Why Your MRI Doesn't Mean You Need Surgery | Dr Howard Luks

0:03You're an orthopedic surgeon. What types of surgery do you normally focus on? So that's changed over my career. When I came out, I was sports medicine trained in terms of my fellowship, the training I did after residency. But my first job was as chief of sports medicine at an academic center, and we happened to be a level one trauma center. So we all took level one trauma call. So it was trauma heavy. I didn't do small little rotator cuff tears. I did shoulder reconstructions of people who were hit by cars and flew 30 feet. And so over the years as I've stopped doing trauma, now I just focus on mostly knees and shoulders.

0:46From what I kind of gather from your writing online, you spend quite a lot of time today telling people that they might not actually need surgery. Is that an accurate reflection of the conversations that you're also having in clinic? And did you go into orthopedics thinking that this would be something that you dedicate your time to? It took me a long time to choose orthopedic surgery, although it shouldn't have because I've been an athlete my entire life and I never completed a varsity season in anything because of an injury. When you're trained as a resident, you really don't get a lot of office time.

1:28You don't spend time with the surgeons that you work with in their office. So you're sitting there, you're operating on a meniscus tear, you're operating on a rotator cuff tear or a labal tear. You don't see the hundreds of meniscus tears before them that didn't need an operation. So a lot of young surgeons tend to come out thinking from an MRI report perspective, this is torn, it can't be normal, it must need an operation. And then slowly over the years, you begin to realize that it's not the case. A lot of people think that I just come down hard and say, no surgery is necessary, never operate on this, that, and this.

2:12And that's just not true. There are meniscus tears or retarded cuff tears, et cetera, that are going to need an operation. We just need to do a better job at determining who. How variable would you say that the decisions are between orthopedic surgeons? If you took the same kind of set of scans to 10 of you, how many different answers would I get? There's a lot of variation. From what I see, a lot of older folks, folks who have actually spent their career learning and becoming wise, learning from their clinical experience as well as what they learned in residency and paying attention to their patients.

2:58tend to operate less on people. I'm part of a few text group, WhatsApp groups, and one trend's a little younger and they're incredibly aggressive. They just wanted to think about how do we operate on what type of surgery is needed for this one? And I'm always the one in the group saying, what are you guys doing? And there's another group where we're almost all retired. And they're like, I saw a guy today that someone operated, you know, I can't believe that someone operated on this So they're far more non-surgical. But the literature is really pretty clear on these issues. It's not like I'm not trying to stand out.

3:39I'm not making things up. I'm following 30 years of office and clinical experience where my patients actually got better and combining that with what I've read in the literature. And when you speak to the literature there, Are you talking about studies that compare surgery to sham surgery and then look at differences in outcomes? Is that how we know whether surgery in a certain context would likely lead to better outcomes than conservative management? Yes. So there are sham surgery controlled studies and there's PT controlled studies as the alternative, both for meniscus tears, for tinnitus elbow surgery, for rotator cuff tears, for labial tears, bone spur removal, etc.

4:24So, yes. How does a sham surgery study work if someone hasn't heard of that before? Yeah, so you're seen in someone's office and they evaluate you and they ask you if you want to join a study because your clinical findings and your imaging findings both match what they're looking for in the study. And so you're indicated and you join the study, but you're going to be randomized to a group, meaning you could wake up and have the actual surgery, or you can wake up and just have two incisions and they did nothing. You won't know until the end of the study. You won't know the next morning. So you'll go to sleep in the operating room.

5:10They will make two incisions on the front of your knee or around the shoulder, and they'll move the arm or the knee to stimulate something being done. Then they'll sew the incision up and they'll wake you up. Of that research, or even the research comparing to PT, are there certain injuries that over the years have surprised you where surgery hasn't led to better outcomes? Let's back up a little because you mentioned injuries, right? Like I say all the time, most joint pain or tendon pain in grown adults is not due to an injury, right? You didn't sleep wrong. You didn't, you know, that milk wasn't too heavy coming out of the fridge.

5:56Our tendons and joint structures were engineered in such a way that if you don't maintain them and exercise them, move them, run them, strain them, they're going to let you down. And one of the ways they're going to do that is they're going to start to hurt. Then there are those of us who exercise a lot and we hurt ourselves. So we overdo it. Very few of the people that we see in the office fell off a ladder, fell off a roof, or got hit by a car. Is the evidence looking at whether conservative or surgical intervention leads to better outcomes clearer when we're talking about acute injuries? So injuries from sport versus more of the chronic injuries or chronic damage, let's say, or aging that you're talking about?

6:45Yes and no. Most of the studies that have been done have been done on routine meniscus tears, routine rotator cuff tears, you know, a 50-year-old walking into your office with no history of injury. There are no clear studies that demonstrate if you fell off a ladder and ruptured your rotator cuff, there are no clear studies that you'll do better with surgery. The issue becomes there are significant consequences if we wait two or three months to see if you do fine without surgery because the return of cough will change in those three months and it may significantly compromise your ultimate result.

7:21I want to get to the biology of tendons and joints and come back to what you were just speaking to with regards to aging. Before we get there, have you ever performed surgeries and then years later as time has gone by and there's more evidence accumulating perhaps you have more experience with with patients and realize that if you had those same patients today you might treat them differently oh yeah of course all the time most of the surgeries that i do now i did far more of in the past and what are those surgeries that you would do today where you would say these these are the ones where there is the clearest evidence that we should do surgery and patients will get a better outcome than than managing conservatively or waiting?

8:09Sure. So one example is a root tear. It's a type of meniscus tear. The meniscus is only attached to two points front and back of the knee and they're called roots. And typically the root on the posterior back aspect of the inner side of the knee is the one that ruptures. And those knees tend to go downhill pretty quickly and they develop stress reactions and stress fractures if you don't address them and fix them. And to your point that if you took the same scan to 10 orthopedic surgeons, you might get four different pieces of advice or recommendations. If we think about a listener now who maybe has some type of issue, joint restriction, pain that they're wanting to get on top of, what is it in your eyes that makes a good orthopedic surgeon and how can someone discern between one that is practicing based on the best evidence that we have and one who perhaps isn't.

9:06It has to feel patient-centric to begin with. Every injury or issue tends to have a personality. The same type of tear is going to behave in 10 people in 10 different ways. Are you a tennis player? Is it your dominant arm? What's your medical status? Are you diabetic? Is your A1C, 12? These all need to be taken into account when we're looking at a person and you have to be examined. That sounds strange, but our physical examination can be very revealing, especially in joints like the shoulder where you can miss a frozen shoulder because you saw a rotator cuff tear on an MRI and just proceeded down the surgery route.

9:56So there's a clear situation where you're going to make that person worse if you miss the frozen shoulder on exam. So hopefully you're asked a number of questions. Hopefully you're examined and then your imaging is taken into context with your history and your exam to come up with a reason for either surgical or non-surgical management in the person sitting before us. I appreciate this. This is a little bit of a difficult question to ask and perhaps to answer, but I think it's something that's on the tip of everyone's tongue, right? Are orthopedic surgeons incentivized once the patients are sitting in front of them to go down the route of surgery?

