RX Physiotherapy
Welcome to the Rx Physiotherapy Podcast – your ultimate destination for expert insights on physio, rehab, health, and wellness. Join hosts April Patterson and Brendan Casey, seasoned physiotherapists as they dive deep into captivating topics each week, covering everything from physiotherapy essentials to nutritional secrets.
Dr. April Patterson, founder of RX Physiotherapy, holds a Doctor of Physiotherapy degree from Bond University. Her personal experiences with conditions like Ehlers-Danlos syndrome and TMJ issues drive her dedication to tailored, compassionate care.
With a commitment to staying updated on the latest advancements in physiotherapy, April ensures her patients receive top-notch, evidence-based treatments. In her spare time, she enjoys fitness, cooking, and spending time with her two dachshund pups and partner.
Explore more about RX Physiotherapy and discover additional resources to support your health journey by visiting: https://rxphysiotherapywollongong.com.au
Gain valuable insights and practical tips to improve your health and well-being each week.
Tune in, unwind, and embark on a journey through the vibrant realm of health and wellness with us. Ready to elevate your well-being? Let's dive in!
RX Physiotherapy
7. Understanding Knee Pain and Physiotherapy Solution
In this episode, we take a closer look at what causes knee pain and how physiotherapy can help ease that discomfort. Whether you’re facing a sudden injury or dealing with ongoing issues, it’s important to understand what’s really behind your knee pain to start the recovery process.
We’ll share insights as physiotherapists along with practical tips for managing your pain and exercises to help improve your mobility. If you’re eager to regain your strength and enhance your quality of life, this episode is one you won't want to miss.
Join us to learn how physiotherapy can play a vital role in your journey to moving pain-free!
Chapters
1:28 - Common Causes of Knee Pain
4:20 - Is Knee Pain More Common in Women?
7:07 - How Is Knee Pain Assessed?
12:31 - How Do Biomechanics Affect Knee Pain?
15:15 - How Do Age, Weight, and Activity Level Impact Knee Pain?
21:31 - Strengthening Exercises for Knee Health
32:05 - What About Surgery for Knee Pain?
41:38 - Rehab Strategies for Different Knee Injuries
44:45 - New Technologies in Physiotherapy for Knee Pain
48:29 - Brendan’s Final Thoughts on Knee Pain
Disclaimer: Before making any health changes, consult with a healthcare professional.
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Welcome to the Rx Physiotherapy podcast, your go to destination for all things physio, rehab, health and wellness. I'm April Patterson. And I'm Brendan Jason. And each week we will dive deep into fascinating topics within the health world. From physiotherapy to nutrition and beyond, we cover it all. So sit back, relax, and And enjoy the journey as we explore the exciting world of health and wellness. And before we begin, we'd like to acknowledge the traditional owners of the land, which we meet today, the Dharawal people and pay respect to elders past, present and emerging. Let's get started. Hey everyone. It's been a while since we have done a podcast. So today we're going to talk through some knee stuff, physiotherapy. Brendan is going to be answering a lot of these questions because he is. He's much more superior in his knowledge than I. Superior? Good word. Cause there are definitely some, quote unquote, knee specialist physios out there. Yeah. But I feel like knees tend to be a lot like backs and necks, that we do see a lot of them. And you do have to be at least halfway decent. Yeah. Definitely. But no, that's, I definitely wouldn't call myself a knee specialist, but over the years I've seen quite a few. Yep. So this is cool. This is, this will be probably remind us both about how much we know again, which is always surprising. It's so true. You just get used to, used to what you know. Yep. All right. Well, let's dive into the first question. So Brendan, can you explain the common causes of knee pain that you encounter in your practice? There's definitely two camps there. There's obviously a traumatic, so like contact sports, falls, trips, stuff like that. And then you'll. A traumatic or whether just like overload Let's go to traumatic first because that's probably easier. Yeah, so say if someone's come in and they've They're a combat athlete and they've taken like a kick directly to the inside of the knee Something's swollen up Or they've fallen and landed in an awkward position and they pop their kneecap out to the side or the I feel like everyone puts this in the worst case scenario. Another one is a big deal like a torn acl This is still not the end of the world It's a lot of rehab. They can sometimes heal conservatively. We'll get into, at the end, some newer urgent research too about cross bracing and whatnot. But that, along with like MCL, meniscus tears, football, soccer, even sometimes just like some people fall down the stairs, miss a step, and that's enough to shift something and cause excess damage to one area. Yeah. Your kind of overload or non traumatic. H Traumatic, not traumatic, most of the time comes from the hip. Yeah. Like if you don't look at the hip, you are missing a huge part of the problem. Yeah. And the vast majority of the time, you look at this person's knee and you think, all right, the tendon's annoyed, or something's swollen, or, mm. They've put all this muscle wastage injury around it, and then you realize the hip's not working properly or, and, or the ankle's not working properly. And then there's some issues in between, the people who have like, already had something atriumatic going on, then something traumatic happens on top of that. But it's definitely those two kind of simple categories, at least what I see. What do you kind of see as well? Yeah, I totally agree with your point that the hip influences the knee. Yeah, definitely. If your hip isn't functioning properly, the knee is going to take so much more of the load. Massive. And it's nowhere near as, like, the hip is a very stable joint. Yeah. Like, A, we, I talk about this all the time, a discated shoulder is a big deal. Yep. A discated hip can literally kill you. Yeah. Yeah, it's so true. And it's such a big issue, because you've got so much bones around the hip, whereas the shoulder's got so much musculature and allows more mobility, but still, it's, it's a big deal. And then the knee, by comparison, nowhere near as much stability. Yeah. But that's what allows us to do so many things with our knee too. Exactly. Once again, more mobility, but