me away from putting a corticosteroid in there. Okay. Very good. Again, excellent points. And again, thinking about a big effusion like that, is there something else going on? And I love the point about always thinking above and below the chain, because this is probably more of a good thing than really anything that got into the patella-femoral joint. The other big point I think you guys brought up is, you know, this is more patella-femoral maybe than even tibial-femoral, but who knows, the fluid will make a big difference in getting it to you. so great points all around a little sucking up going on but hey you gotta do what you gotta do again all right we're gonna go on to the next case the next case is for Pete and this is JB and let me get the x-rays up here for everybody JB is a 56 year old tennis player who comes in with five weeks of right hip pain and no prior history of any pain at all before that this is the first time no injury history but her pain is quite severe she has seen two previous physicians not really had any therapy but she's concerned so what are your thoughts looking at these x-rays and kind of where are you going to go with this lady what are the options 90 seconds so i think the first thing in this x-ray thanks joel is that you know looking at your right and left hip there isn't a large significant difference between the two of them what worries me in this hip is is the lack of coverage i think in what i see in hip that fail are dysplastic hips uh either post-surgical and there's missed or someone has dysplasia and they tend to fail fast there's a very good article out of mayo that looks at you know cam no cam and dysplasia they're already five years old one hip is replaced and they kind of follow them out and cams and no cam do about exactly the same but dysplastic hips rapidly decline second point is if you look at her way she has arthritis there's asymmetry in the joint so congruency plays a big role it's a big term in the pao world but you don't hear that much in arthritis but there's a lot of finite element studies looking at congruency and a lack of congruency increases joint force so when i see someone like this i've got my radar is going off i mean i've got the basics in my mind i want to shut down their activity load management get them into physical therapy but i'm having a con you know a lot of thoughts about this is a joint that might be failing very rapidly i'm not going to i never you know steroids and dysplastic hips are are dangerous and she needs counseling when you look at this and we need to be pretty aggressive on hey this joint may be at the end of its life even though she's young and it's recent pain be very cautious of a dysplastic hip with with a non-congruent joint they are like a hornet's nest of problems another 30 seconds peter and a follow-up so a big question is on the rehab that these people get that's it's very typical for people you got a hip problem they really work for range of motion anything specific you're going to tell the therapist on this one so typically a dysplastic patient is going to have a lot of motion almost too much motion on bad cartilage so in hss we tend to order maybe an inordinate amount of mris and it's shocking how much car loss they have and only five weeks of pain so mobility isn't usually the problem when they lose mobility then that hip is complete is is there's almost nothing you can't solve itself this plastic hip with no mobility that's the end you look at them their bone edema it looks bad you got to look at the abductor and strength that they overload it naturally they're typically weak there they're playing tennis and cutting so really abductor strength control is super important in these patients um let's take a let's take on to that joanne for 30 seconds what about activity modifications for this type of patient they're in pretty severe pain what would you let them do over the next couple weeks as you try to get things calmed down at this point uh given the severity of the pain first of all i would check to see if there's an effusion and how much uh you could do that easily on ultrasound and although i wouldn't do it long term if there is an effusion i'd be inclined to do a two-week course of an anti-inflammatory medication and then i would try to just reduce the uh the weight bearing type activities that anything that involves cutting and and stopping and starting and lunging and rotation so i'd certainly at this point cut her back from her tennis and allow her to walk or do exercise that she is you know basically comfortable with um okay recurring theme that you're going to see obviously in all these cases is where do biologics fit in here if at all and if they do what would be the timing on it kind of want all your opinions we're going to start with 10 30 seconds um so a few other thoughts before i get to that although i don't have much time is in general right i mean this patient is 56 for a couple reasons they're not a candidate they're not a candidate for arthroscopy um you know we talk about joint space of less than two millimeters it's hard to say if that's there or not um we know if you're over 40 you have a three times higher likelihood of having a poor outcome with arthroscopy um as if you're under 40 um and so if we're looking at the end stage treatment of this uh you're right we're looking at hip replacement or potentially hip resurfacing dependent on your current views of that um biologics is a very tough conversation in these folks because uh they don't tend to do as well and i have a lot of people coming in and asking me about them and so i give them my honest opinions um this patient does have fairly uh main does have some joint space left and they do have well-preserved motion even though it's probably secondary to the dysplasia those are the folks that i