10:37Or how, if at all, do incentives, I guess, influence that decision-making? It's a challenging question to confront in medicine. It's not a very challenging question to answer because surgical procedures pay more than treating someone without surgery, right? Most surgeons are on a productivity-based contract based on relative value units or RVUs, and surgery is going to generate a lot more of those RVUs. That doesn't mean that everyone behaves that way but certainly the incentive exists if you've been listening to me or some of my guests talk about the gut microbiome you'll know that it thrives on very specific types of fiber and polyphenols and resistant starch many of which the average person falls short on despite the very best of intentions that's why dr will bolsewitz and i founded 38 terror a gut health company where science meets supplementation.

11:38An independently conducted 15-day M. Scheim study found that our first product, Daily Microbiome Nutrition, or DMN for short, significantly increased short-chain fatty acid production and encouraged the growth of beneficial microbes linked to better gut and metabolic health. It's a simple daily scoop that you can add to water or your smoothie, no sugar, no fillers, just clinically backed ingredients that make your gut bugs happy. So if you want to support your microbiome in a meaningful science-backed way, check out 38terra.com and use the code THEPROOF to save 20 % off your first order.

12:17So if you're a patient and with that in mind, is it a good idea to get multiple opinions? That's kind of immediately what's popping up in my mind anyway. I think it absolutely is. Look, Even when I detach my retina, I went for two opinions. I've seen people for two or three opinions almost every day. And it puts them in a strange situation because very frequently they're seeing someone who says, you need an operation. And they're seeing me, this is probably going to define without one. And then you're seeing someone in between. And so, you know, they don't necessarily just jump to the non-surgical doctor's opinion.

13:00I'll tell you that straight out. Sometimes they think that an operation is absolutely needed. And just to clarify, like when you say there's three different recommendations, is that often because the evidence we have isn't perfect and each individual has slightly different context and there is a bit of gray and ambiguity here? Yes and no. I mean, look, clinical studies are perfect, right? They try to find everyone who's 52 to 56, right? Not too heavy. Their A1C is under six. They're not on 14 medications. They have no disabilities, et cetera. You know, we don't see those people often in the office, right?

13:46Everyone has a different clinical situation. So no one is the perfect patient in these clinical studies. Same as drug studies. So in my world at least, you know, when I see someone in the office and I'm talking to them and I'm listening to them, because that's critical. You need to give them time to talk and you need to be able to sit down and listen to them. You'll hear them say certain things and you've heard this pattern before. And then you'll see the images and you've seen that pattern in combination with their history before. This is one of the benefits of doing this for 100 years is you know odds are given this pattern that they're going to do fine without surgery or they tend to end up with surgery.

14:35And you share that with them. And also what I do is very often, you know, it's not life-saving. So these are often quality of life decisions. and so you have to try and bring that in into the mix are you noticing patients over the last couple of years their perspective is influenced by ai and do you see that as a net positive patients i'm sure are putting in their mri report and all sorts of diagnostics into to claude and similar and asking for advice on you know how to manage this yeah so ai can be very useful in the office. I tend to use it almost every day in clinical situations too, but it can muddy the waters.

15:22AI tends to be a little more aggressive and recommends surgery. It also tends to be wrong sometimes. At least twice a week, I see someone who thinks that they have cancer because of the location of their pain, and they were told by AI. And so they're very upset when you first see them in the office. I want to come to some of the main joints, some of the main things that people are struggling with, like knee pain and shoulder pain and Achilles tendinopathy, et cetera. But before we get to that, I want to come back to this idea of imaging and what's normal aging versus what's pathology. Because I've read quite a lot of your articles and you do write great articles.

16:11And I know you have a lot to say about this. So perhaps we can, let's start with the biology here. And we're kind of less talking about acute injuries here. We're talking about those other injuries that are a little more insidious and creeping up on people over the decades. Broadly speaking, what changes would you say that are occurring in it, whether it's in our bones, tendons, ligaments, that we simply, we do need to accept just as aging versus changes that maybe we put down to old age and aging, but are really just a byproduct of the way that we're living and perhaps the movement that we're not doing?

16:48Not sure they'd look different, right? We don't know that. We don't know that the changes that we see, we know that the changes that we see on the MRI are largely age appropriate. I discussed that a lot. And what I mean is this, when I send someone for an MRI, I'm going to tell them specifically what I'm looking for. And I also tell them what their MRI is going to say, because most people have the same four or five things based on their age. So I don't want them to freak out because they tend to get the reports sooner than we get the reports and see them in the office. Now, are those changes there because of aging alone?

17:36Are they there because of lifestyle choices and medical issues? Or is it a combination? I'd say it's probably a combination. I think poor metabolic health, chronic systemic inflammation tends to make these processes more painful. So let's say I have someone in the office with moderate arthritis and they're a runner, their A1C is 5.2, their C-reactive protein is zero, et cetera. They're having an acute exacerbation. I can safely say to them, look, in a few weeks, you're just going to feel fine. You don't need anything. Keep playing tennis. The next room could be the exact same x-ray in a diabetic with an A1C of 7.2, abdominal obesity, and a set rate of 2.

18:31I can't say that to that person because they may now have chronic pain. The pain very well might go away, but generally it's going to linger a lot longer. Do you find that someone who's metabolically healthy also responds differently to your surgery? Oh, without a doubt. They heal better. They tend to heal faster, sooner. Our surgery creates inflammation. So if someone is going in there with a higher level baseline inflammation, they're not going to resolve that as well or as quickly. If someone is going in with an elevated A1C, they're not going to heal that wound as well. And not only are they not healing the wound, but the incision is a window into the rest of the surgery.

19:19They're not healing where you cut the tendons. They're not healing where you repaired the tendons nearly as well. So it absolutely has a role. So if someone has time on their side is kind of doing what they can to improve their metabolic health, is that part of your, I know the term that's thrown around is prehab. Is that something that you would discuss? Yes. So when I meet people prior to surgery, if it's something, a lot of people with knee replacements, which I do a lot of, tend to put them off in the future, outline what I'd like them to do of the next two to three months. We start them on protein supplements.

20:00I start them on creatine. I address their vitamin D levels, whatever else. If their A and C is elevated. Then we work with them on their diet. We can use medication if they're attending. Internist is on board as well. But I do try hard. And we do start, to me, prehab is actually doing the physical therapy and the work and the exercises prior to surgery. And the booklet that I give people prior to surgery has a section on exercises that I'd like them to do now. Coming back to this idea that if you take people in their 40s and 50s and you do an MRI on an extremity, you're going to find things. What are some of the most common things that you would find, if we just talk about common joints, that we may be over-interpreting from imaging alone?

21:00I mean, in the shoulder, the biggest one is the labrum. Almost everyone over the age of 40, 45 is going to have some degree of labral tearing. Almost everyone over the age of 40 has an identifiable rotator cuff pathology. That might not be a tear. It can be some fraying or some tendinopathy. And as you get older, into your fifth, sixth, seventh decades and beyond, full thickness, tears of one or more tendons becomes the norm. And so the art for you and for a physiotherapist is trying to ascertain whether that finding is responsible for the loss of function or the pain that that person is experiencing and presenting to you with.

21:44Yes, but even if it is responsible for the pain, we're trying to get them past that, right? You're not your diagnosis. You're not the finding on the MRI. What I like to say to people is that, yes, you have meniscus tear. Yes, most do not require surgery. No, they don't actually heal. You're going to keep that meniscus tear. But very often, the pain is going to go away. This is where some patients can get into trouble because one surgeon might say, oh, we'll see you back in a month. If it's not better, then we'll do the operation. A lot of these things don't get better in a month. And it'll take two or three months or some even longer.