more risk of other stuff too. So true. Yeah. I usually see a lot of knee pain in the hypermobility population. And yeah, if that hip isn't strong enough, the knee, especially the inside of the knee just gets overloaded. Do you see it more in, uh, female patients? The inside of the knee? Yeah, absolutely. Yeah. Yeah. So you'll see some individuals when they walk, their knee will actually collapse in. And if you think about the last thing that's going to be holding the pressure up when that happens is the inside of the knee. So instead of the muscles translating force when we're moving, that middle knee is taking so much load. And then we know we have so much more muscle on the outside, like of our knees, so many more muscles. Yeah. So that kneecap just ends up getting pulled laterally. The medial aspect can't control it as much and they end up with the patella just not tracking properly. And, yeah, it's definitely more a hip thing that causes it. But the knee is the main problem. It's definitely one of those areas that I I wonder why we've evolved in such a manner. Because we are so robust on the outside of the knee. Yeah. But, I don't want to say fragile on the inside of the knee, but it definitely seems to, like, put it this way, your MCL, the one you hear about football players doing all the time, is, from what my description I've heard, is like, it's a couple of sheets of paper thick. They're quite thin, and that's why it often tears. Where the LCL on the outside of the knee is like an extension cord. Wow. Which is why it's so rarely damaged. And normally, it's like, Oh, you've done your LCL, probably because your entire knee's been ripped apart. Where the MCLs happen in the sprains pretty often. And they don't have to be the end of the world, or they can be quite traumatic. But it's, it still doesn't make sense to me why we're so robust on the outside. Yeah. Versus so, I guess there's no other better word than fragile. Even then it's like pain perception. Like if you work through someone's outside quality, painful, but tolerable. You work through someone's drawing muscles. You will see the biggest, toughest person wincing in pain and literally tears boiling up. We've probably gone too far at that point. We probably should back off the pressure there, but even just the lightest pressure through the adduct muscles is a lot for a lot of people. Definitely. So whether that's part of it, whether it's just one theory is a fact, how often do you knock the outside of your leg into the inside of your leg? Totally. And for those kind of specialists, one of the big techniques, especially in Muay Thai guys is that they'll condition the outside of the legs a lot. Yeah. But then for years now, a lot of guys have been targeting the inside kick, which sucks so bad. And it's enough to completely make you swap stances and get that leg completely behind it. So it's, once again, I don't know why we're so underdeveloped in that area. Hopefully we evolve. Yeah. Yes, true. What does the assessment process look like when you're evaluating a patient with knee pain? And what are some key indicators that you are looking for? Cool. To really make it, I guess, one blueprint. And it's always going to be different from person to person, how they've done it. But the kind of key things I always look for is It's one how they're standing, can they weight shift left and right, can they balance on that knee? If they can't, then it's like, all right, let's go straight to more passive tests because then everything's going to be positive for pain and not give us too much information. Look at, you always look at your range, always look at seeing what the ligaments are doing. Even if I don't think it's a ligamentous problem, purely to see like, all right, is there joint laxity there? Yeah. Because that plays a big role too, as you know, with the hypermobility population. Yep. Definitely. Definitely. Look at muscle bulk is a big one. So they got one massive quad or one massive calf. Then you're like, all right, clearly this has been happening for a while. And then it's finally said, we can't cope anymore. Once again, always looking to the hip, make sure the range is there, make sure the strength is there, make sure there's not too much tightness in certain, cause sometimes it's good. You don't want to have no tone, but you also don't want to have being bleached, stricted either. Once again, this nerve. Yes being this camp or yes being this camp, it's somewhere in the middle. Yeah. Which would make things so much easier if it was yes or no, but it's somewhere on that spectrum. Yeah. I'd say if someone was So that would be someone who's a lot more painful. Someone who's less painful. We'd go through a more functional test. So like single leg, lunging, squatting, hopping on one leg and just seeing what the knee does, what the ankle does, what the hip does. And already that would give you a big clue of like, all right, foot's collapsing, maybe foot strength issue or maybe deformation of the lobe. Yep. Knee's collapsing, outside of the hip's probably weak. Yep. Or whether just they've got no control. Sometimes it's a lot of time. Sometimes, a lot of times. It's a great way to say it. That it's more of just like a technique thing. That you can cue someone and all of a sudden their technique gets so much better. And it's more about just retraining the muscles to fire properly. Similar to um, like lower back training. Sorry, core training for lower back pain. For those people that do need a lot of stiffness. It's not, for your day to day stuff, it's not about just turning everything on all the time. It's about getting things to fire in the right sequence. That quick on, quick off, and then that lowering phase too. So true. Which is a big reason why, like, going upstairs for people with knee pain, normally not a big deal. Going downstairs, that's horrendous, because you're putting all that weight and then lengthening those muscles through range. So true, I really like that you brought that up. Like, strengthening is such a big part of what we do, because we're improving capacity, but proprioception control movement strategies are so, so important. I want to say it's like half. Yeah, definitely. And like in the hypermobility population, long term we want to build strength, but if you're not moving correctly, you're just going to use other stuff. Exactly. So, yeah, that's really. I really feel you on that one. Sometimes it's something I add in like really early on, which is like the single leg balance and proprioception stuff. And other times it's something that we add in a bit later once they