Ep. 10 - Solving Patellofemoral Pain After ACL Reconstruction with Fin Murphy

Hello and welcome to the PhysioPulse podcast. Today we have a masterclass on ACLV Hub and Psylliphanel joint pain with a specialist in ACL's thin hope you enjoy. (upbeat music) - Jeff, how's your reckon I get to Bluetooth on a mic settings over Zoom? - Yes, settings or the control center for the top right. - Settings Bluetooth, nearby devices, I mean, can you remind us about your job again, Finn? (laughing) - Where are we at? - Come on, headphones. - How much money? - You're clients, waste, just watch. Do you try to figure this stuff out? (laughing) - No, no, I'm proficient with everything so it's not. Sorry about this, lad. - You're not proficient with everything. - It does, I hate you not proficient. - It does, I hate that. Finn, just put the headphones in the octas cable. - Connected to the laptop. - Is it, okay, I think I've connected them. - Are you serious? - I can hear you perfectly, yeah. Oh yeah, it's a lot quicker in business. - Yeah, so Finn, are you normally 15 minutes late for podcasts? So I just fries. - Are we live? - Yeah. - I was so, no, I got retake, now I was surely retake. Stayed again. - What do you mean? - No, no, we're just really going to crack on, mate. - Yeah, well, for first time, Warner, so yeah. It's obviously an unwelcome start to my podcast journey by one of only appearance on a podcast. - Oh, good to have you on, mate. Good to have you on. - It's good to be here, guys. - I'm fascinated by the fact that you're online physio, though, and struggled so much to open Chrome, was it? - Yeah, a bit embarrassing. I had to update Chrome for your, what I would say is Stone Age app that you record things on. - Oh, okay. - Personally, so, but yeah, so I had to read out a lot of them. Jeff had to help me with a Mac, I've recently become a Mac, a Wanker, so I had to get help. - Yeah, well, you were Wanker before, and now you've just got Mac. - Are we okay to curse on this high end podcast? Is that okay? - Hey, we can make you go ahead. High end, thanks for calling a high end, though. - Pleasure. - I guess, should we start by after you're introducing you are? So, I mean, this mystery voice on the podcast, no one actually knows who he is. So, you can try and invent an identity and make self-sign better if you want, or you can just go for it. Just go for what you are. - Yeah, for sure. (laughing) - Oh, that's brilliant. - Well, with my Irish accent, I might be able to pretend to be Andy King, so I'm Dr. Andy King, leading expert at the last putter. Now, my name is Finn, I'm from Dublin. I study sports therapy in Dublin, and worked in American Ireland, and then did a Master's in the University of Limerick and Physiotherapy, and then met a scaus girl from my sins and moved to Liverpool, and met you fine gentleman in the NHL. We worked together for a few years, and then I ruptured my own ACLs. I'm sure you guys are sick of hearing me talk about it. And nearly four years ago, and you guys helped me out, and really just then got really interested in ACLs for my own journey, and dived into everything ACL, and seek dead lots of opportunities within the NHS, and inspire, and really just got after them. And then last 18 months, I've been working with ACL Rehab Online, and have been a predominantly online physio, seeing about 40 to 50 ACL athletes throughout the world on my case level at one time. - Holy shit. CCL. So literally, Mr. ACL at the moment. - Definitely not that. I haven't put this if this can, if you can see the video version, they've done me as Mr. ACL. Definitely not Mr. ACL both. Trying to be. - Do you want to tell a bit of people a bit about the story of you getting into online physio? I think it's a bit unusual. I think it's quite a new thing, isn't it? Tell me all these online physios, something we've seen since COVID, so do you want to give us a short story about how you got there? - Yeah, for sure. So as I was saying, I was kind of seeking out as much ACL Rehab, but in the NHS, Inspire, and there was kind of a ceiling to it, so I was probably seeing about 20 to 30, and just really wanted to get as much as I could and kind of keep getting exposed to them and learning. So then I set up my own Instagram page. It's still probably on the same followers as once I set it up. I was starting putting out some content, and then at that stage Ben reached out. He kind of must have liked some of the stuff I was putting out, or kind of any of my content. And there was a job opportunity at the time to work with ACL Rehab online. So applied and met Ben and Paul Reed and interviewed and then joined the team. Since then, I haven't looked back and I've been working online since then. - Do you miss shoulders, backs? - You know, I can honestly positively say no way