will offer a biologic to when they come in with no joint motion like maybe a case later or reduced motion um i tend to not really even offer the biologics um but i still give them maybe a 60 success rate um and we're kind of kicking the can down the road until probably we'll need a total hip replacement brian anything to add you know well i think the main thing which we haven't really touched on but we've all kind of jumped to the hip but you know she's had five weeks of pain let's figure out what the soft tissue is in addition to that so i think all of the points are excellent but let's bring it back to the patient what's going on probably the other thing i would add is just like a little bit more about how to modify tennis right is she playing singles doubles what level is she there there's some some ways we can modify what what surface is she on um again she has a a joint that is uh degenerative and we're going to deal with that but if we could maintain her her level of exercise and enjoyment of tennis by modifying some of those things right we know there's less stress less running around or she's playing doubles versus singles we may allow her to prolong the activity that she she would like to participate in until she may eventually need a hip replacement great points we have to give you some points back for the sucking up on that one by bringing us back to the soft tissue so that's excellent see i was trained very well by all of you there you go again any other comments anybody wants to have on this case before we move on to the next one we'll give you 30 seconds to kind of make any other general comment go ahead i was just going to say soft issues agreed also obviously need to look at the lumbar spine and this is a tough discussion if you're going to talk about biologics you have to be honest that is probably only going to give you short-term relief but you're a little young for a hip replacement um our surgeons would like us ideally to get people out to age 60 um it gets you know easier uh with each decade in terms of long-term outcome but it has to be a very informed uh honest discussion so i'll say two quick things i'm not against using crutches in some of these pages i i think that we under treat our patients so you have surgery you're you they're they're in on crutches they're wearing braces they can't do any for three months we make it here here's our shot and go back to your activity so i you want to make it serious and i'll put them on crutches sometimes number two it's interesting i seem to find that soft tissues react to the bones beneath them more than soft tissue is the problem so i'd be very interested to see what this hip look like if there's a lot of soft tissue in this hip i'm more worried that there's the joint failing and the soft tissue reacting than the soft tissues the joint i'm sure i want much more motion just a just a thought okay yeah i think i agree the only other comment that i was going to yeah i was going to say the only other comment i was going to make taking us to the beginning of the case and when residents and fellows are presenting patients with hip pain you know it's all about location right i mean i always want to know where their pain is um if they're having anterior versus lateral versus posterior pain it's going to point me in very different directions for what structures might be causing their pain and so i don't think we were it was really explicitly said where their pain was initially uh but like we've alluded to and i know we all do this you know i want them to start telling me where the pain is so we can start honing down on what structures often refer to that area and i totally agree with pete and this is another thing i preach to my my fellows and residents that you know don't look at just hurt and look at what's underlying maybe call the thing to react and i do find the deeper things like the joint are often the thing that's failing and and we should start with the deeper structures a lot of the time again great points of bringing us back to the history and the physical examination to kind of get things started and you know we're kind of going right to the x-rays here to kind of move through it fast but it's again a great point you know what are we dealing with as you're going to do the diagnosis and work it up and i think the other great point about this is five weeks let's relax there's no reason to you know jump into anything too quickly even though if they were a new york patient they're going to want everything done three weeks ago already so let's move on to the fourth case here this one is going to be for brian and this is ai and not artificial intelligence ai is a year old 50 year old active woman with six weeks of left knee pain she's a runner that does 10 to 12 miles a week crossfit exercises five to seven times a week she's got left medial meniscal surgery two years ago she has a small to moderate effusion on her exam and her mri shows that she had had a subtotal meniscectomy and significant cartilage dots so brian 90 seconds what are your thoughts about this knee the alignment at all and with that history of meniscectomy kind of concerns for long-term health sure so let's unpack this a little bit here again she's had six weeks of pain so we need to put in a little bit of perspective and dive into a little more of the history and physical to figure out what's driving all this as mentioned in the previous case though we do see structurally she has some underlying narrowing in that medial joint maybe a little bit of a ferrous deformity involving the knee and we know that can put her at an increased risk for progressive arthritis so we want to you know try to help adapt to that as well you know anytime someone has prior meniscectomy and sort of assuming she had it not as a child but but always two years ago