get more confident, but it's always included. Anything lower body related, it's always, whether it's for the hip, knee or ankle, there's always some kind of balance component. Because this comes back to like early childhood development. Think about all the times you're running around, jumping, hop, hopscotch is a big one. Uh, landing on one leg, jumping off one leg. At one age, we just stop doing that and we lose that ability as you know, like the body just gets rid of stuff that we don't need. Yeah. Like it's fun to ask these, some of these patients, like when's the last time you've gotten down to the floor and back up? Yeah. And they're like, Oh, 10 years ago? Yeah. I bet it's going to be pretty difficult for you to do that. Yeah. So the same idea of just being able to stabilize one leg is a huge deal, but then also can have huge amounts of benefit too. Oh, absolutely. It can be the thing that keeps you, you know, Living independently into your later years. Definitely. Playing sport. Yeah, definitely. And you can go too far with it. Yeah. You see some kind of surface tricks where people are Like literally squatting on a Swiss ball and then like swing a kettlebell around themselves and it's, you're going to get some training effect from it, but the risk of injury is huge. And probably the time to set up is probably not worth your time either. And you're probably going to get better at just doing that as well. Yes, far too specific. So if you have to do that regularly, then we definitely recommend doing it. If you could literally just like stand on one leg, that gets you pretty damn far already. Exactly. We've had, and everyone we've shown, and I'm sure you've seen this as well. Yeah. Everyone's like, oh man, my balance is terrible. And we're just like, yeah, everyone's is. But then as soon as you get better and you kind of progress things, make things a bit more difficult to a point, then the normal sports, if you're looking to get back to sports, takes over. Yeah. And most people, at the very least, see a of the decrease in injury rate, which is always a win, but also performance boost too, which is always nice. 100%. So true. So, so true. I don't even remember what the question was, but I think we answered it. I think we did. I think we did. Yeah. So this is a good segue into the next question, which is what role does biomechanics play in knee pain and how can physiotherapy address these issues? That's such a good question. I mean, short answer, Yes. Yes. Yes. Spine mechanics plays a huge role. Yep. If you look at the difference between, uh, men and women. Yep. Naturally, women are going to have that wider set hip. And the Q angle, for those that don't know, the Q angle is where the neck of your thigh bone turns inwards. So you often see women, especially with wide hips, they've got wide pelvis, wide hips, and their knees are quite close together. So there's always going to be way more forces directed at the inside of your neck. Where men, we're much more linear. Yeah. I don't want to say narrow hips, but it's more a case of the Q angle at the actual thigh bone is nowhere near as severe. So things are much more up and down. Yeah. That's more of a, like a genetic standpoint. If you look at like habits. So if you always tend to walk by, maybe you've had an old injury that you kind of just like limped past and hung on with it. You're always favouring one leg. And that leg is always going to be overworked. The other leg is always going to be underworked. Yep. Have less capacity and all these different things. Yep. So by mechanically standing there, it's setting yourself up for some kind of injury. Different types on each leg though. Yep. So whether one's just an overload and the other one's just, Oh, we can't cope with these demands. Traumatically speaking, we'll just give out. Yep. That's very, very broad brush and very, very oversimplified. Yeah. Yep. But, that's probably the easiest way I can put it, but that's a huge, huge rabbit hole we can go down. And people far more, um, knowledgeable than I could explain that a lot better, I reckon. It's a complicated thing to explain. God, yes. Extremely complicated. I think we might have to do some, some videos on that, explaining the Q angle and, and how bees dive in and how It's not always a bad thing. Mmm. Like, we know you can get, um, Mmm. Mmm. Some high level powerlifters will literally force their knees in. Yeah. Because it stacks the bones a little bit better and allows them to drive out of the hole. Yeah. It's not something like your general population should aim for, because that's much more performance based and these people are pushing that upper limit. And they're training into that over time too. Yes, it's a specialized, same thing when you see them do like a deadlift with a big rounded upper back. Yeah. That's something they've built up to. Exactly. It's not something you should jump into at all. No. It's time for Risk assessment, is that a good way to put it? And whether it's worth it for what you're trying to achieve. Yeah. And this is actually, yeah, we've kind of um, gone through the second question, I mean the fourth question too. So, how do factors like age, weight, activity level influence the knee pain and its treatment? So, I guess those two questions kind of link together where, You've got your, what you're born with. Yep. And then your, so your gender, your muscular and your bony system as well. That's a good way to put it, yeah. And then you've got other things like your age, which we can't change that either. We can't. But there's definitely some certain things that come up. Yep. We'll get into that in a sec. But then we have things like activity level, which is within our control. Massively. And probably the biggest component. If you want to sum up physio to like one sentence, it's we're trying to get you to an exercise program. That's it. Whereas the method works, the hands on stuff, it works. It helps a lot of people. Definitely. But it's definitely the early stage stuff where the strength conditioning or the general gym program is the mid to late to long term. That's going to keep carrying you. Definitely. We say it all the time. We don't want people coming back twice a week for the rest of their life. No, that's awesome. Yeah. In terms of like, alright, we haven't been able to get you there. Some people physically can't happen. But the majority of people, it's definitely about getting you to that stage to where you're on a gym program. And You understand how to rehabilitate yourself. Yes. Especially. We'll teach you that. So, we're outsourcing our skills. Yeah. For that. I