Runner's knee and meniscus tear rehab: look beyond the knee

This is session number 33 of the Performance Place Sports Care Podcast. I think my voice is getting deeper. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey everyone, it's Dr. Sebastian Gonzales with Performance Place Sports Care Podcast again. And today we have a really great guest who is going to be our expert on knee conditions, mainly with, we're going to be talking a little bit about runner's knee as well as meniscus tears.

His name is Davis Koh, and he is someone I met actually probably about, gosh, I want to say it's probably about six, seven years ago. But actually it was interesting when I started looking up other providers in the area because I like seeing other people who kind of think the same way. And he was one of the only PTs, I think, who had some of the same credentials as me. And I was like, who is this guy? And why does he have so many different degrees after his name? So I'll let him speak here in a second. But he's going to go over some of the things that you might ask a physical therapist about rehab on a knee.

So this is Davis Koh. Davis Koh, say hi. Hello. Hey. Okay, so tell us a little bit about yourself, and then we'll jump right into the topics. Okay, well, I'm primarily a sports and orthopedic physical therapist. I've been practicing over 18 years. My background also includes working in the cardiac and neurorehabilitation sections of UCLA Hospital And also in other aspects of my career in the beginning. And then the sports and orthopedic side came as a second half of my career. And it gave me a chance to see a broad spectrum of injuries from all different age groups, all different causes, all different backgrounds.

And to see the similarities and the differences unique to their situation. How many years were you in cardiac again? I was in there about six, seven years and saw a variety of different patients, and again, even from art transplants to brain injury to working even in the psych ward where we're dealing with people with schizophrenia and working around their conditions while at the hospital as well as the pediatrics and even as young as neonatal. So there is neonatal physical therapy, if you can believe that. I couldn't even imagine, other than if they had like spina bifida or some type of... Geez, I have no idea what you'd even do with them.

So then why did you get into like sports injuries and other stuff? Because I know that isn't like for physical therapy, majority of physical therapists, aren't they in... They're not in sports injuries, right? I mean, a lot of them are in, is it home health and... Correct. Yes. So a lot of them have opportunities in hospitals, neurorehabilitation centers, skilled nursing facilities. And so a lot of them start that way. They can start that way. I did that on purpose because when I was in physical therapy school, I did want to do sports and orthopedic. And then my sports and orthopedic professors said, well, if you want to do that, go to the inpatient hospital. And I said, why is that? Because you'll get a nice foundational base.

You'll appreciate different issues that they may have outside of the injury itself, the importance of where certain medications can affect them when they're out of the hospital, what they're taking, what type of surgeries they did, appreciating the development or the after effects of the surgeries from beginning to end. And it didn't have to be orthopedic surgery, it could be liver transplants, it could be other types of heart transplants, open heart surgery. And they wanted me to have that type of foundation where you can see all age groups at the same time so that when you do see them in the orthopedic or setting out in an outpatient clinic, you can appreciate what their backgrounds of hep C or diabetes or they're taking certain anticoagulant medication or this type and the side effects that may come.

And to have a better, well-rounded understanding of the patient that's coming in with a knee pain or a shoulder pain. Jeez, you'd think there's a little less to it. Yeah, it's funny because, yeah, actually, I mean, in chiropractic school, we didn't, I mean, we went through things like blood panels and like we learned about like systemic or like organ types of pathology or injury. And but we didn't really focus on that much. And like, even now, like if you showed me a blood panel without the normal ranges, I don't think I would, you know, I just refer that right out. So good. So yeah, good. Davis Koh has a large background. So when we go into the topic here, I was thinking of focusing on obviously, there's lots of different people who have knee pain.

But let's just say we're going to focus on the runner population since it is pretty prevalent and their injuries are a little different than, say, a geriatric or a 70, 80-year-old with knee pain, right? So, what would be... Tell me about runner's knee. Like, you know, what is it? Like, how often do you see it? Like, what type of person usually comes in with it? When I dove full force into the orthopedic and sports world, the athletes I normally saw were from my time with USA Volleyball, which I currently still work with, or with different sports like USA Weightlifting or the pro athletes that have come in through the clinic.

And what I noticed about the runner's knee is it can happen to a non-runner. So that's one thing that people need to understand that when they say it's runner's knee, it doesn't just happen to runners. It's commonly in runners. You know, it got that name from that. But the runner's knee can be in a cyclist. It can be in someone that does repetitive training or repetitive work related to the knee. And it's become more of a generalized symptom or a catch-all term, a garbage term for a lot of different causes. So I tell patients, you know, when they come in with certain diagnoses like a plantar fasciitis or whatever, there's about five, six, seven different reasons for that particular heel pain that can be contributing or be the actual cause It's outside of an actual plantar fascia inflammation.

Likewise, with runner's knee, there's a lot of different causes and a lot of different backgrounds of the person getting that type of pain. So that's been one thing that I definitely noticed. You can get runner's knee even if you're a volleyball player doing off-season training. You can get runner's knee, and it doesn't have to be the marathon runner per se. Yeah, I totally agree. And I know we have different AKAs for it as well, which might confuse people. The patellofemoral pain, is chondromyalgia patella would be the same thing? Yeah, chondromyalgia patella, patellofemoral syndrome, yes. And they'll all be grouped as that common term, runner's knee.

