Knee pain: four causes, referred pain and simple rehab that works

Keeping it simple for knee cases, resting it for a little bit, and that doesn't mean like bed rest or stay off of it. Let's just basically like what you just said and what I reiterated was just staying away from the things that bother it. You tell us certain things like running or, I don't know, jumping or squatting is hurting your knee. Okay, well, let's see if we can tinker with those or take them away for a little bit. Build up around it. I'm always really focusing a lot on, like I said in the very beginning, things above and below though. So let's focus on glutes. Let's focus on things that will help support that knee so it doesn't continue to be overstressed and then slowly work those other things that cause pain right back in.

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's Sebastian, your host with the Restoring Human Movement podcast. Thanks for joining the Movement Movement. This is your first time. I'm guessing that you're going to hear a difference in audio, actually, if it's your second time. Usually the solo podcast, it would be a little bit more clean probably, but because I got a new mic and I'm trying to make this work in our new office, it might be a little bit less cool audio with an interview.

So we have someone today, which is Dawne Costantino. What is up? So I'm, well, I think you speak up a little bit on your end probably. Okay. Dawne Costantino likes to be soft in her talking. Uh, anyways, we're going to go over, uh, knee, uh, basically all things knee today is what we're going to call this podcast because there's a lot of people suffering out there with knee issues that really don't have a good answer. Uh, and we're going to cover a lot of the things that you questions that you might be wondering how to rehab it, what diagnosis there might be and so on. Um, you okay with that? Sure. Okay. Here, come this way.

Let's see. Uh, I hear people rehabbing out there in the weight room, so let's try to get away from them a little bit. Okay. Um, again, it's your first time to the podcast. You subscribe to all the, um, subscribe and you'll see all the old ones in the bank. Um, there's a lot there. There's like 220 of them now. So please go backwards, listen to them. There's lots of gems in there. So Dawne Costantino, why don't we first start with, um, we'll start with the, what's your first thought when you think about knees, I guess. I think the knees as the dummy joint. That's the first thing I think about when I think about knees.

I wasn't going to go there, but it's a dummy joint. Um, so what does that mean? The knees are the dummy joint of the leg being usually a lot of times when there's something wrong with the knee, um, you can focus local there. Uh, we can rehab around the knee for sure, but we got to look above and below that joint to see what really, truly caused it. So was there something wrong in the ankle or foot that you needed to take the stress in the knee to, um, what do you call it? Compensate for it. Um, or is it something in the glute or the hip that isn't working properly and you're having to compensate through the knee.

And a lot of times that's where knee injuries come from is something above or below that joint. And that's why we call it the dummy joint. The dummy joint. So I think you got a little ahead of what part of what we were going to do today, because I know that there's, um, I was thinking actually a lot of people are, they don't think of it that way. A lot of patients don't think of it that way. They're like, well, my knee hurts. What do you mean? It's my hip. What do you mean? It's my foot. And so we are going to definitely like shift into that realm a bit today about like theoreticals, but I think we should also cover, you know, like what could be causing the pain in the knee and everything like that.

But I completely agree with you. Um, so the first things, and I don't know if I'll necessarily, I'm going to go through I'll go through Dr. Google here in a couple minutes. It's always your approach. Oh, I love like, cause most people will do Dr. Google. So we're just going to, we'll do knee pain, knee pain, which, uh, I'm just going to do knee pain. Diagnosis. There's, there it is right there. Okay. That fast internet. It is fast internet. So the Mayo Clinic is the first one on, on Dr. Google. And it says causes is ACL injuries, fractures, torn meniscus, knee bursitis, patellar tendonitis, mechanical problems, loose bodies, IT band syndrome, dislocated kneecap, uh, hip or foot pain, um, arthritis types, osteoarthritis, rheumatoid arthritis, gout, pseudo gout, septic arthritis, other problems, excessive weight, lack of knee or lack of muscle flexibility or strength, certain sports or occupation in previous injury.

So there's a lot of reasons why you could be having knee pain. Um, let's, let's categorize this into, um, referral local, uh, local sensitivity of certain knee movements, uh, unstable and trauma. Does that sound easy enough? Cool. Okay. We'll come back to referral, but, um, what do you think of when you think of an unstable knee? And I'll go back to Dr. Google here and maybe classify which ones could be considered unstable. So, um, I think of unstable knee as there's certain structures in your knee joint that keep it stable, right? Usually the ligaments around it, the muscles around it, um, the cartilage in between.

Um, so if it's unstable, a lot of times when we are say examining a knee, um, you'll compare from side to side, you'll see if there's any excess movement from side to side. So your knee can move in different directions, things like that. Um, and we're just looking to see like, Hmm, this is moving a little bit weirder compared to the other side. So that's like something I would call unstable. It's usually like ligament laxity or a tear diagnosis of weirder. What's going on? It's a little weirder. Layman's terms. You know, it's funny. I think when you like, like I, over the years I've gotten a little bit more of like kind of loosey goosey on like terminology to the patients.