22:28So I really try and walk people back because I don't want them to think every time that they step on their knee and they feel a little zing, I don't want them to say, oh, that's my meniscus tear or that's this or that. Because a lot of them then go on to change their activities. You know, I can't go up and down stairs. I have a meniscus. I can't squat. I have a meniscus tear. I can't kneel. I have a meniscus tear. And that's lose capacity. And that's when the problems tend to steamroll. Sounds like that the topic of pain must come up quite a bit in these consults. And I'm sure people are asking you, is my pain an indication that the activity I'm doing is making this worse?

23:12Yeah, it's interesting. Pain is fascinating. I'm not, I don't certainly claim to be an expert in pain. But I'll see people in the office for the first time, and when they first discuss their knee, let's say, oh, it's miserable, it's awful, I can't do this, I can't do that, blah, blah, blah, I have a meniscus tear, I saw the MRI. And then I have a conversation with them about how common these are. Your meniscus tear is not unstable, it's going to be a problem. I imagine in two or three months you're going to be playing tennis again, da, da, da, da, da. The temperature of the room goes down. They sit back in the chair.

23:53They're not as acute. And there was a while where I was grading their pain when I first walked in the room and then when we were done. Very often those pain scores, the description of the pain and how much it impacted on the quality of life went down. There were plenty of people who were convinced they were going to need an operation when they walked in, and they were ready to schedule the next tennis match when they walked out. So sometimes the diagnosis alone or what you may be staring at, whether it's an operation or something that's worrisome, that influences the degree of pain that you might perceive.

24:40Not in everyone, but it's not infrequent that I see this. speaking of being defined by the finding that's on a report on on imaging does it help patients to to know that there are people that have the partial thickness rotator cuff tear or the bicep tendinopathy that don't have pain and are there studies looking at asymptomatic people i presume there are that have have have imaged lots of people without any pain and have identified that they do have a slap lesion or they do have a rotator cuff tear? And how do you kind of go about that conversation if you have it at all with the patient? So these are exceptionally common findings in the general population, exceptionally common findings.

25:28So if you're in a crowded room of people and they're your age, if you look to the right and look to the left, a lot of the people that you just looked at have those findings and have no pain. But granted, there's going to be one of them that's going to be miserable and they have the same findings and they're going to need an operation or they might. So not everyone is going to do great without surgery, but not everyone does great with surgery either. So you really, this is really quite an art form trying to determine who might benefit from an operation, who might not benefit from an operation, when to offer it, when not to offer it.

26:08It's tricky. If we click on that a little bit more, what is it? Let's say this person sitting in front of you has a bad shoulder. They do have an MRI and it does show a slap lesion. Okay. And they're coming to see if you can do anything about it. So with that in mind, that a lot of people have a slap lesion and don't have pain, how do you go about assessing that patient and working out whether a surgical correction of their slap lesion is actually going to alleviate their pain or if the pain is coming from somewhere else? Yeah, so our exam techniques for slap lesions aren't great, but combined with the history and the physical, we can usually tell if the pain is coming from a slap tear.

26:54Now, I will tell you again, slap tears are very common in adults, and they are very rarely fixed or operated on. If you're an adult and you have shoulder pain, think of the rotator cuff first, but even though your MRI shows a labral tear. And that labral tear, it's not going to heal. Once you have it, it's there for the remainder of your life. Yes. It's like a pair of jeans that you want for 20 years, right? You look down. I hate the word tear. That's my exacerbation here because if you wore a pair of jeans and one day feel a breeze around your knee and you look down and there's a small hole, you're not gonna say you tore your jeans.

27:38Tearing implies trauma. Tearing implies injury. So I think this is where the radiology world is gonna go one day. Using the word tear, just properly identify these findings. These are just parts that are wearing out. I mean, how many tens of millions of cycles have you put that shoulder through? How many times can you pounded on that meniscus? You know, you're not driving the same car that you bought 50 years ago. You're not wearing the same clothes. You don't have the same refrigerator. Our things wear out. So does our body. So we don't, we should not expect that we will live without these issues showing up on scans.

28:24What's a better way to frame that or a word that you would prefer to see used in academia or on reports? Is it degeneration or is that too scary as well? Yeah, I don't like the word degeneration either. People don't want to think that they're degenerating even though we are. I like the term age or activity appropriate changes and then just describe what's happening. Some fibrillation, some fraying, some age appropriate fibrillation frame describe the finding you don't need to word you use the word tear so you said to kind of usually look past the slap lesion and look to the the rotator cuff if someone hasn't heard of the rotator cuff or rotator cuff tear before what what is this what's going on so the rotator cuff are a series of four muscles that are deep to your deltoid there's a large one in the front there's one on top and there's two in the back.

29:22They're relatively small muscles, but they're incredibly important because the large drivers of the shoulder are the pec, your deltoid, and your lats. But your deltoid wants to pull your shoulder up to your ear, your pec wants to pull it across your chest and your lats want to pull it down into your axilla. So the rotator cuff uses the power of the big muscles and turns it into a useful motion for rotation. So the shoulder stays centered, it stays reduced, it's not unstable, and it can generate power. They're extremely important. And with aging, which are the ones that are usually affected? And does it tend to be more of a partial thickness tear versus like an acute injury is when a full thickness tear or walk us through kind of how how these quote-unquote tears occur so the one that is almost always involved is the supraspinatus on top of the shoulder that's where everyone has their pain in that area a lot of people grab down here though the supraspinatus though look it might be normal physics.

30:39This is going to get a little challenging. I wrote something on this on Substack and both on X as well. But a lot of supraspinatus tendons and rotator cuff tendons have a very complex physics guiding how they function. And there's this cable, this rotator cable that runs from the front of the supraspinatus around to the back of the shoulder, attaching in one of the tendons in the back that we call the infraspinatus. So this cable deloads or unloads the attachment of the supraspinatus. You have to take my word for it. And when a tendon in the body is unloaded, it's going to thin, right? You have to think of the body from an evolutionary perspective and its response because back in prehistoric times, we didn't have food available to us.

31:38So we moved for food and shelter and mating and then we sat still and did nothing because we didn't want to burn through excess calories. So the body is really good at storing those calories and getting us not to want to use them. Dan Lieberman, if you're interested in that topic. So if you have structures that you're not using, your body is going to take them away. Stick your leg in a cast and open up the cast in a week and look what your leg looks like. Same thing happens to the supraspinatus tendon because it's being unloaded by the rotator cable. So a lot of the thinning that we see in the rotator cuff and fraying is just this process.

32:23And then the tissue becomes so thin that it eventually detaches. It didn't tear. It just literally goes away. But from a functional perspective, the shoulder's 100 % intact because the cable has remained intact. And it almost always does. It's when the cable detaches or the tear enlarges that people get into trouble and often need an operation. Today's episode is proudly brought to you by 8sleep. When researchers line up the things that we can actually change in our lifestyles, along with diet and exercise, sleep sits near the top as the most impactful lever that you can pull. The links between sleep and heart health, brain function and metabolism are remarkably consistent.

