This week, we are joined by Dr. Alan Reznik, an extremely accomplished orthopedic surgeon specializing in sports medicine, who literally wrote the book on knee and shoulder health. Pulling from his work: The Knee and Shoulder Handbook, Dr. Reznik shares with us his expertise surrounding joint surgery, treatment protocols, long-term care, and more, breaking complex concepts down to make them accessible for all of us. For David, this was a great opportunity to get more insight into a surgeon’s thought process and key tips to help speed up his recovery.
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“The knee is very smart. It does two things when it’s mad: it makes fluid, or it hurts — or both. In fact, all of your joints are always making a little bit of fluid. When there’s a lot of fluid in the knee, something’s typically wrong. That’s a tip; if my knees are very swollen, something is off.”
“I could take a plug, a round plug of cartilage from someplace else in your knee that you need less and move it to a place where you need it more, just like a hair transplant, right?”
“Once you put a metal plate and a plastic liner on the bone, it will wear at a certain rate. Now the newer materials are very, very good and they wear very slowly. The older materials wore much faster. If you don’t have a super active lifestyle, you’re not a marathon runner and you put it in, it could be good for 20 or 25 years.”
Dr Reznick, great to have you with us here today. How’s your day been so far?
Dr. Reznik: 8:32
Well, thanks first, thanks for having me on the show. Yeah, last couple days been a little busy. I did five surgeries yesterday, I got a couple surgeries scheduled tomorrow and in between I saw patients today. But to loosen up for the show I did a little quick bike ride to loosen up the joints and get myself moving. Heavy, heavy exercise sometimes is a little too much, but a little light exercise keeps me, keeps me going along the day. So I try to sneak in some exercise when I can, once in a while.
Good for you. You’re probably one of the most sensible physicians I’ve ever spoken to. So, dr Resnick, tell us a little bit about your background in orthopedics.
Dr. Reznik: 9:08
I’m an orthopedic surgeon and I practice orthopedic surgeon sports medicine primarily in my practice. I’ve had training over many years and I did my original training in engineering and then came to orthopedics from that direction. So the mechanics of the knee and the shoulder and all the joints and bones was sort of attracted to me. When I finally got that around to that medical school and then it was. I also did carpentry when I was a kid and I taught woodshop and my dad was a master carpenter and engineer himself. So putting all those things together with the love of medicine, bones and cartilage and joints and mechanics all made a ton of sense to me and so I fell in love with orthopedics. And then inside of orthopedics at the time sports medicine was in its infancy and the ability to look inside joints with a fiber optic telescope was just coming to be in a very big way and the understanding of the mechanics of the parts inside the knee were also coming to the to the fore. You know if there was a period of time when they thought the meniscus was a vestigial object and wasn’t even required and you could just remove them willy-nilly and it wouldn’t do anything to the knee.
Make a picture for me when in my knee capsule is the meniscus.
Dr. Reznik: 10:21
So if you imagine the tibia like a plate right and the femur like a ball right or two balls next to each other, right then you know there’s a mismatch between a round shape and a flat shape. So if you imagine a triangular bushing or like washer, that’s triangular in shape so that the edge was narrow in the inside and fat on the outside, you can make the ball and the plate match up. Does that make sense? So if I match the ball and plate shape so now it’s more cup like I can spread the load on the plate more evenly and I can reduce the stress on the point of the ball because not all the weight’s going through the edge, bottom edge of the ball right and that’s what the meniscus does, it shares, it takes. In some cases up to 50% of the load across the surface goes through the meniscus. So if you imagine point loading with 100% versus 50% in the meniscus, 50% on the ball, the ball’s going to last longer if you get 50-50.
And is this loading throughout the range of motion or is it? Is there more loading on the meniscus as we increase the angle?
Dr. Reznik: 11:27
That’s a lot more complicated because the knee is a cam shape, it’s not really perfectly round and there’s a lot of mechanics there. So it turns out that the lateral meniscus actually moves back with the femur as the femur rolls back. So it’s very this is why I was an engineer first right. The mechanics of the knee is super complicated. It’s probably well beyond the course of what we can talk about. But just having to say that it tries to track really nicely with the femur as the femur moves through its range of motion, so it maintains as much of its weight sharing as it can in all ranges. And Mother Nature is pretty smart about that. And if we muck it up it doesn’t work as well.
So let’s say, on this, the meniscus and the repair, so what I had was a clean out, so there weren’t any stitches involved. What is a clean out? What are they doing when they do that?