Cause I don't want them to think that they're broken, you know, but like, yeah, it's kind of like weirder. Like I dig that. I like that, but they're going to go to someone else. So you're going to be like, your knee is unstable. It's broken. And you're like, you'd be like, holy shit. It sounds scary. Yeah. Or so I like even ACL injury and torn meniscus, they sound pretty scary, you know? Um, but I would agree with you. I think that like what, what a lot of people don't do when they have their knee examined is they don't have it load tested, which is, I think a little bit of like what you were alluding to there.

It's like, you'll, you'll stress test, you'll push on the knee, you'll pull on the knee, you'll, you'll, uh, put force through certain ligaments, uh, and certain directions of the need to see if it's really weirder or not, you know? But, uh, but yeah, like generally speaking, you can kind of see if one of those movements pisses it off, then you might be looking at something that's more unstable and then maybe you have to stabilize it, which might require a surgery or it might not, but we might need to, uh, uh, determine that knee as being unstable. And so maybe the ones that we went through here on Dr.

Google is maybe an ACL injury can be unstable. Cause you see a sliding this, a drawer sign to it. I don't know why I'm giving hand motions to you. Um, and fracture, I guess that could be unstable because fractures are trauma is a wild card. Torn meniscus, uh, there's many different grades of this. I think we should classify as that really a meniscus. If you're worried about it being surgical or not, if your knee is locked in a certain position, you might be more of a candidate. It's more of a bucket handle possibly, but, uh, a torn or frayed meniscus, not a big deal. Um, do you have, have you actually, you're a girl, have you had a knee issue?

Surprisingly, no, all my years of soccer and being a woman, I had never really dealt with knee issues. I feel like every girl who's ever worked in here has had, yeah, I had a meniscus or an ACL. I feel like pretty much every woman that has been in sports I've talked to has definitely had a knee issue too. So I feel very lucky for that. Why do you think you're, why did you make it? I don't know. I got strong glutes. I didn't play. I was on the bench. Shut up. That's not true. I was just on the bench. I would let slide people try to people try to slide tackle me and I would jump over them. I would Heisman trophy them.

Oh goodness. Uh, okay. So how about trauma then? Um, cause I know a lot of you will have trauma with their knee and other people will be like, I just kind of woke up with it. I maybe get a little bit too much. I don't get it. And so what would maybe be some trauma things they could be looking at for maybe their diagnosis for diagnosis? Uh, yeah. Well, Phil, if you just spitball this much, you want to, I don't have an, I guess, what's a good conversation about trauma? Okay. Well, trauma being, so a lot of times, like, for example, if somebody comes in with knee pain, we're like, okay, what happened?

Was there an incident that occurred? Um, and a lot of times they usually say, no, they just woke up with it. Or sometimes, especially with people who are active, play sports, whatever, um, got in a car accident, things like that. Something where there was some sort of force through the knee. This is something that we might be looking as far as this is really, truly something that maybe you need imaging for, or maybe, um, consider some rehab or surgery or things like that, but I don't know. I'm not sure where you wanted me to head with that one. No, I think that's good. I mean, I think just, I mean, remember these is, this is all things knee.

So whatever you, whatever's on your mind about knee, you can drop in here. I don't want later you saying, I should talk about this because all things knee. Uh, yeah, uh, I think trauma was a wild card and, and usually when you hear trauma, it's, it's like, yeah, someone did impact you or you landed. Um, I guess in this case with or without impact, there was like a crumpling effect or like a pop or a snap or a, holy shit. I feel it right now, you know, in my knee swelled up type of thing, or it took a day and it really swelled up. Like there's a visible swelling, not like, uh, I kind of think it's swollen and like, that's probably not necessarily too, too big of a deal, but ACL injuries would be one where you hear a pop or a snap and all of a sudden it swells up within the hour, right?

Maybe even sooner. Uh, meniscus are, um, they're usually kind of a little bit more delayed. It's a, I'd say about a day or so. And the swelling is not so abrupt. Um, even people would have, um, the ACL type of trauma, uh, and they hear that pop. Sometimes it swells up in under the knee, uh, under the kneecap and under the quad into what we call the, the patellar recesses where it feels like you're trying to stretch your knees when I bend it. Um, and it just won't go. And it's like, well, my quad is restricting it. No, it's not. It's like, that's, that's a pocket of fluid. They're coming from the inside.

Um, remind me later. I should talk about my experience with ultrasounds and knees, because I think it's going to be helpful to them. You don't think you want to just get into it now? Um, no, I think we should talk about it when we get to, to referral. Okay. Uh, okay. Local sensitivity of motion. Uh, let's see with actually. So, uh, let me go back. Let me look at Dr. Google real quick. Uh, what might be classified in there with the trauma? Again, it could be the ACL injuries, fractures, torn meniscus, usually tendinitis and bursitis is are not going to be that. Those are overutilizations. Loose bodies usually come from that, like little floating bodies.