Yeah, why do we do that? I don't understand why we have so many AKAs. It just doesn't make any sense. I guess it just makes it easier for people to hear it versus chondromalacia patella, and they just go, oh, it's a runner's knee, and it's common, and someone branded it and just took off with it. Wouldn't it be cool if there was the runner's knee trademark term? We'll have to look into that, but it's too common right now. Well, so to explain then with a quote-unquote runner's knee or that type of symptom pattern, what do you usually see? How do these people come in? How would someone that's listening to this podcast know if they are experiencing, or they should be tuning in right now and thinking about, oh, I should be listening, because this actually is more so what I have.

Okay, so for a runner's knee or knee pain in general, one of the things that, when they look up, things that I see is, one thing is they look up a certain diagnosis they heard from another friend, they Google it, and doctor internet mimics, has the symptoms that And they'll label, they go, oh, that is my pain. That's a runner's knee. I've got runner's knee. And one thing I want the, I tell my patients and the public to know that just to keep your mind open. So yes, you may truly have what they are calling it. And it may truly be a classic example, but there may be other reasons behind it. And so when they have a pain underneath their kneecap or in front of their kneecap or the It's related to movements or certain activities, particularly like stair climbing, running hills, descending hills, or what have you, and it acts up to, yes, there's a pain in that knee, and one structure may be involved, a patellar tendon, the tendon, or the cartilage underneath the kneecap, or the meniscus itself.

They can all be the victims, but they may not always be the causes. So people also come in and they say they have runner's knee, and my doctor or my friend said it's because I have weak, or my trainer says it's because I have weak quads and I have an imbalance of tight hamstrings or I have some other condition, or it's just because I do it too much, I've been running too much. What I try to also tell them is that a lot of times the predictor of a future injury is your medical background, so what happened in the past. Sometimes when the knee is not necessarily the cause of your pain, it may be the victim of your pain, meaning that something else, your gimpy hip or a stiff ankle from chronic ankle sprains or an Achilles tendon surgery, on that same leg may actually have been the cause, and that is resulting in a knee pain.

So the example I'll give is, and I try to explain things as simple as possible, because I remember there was a quote by Albert Einstein that says, you don't really know something unless you can explain it to your grandmother. So I try to say, just in simple terms, not simple, but just in easy terms, That pain in the knee, imagine if someone is bleeding. The problem isn't that they're bleeding, it's who shot them. Sometimes I tell them the sniper is actually your ankle, and it's shooting at your knee, and your knee is suffering. You're seeing the bleed, and you do have to stop the bleed. You do have to control the bleed, but you also have to find out who's shooting the knee.

And so a lot of times the knee is a culprit because it's in between your ankle, foot, and it's also in between your hip, pelvis, low back. And so it can be the victim of these other two parties or three parties or whatever the issue is, even your great toe, that can cause your knee to keep recurring. The other thing I would say when people say, oh, it's because I've been training for my marathon, and that's why my left knee is hurting, that's why I have a runner's knee, and I say, well, why is it only your left knee? You know, why, if you're running, are you only running on your left foot and you're hopping, or are you actually running both?

So why does your right knee seem to hold on okay, but your left knee seems to always hurt? So I... Oh, it's the camber on the road. Exactly. They like that one a lot. I'm running on the beach, and it's at an angle or whatever. So, which, you know, but I try to tell them that there is a reason, and when there doesn't seem to be a rhyme or reason, there's always a rhyme, there's always a reason, and it's about private investigating. And so part of what I believe that Sebastian Gonzales and I do is we try to find those clues to find out what is really the problem and what is the source of the problem. Just like CSI looks at splatter patterns or this piece of hair or that little piece of metal or this bullet shell, and they piece it all together to make sense.

Even the most minute details make sense, and it comes together more cleanly, and that's part of our job. And for the patients, look back at your history. Did you always have a left ankle sprain that just didn't feel right? It's a little stiff. Did you have a prior – do you always have your left calf cramp up for years or months prior to starting to have your knee pain, things of that nature? That really helps give the practitioner clues, and even for yourself, appreciation and understanding that those things really do make a difference in trying to problem solve what's exactly going on with your knee.

Not only what is being affected, your tendon is inflamed, okay, but what is actually also causing that to keep coming back, or as we try to treat it, to also treat the sniper as well. I see you're finally striking into your own here. You were a little concerned about your first podcasting interview. Yeah, I'm starting to hit my groove. Yeah, you're starting to hit it now. Well, you present a lot anyway, so it's like you're talking in front of one person right now. - You know me well enough. Yeah, I totally agree. I think on another podcast I said that the knee is the red-headed stepchild of the leg.

It's never its fault, but everyone blames it. But you always need to look around it, look at the hip and the ankle and the foot and the big toe. I mean, they're so far and extreme. And I remember I had a patient just about, it was about a month or so ago, and she just could not see, like the first time, I'm sure you do the same thing, like you spend the time explaining to make sure So that they are on board with what your ideas of rehab are. So her outlier was some hip and trunk stuff who looked really, really sloppy. So the next time we went into some basic trunk stabilization and I could tell she wasn't paying attention.

And finally I looked at her and I'm like, "Are you understanding?" She's like, "What does this have to do with my knees again?" So I'm like, "Okay, okay, we're gonna spend the whole time here talking this time again." But they need to understand it, you know, to really grasp the treatment plan. Exactly. And usually what I'll also, and that reminded me of a story, there was a professional fencer. And if you know fencing, they have huge legs because they're always lunging, that lunging motion. They're diving in, lunging, lunging, lunging. And so this guy had patellofemoral knee pain. And so he was working out hard, and he could leg curl or leg extend over 300 pounds, and he's just going, and he's still getting that knee pain when he's doing that, lunging when he's doing this.