Dr. Reznik: 12:18
So I mean there’s, there’s several types of clean outs, right. So there’s, let’s say, have a carpet and the carpet’s got a lot of peeling on it, you know, and little fuzzballs all over the place and it doesn’t look so good, and remove all the fuzzballs and smooth it out again. That would be one type of clean out. But let’s say the carpet in the corner. Maybe the carpet’s not the best analogy, but the carpet in the corner has a flap that keeps getting stuck on the door right, and every time I open and close the door that flap flaps up and gets stuck right. So if I could glue it back down, that would be a repair, that would be okay. But it turns out the glue won’t work and I just trim that piece off. Yeah, the carpet won’t look so good in that little corner that’s flapping up, but it’ll stop trapping on the door when I open and close it. So the meniscus repairs that you can sew back and glue that carpet back down. That’s one type of repair, right. And the other type is okay. That flap is never going to stick. There’s no blood supply, there’s no way the glue is going to work. It’s too thin but the door won’t open. I got to get cut that flap off. I know it’s not going to look so pretty inside, but at least it’ll work a lot better. So that’s really what it is. I’m going to make it look not so pretty on the inside, but I’m going to give you a better function. Not ideal, right, because we’re not saving the cartilage there, whereas the other one is okay. I can glue that carpet back down and make it perfect, right, and that’s a lot better in some respects. But the reality is, mother Nature doesn’t care what we think. It deals a deck of cards and you got three twos and a five, you know, and maybe a four, and the other guy’s got four, fives, you know. Whatever you know, he’s going to beat you every time, right? So you know. You get the cards, they’re dealt with you. You look inside with the scope and you decide what hand we have in poker, let’s say, and then we play the hand as best we can. I always like to say to my patients like, at this point, I’d like to think that maybe you have a surgical problem. Now would be the time to get an MRI, because I’d like to play the game with knowing all the carts. The truth is we I started practice before MRI was invented and I would say 90% of the time I know what’s wrong before I get the MRI and in fact most of the time you don’t need an MRI to know what’s wrong. You know if you have bad arthritis, you take a plain x-ray. There’s bad arthritis on the x-ray, you don’t need an MRI. You know what’s going on. It’s bone on bone. You need an e-replacement, right, and MRI will confuse things. So the MRI will say, oh, the cartilage is torn and worn and the surface is this and there’s bruising here. And you say, can you fix all that? No, it’s all shot. You know you need an e-replacement. So the MRI doesn’t change the decision making. So I think people get carried away a little bit with MRI. They think like, oh, I hurt myself, I need an MRI immediately. In reality, you need a good exam and probably a plain x-ray if you really hurt yourself and sometimes you have a fracture. Okay, well, a fracture, I see it on the MRI. I have someone operating on Friday fell down a flight of stairs, has a tibial plateau fracture Actually, this is in the book also and she doesn’t need an MRI. The best study next is a CAT scan, because a CAT scan will show the bone fragments infinitely better than MRI will. And a CAT scan can do a 3D reconstruction of the bones and I could see in three dimensions and rotate it on the screen and actually see what the fracture fragments are. And surgical planning with that for a tibial plateau fracture is infinitely better than an MRI, you know. And conversely, if you tear your ligaments, cat scan doesn’t show them as well. You can actually see them, but CAT scan is not as good. If you have a soft tissue tumor, cat scan is not as good. But if you have a bony tumor, cat scan might be better. But very often plain x-ray in a good exam you know what’s wrong, probably 90% of the time.
Excellent, this sort of trimming of the carpet. I really love this analogy. When I had my knee done, they sent me pictures of the before and after of the inside of my knee. It was just like magical to me, and you could see the before it was a little ragged, and then the after it seemed quite smooth. What they told me was that even though it’s been sort of polished out, it’s still going to take, you know, like a few months for the surfaces to mate again. Does that make sense?
Dr. Reznik: 16:27
Yeah, there’s a couple of layers that I have to unpeel for that one. Okay, go ahead. So the first thing is I’ve insulted your knee. I had to put a scope in. I cleaned it up, I give you, I move things around and I irritate and there’s little ports that I have to heal. The ports on the outside, the skin heals within a week to 10 days. Underneath your body makes scar tissue around the tendons and all that and that gets a little thick and then it has to come down and the knee is a little aggravated. You know, if I clean, let’s say, the lining, you have a torn cartilage, you’re walking around with it. The lining will be red and inflamed and the lining will make extra fluid and all of that has to settle and sometimes that takes four to six weeks and then you’ve been walking around a bum knee for a while. You might need a little time for the muscles to get kind of used to the fact that it’s not so. You’re not guarding anymore, you’re not trying to protect it when you walk, you’re actually trying to use your quads more normally. That may take another six or eight weeks even to get there. So now we’re like three or four months out before you really start to feel decent. On top of that there is, in certain circumstances, if there’s a little bleeding there, the body will make fibrocartilage on top of the old cartilage which is not the same as the initial cartilage. It’s not as good quality, if you will. It’s a little softer, maybe a little less flexible and there’s some theoretical advantage that that might help a little bit. But it’s not like giving you a brand new meniscus, so it’s not really the same and sometimes that helps a little bit too. So you know there’s little if you unpeeled the onion, if you will. There’s layers of that and part of it is some people form keloids. There’s some people with very thick scars. You know, like you know, someone has a cut and the scars are ultra thick. I mean it’s usually genetic. Different people get it. Some Mediterranean people get it, african people or dark skinned people get it and some people just genetically get them. You know it doesn’t matter what your heritage, but you know your family members have it, you have them. Once you get them, you know you have them and sometimes people form keloids, will get very thick scar in a tiny little port and some people might actually aggravate the knee a little bit and they won’t want to fire their quads and those people might have a hard time getting better. And occasionally those people we have to treat the keloid to get them better before their knee will feel good. And sometimes that means hydrocortisone cream, sometimes that means a silicone bandaid to get it to flatten and occasionally it might mean a cortisone injection. But that’s a very small percentage of people. But when it does happen it’s annoying, like I had this little scope and I got this thick little marble in the front of my where the scars were. All three scars feel like tiny little marbles that are there that bother me and that’s a separate problem. But that can happen. It’s one of those little complications that we don’t talk about a lot because it’s uncommon. So again, like I’m peeling the onion, there’s a lot of layers to that question.