Um, it then is not trauma dislocated kneecap. That's trauma. Uh, arthritis is not trauma. Excessive weight is not trauma. Those are just things that are very much preventable. Okay. So, um, I know that we didn't, we'll probably have different ways of discussing this one today, but, um, I would classify it as local sensitivity to movement. And this is where I would, uh, a lot of people have, probably half the people have that we see where they can, they can't extend the knee the whole way, but they can flex it and they can twist on it or they can, they can't twist on it. Like it hurts when they kind of, when you're dancing, but not when they necessarily bend their knee forward and backwards or vice versa, some other type of direction.

Like there's a certain type of movement. They're like, ah, it doesn't like this. And a lot of people will kind of blame this as, well, if I can't flex my knee and it hurts around the tendon, it's gotta be the tendon. You know what I'm saying? Any thoughts on this? Are you smiling? Like you go ahead and talk too much. Yeah, no, with this topic, I'm just like, I don't know where we're heading with this one. Okay. So this is, this is just my personal thought. This is what I was talking to Mikey about actually the other day is that, so, um, there, there's a big, there's a big thing where, um, the diagnosis is obviously important, but it's like, uh, I think for rehab purposes, it's more important to actually identify which movement bothers it, restrict that movement for a week.

Like work, uh, work, work and build the other movements and then reintroduce the past painful movement. And an example with this would be is some, there's something called an extension check brace where you take out about five degrees of knee extension because then he doesn't like the extension. Even people who run like they, it's like, well, it hurts when I, it hurts when I really extend my knee. So what do I do? Well, you can still run just for an extension check brace or tape job, whatever. You take that movement away for a week or so. You let them still use the other movements. There's no point in deconditioning the human, um, unless they're unstable maybe.

And then you bring that movement back in with a structured rehab type of protocol. A lot of knees that don't like rotation, which you alluded to earlier. And so a lot of rotation happens at the ankle and the hip. And so you said you, you don't have ACL injury or meniscus because you had the glute, right? Glute work. My hips work. Um, in that case, you're, you're allowing the hip to do some of the rotation and you're, you're decreasing the knees requirement to do rotation. So you never really, I guess in this theory, you never really had the, the, uh, sensitivity build up to rotation because you never really had to do too much in the knee.

See what I'm saying? Yeah, absolutely. I think with this topic specifically, um, mainly the issue being, or mainly the idea being whatever the diagnosis is. So like, say you get somebody like this, right? You're still going to do a knee examination. You're still going to stress all the structures, see what could be causing it. But is that really going to change anything that you approach it with? It's just going to be find what it likes, find what it doesn't like. And then base your rehab off of that. Right? Yeah. What, why does it have to be that simple? Dawne Costantino? You always make it that simple. I go to Seb all the time asking questions like this and he's like, Dawne Costantino, it's not, it's, you're making this way too complicated.

Well, I think, you know, like I haven't punched the devil's advocate with, because people think there's a lot of people come in and say, no, I just, there's gotta be more. Like I've had this for a long time. There's gotta be more. Like, what do you mean? Just put a knee brace on and go ahead and run and then do some squats and work my hip. And that's it. What do you mean? Like, I've tried that. Yeah. Yes. I blinked out for a second. So what do you, what do you mean keeping it? Like you, so you want to keep it simple. What would be keeping it simple for you for, for a lot of knee cases that you see?

Keeping it simple for knee cases, um, resting it for a little bit. And that doesn't mean like bed rest or stay off of it. Let's just basically like what you just said. And what I reiterated was just staying away from the things that bother it. You tell us certain things like running or I don't know, jumping or squatting is hurting your knee. Okay. Well, let's, let's see if we can tinker with those or take them away for a little bit, build up around it. I'm always really focusing a lot on, um, like I said, in the very beginning things above and below though. So let's focus on glutes. Let's focus on things that'll help support that knee.

So it doesn't continue to be overstressed. Um, and then slowly work those other things that cause pain right back in. It really is that simple. Yes. I'm very quiet. Sorry. No, I got quiet. Sorry. I blinked for a second. Sorry. Uh, yeah, yeah, I, I do think it is more simple, but, um, I know that we've, you know, we really challenged people with, you know, the, the areas around the knee, not necessarily the knee joint locally, but you know, the hip and the ankle and the foot, um, when we're rehabbing them. And, um, I, I think I was mentioning to Mike, uh, the other day was that, um, I, I really think it's a, uh, like, so say, say, say someone just kind of wakes up with knee pain or progressively comes on there.

A lot of times they're very knee dominant people. Like they use their knees a lot or one knee a lot. If they shift into that knee a lot. And, um, it's really not fair to make the knee do all the work. And so we can broaden this kind of conversation as your movement options. And if your hip had some impingement or arthritis, or, uh, you just didn't want to use it for whatever reason, you know, you would tend to use your knee a little bit more, you know, and eventually the knee will start to speak up. And so what we've done by having, let's just say arthritis in, in your hip is we've robbed you of, of certain movement options.