think, um, some people listening, one of the ten people listening, we've gone up from five to ten. That's good. Double. We're only talking in percentages here. Yeah. Two hundred percent. Here's um, Lane Norton. He's a doctor of some empowering guy from the States. And he said as you age, you're going to have some form of pain with or without exercise. But the benefits far outweigh that and better pain you're going to experience. Exactly. So the, like the amount of decreased risk in cancer is huge for just the general exercise. And then the decreased risk of cancer, if you've had cancer, for those that did start exercising afterwards, I think dropped by like 50%. Yeah, I saw something similar to that actually, too, recently. Even if it was like 20 percent decreased, like that's more than enough to be like, we should. And then that's adding on all the other benefits. Yeah. I think it's very much a case of. When people feel pain They think oh i'm damaging something there is a cause for that. Absolutely. There's time if it's brand new pain Maybe I should get this checked out and that's definitely the right thing to do. Yeah, if you've had for a long time You've been through rehab And the pain and you feel like your system is optimized and you're doing exercise that aren't aggravating It may just be chronic in nature. Yeah, that may be how it is But if you're still making progress in terms of strength muscle mass balance function And the pace of getting worse, it might just be something to make friends with. Like, hey, it's there, it's not getting worse, it's not stopping you from doing anything. Yep. It shouldn't stop you from doing anything, that's a better way to put it. Yep. So, the activity level, to come back to that question, like age, activity level probably the biggest one to say, because we already covered the gender differences. Yeah. But your older population, we definitely see it. It's not as bad as it used to be, but when I first started as a physio, it was very much a case of people who had retired, people who had worked their whole life, and then felt like, oh good, now I can rest. That's when they started to go downhill, because their job was keeping them active. Yep, I do agree with that, 100%. And it makes sense. You're like, okay, I can relax now, when if anything, that's the time for them to step things up, within reason. Yeah. Because they've gone from working most of the time a fairly physical job to doing almost nothing. Yeah. And they might be getting out for a walk, might be going to the garden, might be going to play golf. That still over the course of a week is not much. Yeah. And they, it's much easier for them to lose muscle mass, therefore there's more strain on the joints. And it's going to bring out the underlying things. There you go. Yeah. Yep. And because you've got more time to think to yourself. Yep. You're more aware of pain. Yes. It's easy to focus on it. So true. Because these little niggles, they don't have to mean anything. Sometimes I do. Sometimes you're like, oh okay, this is actually causing me distress and it's best to get this checked to make sure there's nothing else going on. Definitely. No, it's, if you're someone who has just inactive in general, then we know knee pain is more likely than not. You don't want to say, oh you're automatically going to get knee pain. But your deconditioning, not just the muscles, but also the cartilage, the ligaments, the tendons, Yeah. Even the snowy fluid, we know thickens up with less movement, which means that people say, Oh, my joints feel stiff. Yeah. It's literally just because they're not moving. Yeah. The more you move, the better they feel. Within reason. If we, we were simplifying, but it really doesn't make sense. If you move, everything gets better. So true. Sometimes there's a hump to go to get you past that initial painful stage, but then past that, everything improves. It's just finding the right thing at that right time, which I feel like is, you know, A big reason as physios or even a health professional in this kind of scope is the fact that we're just the ones guiding you in the right direction from what we've seen, from the research, what we know, because we're slightly separated from your situation. We've seen it before, generally, and we're like, okay, we know this XYZ will work for you at this current time, because you can't figure it out, but it's much, much harder, which is a big reason why. You, like, my shoulder was, like, Monday. There's no way I could have done it by myself. I had a general idea what was going on, but I definitely didn't know for sure. And same thing with your hip and your back. It's so much easier for someone else to treat it, even with the expertise we have, we're still outgraded at treating ourselves. Definitely not. Definitely not. No, we're definitely not. That is, yeah, you can underline that. It's so true. Yeah, so we've talked about the difference, importance of muscular control, biomechanics. Now let's talk a bit about strength, strengthening exercises and their impact on the knee. So like, what's the, why, why do we strengthen a muscle? Oh, it sounds so obvious. But then for those, I feel like we always forget. Like our education and our interest in the area is not common knowledge. Although it should be. It really should be. And I feel like we do a good job of just trying to educate people. Like, hey, this is why we do things. Yeah, exactly. So true. Why do we strengthen? If we go off the long list from, cause if we strengthen, we are able to develop stronger, denser, more capable muscles. Your example is always the best one of. If you can lift 1 kilo, your capacity is only 1 kilo. If you then have to lift 2 kilo, that's quite a big jump. But if you can lift 10 kilo, 2 kilo for your leg almost nothing. Best example of that. You make everything in your life. percentage. Exactly. That's what I always try to tell people is that if you have a buffer, that's what we try to get people where they want to be, but also a little bit further above. So it gives you that decreased injury risk because you've just got so much more room to work with rather than being on this knife edge. Like most, um, I can't prove this, but most like, uh, NRL players, their injury risk is so high and so often it's because they're pushing that out the window. Yeah. And whether they're like doing, uh, extra curricular activities on the side, that's affecting their recovery, but still they're just on the edge. And you see it happen closer and closer to the grandfathers because they're just pushing that, that level of duration as well, to where their