Let’s go to cartilage. What is cartilage? Is this cartilage? Like you mentioned, sometimes there’s blood supply and sometimes there’s not help people. What is cartilage?
Dr. Reznik: 19:18
Okay, so cartilage is that the classic meaning of cartilage is the surface of the bones are covered by articular cartilage, that is that smooth white stuff that has the lowest friction component of anything in the world, practically. I mean, there are things that are better now, but years and years the ability for cartilage to lubricate itself and move smoothly was so unbelievable People couldn’t even figure it out. And it turns out that in between the cartilage there are little pits and in those little pits is hyaluronic acid, which is a special giant molecule. The acid is like this big and the molecule is gigantic, and that molecule abides water and that water makes these little ball bearings of water and that makes the friction so low that you can have a knee for 100 years. How many people have a tire that lasts 100 years in our car? Never happened right. But the cartilage is alive, it replenishes itself and it creates this surface that is super lubricated. That’s one type of cartilage. Then there’s the cartilage in your nose and the cartilage in the bottom of your ear and all those cartilages, and then there’s meniscal cartilage, which is the meniscus you tear, and they’re a little bit different. So the components of the cartilage, the amount of collagen, the type of collagen and the other components of it are different because they have different functions and different durability. But there’s multiple types of cartilage in your body. The two main types are the cartilage of your meniscus and the cartilage on the surface. Both really don’t have a huge blood supply. The cartilage on your surfaces have no direct blood supply. It gets nourished by the fluid in your knee. The oxygen nutrients are carried in a little bit of liquid that’s in your knee, in the wholeuronic acid that’s floating around your knee carries the nutrients and they have very slow metabolic structure. They don’t do a lot of metabolism once the cartilage is formed. Hence if those cells die it’s hard to replace them. Your body doesn’t really replace them. We’ll get to like ACLs and stuff like that. If you injure your knee really badly like an ACL tear, you sometimes bruise the bone and injure the cartilage and sometimes 50% of the cartilage cells in that spot have died and they’re not gonna come back. And so I repair the ACL but maybe 10 years later the knee becomes a little arthritic. Why? Because you killed the cartilage cells in the initial injury and you don’t even know it until later, because that cartilage isn’t maintained as healthy as it used to be. Whereas the meniscus, the outer third, has a blood supply and that’s repairable and the inner third doesn’t, and that type of cartilage can have the potential to heal because it has some blood supply to it. Very different structures, really.
We’re gonna circle back to cartilage and transplant and perhaps regrow. But I wanna ask you about this lubrication issue. Now, a lot of us we get up in the morning, we get out of bed and things don’t work. They’re a little creaky and then we move around a little bit like you rode your bike and maybe for the first minute it just didn’t feel quite right, but then suddenly things start to. The lubrication starts to go. What’s happening there? Is it? Somebody told me there’s something called synovial fluid.
Dr. Reznik: 22:23
I’m probably butchered the name, but yeah, synovial fluid is what has the hyaluronic acid in it that has that. It’s not really an acid, but it’s that fluid. It’s synovial fluid. The lining of your knee makes synovial fluid and that’s what carries the nutrients. So the lining supplies the nutrients and the fluid carries them. Some people we get a little sidebar for a second. Some people we feel don’t make enough lubricant and their knees are not doing so well and they’re a little creaky. And there is synthetic lubricant you can inject which is the same hyaluronic acid or close to it. It’s hyaluronic acid, all different molecule sizes, but there’s a few companies make it and some people believe that supplementing hyaluronic acid for people older and they don’t have terrible arthritis so you have to. That’s a distinction. Like, if you have bone on bone, this is not gonna help you. But if you have a good amount of arthritis but your knees creaky and painful, some people get six months, nine months or a year of symptomatic relief from injecting hyaluronic acid into their knee and supplementing the hyaluronic acid that’s in your knee and give you more lubrication. So that’s synovial fluid. Now synovial fluid has a lot of other roles. Right, like if I get an infection in my knee, I make a ton of fluid. If I hurt my knee the knee might swell and might have a knee effusion of water in the knee right. The synovial fluid is that fluid too and the lining also does protection against infection. So the lining get red and inflamed. In fact if you look at a knee and there’s a lot of synovial fluid, it might look like seaweed in there. There’ll be a lot of red, inflamed lining that looks like seaweed, like Jacuzzo under the water kind of thing, and that’s called the synovitis. The lining is irritated. So I might see a knee that’s got a meniscal tear and some calcium deposits. Maybe even gout might be in that knee, or pseudo gout, which is a little different crystals of calcium and the lining will look like a sore throat. It looked terrible. Now you can clean the lining out, you can use anti-inflammatories and it might heal and you might be able to get rid of the inflammation. It might be curative. But if you had Lyme disease you’d have to treat the Lyme right. You get a synovitis from Lyme disease because it’s an infection and if you don’t treat the bacteria then that synovitis isn’t gonna go away. Lyme is a little complicated as multiple stages, but the initial phase that’s in your knees really stage two Lyme. That would have to be treated with an antibiotic. So just start to think about the differential of a swollen knee becomes quite big. You could have gout, pseudo gout, lyme arthritis, rheumatoid arthritis you could just bend the knee really badly and bled into your knee. Or you could just have an inflammatory arthropathy like rheumatoid or lupus or something like that. It gets complicated very quickly. But the synovium makes that lining and the synovial fluid is that fluid Got it To come back to what you asked.