And then what happened was he looked at how low he could sit without plopping onto the chair, and he could not, at a certain point, he would just plop into the chair. And so, uh, the cause was that he had a very weak core. And so they could see that cause he could not do that. And he was, he's super strong, built like an ox at, uh, quads, you know, out the wazoo. And then he worked on his core. And so when, as he lunged and only his core, and as he lunged again, his knee pain went away. So I think there's some buy-in where I will also palpate, feel, look at the medical history, and then see any associated factors that might be underlying.

Once they feel how tender it is, and let's just say that they've had a history of sciatica or something, or shooting pains in their butt, and now they're having the knee pain in the same leg or what have you. I'll show them different areas, and I'll palpate, and if they find exquisite tenderness or in between their hamstrings where the sciac nerve also passes through and say that this is still not resolved, it may have calmed down, but it either didn't heal all the way or it's calmed down enough that you don't even notice it as much anymore, but it can be still part of the problem. So once they feel the difference, I'll go to the other side and go, how's that feel?

And they go, I don't feel anything. So when they kind of, that helps women with the buy-in, and then also as a practitioner, the responsibility of actually explaining it clean enough to where they can understand, connect the dots, and see that for themselves. And say it to their grandma? Yeah, and be able to tell it to grandma so the grandma can explain to grandpa what their doctor said about why they're having knee pain. And I think that helps them a lot to see that. But if they can't see that connection, then you're right, that they won't believe in it and they won't buy into it. The other extreme is you don't want them to, I've heard that where they go, oh, there's this kinetic chain.

Again, either from a friend or from a colleague or they look up Google Research, which I don't mind. I like them to have information, as much information on their situation, condition, whether it be a certain diagnosis or a treatment plan. I have no problems with that, but sometimes the other extreme is they'll go, oh, I have foot pain, and I know it's from my kinetic chain of going to my right low back quadrant, and they'll just kind of put the dots for you. And it's also, again, sometimes you have to, it may simply just be something in the foot. Yeah, I totally agree with the, it's people coming in with a preconceived notion of what they're wanting to get is a little bit of an issue.

I don't know, I think it takes a little bit of the power out of your hands. And I know that there's been times where people come in thinking they're going to get one thing. And I'll play the game a little bit in the beginning where I'm like, okay, I'll let them think that's what we're going to do. Not deceivingly, but kind of like you got to build a little bit of trust and then you got to turn a U-turn if you think that's what their care needs. Because they're just going to go somewhere else trying to get the wrong thing as well, you know, not doing them any help. Right, yeah, you don't want to discount what their belief is or what they're coming in with or discount where they got that advice from, from someone that they may have trusted.

And yes, so I will also respect that and treat that. And then if it plateaus or if it's not getting better, then they tend to be more open with the other possibilities and then going into treating a different muscle in your glutes or in your low back. And if that creates a change in the pain, then their eyes start opening. So I remember a friend of mine from Cirque du Soleil is a Cirque du Soleil PT full-time out in Vegas, and the athletes come from all over the world. And so one of them had a severe sprain in her left ankle, I believe. And so I was about to put ice, and she said, no, no, no, you put an onion on that thing.

And so he didn't know what the – because, no, the onion will reduce the swelling. You have to wrap an onion on it. And so he did not want to, I guess, again, get into a fight and also talk about other – but what he did was he said, okay, let's wrap the onion, and then afterwards we'll wrap the ice. We'll do both. And so she was okay with that. And so even though it was totally foreign to him, but he respected what she had seen, maybe what they had done back in her home country. And so, I think it was Romania, actually. And then at the same time, be able to have her buy into doing other types of modalities, including ice, to help in the ankle sprain.

So I try to, kind of like you were, we try to respect that and try to hit certain areas, and then at the same time to see if one thing's plateau or if it's not really changing the symptoms to reassess and then to try other places and see if that makes changes for them. One time I actually had to do, there was a guy that I was trying to con into doing goblet squats. The only way he would do it is if I would let him bench press. I said, okay, we'll play this today. He walked in the next week, and he's like, can I bench press again? I'm like, you want to gobble squat again? He's like, no, I don't want to do either. I'm like, okay, fine.

Okay, well, let's jump into then meniscus. And just for everybody that doesn't know what the meniscus is, there should be a podcast right before this. I'm trying to line these things up so that I go over anatomy and some of the basic foundational education stuff before we go into theory. But the meniscus is some of the cartilage in the knee, which sometimes gets torn or frayed, and so that is a common diagnosis. So, Davis Koh, tell us about meniscus tears and what your experience is anyways. Okay, so there's growing research and studies about meniscus tears in general and the treatment options. The typical is you have the knee pain, you have an MRI, they show a meniscus tear, you have surgery, and then they'll come in and they'll clean out the meniscus, they'll take out any loose bodies, and then you go to physical therapy or rehab, and then that is the way to go.

One thing that people also need to be aware of is after, I believe, the age of 40, over 40-50% of people will have asymptomatic meniscus tears. It's just part of the process. Just like many people, if they did an MRI when they do studies of people with asymptomatic, no back pain, well, a lot of them will have 2-millimeter, 3-millimeter disc bulges, herniations. But they're still playing golf, they're still running, they're still playing, and they've never had a history of back pain. So non-painful meniscus tears. Non-painful meniscus tears. And so that being said, so when we talked about, like I said, there's many different causes of your knee pain.