If I throw a book on the ground and say, don't pick it up. And you, if your only movement option is to squat, especially a knee dominant squat where you're kind of like heels up and stuff like that, then you're, you might have some new problems. But if we allow your body to re to shift load and some of the work effort into other joints, then your knee won't have many problems, nor will the tendons and all that kind of stuff around it. So, um, yeah, keep it simple. Just use the hips and feet. But that's, I guess that's the complicated part. Um, we will come back to, to local knee diagnosis, I think in a couple minutes, but, um, let's, let's move on to referrals because it is, we kind of find that, that there's a lot of symptoms of the knee that can be referred from higher up and they're not often looked at, which is a very sad thing because it happens about half the time.

Absolutely. Um, I think that with this one, I'd like to share a story personally of what I've been experiencing actually currently. Um, I go cycling and in my cycling, maybe like eight miles and I'll start, it starts in the hip. And then all of a sudden I start to get this crazy knee pain. And if I didn't know better, I would think what the heck is wrong with my knee? Like there's something in there. It just feels like I just want to pinpoint a structure and like, you're the culprit of this. Like you're the, you're responsible for this pain, but because I know better, I know that it is truly a referral from my low back.

I just get up, I bend backwards. It takes the knee pain away, which goes to show you it's nothing structurally in the knee that is wrong. Um, it's truly a referral from my low back, but I think just being the general population, I like that. I've experienced that because now I see like, wow, this is really hard to understand that this could be a referral from your low back. Cause you're like, no, my knee hurts really bad right now. So, um, but it's right there. I know, no, seriously. It's been, yeah, it's like right on the inside of the knee. I'm like, nah, it really fricking hurts. Like just moving.

It hurts all kinds of things like that. And then I just get up to my extensions and all of a sudden the pain is gone. So, well, you know, too, um, like, I guess like how would someone know maybe if, if that is referred or not, it is, is, so you differentiated it. Basically you, you did a movement somewhere else and took that pain away. Um, and, uh, also too, if we did a knee exam, when you, even though you were in pain, I'll probably stress testing, load testing of all the ligaments around the area are probably not going to be positive. And so why would you think local knee, if there's nothing really indicating local knee, when all your, uh, testing indicates referred and even your history indicates referred to.

Um, I know that one of the interns here had an experience where they, um, there was someone that they were working with that had a total knee replacement that had, um, still like their, so I guess their husband still, um, they had a knee replacement too. And so the lady was like, yeah, I can't wait to have the knee replacement. Basically it's going to fix all my problems. Cause it's helped my husband. Um, she had a knee replacement and it was like two or three weeks later. I think you heard the story, right? It was about two, three weeks later. So she wasn't any better than when her husband previously had just felt really good.

And so, um, uh, the intern treated it as a, uh, referred symptom and her pain was gone within five minutes. And so it's kind of baffling to the patient sometimes because it worked for my husband. Well, I think your husband had a local knee problem. You have a referred and yeah, you can easily have different things. And like you said, it can feel very much like the knee when it's not necessarily the knee only that makes that story. Story made me really sad when I heard that one, just completely replaced that knee, went through all that surgery, didn't even make it better. And then boom, she's good.

They got a brand new knee though. That's so cool. That's true. It's like a new car, but you know, I bet too, like there's, uh, I know that there's just thought with, with low backs is they have the virtual surgery. You've heard that one. Oh, so Dawne Costantino, I'm going to give you a, um, you're, you believe that you should have a knee surgery today, right? Yes. Sure. Yes, you do. Okay. And so I say, what about this? Why don't we not do the surgery? And I want you to do everything for the next three, four weeks or however long that they dictate after the surgery that you should do what you're supposed to do.

So after you do the surgery, what are they going to ask you to do? Rehab. Okay. How many days a week? Probably a three to four days a week. Okay. Let's do that. We're going to do that for how about a month. Let's just see what happens. So we're going to exclude the surgery, subject you to all the rehab that you were going to do anyways. I bet you feel better. And that's probably what that, what that patient would have like the experience too. Um, I have a, I have a friend that he calls us earning your surgery. Prove it. Prove that rehab doesn't work. And then you can have your surgery, but until then you don't really deserve it.

Cause you haven't done the steps that you possibly could. I like that. Yeah. Some people will even like, don't work for a week and it's like, well, I can't do that. Well, the surgeons might tell, might tell you too. Okay. Well, okay. After the surgery, I will, you know, cause the surgery is just a big experience where they'll change your life around to accommodate what happened when we could just do that without the surgery period. I like that. They're starting to incorporate it like that now. No, like, no, like, like I have some friends who are like, like say someone like is not listening a little bit and you're like, like you try to do the virtual surgery on them.