33:11And one of the clearest factors that influences your sleep quality is temperature. Your core temperature has to fall for you to reach the deeper and very important stages of sleep. That's the mechanism 8Sleep has been built around for years now and they've just released the 6th generation Pod. The Pod 6 is a smart mattress cover that goes over your existing bed, heating or cooling each side independently. The thermal engine reaches your set temperature about 20 % faster than previous models. And the cover carries 9 times the biometric sensors. heart rate, HIV, breath rate, sleep stages, etc. All carefully measured overnight with nothing to wear, nothing to charge, nothing to leave on the bathroom counter.

33:58The pod is not a medical device and should not be used as a substitute for professional medical advice, diagnosis or treatment, and individual results may vary. Use code theproof at 8sleep.com forward slash theproof for up to$200 off the pod 6. That's 8sleep.com forward slash the proof. I've taken creatine daily for years now. On a plant-based diet, you start from lower muscle creatine stores than someone who's eating meat. So it's one of a few supplements that I feel really adds something to my diet. And the evidence on strength and power is about as solid as it gets when it comes to supplements with emerging data on cognition.

34:40Which raises a question that most of us never ask. do we actually know what's in the creatine that we take every day? The category has exploded and most brands have competed on flavors and formats rather than the quality of the creatine itself. Momentus went the other way. Signature spec creatine is made in a pharmaceutical facility using reverse osmosis water purification verified through a six-stage testing process with four independent agencies. 10 times fewer impurities, heavy metal limits two to five times tighter, screening for PFAS and microplastics. It's also ultra fine so it actually dissolves.

35:19No grit, no clumping at the bottom of the glass. If we're taking something every day for our health, I think it's worth it being the best version possible. If you want to try Momentus Signature Spec Creatine, head to livemomentus.com and use the code THEPROOF for up to 35 % off your entire first order that's live momentous.com promo code the proof for up to 35 % off live momentous.com promo code the proof so with that in mind do you think we should be getting out ahead of that and loading that in a specific way earlier in our life to avoid that so there's no way to do that so the cable is going to offload that part of the super smash, no matter what you do to it.

36:11And it's not in a hundred percent of people, but it's in a large majority of people. So it can be an issue, but, but also you're going down the road thinking that that defect is going to be a problem. That's the point is usually not a lot of these small super smash stairs. They don't get bigger. Some will. It's not common, but they will, and you have to follow them. But not every defect in the rotator cuff is going to produce pain or dysfunction. There are a lot of people, there are professional athletes, there are pitchers who have rotator cuff tears who are throwing 100 miles an hour. Because that cable, if the cable is intact, you have a fully functional shoulder.

36:50So if someone has a partial thickness tear and it is symptomatic, how do you go about determining whether this is something that they could improve through exercise and kind of stimulating that tendon to heal and can it heal on its own? Or at what point do you think about going in and fixing that with surgery? For partial tears, the shoulder is functionally intact. So there should be no discussion of surgery at the outset. Everyone should try physio. And rest is almost never the answer, right? Tendons don't like rest. No tendon is going to heal with rest. Tendons require strength to convince them to change, to regenerate, to build new tendon structure, which is appropriately oriented and capable of handling stress.

37:50So we try physio in everyone, and the majority of people are going to do fine. Now, all partial tears are not created equal. Some are deeper, some are wider, some are in other tendons. But when it comes to the suprasmenators, again, it could very well be thinning just because that tendon is being unloaded. So it's just a normal finding. It's just, it should happen. It's going to happen. And you don't need a fully intact rotator cuff to have a fully functional shoulder. It doesn't have to look perfect on imaging. So then in terms of getting imaging, if a lot of these things are just normal and you kind of expect to see them, why are you ordering an MRI?

38:36What are you actually looking for where you go, right? That's not age appropriate. Or what are you seeing regularly? And let's just, let's at the moment, zoom in on the shoulder as an example of where you'd go, yep. Okay. Not age appropriate. Surgery is indicated here. Yeah. So a lot of that depends on the history, the story that you tell me, my physical exam, and my findings. Do they match up? There's a voice there in the back of your head. And sometimes that voice speaks loudly that there might be a problem here, right? Because every now and then someone in your office is going to have a tumor.

39:13So you need to be listening quite carefully. I try not to pursue imaging for the average shoulder pain that occurs with activity a little at night. The exam is consistent. I'll pull out my ultrasound and take a quick peek. I'm not the best with ultrasound, but I'm good enough to tell whether or not the cuff is intact or not. And if I don't see anything suspicious and I'm not suspicious of anything, I'm going to start with rehab, perhaps an injection, definitely with rehab, and then I'll see them back. And I will image them. I'm not anti-MRI. I like seeing images. I think that the issue with MRIs is the images themselves can harm certain people.

40:00So there's no rush to do it. So that's the rotator cuff. What about biceps? Is it biceps tendinopathy that you're usually seeing? So the biceps can be a troublemaker in the shoulder, without a doubt. It starts as tendinopathy, and then you can get these splits along the tendon. And the issue with the biceps is it's in a groove on the front of your humerus, your arm bone. So that groove is made of bone, and it's covered by a very dense, thick ligament. So if there's any swelling in the tendon associated with fluid, and that causes any friction in the biceps, then your biceps is going to hurt. So it's quite a common problem maker.

40:45Do you ever do a biceps tenodesis? Sure, I do. Does that change the function of the shoulder, knowing that the biceps contributes to shoulder flexion? Or does someone still get good shoulder function despite moving that kind of anchor down? Yeah, so I don't think that the biceps has a large enough role that that is going to be a problem. Plus, in a tendon that's degenerative, elongated, frayed, and inflamed, it's not functioning normally. Can you explain to people what tendinopathy actually is? And if they're more familiar with the older term, tendinitis, that's kind of gone out of fashion. What's the difference?

41:30And is tendinitis still a thing? Have we shifted to tendinopathy? How has this kind of vernacular changed? So tendinitis exists, right? If you go out with your buddy, throw a football for an hour, and the last time that you did it was a few years ago, quite likely that you're going to inflame a tendon or two. Tendinopathy describes the changes that occur in our tendons. Whether you say that that tendinopathy is an age-appropriate process or always say it's a degenerative process, that's arguable. Tendons in a 50, 60, 70-year-old just look different than those of a 20-year-old. If you take out spaghetti from a box and hold it together as a bunch, that's what your tendon and the collagen within it should look like.

42:23Now drop that spaghetti on the floor. That's what severe tendinopathy looks like. The fibers are going everywhere. where the spaces between the fibers are filled with substances that shouldn't be there, some of which are inflammatory, like uric acid. If you have high cholesterol, you have cholesterol there in between the fibers. In many tendon tears, we find cholesterol and uric acid crystals in those tears, so it can increase the risk of tendon disease, whether it be tears or tendinopathy. Tendinopathy occurs in stages. If you decide that you want to be a runner one day and you run one mile the first day, but three to second, five to third, and just keep going every day, your Achilles or your hamstring or patella tendon is going to light up and you're going to get this olive shape in your Achilles and it's going to be with you for a year or so after that.

43:30It's a classic overused form of tendinopathy in runners. That's very severe tendinopathy. So that's an overused tendinopathy. When it first started, it was uncomfortable. And those were the earliest stages. And if you had stopped at that point and listened to your Achilles and started with an isometric program, a loading program, again, tendons don't want rest. They don't want you to run every day, but they don't want you to rest and do nothing. They rarely want to go into a boot. So if you get on an isometric program and curtail your running for a little bit or dial it back, you're going to feel better.