body's like saying, we can't keep up anymore. And they'll have an injury and want to come back as fast as possible. Of course. And there's too much money involved. It's yeah. They're a good example of. Too much pressure on the body. Yep. Massive lip. And then they do an okay job during the off season getting things done, but not always perfect. Have I tried it off? No, no, no, no, that's good. Why do we strengthen? That's right. Why do we strengthen? It sounds obvious. To get stronger. That's as simple as it gets. But from getting stronger. Yeah. We get more joint stability. Yep. We get far less pressure in the joints because there's a reason the whole thing of it as your skeleton is like your scaffold. That's where some of the pressure gets placed. Yeah. Your muscles are the cables. Yeah. That's the pull that air out. Yep. And you tension the cable to take pressure off the scaffold. Yes. That's a really good way to explain it actually. I just thought of it. Yeah. Muscles are here to help us to translate force. So, Our body requires a certain amount of strength in order to stand up against gravity to stabilize the multiple joints that we have. So like ankle, knee, hip, you know, the whole torso. So standing up against gravity, we require strength to stabilize that and the muscles are coordinating too. So like in a pulley system, like you're saying. That's right. So that's where you, you probably heard before, you've got your anterior chain and posterior chain. And posterior is pulling one way, anterior is pulling the other way, and they're causing an equalizing force is a very simple way to put it. But yeah, it comes back to physics at the end of the day. If you don't have the strength to stand up against gravity, and then you need to do tasks that require more capacity in terms of lifting or moving in a certain way, your body's going to sense that as a threat in the same way that everything has a yielding point. Like if you kicked a piece of wood a certain amount, it would break. The body's aware that we have a point that we can't tolerate force or we will break. So it'll give you pain and protect you. So the stronger you are, the more your body's going, okay, we can deal with this. Yeah. Yeah. It's a really good way of putting it. Yeah. And it almost sounds too simple, but that's as easy as it can be. It's literally just finding the way to strengthen. That's not going to aggravate too much. Yeah. I'll stick with it. Allow you to progress. Exactly, and like you were saying before too, the body, the body is concerned with survival. So pain is a protection mechanism. If your body has been under stress for a long period of time, we know that that's even just three months, that the pain signals actually become more sensitive. Is long at all? You take me, I've had hip pain for years now. I actually recently had a scan. Nothing. Unremarkable. So that's a perfect example, right? Which is sometimes, uh, relieving. Yeah. But then also frustrating. You're like, okay, what's the cause then? Yeah. But it's just, I'm hypermobile. I, you know, had an injury previously and my body is still, you know, hypersensitive in that area. Rightfully so, because it has to keep me alive. So you're right. Like if you focus on the pain. Then you're gonna go, okay, this is something I'm worried about and it's gonna grow whereas if you're like, okay Yes, it makes sense that I have pain there. Yeah, definitely and that's I feel like we're There's definitely some people who in vast amounts of pain. Oh, this is easy for you to say Yeah, of course, of course, we're not in anyone else's situation Yeah, and but it's from the little niggles that people have been like, all right, I've had this And then I'm gonna the six, seven years, try to everything that's working. Exactly. Yeah. We can work through it or just work around it. Exactly. All those people on the other end of the spectrum who it's affecting their daily life. That's about getting those small wins of like, all right, can we do this? Yeah. Good. Let's do that for a while and then build on to something else. A hundred percent. And then also too, if they have any hard neurological signs. So like me, I have no neurological signs. I just have pain. So if you've got pins and needles in a certain area, you've got extreme weakness, you've got wasting, you've got obvious signs of like, damage to the nerve, then totally different game. Yes. Versus being someone who had an injury years ago, is hypermobile, so my nervous system is already hypersensitive and hyperprotective. Yeah. Yeah. Yeah. I'm just, yeah, I'm one, one example. And people don't realise that, people don't realise that your, your brain has literally built new neural pathways in that time. Exactly. And it's just, it's thought, Hey, we need to, like you said, keep this protected. Yep. Let's make this pathway super straightforward. Yeah. And then anything can set it off. Yes. Yeah. And then pathway, our neural pathways are great. Yeah. At building. Yeah. They're terrible at shutting off. Yeah. And then if anything, they only just lie dormant. Yeah. Yeah. They can get kind of not redeployed. What's the word? Reactivated. Yeah. Very quickly as well. Yeah. So the only way really to change it is by developing new neural pathways. Exactly. One of the best ways of doing that is exercising. Yep. To challenge that. To challenge that and be like, Oh, I'm getting stronger. Because we also exercise has a pangolin effect. Once again, the right exercise, right intensity, and that's very individual. 100%. But it just flies in the face of what we even knew like 10 years ago. Be like, Oh, you hurt? Stop it. Yeah. Stop it completely. There's definitely a time for that. Definitely. Yeah. If you've broken your leg. Yeah. Yeah. You shouldn't be doing much. Yeah. Unless it's like us up the chain. Yeah. The hip or the muscles in your feet. So it's not an uphill battle, but it's, it's definitely that case of, Hey, if you're not actively trying to get stronger or actively trying to maintain strength, then you're going backwards. Exactly. It's similar to, someone told me quite a while ago that. The reason why we go to the dentist, because teeth don't get better, they just stay the same. Yeah. Or, if you don't look after them, they get worse. Yeah. Total sense. Where muscles aren't as bad as that, we can get better, but they can definitely get worse too. 100%. So true. Alright, let's talk a little bit about medication, which isn't really our area, but maybe just like what we do. Kind of see in terms of how it fits in the picture. Yeah, and then some surgery. Yeah. Well, yeah I think medication for once