Yeah, and in order to get the lining to make the fluid, I need to move the knee right.
Dr. Reznik: 25:17
Yeah, to some extent. I mean, if it’s really inflamed, the lining will make fluid, no matter what, because the knee has very smart. It does two things when it’s mad, it makes fluid, or it hurts or both. Oh Right, those are the two things the knee can do right, and any joint in fact that’s true of all your joints it’s always making a little bit of fluid. When it has a lot of fluid in the knee, something’s typically wrong. That’s a tip of my knees very swollen. All the time there’s something going on there that my lining doesn’t like right.
I’m very curious about this idea of cartilage. Is it possible to transplant cartilage in the knee, this specific kind of cartilage, or can we regrow it some way?
Dr. Reznik: 25:54
Yeah. So again, this is, it really depends on the size of the defect. Okay, so like there’s criteria, it’s the scientific criteria, you know, and the insurance companies love this stuff because they block out what you can and can do based on the scientific criteria, which does make some sense. So, very small defects. You could do stimulate the marrow, you can make little holes in the marrow and you could get stem cells to grow in and now grow some cartilage there. It still won’t be the same as normal cartilage but it might regenerate a little bit. You can take like a hair plug. I could take a plug, a round plug of cartilage from someplace else in your knee that you need less and move it to a place where you need it more, just like a hair transplant, right Little plug of cartilage with bone and move it over. So that’s the next level. The next level gets a little more complicated because big defects sometimes they’re so big you actually have to take a frozen, fresh frozen piece of cadaver cartilage from someone else and actually transplant it. And you can do that with the meniscus not commonly done but it can be done. And you can do that with a big defect, like one time I had a 21 year old bed and motorcycle accident sheared off probably 70% of the Midofermo condyle, half of the knee joint, and I had about a two centimeter which about an inch in diameter, plug from a cadaver that was matched to his size of fresh frozen cartilage and put that plug in and regrow the bone and the cartilage there, because it’s a plug of real cartilage and something that was matched up in size. And that’s complicated. You get an MRI, you measure the MRI, then you go to the bank and you say and we had to wait four months to get one that would match that was fresh. So that’s a little complicated. It was like a kidney transplant, but a little different, right? No problem with rejection with this, though. That’s. The good news is cause, cartilage and bone and everyone’s the same. The cells are different, but you don’t need the cells. Your own body populates the cells. And the last one is which is becoming much more popular, and I’ve done a number of these and I have some patients in waiting for doing it because they’ve taken the cells. As you can go in arthroscopic with the fiber optic telescope you take little samples of the cartilage like little tiny chicklets or little chips of cartilage out of the knee, from the middle of the knee on the edge, where it’s not that important send it to a lab and give them five to 8,000 cells and they make 8 million to 10 million cells and they grow it in culture and then they take a piece of collagen which is made as a matrix, almost like a piece of cloth, and they impregnate your cells into that little thin, thin piece of cloth that’s made out of collagen, which is part of what you have inside your knee anyway, and you can then glue in that into a defect and regrow your cells. And that’s been shown to work for a lot of interesting things and a number of patients that it’s been quite successful in. It’s not always successful, but when it’s successful it’s amazing. Again, for younger patients usually younger than 40, 45, and usually bigger defects, something that’s 2 centimeters square or 4 centimeters square, bigger defects and isolated injury, like I knocked the piece off somehow. I had a traumatic injury and there’s a piece of cartilage missing and it’s in a place like where my knee weight bears the most, on the femur, and that area is just no good. But I can put cartilage back and grow it. But it is a bit of a process right. You have to do two operations at minimum, because you’ve got to harvest it, grow it and then put it back.
Do you see this in the future as something for arthritis? Could that be done?