44:11As tendinopathy progresses and it starts to look like that spaghetti on the floor, you cannot normalize those tendons. But if you cross-section a tendon and look, the entire tendon is not involved. Typically, it's the center of it, right? So the therapy and the physio in those instances is to build up and develop the normal remaining tendon. You're not going to reverse severe tendinopathy at that stage. So is this an argument for not going for prolonged periods, like a decade plus, being very inactive, not doing strengthening work, not doing plyometrics, kind of jumping dynamic stuff, and then all of a sudden going and taking up basketball or tennis?

45:03What I'm picturing is that person that comes back at 50 and ends up rupturing an Achilles, is that likely from an underlying tendinopathy? Maybe. I think it has a role. So do these other things like cholesterol crystals. And your tendons will respond to the load that you put on them. So if you're a 50-year-old who hasn't played basketball in 15 years and you want to get back to it, you can start doing poga hops, start walking on the court, and you can build the capacity in that tendon over months. It's not going to happen quickly, which dramatically diminishes your risk of a rupture. It's about kind of coming back to activity in a progressive manner rather than going from absolutely nothing to all of a sudden a very high level of activity too quickly.

45:58That's how we get into trouble. Talk to me about knee osteoarthritis. How often are you seeing people that have knee osteoarthritis, whether it's patellofemoral or tibiofemoral or both? five times an hour. It's incredibly common. Whether it's the cause of pain, that remains to be seen, but I will see it on x-ray or an MRI all the time. The most common cause of arthritis is aging. So you see an older demographic and it's going to show up. So what do you see on an x-ray or an MRI that is indicative of arthritis? So the x-ray is going to show a decreased space between the femur and the tibia. You're also going to see the bone of the tibia and the femur become more dense as that space narrows.

46:48That's a process that we call sclerosis. You can see swelling in the knee or an effusion. And then you start to see bone spurs where the bony anatomy of the joint is going to change. And then the bottom of the femur has two condyles and they're typically curved. As arthritis progresses, they tend to flatten. So the changes are pretty obvious. MRI can be far more sensitive because it can show structural change within the cartilage itself. It can show inflammation within the bone. It can show inflammation within the synovium, which is the lining of the knee joint. or the capsule, which is just deep to the synovium.

47:37And so it can give us more information about the severity of the arthritis or whether it's painful, but x-rays alone usually work to show it. I sensed you being somewhat deliberate or careful with the wording decreased space. And I think you've written about bone on bone being quite a harmful three-word phrase. Yeah, I mean, it's an awful phrase, right? I run with people on weekends who have bone-on-bone arthritis in their knee. And the one I'm thinking of, he's my age and bounds over mountains and hills and rocks and roots. He's not disabled. So there are so many studies that show that your x-ray findings do not correlate with your symptoms.

48:26Same goes for the lumbar spine and the lower back, et cetera. So for some reason, the words bone on bone really strike at a patient's heart. It makes them very nervous. And as I alluded to before, they went to an exercise class. Some of them might stop. I can't. I have bone on bone. Or they need to lift weights for osteoporosis. I can't. I have bone on bone. Or I need a knee replacement because I have bone on bone, which of course is not true. You might need it if you're bone on bone and have severe pain. But the finding alone, you know, so a lot of doctors online came back at me when I wrote that and said, why?

49:15We're just being descriptive. I'm like, no, you're not. You can say severe grade four arthritis or severe arthritis you don't have to say bone on bone what good is that doing language matters and and ultimately if it's causing people to give up exercise and there's evidence that exercise can improve someone's outcomes with osteoarthritis which is what people really care about right they you care about can i do the physical movements or activities that i want to do and can I do it pain-free or with less pain, then I think that we have to be responsible with the language that we use to describe someone's condition.

49:55I agree with you fully there. Is the evidence on exercise for someone with osteoarthritis, would you say that's a strong body of evidence that says, look, if you have knee osteoarthritis, doing this type of specific exercise is likely to be net positive for you? So for the most part, yes. There's a fair amount of evidence that supports that. And there have been times when I've had patients lined up for surgery. And there was one time in my practice when we had a lot of financial problems in the U.S. with the collapse of the finance system. And a lot of people were afraid of losing their jobs. and they were signed up for surgery and held back.

50:43And we started them in physical therapy. And when things lightened up, a lot of them didn't need the surgery. Same thing happened around COVID. You had a lot of people scheduled for surgeries. And when the ORs opened up again and we called them, they're like, actually, you know, I did the exercises that you sent me and I'm doing pretty well. So if it's not just someone's x-ray or MRI result that kind of dictates whether they're going to be a good candidate for a knee replacement, what does that decision making look like? And outside of surgery, what are the other interventions, you know, injections for whether it's corticosteroids or I've seen some people talking about, I think like a hyaluronic acid, sodium hyaluronate injection.

51:29What are the different interventions that are available to people and how would you grade their effectiveness? So in general, surgery for osteoarthritis of knee is based on not their x-ray finding, but instead their quality of life. And it's around patient-centric values. Can you walk? Can you exercise? Can you do the things that you need to do? Do you stack everything on the stairs so you only go up once a day? can you get through the supermarket? You know, everyone's going to make that decision and that determination at a different stage, right? Someone who's used to playing tennis four days a week and now they're down to one and then all of a sudden can't play tennis.

52:20Now they can still walk, but they want to get back to a more active lifestyle. And if their age is reasonable and they're healthy, then you go ahead. Others are going to wait until the day that they can't walk anymore. And that's fine. You know, they made an informed decision. So, yeah, the decision is made more based on their complaints and how it's impacting their lives than what their extra looks like. It sounds like a pretty big operation to do a total knee replacement. What does that look like in terms of someone's recovery? And you just mentioned tennis. It's possible for someone to get a total knee replacement and get back to a sport like tennis that is incredibly dynamic.

53:06A knee replacement is a big deal. It's a large incision down the center of your knee. We have to resurface or cut the ends of the bones, cement or components back onto the ends of the bones and put a plastic piece between them and then close everything up. But, you know, hip replacements do very well very quickly, right? The hip is a ball and socket joint, but the knee is a hinge joint. And so the physics are completely different. That incision is in the front. They're highly reactive tissues. The quadriceps can bind up. The swelling can make it quite a challenge to bend. And also, as we talked about, your metabolic health is going to have a big role in this too.

53:55The more inflammation you bring into the procedure, the more you're going to have coming out. So things have changed in terms of how we manage people after surgery. With the medications, we use medications to diminish inflammation, to diminish oozing and bleeding. And they've improved the process a lot from what it was when I started. But by no means is it easy. Now to your second question, injections. So cortisone injections are okay in a few circumstances. You have someone with an acutely swollen knee due to osteoarthritis, not chronically swollen, and they're miserable, and there's no stress reaction or something like that.

54:44They should respond well to that, especially if it's very early in the process. Someone who has high uric acid, not enough for it to be gout, but enough for it to burden the knee and increase the inflammation, they might respond well to a corticosteroid injection as well. Should you get one every three or four months? Absolutely not. It degrades the cartilage and soft tissues, and it's just not working for you. Hyaluronic acid can be useful if you have people with mild to moderate arthritis. The pain is starting to get pretty spicy. It's enough to bother them, not enough for them to want to have a knee replacement.