Like it's just like a, it's like a tough love talk. That's great. Yeah. I love that. I'm going to start using that. Yeah. Virtual surgery. Yeah. Let's do a virtual one. Don't you want to not get cut? Cool. Let's test it. Honestly. So yeah, they can do that for a lot. You can do with a lot of things. But I just come down to like, people don't always do their homework, you know? And like, but if I'm pretty sure that if I like went in for a surgery and I came like, it's a serious experience, like I would probably do it at home as much as you wanted me to, you know, and make sure it's successful after going through something like that.

Yeah. But I think there are a lot of people with the mindsets of they just want this thing to be done for them. And it, you know, it cures all the issues. And I don't think it's that easy most of the time. Well, the, the, there is the, I mean, yeah, that, that I guess, quote unquote, fixing of the instability is done for them, but the, but the hard work is never done for them. The hard work comes after, you know, you're, you're knocked out. I mean, the surgeon probably, I mean, they might have their, I guess they might have their iPhone. Like I, I like, they might be listening to music. It's not probably not a lot.

Like I'm sure it's diligent, but it's not like they're like doing the hard work that you have to do for, you know, six months after. Um, and also too, like the, there's, even if you did have the surgery done or if you had an injection done, or even if you just, even if I treated with you as like a reduce the pain approach, you don't reverse the adaptation. Like you said, you're a strong hip made it. So you believe that you didn't have the, uh, like the knee, the knee issues that everyone else had that happens over the course of a long time. I'm sure. Did you, did you lift in college? I did. Did you go to college?

I just became a chiropractor one day when I woke up, I didn't go to school at all. Did you, so did you, what'd you do in college for, um, so I, I think I was pretty, um, lucky that my coach did a lot of strengthening days. So she, I think it was probably two to three days a week before, um, practice and stuff like that. We did a lot of weightlifting. So that was really cool. I think it probably made a role. I don't even know if I knew many girls I played with on those teams that with this coach that had a lot of knee issues either. So who knows? Maybe that did play a role in it. Yeah. Well, there was, um, I know there's, there's a lot of mainly soccer is going to be like ACL things like that.

And there's a lot of different factors, even hormonal ones. But I remember seeing this, it was a pretty large scale study, by the way, if people are looking for studies, I don't know where it is. You can feel free to go look it up yourself. Okay. I'm not a study nerd, but I do remember reading this one. It was interesting. Um, there was, it was like 400 college girls, like they were runners. Um, and they basically just, they, they, they brought them in and they tested their core string and frontal plane, which is side to side forward, backwards. I don't think that they're rotational. I think they just did those two planes of movement.

Um, either ways they eliminated the hips at the equation. They kind of put them in this box and they had them like, kind of like straight up, right. And at some point they're just like the, I think the cue was like, don't like just stay straight. Right. And they would release tension off one side and they would kind of teeter around like a, you know, like a jack in the box at that point. Like who can stay the stiffest, especially reactionally based. And so late they took the data and they, and they, they said, okay, go about your life. Come back. If you have knee pain, not related to trauma. And so people who came back, like, I think there was an overwhelming, like 80, 90% of the people who came back had deficiency in the ability to control frontal plane movement, side planking, you know, basically suitcase carries farmers carries.

Um, so yeah, I think you're, you probably, do you do carries in college? No, I don't think we did. We did do a lot of kettlebell work though. There you go. Yeah. That's unilateral. Okay. Um, so, uh, referral, it could come from the low back could come from, I mean, usually nerve based. We categorize it as that. Did you want to talk about your ultrasound and referral? Oh yeah. Good memory. So, um, yeah, so there was, so I did, we did a lot of ultrasound, you know, a couple of years back cause I was setting for the, uh, RMSK, um, credential. And, um, so we just image everybody, you know, and I'd look at a bunch of shoulders, a bunch of hips, a bunch of knees.

And so there was, I think I had to do 250 scans just to even sit for the test. And so, um, looking at the knee, like there was so much, there was, I remember looking at the IT band was like the thing that was kind of interesting to me. And even, even the patellar tendon, cause people would come in and they'd say, yeah, I have pain there and pain there. And so you'd look at it. And so there's no eternal Doppler and it's like the Doppler would show vascularity. Is it acute? Is it an acute issue? Did it just start? Is there neovascularity? Is there new blood vessel formation to the area? Um, most of them know, like I found like two tendons, two patellar tendons that had that in the, in the, the, I think the most, the most impressive thing to me was you look at the IT band, it looks like a fricking sheet of paper on the screen.

You're like, where is it? Oh, it's up there. And let's say we're going to talk about like lateral knee pain, outer knee pain to think that it's the IT band versus all that massive muscle below it or anything referring to it. If you look at entire screen of an IT of, of like a lateral knee thigh kind of area, I'm going to guess and say under 5% of the screen is IT band. The remainder is muscle. Why do we think the IT band is this fricking problem all the time, right? Like anyways, most of the knee scans are normal, structurally normal, meaning they're referred or there's some type of reciprocal inhibition or sorry, overuse type of case.