Dr. Reznik: 29:30
That’s different. So if you have arthritis all over the place, these things don’t work Because the criteria for doing it is within a certain size range and also the wall you have to be able to put in a spot that has good wall. So it has to be like a nice-sized pothole that has good walls around it. If the walls around it aren’t good, it’s very hard to find a place to put that matrix and glue it in that it’ll actually stay. So you can’t really coat the whole surface and get structural integrity. But if you have a nice defect with a good wall, you can do that procedure and that works relatively well. Nothing’s perfect, but it seems to have helped them quite a number of my patients.
Then let’s go to somebody who doesn’t have cartilage, who has terrible arthritis, and would you be looking at knee replacement then?
Dr. Reznik: 30:16
Yes, you could look at knee replacement. Again, it depends on your age. Knee replacement, unlike normal cartilage and bone, knee replacement doesn’t regenerate itself. It’s a mechanical device. So your normal cartilage and bone. Every night you go to sleep your body is trying to repair it. It does things to add more collagen, more matrix, reinforce the bone when there’s more stress and so on. That’s why it lasts so long. But once you put a metal plate and a plastic liner and another metal plate on the bone and that device is in there, it will wear at a certain rate. Now the newer materials are very, very good and they wear very slowly. The older materials wore much faster, so they’re quite good. If you don’t have a super active lifestyle but you’re active, you’re not a marathon runner and you put it in, it could be good for 20 or 25 years of knee replacement. But if you give it to someone who’s 17 and say, well, go out and do whatever you want, it might not last 10 years, then you’re looking at a revision. It turns out that every time you revise a knee replacement the results have more risk and complications, because every time you go into the knee there’s more scar tissue. Every time you open it up, there’s more chance that you’re going to affect it, and so on. So you can’t say, oh, I’ll just do a knee replacement every 10 years I’ll revise that. That doesn’t really work. So our goal most of the time for most people is to try to get you to a place where we could do one and done. You can do a knee replacement when you’re 60, 65, or 70, or 75, and then it’s going to last to 90 or 100. And you say, okay, I’m going to put this knee in and hopefully it’ll be good for the rest of your life. We try to avoid these situations if we can, where you have to replace someone’s knee, where you’re going to end up looking at two or three revisions in their lifetime and that’s going to be more problematic and with more risk Not saying that you can’t do that, but it’s not ideal at all.
Do you have preventative strategies for reducing the wear and tear on the cartilage?
Dr. Reznik: 32:20
Yeah, there’s so many things you can think about. So let’s say ACL tear. So if you’re an ACL tear and your knee is unstable and you remain active, we know that down the road if your knee is unstable, that you tend to get cartilage injuries. In fact there’s a lot of great data in kids, young kids, that they get an ACL tear. Their likelihood of tearing their meniscus goes up dramatically likely of damage to the cartilage and even in one or two years after an ACL tear in a young kid, we’re looking at damage that will be lifetime and problematic. So if you have an ACL tear in someone young and they’re unstable and I’m going to qualify that in a second then you probably want to fix that so you reduce the instability and reduce the risk of meniscal tear is going forward and cartilage damage going forward. If you have someone who has an ACL tear and they’re not unstable and there’s ways to measure that and figure that out and have low demand, let’s say I just play till the wings and I have an axiotripped on a curb and I tore my ACL. But it turns out all my other ligaments are excellent and you test me and there’s very little difference between my two knees. Well, maybe a little rehab and a brace might be fine. You don’t need a reconstruction. But let’s say you’re an elite athlete and you tear your ACL and you have some instability and you play at 99.9% of your max All the time. You may be unstable even with a knee. That’s subtly problematic and you’re looking at maybe more injuries down the road if we don’t stabilize. For me, having said all of that, if you look at long studies and let’s say I have a very traumatic ACL tear like I got piled into in football and I tear my ACL and my MCL and I bruise the bone and I tear my cartilage all in one shot. Remember I said before the cartilage cells could be killed by trauma and I killed off 50% of my cartilage cells and that injury. Initially I can stabilize the knee, fix the meniscus, do everything, but part of the die has been cast by the fact you’ve knocked off some cartilage cells that are not going to come back. Everything will look fine and the x-rays will look fine and everything will be hunky dory Down the road. You might pay a price for that. So you know something we can’t. You know, been hit by a truck. We could put you back together, but I can tell you can have a lot of scar tissue and things aren’t going to be normal, you know. So you know. That’s the difference.
With these ACL and MCL tears. I want to address a couple of things here. So gender differences I’ve read that women playing sports, it’s something like four times the likelihood of an ACL tear as men. Why is that? Yes?