55:33Their grandchild is getting bar mitzvahed. Their daughter is getting married. They want to be able to travel. It's useful in those circumstances. same with prp injections with the understanding that not all prp is created equal there are good systems out there and bad systems there's no real tremendous advantage over to stem cells which are far more expensive there are doctors on instagram claiming that they're going to cure arthritis and rid you of your chronic knee pain forever you know that's just simply not true but they all these things do have a role. They have a role in older folks who could have the procedure, but there is something scheduled that they would like to tend to first.

56:23They're useful in younger people where you're a little too young to have a knee replacement. So let's throw everything at you that we can to get you through it. You've seen some good results clinically with people that have had PRP or is there evidence that's being published that shows that PRP can be effective? Yes. If you indicate it properly, if you use it in the right circumstance, in the right severity, right situation, they don't have any contraindications, yes, it can work. And you mentioned that not all PRP is the same. Is there a way for a patient to know whether their provider is using a good or a bad system?

57:05You need to ask them what the platelet count is and what it contains that they're injecting. It seems that for arthritis, around 18 billion platelets seem to be the sweet spot. It doesn't mean that more is better. Some studies showed that fewer platelets are better, but I'm not sure what that number was that it revealed. But there used to be a lot of garbage systems on the market where the blood was drawn, it was spun once for four minutes, they only drew 10 or 15 cc's of blood, and you're just not going to get the right product out from those systems. We all have the draw. Half a bottle of magnesium that never did anything, a probiotic from two summers ago, a greens powder used twice.

57:56And the question I get more than any other, are any of these supplements doing anything? Often no, and it's not just the ingredients. The dose is too low, the form is the cheap one, or worse yet, what's inside the container doesn't match the label. I sit on IronMate's scientific advisory board, so I've seen firsthand how Daily Essentials is built. 90 ingredients in one sachet in the right dose and form. NSF certified for sport, every batch screened by an outside lab against more than 200 banned substances. Not just the first batch, every single batch. So you know what's on the label is actually in each serve and nothing else.

58:36Importantly, it tastes great. I'd bet that the powders that are going hard in your drawer are the ones that taste a little bit like pond water. One drink that you take consistently every day beats 16 you keep meaning to. Give it a month and judge for yourself. 90-day money-back guarantee on the quarterly plan. Go to iam8health.com and use the code Simon at checkout for 10 % off your first order plus a free welcome kit. That's code Simon at iam8health.com. Most people don't think about brain health until something feels off. Personally, I'd rather look at the data while everything's functioning fine.

59:15That's part of why I use Function. It gives you access to a set of tests you'd otherwise chase across several appointments. Two markers I pay a lot of attention to, Omega-3 Index, which reflects your EPA and DHA status. DHA, of course, heavily concentrated in brain cell membranes. and homocysteine, which is consistently associated with cognitive decline risk. Both of these are modifiable, which is the point, measure, and then intervene. Members can also add on tests like APOE, the genetic test for inherited Alzheimer's predisposition, if that's something that you want to know. None of this, of course, replaces your doctor, its information, a more comprehensive view of what's going on inside you, so the conversation starts from data rather than guesswork.

1:00:00Check your health the way that I do. Function provides more than 160 lab tests for$1 a day and member pricing on advanced imaging. Join at functionhealth.com forward slash Simon Hill and use the code Simon25 for a$25 credit. And if someone hasn't heard of PRP before, there's a high level description of this that essentially you get a blood draw and then you're kind of concentrating growth factors that are injected into whatever tissue you're trying to regenerate? So you concentrate the platelets that have the growth factors in them. And then when you inject the platelets, they open a rupture and then release the contents at the site.

1:00:49Do you see similar results with these cortisone injections or PRP in the shoulder as well? So I use a fair amount of cortisone injections in the shoulder, the vast majority under ultrasound guidance. So I'm not injecting them into a tendon, but layering it in what we call the subacromial space on top of the tendons. PRP can be useful there too for some cuff-related pain. You know, you have someone with some tendinopathy, maybe some of the fibers are frayed and they're not quite getting there with therapy. And maybe you tried a cortisone injection a while back. And so you can do intratendinous injections there and they very often work.

1:01:37And you don't inject into the tendon because that would damage the tendon? The cortisone you don't inject into the tendon because it can have deleterious effects. Yes. I laughed when I read one of your articles where you joked about rebranding to a regenerative orthopedic surgeon. Would you say this space has got quite out of hand with people flying all around the world to get access to certain treatments in the hope that they are regenerating tendons and ligaments and cartilage, meniscus? Yeah, you don't have to fly around the world. You can go into any major city. We've gotten so far ahead of the research here and what the actual reality is.

1:02:21People just are, they are claiming they're going to regrow ligaments, regrow cartilage. You're not going to need an operation or a joint replacement. Just give me$10 ,000 and I'll stick 10 needles in you and you'll be fine. And that's just not where we're at. It's just, yeah, unfortunately, that's not, it's a worthwhile goal. Let's put it this way. When I was a fellow in the city, the Hospital for Joint Diseases, we did some of the original work in cartilage regeneration, where we filled little defects in the articular cartilage of your knee. We put a little membrane there and put some cells in there, and we could regrow articular cartilage.

1:03:11That procedure still exists today. It's done a little differently. The implantation is easier, but we're still at the point where we can only regenerate a small hole in the cartilage. Osteoarthritis is like losing all the asphalt on a street. It's all gone. Cartilage regeneration, now the state of the art is we can fill a pothole. So if there is a structure there, and because of injury there's now a defect we can fill that defect level with the pot with the rest of the street but if all your cartilage is gone we can't rebuild it back to anything there's there's no scaffolding there so the future looks bright but it's looked bright for 30 years for me I'm you know from when I did the original studies are you hopeful that there's a sort of quote unquote, cure in the future?

1:04:08I am. I think that there will be. I won't put a time on it. I mean, a lot of the older orthopods and I sit back and talk. We were quite green back then. We're still doing an ACL pretty much the same way that we did it when we trained. We still talk about the same graft choices, right? You do the patella tendon, hamstrings, the quadricep tendon. We're still talking about rehab techniques. We're still arguing about rotator cuff fixation techniques. But as we alluded to, most rotator cuff tears occur because of failure of biology. So we don't need stronger anchors. We don't need stronger sutures.

1:04:50We don't need more sutures. We need to find out how to alter the biology of the environment that led to the tear in the first place. Let's say you have a traumatic rotator cuff tear two centimeters long you fail non-surgical management you decide to have it fixed so you have it fixed we get an ultrasound six weeks after surgery it looks great we get an ultrasound in three months looks great we get an ultrasound in two years without a new injury it's torn again it didn't tear because you did anything wrong It tore because we never changed the biology of why the tear occurred in the first place, this degenerative process that you alluded to.

1:05:32So yes, I am hopeful. There's a lot of interesting research in the cartilage community, but a lot of it is mouse-based, and it's going to take 15 years or 20 years, even in the presence of AI, to get it until it's implantable in humans. So I'm not hopeful it's in my life, but it will occur. Absolutely. So with the biology in mind, perhaps across the internet, if someone finds this show, they might be listening and thinking, this is exactly where BPC-157 and TB-500, these peptides, this is what they're doing. They are targeting biology. We're speaking the same language here. So what's your view?