so you know the more you take out of that cartilage right that's that support in between the two bones that you're going to have a chance for increased arthritis in that area as well so we have to think about it again about load management in regards to her lower extremity itself her treatment options come into play or depends what she's doing you know she's doing a lot of she's running she's doing crossfit this may be too much of a load for her in regards to that so i'd have a frank discussion about like why she's doing is all these exercises and how they fit into her general health program and maybe we can make a shared decision making in regards to how much activity is is appropriate for this but and then what's her goal in regards to long term because if this continues to progress it could lead to the potential for a knee replacement i think like all of us as physiatrists we want to look at the biomechanics above and below as well and then this is where some of the various injections come in i'd be really cautious about putting steroid in there knowing she had cartilage meniscal loss and cartilage load loss some of the orthobiologics come into play as well and i definitely would try to avoid surgery on her good let's talk about the orthobiologics again that's always a hot topic and let's say that it's now you've gone to physical therapy for a while a little bit better um is she decreasing her exercise you had the conversation with her but she is from new york so doubtful that she's really cut back at all so pete that let me ask you when is any kind of biologic appropriate and what would you even consider on her if anything oh so so i she's an interesting you know interesting case i i worry when you take out the meniscus so a 30 meniscal resection is i think three times increased load through that compartment of joint it's a shocking amount of change and so some meniscus is always good and she doesn't have a lot of meniscus so she's loading into that you know we can get a lot of mris again you know bone edema failure of the joint is something that would make me believe that she's in big trouble if she doesn't you know looking at biologics i think you know the acp tends to have the most research um looking at joints uh and i think that that's probably what i would consider in something like this if i did a biologic after therapies and and you know just a lot of diffusion um i would put her an unloader brace you know the the the the varic knee is very receptive to that so you do a procedure you unload it they typically i've had the most success doing that i wouldn't say it's the majority of my patients getting uh acp but that's where we've gone as far as the biologics in our in my practice does anybody want to add for 15 seconds yeah i just want to just yeah i just want to say assuming her pain is medial uh the delivery choice of biologics and where you put it i think can be very critical so in addition to an art intra-articular component to this they're very melt maybe meniscal extrusion tenting of the mcl has tendinitis there are other things on the medial surfaces of the knee that could contribute to pain and i would suggest that we include those in any biologic treatment that we do sometimes we address the meniscus directly but if it's extruded enough it may not be as helpful so it's not only what can your response um yeah two comments i'll take 30 seconds so uh the first one is we haven't discussed today but when people come in with this sort of story i always have a supplement discussion with them as well a lot of my patients come in asking for biologics so they're very much not into anti-inflammatories and so um if you haven't read it there's a great bjsm article from 2017 which really outlines all the meta-analyses on randomized controlled trial of supplements and things outside of glucosamine and conjoining which only have kind of mild to moderate evidence for it and not not great but things like curcumin and boswellia extract and vitamin d and these collagen denatured collagen products and all these things so look at that article if you could but i found a lot of my patients benefit from that and to pete's point though on the biological front i want to disagree since that's fun and say that uh you know i would go with the leukocyte poor kind of double spin method of prp um over the acp you know the goal of acp it has low neutrophil but it doesn't have a very high platelet count sometimes only two or three times baseline whereas you know our our double spin leukocyte poor prp you know can get five to seven time platelet concentration and if you look at brian cole's study where he looked at all the different formulations uh he found that leukocyte poor prp was the uh seems to do the best with knee osteoarthritis great you actually do get one point there for disagreeing even if you're right or wrong i don't care but you disagreed so you get the point brian you had a point ah there you go let the games begin so you know we we often go to this what's the concentration and this stuff but we don't have the research to really really truly support the clinical outcome so i think it's a well point it intuitively sort of makes sense if you could have more of those growth factors there but but i think we we need to acknowledge that perhaps there needs to be a little bit more research and to link that truly to clinical outcomes the second point um not necessarily in this individual but just for those of you who are involved in sort of olympic level athlete um really cautious about supplements you know global dro is a is a website allows you to look at various different um products but but for those who get doping testing we want to make sure and certain types of athletes that that we're really cautious about providing supplements because that can get them into trouble