Dr. Reznik: 34:46
It’s believed. There are several reasons for that. One, anatomically, women’s knees and men’s knees tend to be a little bit different. The notch where the ACL lives, the space in between the bones where the ACL fits, is in some women very narrow, and they talk about A-shaped notch, where it’s kind of pointed and high and tight, so that puts the ACL more strained. There’s also a concept that biomechanically, women cut and turn and land differently than men. There’s actually programs to teach them how to cut, turn and land and change direction, to teach their muscles to do it differently and reduce, and it’s been shown in high level sports that you can actually reduce the injuries by doing that. Some people believe that hormonal levels vary during their cycle, their hormone cycle, and that when their hormones are the most that some of the ligaments are actually a little looser, a little more pliable and actually softer, and they believe that that’s part of it. So those are the three main reasons. And then the other thing is hours of participation. So women, because they have reasons for increased risk of ACL tearing because of the anatomic factors, the way they cut and land, and maybe hormonal reasons. If you increase the hours of participation the risk per hour is higher than men, the total number of injuries will go up. So before they had title I think it’s title eight when women’s sports were elevated to men’s sports in schools and stuff, where they said, okay, everything’s got to be equalized. Before that women’s sports were not practiced as much. The practice times of the seasons were shorter and less participation. Acl injuries were just as common in girls and boys and as soon as they made it on par, the amount of hours to play and the competitive level went up. Women ACLs start to outnumber men. So there was a time you had an ACL tear and played soccer and had college scholarship. They wouldn’t take you. Now it’s so common to have an ACL tear, have a reconstruction, return to soccer. You know that having an ACL tear is just considered a one year out and then you go back, you know, because you can reconstruct and repair and you can return to play. So the thinking about it has changed, the participation levels have changed. The risks still remain higher, but there’s certain things you can do to reduce or mitigate those risks as well.
How do you repair an ACL, Say a terrace, what?
Dr. Reznik: 37:14
are you going to?
Dr. Reznik: 37:16
so in general, most of the time ACL is really not repairable. There is some stuff now, some new cutting stuff, where you might be able to repair an ACL, and I’m going to make a distinction of the word. So when you have a rope and you pull it really really hard and it ruptures in the middle, the ends of the rope explode. You’ve seen that. Right, you pull hard enough, pull, pull, pull and it goes like that. So in those settings the collagen in the ligament has really been disrupted and the quality of it remaining is really poor and if you try to sew that back together it just doesn’t have the same mechanical properties. So in that setting it’s really better to replace the ACL with a new ligament and you could take a hamstring tendon or a patellar tendon or a quads tendon from the person, or you could take a frozen tendon. There are different reasons and pros and cons to doing all those things and then you could put that in its place and in general we do it and it works very, very well. On the flip side, you can in the young you can tear the ACL directly off the bone with a little fleck of bone from either the femur or the tibia and if the ligament itself really hasn’t been deformed by the injury too much, you can actually sew it back and get it to heal to the bone and repair it. Now there is a newer thing where we do it’s actually a sleeve of biological material and you sew it back and add this sleeve of biological material and then you can repair it back with that, augmenting the natural ligament with this extra biological sleeve. There’s some data showing that that seems to work. But again, it’s very limited circumstances where that’s the right answer, because it has to be a tear where the substance of the ligament itself hasn’t been destroyed by the injury, right, and it has to be very injured very close to the bone. So it’s a very small percentage of the injuries are even remotely candidates for that, and you have to be on the younger side. You can’t be 50 years old and say oh, I happen to have a tear near the bone, not on the bone, but near the bone. Give me the biological repair. It’s probably not going to work.
What I understand you just said here is you would take part of patello tendon or hamstring tendon and then put it in its place. So now we have two injury areas. Right, We’ve got the place that you removed, yeah that is complicated.
Dr. Reznik: 39:32
Yeah, that is complicated. We have a heart to heart with the patient about that. There is an alternative using a frozen cadaver tendon and for some people for a lot of different reasons, that makes sense to use that instead. And in my practice I found that certainly people over 40 and 50, the donor site, morbidity, taking the donor site. Sometimes for some of those patients and I learned this the hard way with a very high level skier I’ve had some skiers who are like national international ski level at 60 and 70 years old and they tear their ACL and if you take their own patello tendon or hamstrings they don’t really regenerate it as well and they weaken those areas and they don’t. I’ve had one or two patients not really recover from that and this is years ago but when it happened it was very surprising. They would take the tendon and they just don’t really heal that well and they always complain of anterior knee pain or weakness in their hamstrings and that alone was more limiting than the reconstruction itself. So in those patients I do talk to them about doing a frozen tendon instead and in general those patients that have a frozen tendon in that setting do very, very well. Now you can look at some of the literature and they start to say like below the age of 20, it looks like taking your own tendon might be better. But sometimes someone less than 20 isn’t compliant. So maybe you put a tendon in and they don’t have a lot of pain because you didn’t take your own tendon. Maybe they do a little too much in the early phase and they re-injured themselves because they’re just too active. So the answer to that, the common answer, is younger patients get their own. Older patients might get a frozen In between. You have to have a heart to heart and make a decision. But I think longer term we’ll have better answers, even going forward after this. You know that every year we get better and better answers about what the right answer is for people.
And we understand it better and better.
Dr. Reznik: 41:20
But even now our understanding is a thousand times better than it was when I started my practice.