1:06:16I'm sure that you, as someone who thinks so much about tendons and ligaments and connective tissue and healing, what is your view on these peptides that are not FDA approved, like BPC-157, TB-500, that people are accessing through the gray market for soft tissue healing purposes? I'm sure you can do a whole podcast on this. but I'm not anti-peptide. Let's get that straight. I am very much anti-lack of long-term data. We just don't know what these things are doing inside of. We don't have great research on mechanisms. We have some, but mechanistic data doesn't always turn into clinical reality or to the contrary, is sometimes it turns into quite harmful effects.

1:07:11And we just don't know. So it might be helping you, it might not be helping you. It might be harming you, it might not be harming you. The bottom line is nobody knows. So I, for one, I'm not jumping on the bandwagon. I don't think that physicians should until we know more about it. Once we know more, I'll be the first to inject your tendons for you. I'll be the first to inject my tendons. I'll have a full stock supply in my refrigerator, but without the research, some research to support the usage, especially from the gray market where you have no idea what you're getting. What could go wrong as a surgeon who understands the physiology and the anatomy?

1:07:57What could go wrong if someone was getting their hands on BPC-157 or TB-500, not even considering purity or contamination, but just the act of trying to inject that locally? I have to think that someone could inject the wrong place or hit something that they shouldn't. Of course. Most are injecting it subcutaneously. I haven't seen reports of a lot of people injecting it intra-articulary or into joints. I think before we know anything, that's a really bad idea, especially if you're not sure of the sterility. And plus you're dealing with multi-dose vials. So anyway, we just don't know. It might cause blood clots.

1:08:42It may not. you can't say it does. I can't say it doesn't. It may cause cancer. It may accelerate cancer. It may not. But again, you can scream at me all you want, but we just don't know. So do the studies and let's find out. I think you might be surprised in my kind of preparation for today, I was doing some trolling of the internet and I came across some forums popular websites talking about bpc 157 and the animal research showing that it was locally injected and people talking about literally injecting locally into their elbow into their ankle into their shoulder by themselves or having a friend do it and then posting sharing you know injection charts of if you're going to do it here's here's how to do it which i thought was a little bit scary.

1:09:34That's really scary because if it's not sterile, I've seen people in the office with infections in their belly or thighs from either testosterone injections or GLP-1s, et cetera, because any time you puncture the skin, it carries a risk. Fine. But if you get a joint infection, that joint is gone, right? It's going to destroy the cartilage and anything that you were trying to heal it's just not worth it you mentioned the acl before so far we've we've kind of spent most of our time on on tendons and and joints and you and you alluded to this but how would you summarize what the the best kind of evidence-based management of an acl rupture a full kind of tear from sport let's say is today is it is is there evidence that surgery is is significantly better than conservative for someone that is a kind of recreational or professional athlete so yeah especially in kids right kids don't tolerate non-surgical management of an acl tear well because the incidence of secondary injuries to the cartilage and the meniscus rise dramatically so many people who tear their acl whether or not they go on to subsequent surgery are going to develop osteoarthritis as a result of the trauma.

1:11:01If you develop a meniscus tear or a cartilage injury, then that rate of arthritis development jumps dramatically. So there's many times that we can reconstruct the ACL to give you the stability you need to cut, pivot, or twist. But even if you don't play sports and have an unstable knee, by reconstructing the ligament, we're protecting the meniscus because every time that knee buckles and subluxates, you run the risk of injuring a secondary structure. But now, I don't want to be heard saying that every ACL needs an operation. It's just not true. The vast majority of adults can be managed fine without surgery, but some people are going to need it, even in their 50s and 60s is there any blood supply to the to the acl and if you have a kind of partial tear not a full tear does the body heal in in any kind of significant way so there is a blood supply to the acl that's why your knee really swells a lot because you've torn that and the synovium that lies over it there's certain partial tears where the knee remains stable and functional i call those are functional partial tear and those where the knee is now unstable or so non-functional.

1:12:25Everyone deserves, of course, a rehab in that situation. Build the strength, build the stability and balance and test it out to see how it does. And the knee will tell you. As we sit here today, do you have a preference for a graft coming from hamstring or from patella or another site? Yeah, patella tendon. I mean, it is the gold standard. And the Moon Group, which is an international academic group that has studied this extensively over 15 years, when they declare that another graft is better, I'll start using it. We have a lot of choices. So in revision situations, I'll use a quadricep. In kids with open growth plates, I might use either the quadricep or a hamstring.

1:13:15But in adolescent, high-functioning athlete, they're getting a bone tendon bone graft. Have the synthetic grafts fallen out of favor? Yeah, well, we've tried them over time. When I was a resident, we used to pull out old Gore-Tex grafts from people. So we've tried them in the past. They just don't work. They don't stand up to the test of time. How does your thinking with regards to managing a ligament like the ACL differ to a ligament like ITORS, the CFL at the ankle? It depends on what the functionality of the joint is going to be without that structure or with that structure in a stretched state, right?

1:13:58Ankle sprains and tears of the ATFL or CFL tend to be well tolerated. You know, yes, they hurt. You got to go through a lot of rehab, but you generally remain stable and functional after one or two major sprains. And so the knee is a lot more sensitive to the absence of the ACL than the ankle is to the loss of the CFL. And in terms of coming back and healing, let's say someone has an ankle sprain like I did, and they tear the ATFL either in isolation or with the CFL. For me, it was CFL in isolation, which I think is a little rarer, a little more unusual. I was like in a very position of dorsiflexion when that occurred.

1:14:43what's actually happening at the ligament level over weeks and months and how long would it take for that ligament i had a high grade tear but we could say we could talk about the most common ankle sprains or mine or both how long does it take before that tissue is is kind of back to pre-injury strength if at all i can't give you a hard number on that it's typically back to functional strength where you can go out and do things in about eight weeks or so. It might be sooner, but your ankle won't be functionally ready, right? You won't have that balance, the quickness, the turning, the twisting.

1:15:20You won't handle plyometrics or drills that well at six weeks. So when you have rehabilitated the ankle, by the time that's done, the ligament is ready. The reason why the CFL heals and the ACL doesn't usually heal is when a ligament tears, you get bleeding around it, and that blood surrounds the ligament. It releases growth factors. You get white cells in. It dissolves the dead tissue. It attracts new cells in there to lay down a new ligament. The ACL is inside your joint, and the joint has substances that destroys that process because if our joints allowed scarring across the joints we wouldn't be able to move them so when the acl tears usually the synovium which covers it tears as well so now if a blood clot forms at the ligament the knee joint is going to dissolve it and take it away so you lose all those growth factors and healing potential on.

1:16:28I've been using Whoop for over six years and I can confidently say it keeps me on track when it comes to my sleep and exercise routines. The next generation of Whoop isn't just tracking your workouts. It's monitoring your sleep quality, your recovery state, and even giving you insights into your biological age. No screen, no distractions, just continuous data on what your body actually needs. And here's what matters. Daily WHOOP wear is linked to increased physical activity, to better sleep, and improved heart rate variability. I have no doubt that my WHOOP is helping me train smarter, recover faster, and make decisions that support my long-term health.

1:17:12Head to join.whoop.com forward slash Simon. That's join.whoop.com forward slash Simon to get one month off your first subscription.

1:17:27I spoke to you when I initially injured my ankle, and I think this is interesting for people to hear because ankle sprains are quite common. So again, my MRI report showed high-grade CFL tear. There was a little bit of a deltoid tear, very mild on the inside of the ankle, but no joint pathology. There was no fracture, any kind of tricky stuff. And I got some mixed advice which i shared with you so some some people said you should be in a boot wear a moon boot for you know at least a couple weeks and then some like you said no if you if you can wait bear without pain you know you should you should begin walking as as soon as you can sort of tolerate it for ankle injuries today where there is not a fracture what is the best practice in the first one to two weight to?