And some of it is osteoarthritis, some of it is a certain tendonitis, some of it is a past history causing you to move or run in a certain way That is causing pain or undue strain on certain structures in your knee, and those are all true. So when you see the pain and then you go right to the MRI, it's not always, but I don't want to undermine those facts that it's okay to go. If you choose to have surgery, that is totally fine, and there is nothing to say otherwise because you did have an MRI. They did go in, and there was a definite tear. But it's for those people that don't necessarily feel better after the fact, and they go, it's still there.

I just had meniscus surgery. I'm not sure. It's been two months. It's still hurting the same way. And so it's not that necessarily the surgeon did a bad surgery. It's not any of that at all, or the PT did a bad rehab. It's just that there may be other underlying factors. And so I think there was a study in Finland. They've done a couple of them. It's difficult for surgery, but they did two things. One of them was that they did sham surgery on the knee and an actual meniscus surgery. And the sham surgery, they just did an incision. They didn't do anything, and they sewed it back up. What they found a year later was that the overall performance and pain reduction was similar.

There's no statistical significant difference between the two groups, But there were more side effects from people that actually had meniscus surgery. The other thing, what they also, again, it is difficult to make those type of studies. It's expensive and risky. But what they're trying to show is that they also did another where they had one group just do the physical therapy, and the other group had the physical therapy and the surgery. And one-year follow-ups and two-year follow-ups found no significant differences in the recovery, overall performance, range of motion, pain levels, so on and so forth between the two.

And so there are options where people who do want to avoid surgery, it's not a bad idea to what I call earn your surgery. So where you try the physical therapy, you try a chiropractor, you try someone that you trust, a medical professional that you trust in conservative care. See where that goes. If nothing comes of it, then yes, you've earned your surgery because you've tried everything else. Even if you go that route, it wasn't a waste of time because I tell people what is also very popular now is prehab. What you're doing is you're prehabbing your surgery, so the recovery rate is much faster.

And so when I had a patient with a total hip replacement, he fought it for years, and we were able to get him to a certain point, but eventually he needed surgery. He was scheduled. We worked on him for six to eight weeks prior to, and he had his hip replacement. It was successful. And then when he did his follow-ups, his surgeon told him, he told me just offhandedly, his surgeon offhandedly just said, you know, in 20 years, you're the fastest person I've ever seen. I think part of it is him being diligent with his home program and being diligent with going to rehab, but at the same time, the prehab, cleaning out all the collateral damage that's happening because of his severely arthritic hip, getting all that cleaned out, ready to go so that when he does do surgery, it's a lot less complications from the other surroundings.

Surrounding tissues that were damaged leading up to the surgery that enabled him to recover and get to the exercises and strengthen much faster, I believe, than normal. Yeah, yeah. They show that people who move better and are stronger will recover quicker. Yeah, I don't think there's anything wrong with earning your surgery with the rehab. Yeah, I like the saying, but I know there's probably a lot of people who think that, well, so you said there was that study who, or that showed that surgery and rehab was kind of the same outcome, why not just do the surgery? Like what is, just to play devil's advocate, why would someone want to, if they're not opposed to surgery, they're like, I don't mind getting cut into, let's just do this thing.

Okay, so that's a good question, so why not just make sure. One thing about surgery is, again, it's surgery, so there's complications, there's a risk of infections, which we've both seen. If they've cut too much, if the onset of arthritis is much higher for someone that's had surgery, and even for someone that's had back surgery, The statistics show that there's a 10 times higher onset of a second surgery for those who have had back surgery for the first time versus someone that's never had back surgery. And number two, the onset of arthritis and becoming arthritic is much sooner and faster on average.

So now you're putting yourself up. And then also the other thing is surgery, there's only so many tickets you're afford. So if you've already had your first knee surgery, then do you really want to be, five years later the knee pain comes back, do you want to be a two-time offender and get second knee surgery, and then another 10 years later it comes back, you want a third knee surgery? I mean, that's just a lot of surgery on the knee, unless you're a professional athlete and you're getting paid Boku bucks for that. But that is the issue. So you really want to save the surgery, any surgery in general, for, you know, you really want to, you don't want to do it more than once.

And once you have it once, you're at much higher risk of other side effects. Like that study showed that there, one of the studies shows that there was, the only difference was that there was more side effects with people who did have the surgery, the actual surgery where they actually did cut in to certain structures. Now, with meniscus tears, it's very complicated. They're like snowflakes. Everyone's a little different. So just because one had meniscus care and you have meniscus care, where it tore horizontally, vertically, or what have you, or if there was a loose body, where the location of some of that debris is makes a world of difference.

And sometimes it's just physically caught, and that's why they can't bend their knee to a certain level. Or sometimes it's in a benign area. And so you do have a tear. And again, that's why sometimes people who do have the meniscus surgeries and they don't have a favorable outcome, maybe that wasn't the main number one cause. And so I don't have, again, I don't have a problem when if their surgeon says, here's a meniscus tear, we have an MRI, you match the profile, let's do this relatively easy surgery and let's get that cleaned out and have you at rehab. If you want to go that route, I have no problems with that.

I'm not trying to tell you no and that the surgeon doesn't know what he or she is talking about. I am just telling you that there are certain options and the risk, which I would do for anybody, the risk that I've seen either in the clinic but also in the latest research that I've seen, that to earn your surgery is what I would recommend to my own family members. And to save that surgery, if you possibly can avoid it for when you really absolutely need it, is better for the long game overall, in my opinion. Well, is there certain types of meniscus? I know there's many different types of meniscus hairs, like you mentioned.