Well, I’m 64 and I’m a ski racer.
Dr. Reznik: 41:27
Yeah, you’re probably the frozen tendon.
Well, I hope that I never have to go in and do this. I’m good to know that whole idea of like cutting the patellar tendon or the hamstring tendon. That just seems like bad.
Dr. Reznik: 41:46
Well, yeah, when you do the hamstring you actually take one whole hamstring tendon out. You take the whole hamstring tendon out, so you leave the others, but you remove one. When you do the patellar tendon, you do the central third and the other two sides fill in eventually, but the middle third of your patellar tendon is removed and then you want scar tissue to fill in after.
Wow. And then, in your experience doing an ACL, what are the looking forward 10 years ahead? Does the person have a higher likelihood of arthritis?
Dr. Reznik: 42:19
Well, like I said before, if there’s a lot of damage to the cartilage surfaces and the ACL doesn’t really work, it doesn’t really stabilize the knee for sure, and there’s a lot of technical factors there. Is it placed properly? Was it tension properly? What were the mechanics of the knee at the time of the surgery? That makes the ACL positioning on atomic and then work the right way, and there’s ways to check that while you’re doing the surgery. So that’s the technical point of it. And the other piece of it is like was the articular cartilage really damaged badly, right? So if the ACL successful in the articular cartilage is not damaged badly, then I think most people will do well. I have a patient who I see periodically that I did his ACL over 30 years ago and I’ve actually followed up on him and he tells everyone that he hasn’t had a lick of pain in 30 years. His knee is perfect and I’ve taken an x-ray 25 years after the initial and he doesn’t have a drop of arthritis. And I did his ACL using a lot of scientific methods that we now really understand as being the gold standard for it. I was very fortunate. I trained with someone who was like also like an engineering kind of guy and he had all these ways of measuring how the ACL is done to make sure it was accurately placed, and using those techniques. Now we understand where to go and basically all the ACL techniques have kind of converged on the idea of where the ACL should really be when you do the reconstruction. I think we’re less critical about it 30 years ago and the ideas have evolved over the last 30 years, so now we kind of really understand much better how to put it in, where to put it in. The fixation methods are better and the quality the reconstructions are better and if it’s done properly and there’s less cartilage damage, then people can do well for a very long time. It doesn’t stop people from re-injuring themselves, though, you know. Going back to full sport, because I have that too.
Let’s take somebody who say their knee is stable, they don’t have any ACL issues. There I’m going to say they’re moderately sporty. They’re not world-class anything, but they’re, you know, pretty active. Are there things that they can do to reduce the wear and tear in their cartilage?
Dr. Reznik: 44:38
I think there’s a lot of interesting things we could talk about in that area. I mean, I think listening to your own body is important, you know. So, like some people say, oh, every time I run it hurts and I think that’s good because I’ll run through the pain. And I like to tell people, make a distinction for yourself. Like if it hurts in the muscles and their sore, the next day it goes away, that’s normal stuff. You know, you’re training, you’re up to training. Muscles hurt. If the joint itself hurts or the joint itself hurts and then swells, that’s a little different, right? So I would be more hilarious. Like, every time I train my knee hurts but I run through the pain, it’s so good for me and, by the way, it swells and I have to ice it for two hours and I take six motoring for the next day and then I can train again two days later. I think there might be a problem. You need to have a chat, right? Whereas, like you know, okay, I, you know my calves are sore and my quads are sore because I just did this crazy workout I haven’t done in six months and you know, I’ve been limping around for two days because I’m just so sore in my muscles. Do your joints hurt? No, they don’t hurt at all. I just I’m just overdid it. That’s, it’s okay not okay maybe. And then I say beware of things that are funny but not healthy, right? So we all know the people in the gym. When you listen to them run, it sounds like a pile driver right On the. You know they’re on the treadmill. It’s bam, bam, bam, bam, bam bam you could hear them across the whole gym. The other people on the trip well, it’s whoosh, whoosh, whoosh, whoosh. You barely hear them. I could tell you the bam, bam, bam, bam people are like it’s like hitting your knee with a hammer. That loud noise is your heel strike is heavy. The forces go through your knee and your hip. It can’t be great for your back either. It’s probably not a good thing, and it usually happens because people have the treadmill set way faster than they can run Okay, and what happens is they’re falling forward so hard they end up with a very heavy heel strike as they crash against the surface because their body’s being propelled forward faster than they can catch it. So if you see that you are the bammer, right, that’s a funny way to say that, but you’re in the, you’re making more noise than everyone else in the gym. Maybe the stationary bike or elliptical would be better for you, or slow the treadmill down one or the other right, because I think you’re going to get in trouble over time. So I think listening to your body, looking for good mechanics, paying attention to things that you know clearly are hurting the joints over the muscles are really great ways to save yourself from some grief later on in life.
Let’s assume someone is having a problem with their knee and they want to see somebody like yourself to you know to evaluate and then possibly surgery. What sort of advice would you give for people to how they would source a good practitioner and then how to discern whether you know no offense but surgeons often like to do surgery, and whether that’s the right thing for them? Yeah, so this?