Not even to the degree where there's any structural deformity or any evidence of structural deformity period. So, uh, and, uh, in case you're wondering how sensitive is ultrasound under the age of 30, I think one of the studies showed that, um, if you have a negative ultrasound, there's no need to have an MRI done period. It's that good. Uh, unless you're going to ACL and internal structures, but, um, these people didn't have blatant trauma based findings either. So they probably weren't ACL either. Do you remember the, the article, the percentage of, um, the like extremity areas being a spinal source?

Do you remember what the percentage was for the knee? Yeah, I have it. Uh, I have it here. We can remember it. Uh, well, I don't think that one's not right. Let me find a, you want to, while I look for this, you want to fill some slot? What are you talking about? I don't know. The knee is an interesting joint, honestly. And, um, I think that, I mean, I think that's surprising when you talk about that IT band one. Cause I remember, you remember just, uh, cutting into it in anatomy, going through the body and getting into like the IT band area and actually seeing how thick it is like in person though and being like super surprised, but that's just the comparison of it to other ligaments.

I thought that was really interesting. You just brought it up. Cause that just kind of was different from what I've always thought of the IT band as. It was so thin. It was so, I mean, it was so thin in comparison to everything else proportionally, you know? Um, so Donna's mentioning the, uh, there, there was the, uh, what was the study? It's Roswell, Rose, Rosedale, 2019 journal manipulative, um, and manual therapy. Feel free to look it up on your own if you want to. Um, anyways, uh, we referenced it a couple of times through other podcasts, but, um, so spinal referred source in the absence of back pain to the knee is 20, 25.6%.

So almost 75% is actually local knee when in the absence of low back pain. So, um, yeah, I mean, there is a, there is a good probability is going to be the knee, but there's still a 25% chance that, I mean, well, let's, let's look at it. Let's look at it this way. If you, if you did really good knee rehab and it didn't respond to knee rehab, maybe it didn't need knee rehab. Maybe it needed spinal hip rehab or foot, ankle, something like that. Simple, simple. Keep it simple. The cool thing is knee rehab should encompass hip and core rehab. Anyways, and that's an important point. If you're not getting hip and core work done at the same time as rehabbing your ankle or sorry, your knee, you kind of got to add it.

You're missing a huge win. Okay. Treatments, stretches, strengthening, core. Which one are you going to start with? Stretches, strengthening, core, hip, ankle. Let's just go in order. Okay. Do you stretch the knee for, for treatment, for treatment with, of my patients with knee pain? No. Yeah. I really don't give it. I really don't either. Um, why not? I mean, personally, the knee cases I've seen have always been referral and I've never actually seen any true local knee. Um, and so I don't think that stretching would be beneficial for a referral based knee because if it is nerve related, you're just tensioning the nerve, which can make it worse.

Um, it might be good for post-surgical though. It might be, you get to a point where, you know, soft tissue in those areas that have been cut through or stretching the areas that have been cut through would be beneficial. Um, I personally haven't seen that though. And that's why I haven't used it. Yeah. Well, I, I tend to use, um, when at all possible for let's say passive stretching versus like active stretching or active motion, like a good way to stretch the knee into knee flexion or bend is to squat deep, you know, cause there's, there's some type of active component with that. So it's still going to stretch.

Um, but, uh, I do think that if we're going to encompass in some stretching, like things like, like your endurance loading protocols, stretching the actual joint capsule might be helpful, but I don't think really stretching the, like the muscles too much is really, is that important, but I'm sure it feels good at the moment. Um, so, uh, strengthening of the knee itself. Do I use it? You like that? Sure. Okay. I like it more for, so my knee cases, I find myself more going above and below. Honestly, I'll start at the hip and see what it does for the knee. A lot of times I'll go more local to the knee when things above and below aren't working.

That's kind of my approach to it. Um, but strengthening of the knee is wonderful for, um, actual knee issues itself to meniscus, ligament stuff, things like that. I think it's great to do very local knee strengthening exercises, lots of hamstrings, things like that. I think the, probably, um, the only thing I have to add to this is make sure that your knee strengthening is, is specific to your capabilities. You shouldn't walk out of your rehab thinking, God, that was so easy. Yeah. Right. It should be challenging. Absolutely. Like the whole thing about like, um, creating an adaptation in the knee, in the muscles, in the joint, in the cartilage, wherever we're talking about, even bone, it comes down to, uh, stress.

So you have to be able to, um, uh, subject it to some stress. That's helpful, not harmful, not painful, but challenging to create an adaptation over time. That's the whole point of rehabilitation. It's not to make it easy. Uh, it's to make it challenging so that your body adapts and then thrives later, becomes resilient. Um, but core work, we talked about that. Um, do you want that one core work? I think we touched on it, right? I mean, you pretty much said you, you gave that, uh, but, uh, study, which I think is great. Um, I think core work plays a huge role in it. If you don't have the ability to activate your core or to, um, you know, challenge yourself in different planes of motion, then you're going to find abnormal movement through the knee.