Is there a type that when you see it on an MRI, you're like, oh, yeah, this is going to be a surgery right here, just because the outcome is really low with rehab? You know, that's probably one that I would probably leave for a surgeon that's seen the MRI, been clinically, have a body of work if they are a knee surgeon. And then they'll have just, they've seen a million MRIs. I haven't seen a million. I've seen some, but I haven't seen a million. So that's, I'll leave that. And then they have the eye, the keen eye of seeing exactly those tears, that location, and then what their background is.

So one of the things that you also see with the radiologist versus your orthopedic surgeon is the radiologist may have a report of a tear or say nothing. But then when you go to certain specialists, they've seen like a knee specialist that is respected. They've seen a million knee MRIs more than they've seen maybe a hip MRI, and so they'll be much, they'll have, on average, a much keener eye for certain little things. They'll catch a fracture. They'll catch this that wasn't, or they'll say, you know, that's not really a tear. I think that's actually this, and so they'll have a much keener eye, so sometimes you'll see that happen when you go, when you get your radiology report, you see the paperwork, you see what the radiologist says, who sees, you know, all over the body, And then you go to a specialist who only sees 90% knee MRIs or x-rays, that person will probably, in general, have a keener eye for those things and then can give you another version of events where they say, you know, it's not that bad.

Or, you know what, okay, it is torn, but it's not really that bad. Or, you know what, oh, no, no, no, no, it's not that, it's this. And so just a little FYI from when you see differing opinions, there's some good reasons for that. And it has nothing to do with one being competent or being incompetent. And that also goes in with a physical therapist or the chiropractor where they see certain tests or palpations or their conservative tests over the skin. Without a benefit of an image, or an MRI image at least, that they still may have an opinion based on what they're seeing, but then again, there's a consensus confirmation.

The old tangent a little bit here, because I wanted to ask then, although, so we've got two different types of conditions here. We have runner's knee and meniscus that we're talking about. How similar, when we're doing physical therapy for it, how similar are treatment plans of Both. Are they really close? Are they extremely different? Because I know that a lot of patients, a lot of runners that have these conditions, they probably think, well, I got to have something specific for, you know, the runner's knee or specific for meniscus. What do you think about all that? I'll open it up to you. Okay. So in some ways, there's going to be some commonalities, but in some ways, there's going to be patient-specific. That's why you have to always look at their history. Someone has a history of osteoporosis. Someone has a history of high blood pressure. Someone has a – or taking a certain type of medication. Someone has a – another condition that limits them from certain exercises and so on and so forth.

So you have to do tailor it according to the situation. Someone is having a bad reaction to the surgery, and so their knee is constantly swollen. Someone had an infection. So all those things need to be taken into account. So there is, yes, there are some common general themes that we want to accomplish, but also there's also specifics to make them unique. That's why you never want to go to a place where they just, you go, oh, okay, you had You had an ACL tear, or you had a, this menaceous surgery. Here's your exercise program. Go to town. Enjoy. And then they just supervise you. And then they do the same thing for every knee patient or every, you know, that hip patient. That's a red flag, in my opinion. There needs to be tailoring. There needs to be some one-on-one. There needs to be some uniqueness to your rehab versus someone else, whether because of age or because of specific needs.

You are a high-level athlete, you are a high-level avid marathon runner, and someone else is an 83-year-old patient that just wants to be able to walk 30 minutes a day with their husband. It's very different, so there's activity needs, there's past histories of multiple back surgeries that you have to take into account. So we try to tailor things, and that should be, if you're not getting that unique for you type of situation, then you have to have pause. That should not ever be a case where you're in some, maybe on occasion, but in my opinion, because there's so much individuality and to get the best results for that person in particular, The more individual that you can tailor everything and even modifying the same lunge exercise to strengthen the quad and the glute differently for that patient versus another patient.

And I think that would be very helpful. So the other thing I would say with the surgeries and as a preventive, so the second part would also be as a preventive, to look for those other things outside of just rehabbing the knee because you come in with a diagnosis of post-surgical knee meniscectomy, PT, go ahead and evaluate and treat. To look into the causes, to really make this the end goal is not that you had successful surgery. That's not your goal. The end goal is not that you strengthen your quad. The end goal is that you've really eliminated the pain and also eliminated any future causes that may contribute to it coming back again and again and again and again.

And the more you can do that and have that lapse of it never coming back, or even if it's going to come back, it doesn't come back in two months, it comes back in two years or five years or what have you, then that's the better for you. And so I think there's a preventive part that I always try to incorporate to my patients, rehab, to not just get the full range of motion back in the knee, and then there's no more pain. Oh, great, now go ahead and run. No, no, no. What, you know, what is the, what's going on underneath that would always help the patient. And I think it's worth the investment since they're already getting there anyway and to look at things.

And so patients, if you, if a certain patient, I tell them, you got to look at if there's any asymmetry beyond a ballpark, 15% difference in how flexible you are left versus right, How much motion you have in your ankle, your knee, left versus right. How much strength you have, left versus right. Balance, left versus right. Muscle tone. If there's an imbalance over a certain significant where it's noticeable, that is a big predictor of some type of future injury to occur because of that asymmetry. So I would also encourage people to, not only as they're rehabbing, make sure that there is a symmetry that's involved when you, even if you're not injured at all, if you want to prevent things from happening, look at yourself and see if you're noticing, oh yeah, my right shoulder is always a little tighter when I lifted overhead than my left.