Dr. Reznik: 47:36
- That’s a very hard question because you can’t get into the mindset of every individual, because some people come to me they want surgery, they don’t need it and they can’t convince them otherwise. And other people come to me and don’t want surgery and absolutely need it, and I can’t convince them otherwise and they’ll doctor shop right Until they find the doctor that agrees with the plan they wanted to hear. Right as a joke. You know, you have cancer. You never survive your third opinion. You know, and I have patients who see me and they’re I’m the fourth person they’ve seen and they don’t believe me and they don’t believe any of the other people because they haven’t heard the thing they wanted to hear, and that’s not right. You know that’s not great. So sometimes I tell people the truth. They don’t want to hear it. You know that’s a problem. So it works both ways. You know can doctor shop and see if you’re happy, but you can also doctor shop yourself into something that’s probably a bad idea too. So it works both ways. It’s very hard. You know there are two components to knowing that the doctor’s right for you. One is if you’re comfortable asking questions and they’re willing to answer them right, most doctors will explain what they’re doing, will give you some reasons for it. You usually have a sense you feel comfortable whether they don’t trust them. You know I don’t like the idea of relying on online reviews, but sometimes online reviews do help a little bit. You know someone’s got five stars, it’s good. You know they got one star from everybody maybe not so good.
Absolutely. I picked a doctor who did my knee because he does all the knees of the US ski team and I thought they probably know, and somebody like yourself, if you’re doing elite athletes, they check around. I do want to say, being a recent patient, I have up on my desk now it perhaps 20 page document from the insurance company with all these codes and costs and all this. I’m not particularly dumb and I what? I have no ideas no one can figure it out.
Dr. Reznik: 49:31
I have the same thing. I’m a physician and I get that and I looked at the insurance company thing and I don’t even understand what they’re talking about. I had in fact we have a team of people who are coding experts who deal with it, because it’s it’s so much information I’ve actually took care of him, kept up on the literature for orthopedics I couldn’t possibly do that as well.
Right, yeah, it’s just madness. What can we leave people with today? What do you want to? What do you want to tell my people today?
Dr. Reznik: 49:56
You know, I I like the idea of listening to your body, I like the idea of understanding when, when things are not right, you know that, that the pain is persistent, it’s recurrent, there’s some swelling associated. I have a section of my book called sports tumors and I have a couple of vignettes in there, but one of them I’d like to share, this last little one, because I think it’s very important for parents and coaches, although children don’t get tumors very often. But I had a kid wrestler could not get in the wrestling position, couldn’t get all the way down, and they tried therapy and they were ranking on his leg and pushing him and massaging it and wouldn’t move and finally somehow, miraculously, the child came to me for evaluation. I was a teenager, about 15, 16 years old, and I took an x-ray, just a simple x-ray. His knee wouldn’t move and he had a bone growth behind the back of his femur that was blocking his tibia, which was actually bone. It was a bone tumor in a dangerous area because the blood vessels and the nerves sit right on top of it in that area. So I removed it and he had phenomenal improvement. His range of motion came back and everything was fine. And then it’s not the type of thing if you remove correctly won’t recur and it should do good. The reality is they could have done everything to Sunday. That knee was not going to move and at some point you got to say, okay, time out, we got to see a doctor, you got to see why this knee is not moving. You got to go to a chiropractor and get that manipulated. So in the end of the day, for most diagnoses, a good history, matching up the injury of what happened in the exam, a good exam to match up what the physical findings are, and a plain x-ray to assess the bones and those three elements together in a good exam Most things can be figured out and if it comes to that, you might need surgery because it’s a mechanical problem. Maybe then you’re going to get an MRI, or there’s no clear diagnosis and things are still a rye. You might need an MRI at that point. Mri overreads and underread certain things. We know that. So I do want people to be aware that if you’re 65 years old and get an MRI, a lot of people gonna have meniscal tears. They’re asymptomatic and they buy themselves a surgery that they don’t need. So jumping to the MRI is your first choice. I say to my patient Listen, do you want it? You don’t have mechanical symptoms. You don’t have any reason to get an MRI. I know that at your age, 60 percent of patients going to have some kind of meniscal tear. You want to have a surgery because if I do the MRI you could convince me that you’re going to want a surgery that you don’t need, you know. So I I kind of hold back on MRI In some settings just because I know the odds are it’s going to be falsely positive In those settings, right, and it’s not going to change your treatment course by getting it. So listen to your body, get a good exam. If it’s not right, get a good valuation, give a good history, see someone who can ask questions of and get an x-ray and then, if you need an MRI, sure, if you don’t, maybe it’s PT injection, anti-inflammatory therapy, whatever you need bracing, you know whatever works. You know the appropriate conservative measures first and then, if those fail, then maybe surgery if you need it. Thank you, oh, you’re welcome. Thank you so much for having me. It was great, great talking to you.
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