so thank you for disagreeing and you sucked up to me by disagreeing but you do get yeah right so on the supplement front you know look for that nsf certification on there which which should make it a safe supplement that's what most of the organizations go by um i agree with that point and since we haven't talked about stem cells certainly that would be a discussion of what sort of inject they maybe go beyond prp i i do tend to mostly start with prp in these uh patients um and then you could have a discussion about a cellular injection of either fat like lipogens or sorry micronized fat uh versus a bone marrow asteroid concentration even less data than there is for prp um but in in our clinical practices we've been doing it for a while and tend to see a little bit longer outcomes than maybe with the prp alone which the effects around 12 months tend to um dwindle ryan you wanted to respond i could see yeah i just say uh even though they're you know just to that supplement um no supplement is 100 analyzed so i think you still got to be a little cautious there's ngbs that definitely will stay without 100 but ken's point is at least if you can look for something that's been analyzed you're more likely to feel confident but but just to emphasize it's never 100 that that these may not be tainted i want to go ahead pete i just think in talking to your patients too what are you saying you know i got a lot of people flying in for all these things and they talk about building new cartilage all these shots i think you can make a statement that now at this point we have not no one has built more cartilage or obtained more cartilage from any injection there's a study recently out of stanford where they look at building you know forming cartilage and rabbits and it was like a triple quadruple drug therapy they shut down their immune system they we're not going to make cartilage and people with one shot any time in our lifetimes i think you're looking at multiple things a lot to take place to make it come about so i think to be careful what we're doing we're making environmental changes so how many cells may make a big difference may not we're not sure and i think that's the thing is just be honest the patients are informed them i give as much information as possible i try to take but a lot of to then discuss your clinical approach but we tend to focus a lot on therapies i tend to look at these knees this is a worrisome knee with a medial side and try to look at where where your win is going to be where your loss is going to be when i try to pick winners they're going to have a better outcome because it's expensive and i i want you know i i hate when people don't do well it's upsetting so where are you going to win we're not the one case like where you're really going to win seven or eight times out of ten that's what we should be trying to find not i'm going to i'm going to move this conversation a little bit i'm going to give brian 15 seconds and then ken because you had your hands up and then we're done talking about biologics for a while but you get 15 seconds a piece and i'm going to turn the conversation a little bit go ahead brian yeah sure just to emphasize what pete said you know like the reality is we should be calling these slow degeneration clinics because that's what the research suggests but that's not as sexy as regeneration clinics. That's my only point. I like the term. You get a point. Go ahead, Ken. So I agree. That's what the literature says for anything that's FDA approved in this country. There are culture expanded studies in other countries that have shown a small amount of cartilage regeneration, 20% or so in knees and some other areas. So I do think that regenerative medicine in this country is not regenerative at all, but we are working towards something for the future. All right, Pete, I'm gonna give you five seconds just because you're my partner, but okay. One quick thing. Just, you know, my analogy is always to cancer. Back in like the 60s and 70s, people were going to Mexico and Central America for special cancer treatments not available in the United States. Just be careful. If you have cancer now, you go down to Mexico, I'll yell at you. You go to MD Anderson, you go to these big Sloan Kettering, you go to Dana-Farber, you don't go out of the country because scientists looked at knowledge. So we need to improve the knowledge and I think it's gonna come out of big centers like Emory, Harvard, Washington. It's not gonna come out of little centers. Keep that in mind. I don't think it's going, they just don't have the scientific power. The salt studies on cartilage regeneration out of South Korea were done in good centers with numbered cells and followed with MRI mapping and didn't show sustainable, but it showed improvement in cartilage for one to two years. And we're just not there, but that was good science. All right, we're gonna go old school for a little bit. Now we're gonna go old school, I'm cutting you off here, Brian, just to keep it moving. Because what I wanna get to is, obviously the biologics are important. I brought it up like four or five times already, but let's go back a little bit to this patient in particular. And I wanna talk like 1980s, like when I started practicing. So there was no such thing as all that stuff or maybe not in the United States. What are you gonna tell them or what are you gonna tell the therapist if you've got like one or two exercises that you said, boy, this would be the most important things that we probably do for this patient at this point? I'll give everybody a chance to kind of chime in on that, but kind of let's think about it from an extra standpoint. What are the key findings that you think you're gonna see on this exam that you think need to be addressed? Whoever wants to go first, raise your hand