You may want to look at that because if you can't do that and you're doing overhead presses a lot, you're going to be compensating and twisting things and that can cause future problems. Do you have a good, I usually ask people for some type of actionable thing someone can do that's listening to the podcast. It sounds like they can probably measure their asymmetries. Do you have an easy way to do it for one of the joints, which might be a predictor for a knee condition? Is there a certain way that they can do it right now, listen to the podcast, hopefully they're not in a car or an airplane? Yeah, well, there's some simple, usually the patients will tell me, because they've had this history, oh, I've never been able to reach, you know, after my shoulder dislocated in high school football, haven't been able to reach overhead, you know, or it still grabs me.

Or if they're doing a knee, sometimes I'll just have them do like a deep knee bend, just go all the way down to, and then does one feel tighter than the other? And is there a certain pressure where, is there a certain pain or discomfort? So more often than that, they'll just tell me if it's something obvious, like, you know, I've never been able to. And sometimes I'll have to show them or explain to them the importance of that, and then they'll bring it up because sometimes they won't. Someone with shoulder pain, they can't lift their arm up all the way overhead, and they won't mention anything, nothing on the medical history or anything they've written down in the questionnaire.

And then they'll say at the end, oh, by the way, yeah, I did have breast cancer and, you know, mastectomy, or I did have a breast, you know, augmentation. And, oh, but that has nothing to do with my shoulder. Yes, it does. Yeah, it does. It definitely has nothing to do with your shoulder, the scar tissue buildup, the surgery itself. So there is, so they, so just little things like that will help. But if, just, yeah, you take your, any of your, your shoulder, raise it above your head with your elbow straight. Don't, you know, don't let it bend and see if one is, if you feel one is looser, more comfortable than the other, noticeably, that's fine.

Oh, wait, for the, for the leg, for the leg. Oh, yeah, for the leg. You got distracted. Yeah, like deep knee, bend, you know, I'll have them sometimes just strain out their leg and push on the top or the, or part of the thigh right above the kneecap, and if there's And over push some pressure, and a little over pressure, and if there's any pain, or if they notice one stays more bent, and it's harder to straighten out than the other, that might be an easy check. Okay, that's a good tip, good tip. Yeah, so people need to start looking for their asymmetries, and report them to their therapist when they go.

Oh, the other thing you also want to do is, when you do like even squats or deep squats, turn your feet out, turn your feet in, go straight, you know, just find different angles, lean on one side versus the other side. Put your weight on one or the other and see if there's a difference that way as well. Do you guys use the Trendelenburg test for anything or like some type of finding balance for like the hip or the ankle or anything like that? Yeah, so we'll do a quick assessment of just seeing the balance level. So a single limb balance, eyes open, how many seconds, eyes closed, And then take out the vestibular part or the proprioceptive part or the visual part of balance and just kind of tease out and see what one's available.

And then we also look at the quality of what's happening as they're trying to balance on one leg or what have you. And so we will look into that. And then based on what we see on movement analysis or just the test itself, we may go into palpations or ask about any histories of something that may have contributed to help us with the private investigation. By the way, I don't know if everyone knows. So palpation, we've said that a couple times. Palpation means like touching. So kind of like the way we feel muscles or structures. So let me ask you, I know that you're an instructor for instrument-assisted soft tissue mobilization.

Or IASTM. Gosh, it's hard for me. I think I'm dyslexic. Tell me about that as well as how you would do, or if there's any certain treatments you do actually in and around the knee to decrease pain. Because I know that some people probably tried some of the stuff. Or what are the top three, four that you like to go to? Okay, so the IASM, the Instrument-Assisted Soft Tissue Mobilization, for those that haven't seen it or heard it, it's using metal instruments with a beveled edge to create, to help break up scar tissue in a tendon, in a ligament, in a muscle, in your connective tissue like fascia or anything around the nerve.

It's just another tool that you can use. You can even call a foam roller an instrument-assisted soft tissue mobilizer. You can also call some of these massage knobby things technically an instrument-assisted soft tissue mobilizer, mobilizing the soft tissues. Soft tissues, like I said, we mean that, is skin, muscle, tendon, ligament, nerves, and connective tissue. The one that Sebastian was talking about is a specific set of tools designed to help break up scar tissue, designed for soft tissue work specifically. The way I got into it was back over 10 years ago, I heard about it from colleagues that I totally respected.

One of the colleagues, but these instruments back then and even now were about over $3,000, so they were quite cost prohibitive. I didn't know if that was even worth the investment. You had to pay that amount just to take their course, didn't you? Oh yeah, you have to take a course, so you have to take a level one, I think it's $750 without the instruments, and then you take another course to be a certified provider, and it's another about $700, $750, so that's already about $1,500 plus the time of travel and other things. And then you have the right to buy the instruments themselves, which are about $3,000.

So back then, that was a big investment for me. And so I called up one of my colleagues. His name was Mark Feil. And if you Google him, he was the former athletic trainer of the year in the NBA. He was the head trainer for the Chicago Bulls when Michael Jordan was playing during the heyday. And so I called him up, and I said, hey, Mark, do you use these tools a lot? I mean, these instruments? He goes, oh, yeah, all the time. I go, really? I mean, are they really making a difference in your athletes versus your hands, which we always use? And he goes, let me tell you something. Michael Jordan just called me three weeks ago, and he told me that these are the only things that saved his knees throughout his career.

So I don't know what else to tell you. And so that kind of, that and a couple other people talking about it spurred me on to go ahead and make the investment, see if I can bring faster change, better changes, more efficient changes in less time and in a better way for my patients outside of what I was already doing. When I went to the Olympic Training Center in Colorado Springs before the Beijing Olympics, I noticed they had stacks, about 12 stacks of these instruments. And in my experience, I have not met, working with Major League Baseball, professional volleyball, NFL, NBA, Division I, NCAA, I have yet to have met an athlete in the pro Olympic level who has not either has had it done to them or has at least heard about it.