again the right person. I Feel like we always have the kind of same Uh, attitude towards it and that it's good when it works. Yes. And it's good to kind of get you past that initial stage, whether it be like any inflammatory is to really, cause we want some information. We know that information is part of the healing process. We don't want to cut it completely because we need it to actually get things moving. Yeah. But if it's stalling progress, that's when it's time to get on top of that pain relief just in general. Absolutely. Absolutely. Absolutely. Talking about like your older patients who have like really severe osteoarthritis, pain relief before exercising can be a great idea so you get them through it, and then over time they take less and less, or maybe it's not as severe, as their muscle gets stronger, as there's less strain on the joints. So it's much more a case of we use it as like an extra Yeah. And some people it might be a big, big thing. Yeah. In the early stages, like the medication is like doing the bulk of the work, but then slowly but sure the medication comes down. Yeah. And then all of a sudden they're much more into the more of the exercise and just being active. Yeah. So it's like a A short term. A short term, absolutely. Yeah. Some people, not a long term solution, some people really shit on it and like, oh, I don't wanna take medication. Like, Hey, it's good when you. when it's for the right person and for the right thing. Totally agree. And some people get very funny about it. They're like, Oh, I'm still in pain, but I don't like taking pills. We can't force anyone to take anything. And officially we, I tell people when they ask for pain medication, officially we can't say anything. Yeah. Yeah. Um, but if it's helped and it's slowing your progress by being in more pain, yeah. Might be a good idea. Yeah. To talk to your doctor again or your chemist at least and be like, Hey, maybe we could step things down. So if you don't feel comfortable taking something heavy dosed like your Pilex or your Endone, maybe something just a little bit more lighter on like Panadol or Nerf and stuff like that. But it's still, it's got its place, that's for sure. We're definitely a clinic that's not against pain relief. Like we, because we deal with so much TMJ stuff, Botox is a great thing for the right person. Once again, just to get you moving. To get you moving in the right direction to allow your jaw to work. So true. It's like there has to be the correct logic behind it for that individual person. There has to be a goal for it. Totally agree. What about with surgery? Once again, it's, I think there's definitely a, you hit a threshold of like injury. And let's talk more traumatic first. Like say if you've done your CL and the discus, almost definitely you need surgery. Like there's no real way around it. Yeah. pending on your age, pending on your function level. Cause it's, you can definitely live with the average ACL. It just depends on what you want to do afterwards. If you want to still be really athletic and do lots of changing directions, you can still do it. And I've worked with a few footy players who have, they run through tape like crazy because their knee is just a mummy by the start of the game. But it's more about the forces applied to the remaining structures. Cause we've only got four limb bits in the knee. With all the muscles surrounding it, you take away one of the main ones, which is the ACL, then the meniscus does a lot more work and can cope with it. But then it's almost like a matter of time before the meniscus happens. Then you're left with even less of the structure. Yeah, it's true. And the ACL is inside the knee, just helping with the tracking and the stability. So if you take that away, there's going to be more micro movements in there too, which means that Upgraded chance of things like osteoarthritis. Yep. Affects to other ligaments as well. So, you're definitely right. ACL surgery is definitely dependent on the person, their age and what they need to be able to do. Of course. And then if we talk more about meniscal surgery is really dependent on whether the severity of the meniscus as well. Because you can have just, uh, isolated meniscus tears. Yes. And sometimes they can, depending on where they're at, depending on the severity, they can heal on their own. And what we do in that stage is, once we know what we're dealing with, most of the time we want to talk to, at least talk to an orthopod to get their opinion too. And a lot of times the surgeons are like, yep, just keep going with physio for a bit, see how you tolerate it. If things aren't working, then we'll talk more about surgery, or maybe we want like a prehab program first. But if you've got like full on like locking of the knee where you've got literally this gets rolled over and stopping your knee from moving properly. And that's when it's like, all right, you literally inserted to remove this. Yeah. It's become a physical block to movement. If it's just pain, then it's like, all right, cool. We can work with this, see what we can do. But if it's physically blocking the knee from doing stuff, then it's going to cause more damage being in that position. So yeah, that's definitely the case when it's definitely the severity. the type of person, the type of area. Once again, there's no easy yes or no here. Yeah. Yeah. And then if we move to more, I guess, not even the older population, but more the overload, you've got, uh, like the sinus around the knee or fat pad impingement, or say the tendons are inflamed. Rarely does that result in surgery. Yeah. Most of the time, they all do great. conservative treatment like physio or maybe some injectables or pain relief. And if they did have surgery, it's actually more the fact that they ended up doing the rehab after that. Yes. Which is always so funny. And what's a really good point when we were developing the, uh, the protocol for total immune replacement, but they found no difference in at least in that study of doing prehab before surgery or adopting any prehab. Even though we've seen it hundreds of times, the people that do prehab doesn't have to be here. Yeah. Can be straight at home, do so much better. Oh my God. Yeah. It is night and day. Yeah. They go through it so much quicker. They know what to do. They know what to expect. Uh, pain is often a lot less and their function before surgery is far better. And then after surgery it's, they're ahead of the people who haven't done prehab. Wonderful. I love, love, I don't know how. That study yielded that result. Yeah. Yeah. This is, yeah, we could go on a