first. I'll just take a stab at it. You're on. Most of the time, especially in women, we gotta look very hard at the hip and the control of the hip and femoral adduction during controlled squat, lunge activities. So in addition to whatever we do for the knee, we are very big into looking at the hip. Very good. Brian. I agree. We work down the whole kinetic chain. So look at the hip, look at the spine, but also the foot. There's some thoughts about that interface with the ground and we need to think about how the person perhaps is landing if they're into running, looking at step rate, looking at the flexibility and strength in the foot itself. I would add that in addition to the hip and spine. Any particular finding that you're seeing in the foot in these patients? Anything that jumps out? Well, a lot of them focus on stretch. They say, oh, I stretch and strengthen. I find that people have some inflexibility around the ankle joint, which I then feel changes the dynamics. So I like to focus on getting a little bit more flexibility around the ankle or even the great toe. Sometimes these older patients have had some arthritis in the great toe and they don't appreciate how much that plays in the running biomechanics. And if there's a bony block in the osteophyte, there's only so much you can do, but there's subtleties you can make in regards to those two areas that could be very beneficial. In addition, just Irene Davis, just to follow up on your foot, we do look at their foot core strength on every patient. So we'll have them rise up on their toes and look to see how they control their foot and ankle and can they do doming and do they flatten out? So we've become very enamored of that foot core paradigm up in Boston as well. So spot on, Brian. Oh, now you're sucking up to him. That's good. No comment. So, you know, back in 1980, no one was looking at the hip, right? Not till Joel started telling people to look at the hip did people start actually looking at the hip, which was I think in the early nineties, maybe. That's my suck up to Joel for this lecture. But what I will say is back before we were looking at the hip, there was evidence and still is evidence that quad strengthening reduces, you know, knee osteoarthritis pain. And so in addition to the hip, we do want to work on quad strengthening as well. I think that gets into two issues. Load management, I think it's super important and it's a long discussion. You're doing too much, crossfit, all these things, bring it down. You're running five miles, go down to two. We really reduce the load. And eventually I think we'll have wearables that help us there. If necessary, I think the bracing can be helpful. And I think, you know, into the quad, it does get into controlling effusions and those will shut down your quad. And so to Ken's point, just try to get the environment of the knee better too to be successful. Sometimes that can be also very helpful in their recovery. A chronic effusion will keep their quad strength down. Brian, you got 30 seconds. I thought Ken was actually going to say he hadn't been born yet, but that was true. But he's so smart. Anyway, I do think Pete hits the heart. I was seven. No, I think you're seven at this time. Okay, no comment from me there. I think load management is a key thing, right? If there's somewhere where we have a knowledge gap is what is the exact load management for rehabbing these issues? I mean, I think that's what the future holds is trying to figure that out. We all see patients and it's all about return, right? How do I maintain activity or return to play? And we don't quite know the load. I mean, we have some basic understanding, but in that rehabilitative process of load management, that's where I think we need some really good research. Yeah. Back to Pete. Ken, you get to end it up there? Yep. Yeah, so just on that comment, right? We used to always talk about, we always used to talk about less load and doing less, but joints, just like tendons and soft tissue need motion to heal. They need motion for chondrogenesis to occur. They have that, so the interesting MRI study is looking at people who run ultramarathon and actually can get a little bit more cartilage when they're done based on loading the bone and the cartilage underneath it. And so I agree with what Brian was saying. We need to rethink about what the right load is for these athletes. I was just gonna say, since I don't know how many of you were practicing in the 80s, one thing that I told them that I still do is if the next day you're worse and you have an effusion and it doesn't get better, that's pushing it a little too far. So I still use that as a marker of overload, whatever that magic number might be. And that's a great practical point to end that one on. Thank you. Okay, we're gonna move on to the last case where we're doing a great job on time and I think we're down to our last 10 or 15 minutes here. So the last one, I think we're gonna throw it back over to Ken and this is RR. RR, and let me bring up the first slide. There we go. RR is a 65 year old active runner, cyclist and rock climber. Right hip pain for about three months. It's a constant six over 10, groin and lateral. So at least we remember to tell you where it's at this time with an occasional limp. The x-ray show the lateral central edge angle around 30, tonus angle of 10, a grade two tonus with some cysts in the acetabulum. And the MRI shows really significant cartilage loss and synovitis. Hard to get that up there, but a lot of cartilage loss and synovitis on the MRI. So again, kind of overall thoughts looking at this and hearing the story and where you might go with this patient. Yeah, so we've already unpacked a lot about the hip. For this patient, the one thing that wasn't talked about was his range of motion. So this isn't a dysplastic