And yeah, I think, I mean, we always talk about this. It's just, you have to take the whole body into consideration. You can't just look at the spot that is painful. Well, you know, and, and kind of rolling back onto the strengthening part is, is yeah, we can do, you know, knee flexion extension, hamstring quad exercises and things like that. But really it's, I think it's best practice to do the entire limb, you know, from, from the belly button down, even utilizing like the arms to help out with this single leg stance, squatting, lunging, um, deadlifting or hip hinging, things like that are all helpful.

And they still do encompass. They, they require the core to keep position. So it's, it's treating the body as one big unit. Cause if you just do in a small section, um, I think we're, I think it better to start off with global stabilization rather than local, unless you really have to go local, um, like such as a knee brace or something. I think too, like the, all of this stuff doesn't mean that like you have to have a core exercise and then a glute exercise and then a knee exercise. And then like, it's not, it doesn't have to all be a bunch of different exercises for each area. It's picking and choosing big movements that will challenge all of those things too.

But I was given a sheet of paper with 30 different exercise on that. You don't mean I shouldn't do all those. I mean, if they work, sure. Okay. I think you're going to go there, but sure. If you got 20, 20 hours. I don't think there's anything wrong with what works. Right. But I think that if you're just speaking from our perspective and how we work here, we like to, that's kind of how we focus and keep it very simple, you know, very, um, small amount of exercises that'll really challenge all of those different things. Yeah. And you know, um, it's probably speaking from timeframe too, or, or, uh, duration of time you can really get good knee rehab done.

If there's not a side conversation and like kind of wasting time, you can get it done in under 15 minutes. Um, and, and even for clinicians out there listening to this too, if you don't feel comfortable doing that, just get more structured in your recommendations, because if we do have 30, 30 things on a sheet of paper, um, that's going to take a long time. And so rather than doing a clamshell and a glute bridge and a deadlift, why don't we just do the one that person could do the eat that still do well, but it's challenging because they're kind of all the same patterning. So just pick a pattern, load that pattern.

Um, if they can't do that, then scale them back. Yeah. Or set them up for success. Cause they have too many exercises. They won't do them at home and then nobody's getting better. Dude. I wouldn't, I wouldn't do more than three personally. Yeah. Unless you like turned it into like, like, okay, I want you to go lift some weights too. I'll say, great, cool. So you're telling me to have fun and rehab. Sounds good to me. I want you to go play baseball. Perfect. I'll do that. I'll, I'll, I'll rehab for five hours if you want me to. Yeah, there you go. Um, okay. Knee injections and surgery. What do you think about the, like what, I guess, what are your experiences with those so far?

Um, so we've touched on surgery a little bit. I think as far as injections and things like that, the only time that like my brain always goes when it comes to injections is I can't get this person due to anything cause they're in too much pain that an injection might be necessary. So we can decrease pain a little bit and be able to do certain movements that we know are going to be beneficial for it. I think that that's a great way to use some injections. I don't think it should be like the first go-to, um, a lot of times, but that's just kind of my opinion on it. Yeah, I, I've actually used one myself cause I was trying to rehab my knee after some impact and, um, it was like, it was like two months.

It was just the only way I could describe it, uh, was that if I tried to bend my knee, it felt like a balloon was in it or like a Ziploc bag full of air and it was just compressing. You know, I couldn't get into a deep knee, deep knee bend position. I couldn't rehab the squat really well. And so anyways, uh, I had a local injection there. It killed it down in about two, three days. And then I was able to rehab after I was able to complete it. Now I don't have any problems anymore. Um, but it was, it was a tool in the process to get into the proper rehab. Um, but some people, I think they use them too much as like, Oh, that's the answer.

You know, just a pain management tool to get you to an adaptation. So for you specifically, it was, I use it at this one time to be able to do the things I know is going to help it. Where I think sometimes people get caught in that loop of when pain starts to return, I'm going to go back for another injection. And that's going to happen. You know, that's going to be good for a couple months and then pain starts to return and go back for another one. It's just, some people get caught in that loop sometimes. I think it's really unfortunate. Well, you know, like I'm, I'm sure some of the people are aware that like for, for, uh, I think it's, I think it's cortisone.

They only allow three per year. You ever wonder why? Is it not, it doesn't work after that or what? Well, I would imagine it's probably not, uh, it's probably harmful. Yeah. You know, I, I don't want you to stick your head in the microwave either, you know, like it's, but you know, it takes your pain away. Sure. Why not? Three times a year, you know? So I, I'm not saying like, it's not good to have it done circumstantially. Everything has a cost and benefit. I did cortisone. That's what I did. Um, but I didn't go back for multiples and, uh, um, yeah, you shouldn't, now that now that I'm thinking about it, yeah, people do go back.