tangent about how you have to be very selective with the, uh, evidence that you follow based on the way they've done the study. I think that was quite a large study too. I think there was like a hundred people in that, which should have accounted for those outliers, but maybe they just got all the quote unquote wrong people. Yeah. Potentially. Which is a bit, and even logically. Makes sense. It makes sense If you're stronger going in Mm-Hmm. you're gonna be better coming out. Exactly. And all the surgeons we've talked to as well, they're like, yep, totally degree. A hundred percent. They'd much rather, especially if you are a bit younger, um, they definitely want you as strong as possible going in.'cause they know that once again, if they do surgery on someone that's their signature. They don't often, if people have a bad result from, uh, surgery and rehab, they don't often blame the rehab. They often blame the surgeon. Yeah. So, the surgeon knows anecdotally, like, what's gonna work. That's why they're often talking to us and like, Hey, see these guys. And we're very on top of them. I mean, like, this has to happen, we know it works. Because of the results that we need to get. And also, at the end of the day, we just want to get people better. 100%, like, a good example is, if someone, um, Like comes in and they can't even do a sit to stand. So they don't have the capacity in the cords even for that. Then you do surgery and they've now spent, you know, three weeks not doing a lot. They've now deconditioned even further. So the level of exercise that you're going to need to start out and taking into account that when you have surgery, you've got pain inhibition, things, muscles aren't working like they were. Exactly. You're putting yourself. You can definitely get back. But you're putting yourself at such a disadvantage. You're starting backwards. You're starting well beyond where you were. Exactly. A conversation I had with a few people, and we'll talk about more like, totem near replacements in a sec, of people who can just watch them both the dogs wrestle for position on the bed. People often worry, especially for the uh, like how long it's going to take After a surgery to get back to where they were. And if they're thinking about where they were, like say if you've had knee pain for 10 years, and it's, like, you're, everything makes sense for you to have a total knee replacement. You've done all the rehab, yep, pain is a little bit better, you're stronger, but it's still affecting your day to day. Makes sense, you're probably in that kind of role. But you've done all the prep work first. Exactly. You're gonna get past, yep. that stage where you're at now fairly quickly people are thinking it's going to take 12 months to get better when if anything it's going to take 12 months to get beyond that stage but they're going to hit the stage right now if that makes sense fairly early on in the piece definitely which is really encouraging it's like oh i've i'm equal to where right now how many months later yeah and now it's only up from here exactly as long as they're and people don't want to hear this you have to be religious yeah it turns into a full time job definitely People are surprised by that, I feel like the surgeons tell them that, physios tell them that, and they think, oh yeah, whatever, it's a bit of a joke. It really has to be. Those are the people that do exceptionally well. Oh, yeah. I've got a few in my mind over my career that have been absolute gems and just done everything they need to. Oh, and you wouldn't know they had surgery, you'd think, and they're doing almost it. It's a big one that kind of drops off in terms of. Because obviously if you've had like minuscule ACL repair, stuff like that, running's back within your wheelhouse. Yes. Total knee replacement, running probably a little bit, I don't want to say unheard of, but most surgeons advise against it. Yeah. Just because the surgical steel's not going to adapt like bone does. Yes. That's a great way to put it. But still, they can, us, from riding bikes, power walking. Yeah. In the garden, playing golf, doing everything they want to do, with almost no. No awareness that there's anything actually going on in the name. Exactly. So true. And I feel like every time that I meet one of these individuals and they rehabilitate really well, I'm like, Oh my God, you're a superstar. And it just really just shows you what can be done with discipline and yeah, with discipline and diligence. And it's, it's somewhat, once again, I think it's easy from our point of view, because we see it, we see the people who do well. Our buy in is so much higher because we've seen it. Yeah. Which makes logical sense too, if you haven't, if it's a hypothetical thing and it's going to require like, every day of your life, time and consideration, Yeah. They may have heard bad stories from other people, like saying, oh, my auntie had toenail replacement and it just didn't work for her. You don't know the whole story. They could have been a smoker, she could have done no pre hab, no post hab. That's so true, yeah. Yeah. Had postoperative infections, she could have done everything wrong. Yeah. And then that's more than likely that not to place the blame just on the patient. As an example. As an example. Yeah. Yeah. All variables could wrong. They could have done everything what they shouldn't have done. Yeah. And then that's the reason why not the actual surgery. Such a good way to put it. I think that answered the question in a very long-winded way. Yeah. No, I think that was really good. Yeah, are there any specific rehabilitation strategies that you recommend for different types of injuries, like an ACL tear or like versus a meniscus? The very low hanging fruit, well I mean, we as physios, we love protocols because that gives us something to work from and we don't always fall into a team because we always try to individualise them for each person, but the, the one gold standard protocol we have is the ACL Melvin Guide. Yeah. And we've seen it time and time again work wonders for people. Yeah. And if Reece is listening right now, you should definitely have read that earlier. I did see he printed it out actually. Good, I'm glad. It was going alright. I feel like as soon as he read it, he was like, oh, I get it now. Yeah. No wonder. Um, the fact that it's criteria based is, makes it so much different. So yes, timeframes are a key. If you can't hit, like, say, oh, Because I think early stage it's like, get rid of swelling, get range back, get some form of normal gait pattern back, then you can move on to the next