hip. And so the lack of motion in that hip will often kind of maybe be a predictor for me and definitely dictates what I recommend to this person. They're 65. It sounds like the rock climbing, which the positions you get in can put a lot of strain on the hip with some of the internal and external extremes of motion that occur. So that might be something to look at. And the other thing that we see sometimes in these folks is that they have this kind of progressive kind of decline in their hip joint or the hip structure over a relatively short period of time. And so I'm gonna start with the basics that we talked about before. I'm gonna work on range of motion of the hip. I think that's important that they lost motion. We're gonna work on strengthening their hip abductors. We're gonna look at their kind of biomechanics. I like to tell these people to avoid things like squats and lunges and deep kind of activities for the groin and the weight room to try to keep them active with more functional things that they are interested in doing. Obviously, we're gonna look at the back as well. And then we might get into a discussion about what his options are. And at 65, my line is, I'm never gonna tell you when to get a hip replacement. You're gonna tell us when you're ready. But if you look at the orthopedic evidence out there for someone who's failing conservative treatments for a hip at that age, it is far and away the most effective long-term treatment strategy, but only when they fail the things that I have to offer them. Other comments? Pete, what would you do? What do you think? Yeah, 65, I think Joanne has brought this up before. You gotta look up top at his spine too. We do a lateral hip on everybody and we look at the pelvic tilt and spine stiffness and how much load that might bring to the hip. So as Ken was saying, I wanna get motion. I wanna make sure that the spine is mobile too so they can get in the right position to their hip, particularly a rock climber running. My favorite theme is load management. He's running. And the one thing we haven't really talked about, but I do a catastrophizing score on all my backs and hips. And it's really helpful sometimes to look at where does RR look at his life? Is he a low catastrophizer? Is he bothering me? I still wanna run a little bit and climb rocks. Or are they a high catastrophizer? The worst thing that would happen to me? And then you kind of have a conversation with them. What makes you happy? What is enough to be happy? And work with them on that. So I kind of look a lot, I look on everybody above. We do a lot of measurements here. We like to measure things. And look at it and say, you know, he's got a congruent loss of joint space. It's not, you know, there's no, no, it's not. The congruency to me is a good sign. So he's kind of survivor. He's got an ugly looking hip, but he looks like a hip that, you know, if you do the right things with the range of motion, the strengthening, look above, below, and you modify him, maybe you can get some time out of this hip. You guys know this guy is gonna definitely ask you, can't I put that stuff in there to regrow my cartilage? Everybody's told me that's the thing to do. I mean, I don't wanna keep going back to it, but you know, that's what they're gonna ask you. What's your answer? Would you do it? Go for it, Joanne. I would say that that's a good question. If he had well-preserved range of motion and he understood the parameters of what we can accomplish and what we can't, and we've tried other things, and yes, I would offer him a biologic. With a lateral hip girdle pain, although it certainly may be intra-articular in the lateral hip capsule area, I would look closely at the gluteal tendons just to make sure that they're not also involved. And with the limp as well, although it may be from hip joint pathology, if there's a little bit of a Trendelenburg, there may be a gluteal tendinopathy that would be extremely amenable to biologics. Ryan? Oh, go ahead, Pete. So yeah, I think everyone brought up some, okay, Pete, go ahead. I think you were gonna comment on. Just on the gluteus medius, we replace more hip stenosis in the country, and it's shocking how well the gluteus medius does when the joint has been replaced. So if I see an arthritic joint and a gluteus medius, I never touch the gluteus medius. It's been my big failure because the joint is driving everything, I think. And then when I see these patients, they'll get your hip replaced. If gluteus medius still hurts, I'll do the procedure for free. Just do me a favor. And they never come back. I gotta take this one, guys. Sorry, step aside. Pete, we are here to manage the overall function and pain of the patient. So of course, some patients we think just have intra-articular pain and all the referral to the buttock and to the lateral hip is just part and parcel of that. But if you have a superimposed extra-articular process that could legitimately contribute to the pain, I see no reason. And I would strongly advocate and teach that we treat the whole region. Now, my last- Go ahead, Pete, you can respond to that. You get 30 seconds. She came at you. Yeah, so good point. And I'm not trying to make everyone suffer. I'm trying to make many people suffer. I do think that you get to that kind of layered theory that you start at the bony layer, you look at those kind of soft tissues, you look at the dynamic layer, and you look at the nerves. And you gotta be, that's all gonna go with your head. I have historically just found that that lack of motion, everything else, lateral pain to me in the face of arthritis has not been my most successful. When we did our study, it was the failures were either L5 radiculopathy or arthritis that we underestimated is where people seem to fail. I 100% agree, but that's only if you just acknowledge the