it is breath or fresh air. I don't miss the NHS bullshit culture as well. That's something that's. He's probably the best perk of online physiotherapy. - Wait, that's amazing. And I mean, something that I've always been interested in. I know we've spoken about this a little bit. You're a really personal guy, obviously. We've been met during working together in Covid. You've always wanted to chat to people with the corridors and all that stuff. And I wonder how you're finding it with the online space, like the communication side of things. How you finding that? - Did you mean from a personal point of view, or with the clients or the athletes? - Do you want a put a bit both, actually, yeah. How you finding it? As far as, yeah, personally, I work from home and also, yeah, with the patients as well. - Personally, yeah, very difficult, because you go from working with lots of physios who are usually quite sporty and outgoing and active. And there's a lot of common interests. So you do miss that. And there's been, sometimes, there might be some quiet weekends. And you start one day morning, you're like, "Geez, I haven't seen anyone. I've nobody to tell about my week." Because you know, the chitchat and the NHS people ask me "Weekend plans, things like that." And I was like, "Well, I've nobody to discuss this sort of stuff." But that's probably, you do miss kind of the crack and the camaraderie of working with people. And that's kind of, probably the only bad thing about being online physiotherapy, I must. - Yeah, yeah. Yeah, I can imagine. Yeah, it's big shock, isn't it? And then, and what are the patients as well? How do you find that sort of aspect of things? - Well, that's where online goes through the roof in terms of your ability to communicate with patients because we have what's up support. So any issues or anything they're having, they can just reach out. And you can get instant answers back to them. And essentially, we all know like, what are the best intentions you send people away for two to three weeks? And then they come back with issues. They've done things they shouldn't have done. They've forgotten what they supposed to do. And a lot of times you're kind of re-engineering and kind of fixing things that they might have done. But just being there, I'm able to reach out straight away. And you can just keep them on the right path. And build up quite a good rapport, true texts, and Zoom calls as well. It's quite surprising how you can get to know people based on just Zoom calls and what's up. - I imagine working with people who are properly motivated to get back to being an absolute best as well as it's quite different to me, yes. - Yeah, that's, that's another huge thing. And like, it is a financial commitment to join the program. So a lot of people have skin in the game, which is another massive incentive along with their desire to get back to sports. So yeah, most people, you know, if you say how, like, Jump does say how high, how much, how often. And which is amazing compared to what we might be used to in the traditional setting of the NHS. - That's so true, I actually never thought about that. But it's almost a selection bias, isn't it? Because you're literally choosing, I mean, ACLs generally, they're going to be sport people, pretty keen to get back, generally. And you're almost selecting out of them, the ones who are willing to pay as well to get back to set levels. The almost choosing is really high-motivated people, aren't you? It's also really nice. - Yeah, probably 50% would be that kind of cohort and then the other 50% would have a history of poor experience with physios, so we'll be struggling. So then when they get on the right path and they start working with, I guess people will understand ACLs a bit better than their current support. They're even more motivated because they're like, "Oh, wow, this is what I should have been doing." And this is the level of support I should have been getting. So their motivation goes through the roof as well. - Yeah, that's, yeah, that's really interesting to hear. Just out of interest, I'm sorry, this has turned into a bit of an interrogation, I'm really sorry about this. It's not what you signed on for, but I'm genuinely interested. What's the most common mistakes that are made in the NHS or bad episodes of care that you've seen with these patients? - Yeah, I'd say the biggest one is not getting extension or hyper-extension. That'll be the big one that a lot of people come to us. And it's sometimes in four months, five, one, six months down the line. And they haven't heard once the physios say hyper-extension. Like it's kind of agents that are like, "What? My knee hyper-extends." So that's the big one. And then just exposing them to new stimulus, running, juggling, multi-directional, whatever