There's not a single person yet that I've ever met that said, what is that? I've never heard of that. And if you look, Kobe Bryant's PT will talk about it. He's talked about it. Michael Phelps, he's talked about it, getting it done to him. And so it's been around for a little over 20 years, and it's growing considerably in popularity. And the thing that I want to caution people is make sure you go to a certified ISTM provider or practitioner or someone who has taken the courses because these are stainless steel, surgical-grade, or they should be surgical-grade instruments. And they are going to be working on areas of your pain, your tendonitis, your areas of ideally that have scar tissue and are injured.

So you want to make sure someone is not putting too much pressure, going too long, too hard, too fast, too strong with these instruments because they can cause quite a bit of pain. In my recent last few years, the last seven years, I've been contracted expert witness for the U.S. government and the U.S. Department of Health, testifying in federal court on Medicare and other physical therapy-related cases. And I'm also noticing more and more cases of instrument-assisted soft tissue mobilization practitioners and patients inquiring because they were used by people that weren't certified. Maybe their boss was certified and they were just using the instruments or they just grabbed some instruments that they bought on Amazon and just went to town.

And so I'm hearing more and more of these cases as a population is growing within the PT, ATC, or athletic trainer, chiropractic community. And so I do want to caution patients to make sure that you do go to someone that's a certified provider and make sure the instruments are not plastic or made of bone or cheap aluminum metal. Because the reason why is the bacteria, the porosity of some of those materials, can collect bacteria over time. And you can imagine they're scraping on dozens and dozens of patients and they come to you. So you want to make sure that the things that is surgical grade, has a mirrored finish, those things were, at least in terms of cross-contamination, is covered.

But then also make sure that the operator, the guy who's holding the instrument itself, is also well-qualified and has the instructions to understand how to use it properly to keep you safe and also to prevent him from causing, or her, causing more problems to you. With some of the instruments, it's just that there'll be some, it's not bruising, is there bleeding? Is there a little bit of bleeding? Mainly the bruising. And so what the bruising, what you'll forewarn the patients that that is a common phenomenon, the way the instruments and the original patent was on the bevel edge, creating a certain friction over areas of scar tissue in general.

So what will happen is if they go over an area, the operator goes over an area and there's no scar tissue, it'll just feel like metal sliding on your skin. And there might be a light, very, very light pink, but almost nothing. The other time is when it goes over scar tissue, number one, the patient will also feel like, oh my gosh, that's it. And even if it's the same pressure, like if they're going over someone's lats or muscles or their tricep muscles, and they go over a certain area and it's nothing, and in certain areas it'll just be super sensitive and they'll feel that. What may also happen is that that area most likely will have an area of scar tissue contributing to their pain or sensitivity.

Scar tissue has very weak blood vessels. The blood vessels within scar tissue are very thin-walled. The blood vessels in a healthy muscle tissue, for example, are thicker-walled. So imagine there's an area of scar tissue on their thigh or their thigh muscle, and the instruments are going over part of the thigh that has no problems, that's fine, and then they go to an area where there's some scar tissue where there may have been damage or strain or a mild tear, And that's causing their pain in their quads. Then the scar tissue over that area will be the one that's sensitive. The scar tissue, as you're breaking it up, has a thinner-walled blood vessel.

So they will break easier as it's having a friction massage through the instruments. And so that will create a phenomenon called petechiae. And that phenomenon will look like a bruising hickey or what have you. Depending on the patient's skin tone or color. And you just want to be cognizant of that, tell them it's not unusual. And there'll be also some of the other things that they'll notice is a tenderness to touch to the skin. And so you just remind them if it's tender to touch in the next few days versus tender to movement. If it's just tender to touch, like, oh, I put on my slim fit shirt and it's really sensitive or something.

Or they're skinny fit jeans and it's rubbing on that thigh that you just worked on. Yeah, they'll have tenderness, but not to worry about the tenderness. It's like, and I'll ask patients, well, are you moving better? Is it less, yeah, it's less painful when I move, but it's really tender where, yeah, tender to touch is no problem. Tender to movement is the problem. So I will tell them to make sure you understand the difference. And eventually, like some of these other Olympic athletes or pro athletes, you do build up a tolerance over time, so it's not as big of a deal, or they know the game, and they're much more aware of that. But again, that does lead to, if you're not having gone through courses, have it done to themselves, the person, the doctor, having it done to themselves, getting feedback, getting the learning and the education, and who to avoid doing it and where to avoid doing it. So not every area is ideal for this instrument-assisted soft tissue mobilization technique. If they don't have that understanding or learning, then they can be putting somebody, or an area that they shouldn't be at at all at risk.

So how would we find someone who is certified? Okay, so there's different websites. There's one, I think, called istmexpert.com. There's also certain brands will have their own educational component. One is fibroblaster.com. There's some other ones like grafton.com. And so you can look at these other groups, look at what their learning, their courses entail, look at they even require courses. The ones that really don't require courses are just kind of selling it to anyone and anybody, regardless of if they're even a health licensed practitioner, you may want to shy away from. You also want to shy away from places that don't have any educational component because, I mean, they haven't vetted that through.