stage, which makes sense. You don't really need to move me on to stage 2, 3, and 4, and you've still got all these problems from the first stage. Definitely. Like I said, time frames are important, but I feel like post surgery for an ACL, I feel Carotid is far more important. Definitely. Meniscus is far more up in the air depending on the type of surgery, who's done the surgery, how you reacted to it. Because sometimes they stitch it together, sometimes they remove it. It's, it's much more gentle. It's much more around trying to get, like, everything firing in a non weight bearing position first, where ACL rehab is much more active. Yeah. Especially after that kind of first criteria phase, where they're starting to come out of their brakes and they're walking normally. Mmm. Because the meniscus takes so much load, Through our joint. That's a really good point. We need, yeah, we need to give it time to actually just settle it out. Yeah. Because then otherwise we're just gonna cause more pain. Yeah. And then there's more inhibition and there's more, more pressure against that kind of vicious cycle. Starts again. Point I say that's the, the two big differences between ACL versus meniscus. And then what was the other half of that question? Yeah, I think you've covered it to be honest. Um, and then once again, go into like total joint or partial joint replacement, which is. Much more, I don't want to say easy, because there's still hiccups and a lot of times it's up and down days, but they tend to get better and better throughout the day, better and better throughout the rehab process. But, I always say, like, hey, the knee that was causing issues is gone now. Yeah. You have a brand new knee. Yeah. The pain you're dealing with is from the incision. Yeah. And the fact that your bone has literally got a metal shaft through it now. Yeah, exactly. Gone through the trauma of surgery. Yeah. That's the pain you're dealing with. Yeah, exactly. That's such a good way to put it. Yep, no, I think that answers that nicely. I think if I ever had to have like a joint replacement, I'd want to keep the joint. Like in a jar or something. I probably wouldn't. I'm sure they'd do something with it. But like just to have it on like, in like a specimen jar somewhere. That would be cool. It would be cool. You'd be like, hmm, aloney. Oh, well, this brings us to our last question. Wow. Yep. Yeah, can you share any recent advancements or emerging technologies in physiotherapy for knee pain? For knee pain in general? Yeah. Oh, most recent? The most recent one I know about for, like, ACL repair is the cross brace method. Yeah. Where they literally put you in like 90 degrees of flexion in a brace for a few weeks to allow the ACL to knit back together. Oh. But that's a very specific type of person. Yeah. And then the acne of blood thinners as well for risk of, uh, blood clot and stuff like that. But for knee pain, I'm not sure. I think, I'm sure there's newer research out there right now. Yeah. But the effects of exercise, hydrotherapy, which is essentially, um, exercise and walking in a warm pool. Yeah. There's a very specific temperature I always forget. Yep. Isometries have been around for decades, well, hundreds of years even. And we know the, the pain with effects of those. I think a cool one that I recently just bought, one of these machines, is the, um, Compex machine. Oh yeah. It's like an EMS. Hmm. Which you, especially in that initial stages where you're gravity eliminated and getting that muscle to activate. Makes sense. There's been some really good research into that. Oh yeah. How the, yeah, the rates of strengthening, especially initially, were exponential. Makes a lot of sense. Yeah, you're not having to. where you're able to get the muscle to activate at a higher amount with less load than otherwise. Yeah. And especially knees when they're at that point where they're really, really weak, they're really hard to load without annoying them. Yeah. Once again, that's just the joints taking the brunt. Exactly. The joint is taking all the load. Yeah. So I find That is very interesting. I've definitely done some, um, not to frighten anyone, but definitely some, um, electrical stimulation by dry kneeling. Yes. Post, um, knee replacement only needed to be done once because it was so painful, but it got to the BMO, which is a muscle on the inside of the knee, which is often, it's weird how it's probably the most important muscle at the knee, the knee health and stability. It's the first one to shut off, by far, and it's so hard to get active again. Isn't it like 10 mils of swelling or something? That's all it takes. Oh, it's a huge amount of fluid in the neck that causes things to go haywire, which is ridiculous. The body's like, no. Yep. Whereas, driving them quite deep into the VMO, the inside muscle, and then getting an electro stimulator. You see huge contractions very quickly and it's very sore. Like in two, three contractions, they've got dogs for days. But then after that, they're like, Oh, I can feel it working again. And most of the time they refuse to have it done again because it's so painful, but I'm like, all right, at least it's done its job. Yeah. And now you know what that muscle feels like when it activates as well. Massively. So yeah. I mean, I maybe we should invest in one to have for the clinic just for those people longer term. No, I did buy one. Oh good. Yes. It's on its way. Nice. That'll be good. Just for like, yeah, for just knee pain in general. I mean, if you talk about the older population again, the, we're actually finding that the right dose, the right kind of exercise can actually help regrow parts of the discus, especially in patients who are quite bone on bone. Even though we don't. Bone on bone isn't the Isn't what it seems. Isn't what it seems, but also isn't always the cause of the pain. Because there's so many structures in the knee that can get sensitised. So true. Yeah, that was good. Mmm, we're going to have a lot then. Yeah. Is there anything else you want to add before we close up this session? No one has a bad knee. Yeah. Everyone's knees are their own. They're just misunderstood. Yeah, that's a really weird way to put it. And they can always get better. Yeah, there is. I tell everyone, every patient, it'd be rare if one of them just dropped a massive, massive fart in here, and then just acted like it was someone else. Definitely. Pooped in the corner. Oh. That's probably why. Oh my god. Well, we'll see. Yep. Let's finish on that. All right. Thanks everyone. See you next time. See you next time. We'll send you a photo of that. What? Ha ha!