tendinopathy. I think one, I'm agreeing with you. Essentially, you have to acknowledge all of it. And since we're not sending him for a hip replacement, we wanna get the most out of our biologic treatment. Okay, before we end, we only have a few minutes left. I really have like one or two other questions that I just kind of wanted to make as a general thing. Because again, we're talking about the hips and knees here. And again, I wanna go old school on my last couple of questions. And as musculoskeletal experts, and you guys really nailed it on all of these about really some of the different options we can go about. The one thing we probably didn't spend enough time on is the history and the physical exam. And I guess I wanna ask you, each one of you get to end with just one or two things that you would tell your residents, your fellows, anybody, if you're looking at a new hip or you're looking at a new knee, what are one or two like pearls that you've learned over there? This is like a go-to thing that I like to use when I'm asking a question or doing something in the physical exam. We'll go around the horn here. Ken, you get to start, then we'll go to Pete, and then to Joanne and then Brian. One minute. Okay, well, first off, I'm glad that, I mean, this has been great because I'm glad that around the country, we are all doing very similar thought processes, it seems like. So that's been great about this, that four centers, four different backgrounds. I haven't trained with any of you guys and we're still doing a lot of the same stuff. So, the one thing I will tell patients, the one thing that fellows miss a lot in this area is when I'm examining a knee, I always check my hip range of motion. And a lot of time, people who have hip pathology will have isolated knee pain and no hip or groin pain whatsoever. And so especially with lateral knee pain sometimes or vague knee pain, always move the hip around, always look at the hip as it could be the source of their pain. And if you have in the, even if they have any arthritis, if they also have hip related pathology, we gotta make sure we recognize that and we treat that. Otherwise, a lot of them won't get better. I have 15 more second, but that was the first thing I thought of. The other thing is, hip x-rays, always get standing hip x-rays in your clinic. You can see so much from a standing hip x-rays. When people send me $5,000 MRIs, I still wanna get a standing hip x-ray because that gives me the most information about somebody's hip joint that I could get. Pete, 30 seconds. 30 seconds. So number one, limping is a very important feature. We know you can kind of spine hip. A lot of tracers are three times greater that if you limp, you have a hip problem, not a spine problem. So fellows are always going in there and they're complicated patients, a lot of people, and they're getting confused. And sometimes they're confused too because a good history still goes a long way. You gotta listen to them and that's what's going on, where's discomfort, location, why, and just drill down on those things. So I think the two things to think of are a really good history still gets the diagnosis most of the time. And then if they're limping, think more about the hip than the spine. Joanna. Great points all colleagues. I would just add a couple of things that I'm stickler for. One, get the patient completely undressed down to underwear or shorts or whatever the first time. I make a big point to that because you just don't know what else is there that you're gonna miss. That's more of a connective tissue or autoimmune or whatever it is. So I think that's my number one take home point. The second take home point is to not to forget all the information you'll get from functional activities. So looking at gait, tie their shoes and untie their shoes. So really emphasizing not forgetting the functional look in addition to the individual joint mechanics. And Brian, you get to end it off here. Sure, yeah. I think this has been a great discussion too. I think the one thing in the history is make it functional. We all do different movement patterns based on what we want to do. And so connect with that patient through the function and how it's impacting them so that you can help them achieve their goal. Two, the kinetic chain goes all the way from the head to the toe, right? We know that. We have a baseball pitcher who comes in and their shoulder hurts. It could be from their knee. So not just the joint above and below, but understand the entire function of the body and the movement pattern that is causing overload to a specific area. Great. And that is like literally right at one hour. I think we covered almost everything. This was incredibly great presentations from all of you. And you guys were just, you did it off the cuff like that. I think when I have to pick a winner, it becomes very, very difficult because everybody, I think that really the big winner for this whole thing is anybody who sat in and listened to this whole thing. But I guess if I really had to, I would just say that Ken, you did this hockey right from the beginning. So that's going to just hold you back. Brian, you did suck up a lot and not to me enough. And that kind of made me disqualify. You didn't suck up to me at all, which kind of pisses me off a little bit. Plus I work with you. So for sure I can't. So I want to thank Claire, Joanna, Eric Stein, the winner of this year's Around the Horn. I want to thank all of you. This has been outstanding and I hope everybody enjoyed it. And thank you all for your time. This was great. Thank you everyone. Thanks Joel. Thanks everyone. Thank you. Joel, that was fun.

joint pain

joint dysfunction

case discussion

treatment options

patient goals

lifestyle

biologics

evidence

history and physical examination

diagnosis and treatment