Like I'm going to go back multiple times a year for injections. Um, and, uh, but there's multiple types of injectables. Um, sometimes you'll do ozone and PRP and things like that, which those are different purpose, purposeful ones. Uh, and it's a whole different story, whether those are helpful or not based upon the circumstances. But, uh, I think in the, I think the injection should be for a purpose of repair or chilling it down. It doesn't create the adaptation surrounding the area. Like you said, it's a dummy joint. So make its neighbors smarter, dumber, more aware, more aware. Okay. Um, and I think lastly, we just covered prognosis.

Uh, what should people really expect? Um, if they had something that is, let's just, let's, let's pull trauma out of this thing. Cause trauma is a wild card. Surgery is a wild card. Um, why don't we just go with most of the knee pain people have? It's just like, well, I just kind of started. What is a reasonable amount of time for them when they, when they, when they do some, when they do like an intervention or a treatment, how long should it take to reasonably be out of pain? To be out of pain, I think, um, reasonably maybe a couple of weeks, honestly, if we find the right first aid for them that can reduce their pain, it shouldn't really take that long.

So then how about with, uh, when can they return to soccer? Cause soccer was, it was, it was painful to kick. It depends. Um, I think it's, that's the harder part is that that little transition in between decreasing pain. We always say is really easy. And then once people have less pain, then it's like, oh, cool. I can go back to what I was doing. And it's not necessarily true all the time. You gotta, you gotta build up support and create an adaptation that will allow you to get back into whatever was causing that pain in the first place anyways. Um, so I think with that, I'm going to go maybe a few more months.

That doesn't mean that has to be, um, you know, coming in here to see us twice a week for a few months. It's just do what we suggest for you to do. You can do this all from home for a few months to just build that adaptation. I think, and I think, um, usually for return to like full capacity, like I would, let's just say we're talking about a distance runner now. Um, I'll usually just give them like a rough idea and this is very, very rough, but, um, how long have you not been running because of this? Like basically like very limited mileage, six months. Okay. Assume it's going to take six months to return back to full capacity.

And I don't say that because their mind is not there, but they've also had probably demon, demonization of the bones, you know, all of a sudden their mind says, yeah, I feel good. And I'm going to go run as much as I want to. And all of a sudden they get a stress fracture in, uh, like their foot. And so, um, they'll have to be a little bit more strategic, which is not necessarily the realm that I go into. Uh, I'll ask them to talk to their coach about it, but they might just have to get more creative. They can still have a good time and challenge themselves, but it might not be that their body is fully back.

Um, and, and I know that one of the, one of the workshops that, or one of the seminars I went to, they were, it was a strength condition when they were talking about, uh, basically it was an ATC came in. It was talking about management of, I think you're talking about football or something. What should we have this person do if I had this, this ankle turn and they're like, should they just go home and not do anything? Like the local, the local joint is the problem. We have to take care to like rehab that thing appropriately, but there's no way we should decondition the entire human to help rehab the ankle.

And so there's a lot of stuff he can do. I mean, shit, he can, uh, I was gonna say he can, he can probably crawl, you know, there's a lot of things he can do probably a practice. Um, maybe the ankle is a bad idea. Your shoulder hurts. Don't run. So, but you might not throw a baseball, you know, very hard for a little bit, but that's the point. Just rough guidelines like that. Don't decondition the human. Uh, all right. What do you want to finish up on while we speak over max? I'm curious if you'll hear any of that background noise or not. Yeah. Um, finishing on being, let's see. I think knee pain specifically.

It's really hard to find yourself somebody who can give you the right guidance and the right treatment. If you find yourself in those, I'm just going to summarize what we went over. If you find yourself in those little, you know, loops of having to go back to pain management, um, but you're not considering any sort of good rehab, um, then maybe consider that if you really want to restore function again. Um, if you are currently seeing somebody who is only, uh, focusing locally, then maybe you should consider something different because it's important to take the whole body into consideration. And if you've been focusing on the knee and areas like that for a long period of time and you're not noticing any difference, take a referral source into consideration because it's a lot more prevalent than you think it is.

Yeah. Good recap. Um, yeah. So, uh, obviously go back to the old podcast and listen to them. There's some that are more doctor friendly, more patient friendly, but as you can see, we try to keep things a little bit more, um, common lingo anyways. So you still might get some good stuff out of those too. Uh, if you do want help from us, you can always reach out to, um, uh, you can reach out to us as well. There's, there's links in the show notes. Our website is P the letter to the number sports is pro plural care.com. So P2 sports care.com. Um, as Dawne Costantino likes to say, we have endless options to help you no matter where you're at.

There's no reason to ever feel like you're in pain ever again. Is that how I sound? Something like that. So yeah, if you do want help from us, we can help you. So just, uh, let us know. Do you want, do you want to close us? That was the close now? No, you got to do the. Oh, I forgot what it was. Oh, thanks for being part of the movement movement. Thanks for being part of the movement movement guys. See ya.