So that's another red flag. You also want to look at, you can inquire if you're looking at certain instruments, if you're a practitioner, but if you're a patient, what is the materials that they're using? And there is a different reason why some materials or some instruments are only $50 on Amazon, and some of them are $3,000, and there's reasons why. So the first thing I got certified in was Graston, because the Graston technique was the first company to have a patent on this type of technology. And using these surgical-grade steel instruments for the purpose of soft tissue mobilization treatments.

And since their patent expired, about 50 or 60 different companies blew up. It's international. When I go traveling with the different Olympic teams for world championships or what have you, Team Finland, Team Netherlands, Team Russia, they all have, Team Great Britain, And have instrument-assisted soft tissue mobilization instruments that they use. So it's not only national, but it's international. So I don't want people to think it's just something new that is out there just the last few years. It's been around for over 20 years. But as one of my friends who's a professor at University of Miami Physical Therapy School and at USC said that Uh, by the time anything cutting edge has, has gone through its full body of work and research and studies, it's already 30 years too old. And so there is an importance of having the research and making sure we understand its place and its effectiveness within the, um, uh, healthcare community, but also, uh, some of these things that you see, uh, you don't want something that's It's only a year or two old, but you do want something that's proved itself over the test of time.

And again, these instruments have been around for about 20 years, and it's only grown in popularity. And that's why professional athletes who are worth over $100, $200 million are willing to go through those type of treatments, which are not always pleasant. Yeah, I'm sure. Yeah, so if they're willing to do that, there's other than that may come about. I'm seeing more and more invitations to speak at different physical therapy schools, and chiropractic colleges actually, on instrument-assisted soft tissue mobilization, and it's coming into the academia more and more. More and more research is coming out, so I'm excited to see more about that.

I thought it was funny when I went through school, actually our physiotherapy class, I think we had diathermies in there. I've never seen a diaphragm in real life out of the school. So you're right. The stuff that they seem to teach, they're borderline archaic. And then I think they're just barely now teaching how movement's important and instrument-assisted. So it's funny. They have to get all that education later after they get out of school a lot of times. Right. And again, I don't want to poo-poo people in academia or poo-poo evidence-based research. It's an important necessity. We want to know what certain instruments or certain modalities like an ultrasound or a diathermy machine does for the patient in its proper place and what it's actually doing.

So that's all very, very important. But you can't be cutting edge and it completely doesn't work that way. And so that's why you'll notice a lot of other things like PRP and injections, which are now very popular. That was in Europe and Canada and other places outside of the U.S. because of the FDA and other things that was already going on. And that's why Kobe Bryant and all these people would travel to Germany to find these people that have been doing it for a lot longer than some of the people here in the United States. So that's just an example of something that's cutting edge, that's trying to gain headway.

And now it's in many, many well-qualified surgeons in the U.S. and other practitioners, osteopaths or what have you, are performing PRP and stem cell injections. Yeah, I still have a lot of patients now that I've kind of like dropped a little bit of, you know, like, hey, have you heard of this? Have you heard of that? And they're like, no, never. I'm like, really? Like, it's kind of older now. Like, actually, I did a podcast about probably about five to six sessions ago with a stem cell doctor. It was enlightening. Actually, I went to his office and saw that all the procedures and everything. I'd never seen it all in person, but it was interesting.

Yeah, yeah. And even that, there's all details about how they collect the growth factors from the platelet-rich plasma for the period. So, again, it's not about finding the bargain basement price. There are certain issues of how they're collecting it, who's been doing it, how long they've been doing it. That makes a difference. So it's good to do the research. We're coming up on, I think we're about 50 minutes. This might be the second longest podcast yet. Is there anything you would like to finish with? Or I know that we've got to figure out how to reach you in your office. Yeah, well, I have two locations, Tussin and Irvine.

Irvine is our main location. It's in the Irvine spectrum area for people who live in Orange County. California, by the way. California. And you can go to the website, www.kohpt.com. And it also has some information on some of the things that we did talk about and some of the techniques being utilized, including IASTM, to give you some background information. But again, I encourage the research, knowing what you're getting into, understanding the problems, but also appreciate that there are many different ways to treat and also getting as many different ways that are tried and true is nice. Because your hands may not be as good as the instruments for a particular problem for a particular patient and vice versa.

But having the option to is nice. And then also to be open to hearing some other possibilities beyond what may be internet search or from what you've heard from other people to appreciate the individuality of your own meniscus injury or your knee pain. And to appreciate that as well, that every person is going to be a little bit different with the exact same diagnosis, exact same surgery, or exact same pain. We'll have different unique aspects and causes and to embrace your individuality and make sure the practitioner embraces your individuality and doesn't put you on some recipe that's good for anybody.

And also to recap, look for the sniper, not the bullet hole. Yeah, exactly. Don't look at the victim. Look at who's shooting the victim. Well, cool. Thanks for coming on. I know that you're a busy, busy guy, and it's hard to get you when you're in town, but thanks for coming on. I'll close the podcast now. I appreciate it. Well, cool. So, everybody, again, if you would like to get a hold of Davis Koh, his website is www.kohpt.com. Again, if you want to reach me at all and ask questions or suggest providers that you'd If you'd like me to interview and ask the questions that you might not have gotten to at your doctor's appointment, just go to P2, that's P, the letter to the number, sportscare.com, and I will answer any questions you have.

There is a button right there on the page, which is a voicemail button. You don't need a phone. You don't need anything. Just speak right to your computer, send it, and I will get it and answer the best ones. So, again, p2sportscare.com. Don't forget to subscribe and share with your friends. It helps me out a ton. And please, if you would write me a comment on iTunes, it would be absolutely amazing. So I will speak with you guys soon, and have a good one.