1:18:16So it depends on the location and grade of the sprain and whether it's one, two, three ligaments, et cetera, right? Some ligaments are a little unstable because it's torn all the way around the lateral or the outer side. So assuming the ankle is stable, it's a standard sprain, as you alluded to, either the ATFL and the CFL or the ATLFL or CFL alone. Now, if people tolerate weight bearing, I let them weight bear on it immediately. If they tolerate motion, I start them on motion immediately. Very few people need a boot. And if they do, I'm seeing them back in five days to see if I can get them out of the boot in five days.

1:19:00I want to get them out as soon as possible. Again, think of the ligament like that spaghetti in the box. You want those fibers to align like when you just take the spaghetti out of the box if you leave the ankle immobilized those fibers are going to go any direction that they want in an attempt to heal so there's no directionality or to the lines of force or strain that the ligament feels so it won't align or heal well enough so you want to get that stress and strain across that ligament as as soon as possible. And where have we landed on the other bits of advice that people often get in that acute period?

1:19:47I'm thinking about ice, I'm thinking about anti-inflammatories. I know at university I learned the acronym RICE, which involved icing and compression and elevation and rest. But I believe, at least from what I've heard from friends who are physiotherapists, that maybe that's been walked back and now ice and anti-inflammatories aren't recommended as much. Do we understand whether those things are beneficial or harmful from a ligament kind of healing perspective and outcomes? Not all inflammation is bad for you. The acute inflammation that follows a ligament or tendon injury is actually quite good for you because the body needs to recruit new cells, specialized cells to come into that area it needs to turn on cells that already exist in that area but might be asleep and so it all starts with the blood clot all these tears bleed that's why it gets swollen and black and blue as the blood clot resolves the white cells are doing that the macrophyses that's the chemicals that the macrophyses releasing is summoning new cells to that area so that when the cleanup is done, those new cells will start to come in and repave that street or start to heal that ligament and new fibers.

1:21:12So icing shuts down the inflammatory process. And in the end, it doesn't lead to less swelling. If you sprain your ankle, stick some ice on it for 20 minutes. You can't leave it there. I've seen third degree burns from ice packs left on skin too long. And then you take the ice pack off, the swelling is just going to start immediately again. And any superficial veins or capillaries that were injured have now been damaged by the ice because the cold will damage the vasculature even more and make the vessels more permeable and allow the fluid to come out. So it might actually make the swelling worse in certain circumstances.

1:21:54But don't over-interpret this. So if you go out and play tennis, you have a sore knee and it swells a little, put ice on it if it feels better. That's a different story. And then same thing with NSAIDs, right? Anti-inflammatories. You don't want to shut down the inflammatory process in this situation because it's your friend. You want the inflammation. You want the process to proceed. So elevation is always your biggest friend if it's a low extremity injury by far get your leg up above your heart before you reach for any bottle and then unfortunately it's Tylenol more so than anything else preferably before anti-inflammatories is that kind of ice principle more relevant for someone when they have an acute injury like they they twist their knee or their ankle and does it also apply you mentioned there the person that was kind are playing sport and put a bit of ice on their knee or something.

1:22:52But I'm thinking about the person who goes and does a couple hours of playing tennis or basketball and then hops into an ice bath, which is very trendy now. Is that counterproductive or do you think ice in that context is helpful for that person's kind of joint recovery? Ice in that situation is going to increase the chance that they can play again tomorrow. It's going to decrease their adaptation to the exercise. So you're going to get less benefit to the exercise. Some people just love the way it feels. So I don't mind if they do it in this circumstance, but just understand you're not doing it for any obvious proven benefit.

1:23:40If you're on the Tour de France and you want to ice between stages, it might be a good idea, but it's okay. I can take a day of rest. When you say it could blunt the adaptation, so that exercise is going to send a signal to tissues, to muscle and to ligaments and whatnot to reorganize and grow stronger. And you're saying that that would be blunted by going into ice. It blunts that response. Yeah, it blunts that response. Yes. Okay. So it's a bit of a balance. Are you trying to get up for another bout of exercise very quickly and tomorrow but if presumably if you're doing that all the time and you're not getting the the adaptation time and time again you might be contributing to that biology or degeneration story that we were talking about sure this has been awesome howard i clearly need to get you back on i think we could do a whole episode on on bone and osteoporosis dig a little deeper into regenerative medicine i really i love the way how thoughtful you are with with the words you choose and deliberate in terms of thinking about the psychological effect that that this conversation has on on people and and ultimately what matters most being their quality of life and and their function and their experience just to finish here at a personal level what are the things that you do with your lifestyle to impact that biology and in a favorable way and and to try and keep yourself off the operating table yeah it's very boring i eat well i cook a lot of my own food i sleep well i'm up at the same time every day i get my aerobics in i get my strength training in i get my plyometrics in in i see my friends i have a good sense of purpose i just i don't drink too much i do everything that i wrote about in my book and i talk about online i just try and keep it simple.

1:25:33I saw you did a post the other day about plyometrics. Sounds like you think that's something that is a little bit underappreciated. Oh my God, we could do a whole episode on that. I think training has to change as we age, plain and simple, because falls kill people. It may not be the fall you bang your head and bled into your head, but most people are not training, right? Many people do not remain independent as they get older. These two are related because it's due to a loss of functional capacity. So you lose functional capacity because of aging and lack of training. You fall, you sustain an injury.

1:26:11Maybe you're in the hospital for a few weeks because you broke something. Your function is now 20 % less. You go to rehab for a week or two or three or four, it doesn't matter. You're not back to what your baseline was. So now you're at a lower functional level. Now you fall again or you get an illness or pneumonia, you're in the hospital for a week or two, your functional decline again. Now you're at the point where you need a cane. Now you're looking down and you're afraid of curbs. Now you need a house with the bedroom on the first floor because you can't negotiate stairs. Your life, your world is narrowing.

1:26:49Your capacity is diminishing. and plyometrics, back to the original question. Sorry, I digress. We don't lose much strength as we age. I can bench almost what I benched when I was in my 20s. Leg extension is the same. We lose a lot of power. We lose a lot of quickness and a lot of balance. When you trip, very often you don't fall because of the trip. You fell because you couldn't recover. You couldn't get that other foot out in front of you. I mean, it's horrible to see all these older people who tripped and what impacted the ground, their face. They didn't even have the ability to get their arms in front of them.

1:27:36Forget about their leg to stop the fall. Nothing stopped them before their nose hit the ground. These are horrible situations. These are very scary situations for people. So the type of training that we need to start in our 50s and beyond are plyometrics, balance, power, and quickness. As equally as much, if not more, than strength and power work. Because if you wait to the point where you notice the loss, you're also now at the age where you have anabolic resistance. we don't train we don't get the same adaptation from a workout as you do in your 40s so we're going to have to work harder and longer and probably won't get the same result so it's something you really need to take seriously in your 40s and 50s there you have it friends i hope you enjoyed this episode if you did and want to stay up to date with future episodes be sure to hit that subscribe button on YouTube and follow on Apple or Spotify.

1:28:42Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.