the sufficient strength, that'll be the big one. And then they kind of get into a lot of issues down the line and then we'll come to us. We had one woman, she's 49, used to play hockey for England. And was back doing multi-directional running. As she was about 60 kilos, she was doing 10 kilos on the leg extension. - Oh, God. - I'm sorry. And it's not even the people we work with. Because I'm on the onboarding team at the moment, so we'll talk to a lot of people to see if they want to join the program or if they can essentially or if they're a good fit. And the amount of crazy stories you hear from Carriage about the world is mind-blowing. And then you remember why you're doing this job, or you remember like, "Wow, there is a real need for this." And it's not just in England. Like, I'd say England's probably the best America. Some of the stuff happens there is mind-blowing. - Really? - Yeah. - That's crazy. What's your kind of case at the moment? Are you having any contrusions? - Probably 50% from the UK. Maybe 25% from America, Canada, 15% from Europe. Maybe 10% from Southeast Asia, Australia. I hope those numbers have added up, but I think that is 100%. - I wasn't counting, three, five. - Again, I don't think I can tarnish all the countries we're bad-care. So it's the people that we see, obviously, so they've had bad experience, but thousands have amazing experiences. or America can be the big one that a lot of times they go in for quite intensively. Physiotherapists would just delegate to a physical therapy assistant. So they might be getting an hour and a half of rehab, put it with a physiosis assistant. Which again, they may be amazing that we know lots of great physiosis assistants, but a lot of times that is the big issue that they're getting lots of care and they're paying loads from insurance, but ultimately they're not getting the support they need. To talk about lack of high-freak extensions, particularly with the topic of today's discussion I suppose where we're talking about anterior knee pain after ACL reconstruction. Which we've got paper about and obviously the paper is just part of the obviously we're here to hear from Mr ACL himself and talk about how to manage anterior knee pain or even prevent it if that's possible after ACL reconstruction. Before we do that, I've actually just got a bit of a piece to be with you guys, wouldn't mind indulging us. We've got a fan of the show who's reached out for some help. Of course, let's do it. Let's go. So this is a guy who's 27, no significant personal history or trauma, but has got a few years history of left anterior knee pain, which came on gradually after going back to the gym after some time off in football, post-COVID, so it's been gone for a few years now. Since then, he's felt like his knee is good as sub-luxed a few times, mainly when he's doing high level activity like twist and all, or kicking a ball. He doesn't feel like he's got the same control or proprioception in my last 20 degrees of knee extension and he has a consistent click every time he goes into end range knee extension and pain during that range. Other than that, he's got pain on deep squats, doing stairs and even running, can sometimes aggravate it. He's been doing some gym work for the past few months, trying to progressively overload, but it's become somewhat chronic. That's the first bit of information, what were you immediate thoughts on what could this be diagnosis wise? So I do, my title is Mr ACL, not Mr PFG, so I'll have anybody to use my friends. Sorry mate, he said it was insidious over the last couple of years, that right? Does it have to be a trauma? No. Okay, I'm sorry, is it one knee or two? Just the one. The left one, if that's important. Oh, I don't think it is, but I hope. Right, so he's had some, like some feeling of instability, is that right? From the kneecap? Yeah, in the last 20 degrees of extension. Okay, because I know a history of dyscation, to anything else, I treat a scar. No true objective dislocation, does that? Okay, yeah. And is, so he gets a click as well, did he say? Yeah, apparently he gets quite a consistent click coming into extension on the knee extension machine. So not all the time, but on the knee extension. Oh, okay, go ahead, then. He's 27, Jeff, so we can kind of rule out DGN, well, our suspicion is lower. Yeah, especially with our history of trauma or previous management, you'd kind of assume hopefully it's all right. He doesn't do lots of jumping or hopping? You face 40. So I assume just why he's playing 40, but outside does that know I don't think so. And location of pain is it a very general vaginipane? So that's a good question. So it's more lateral anterior knee and sometimes feels inferior to the kneecap as well. But that if you really try and narrow it down, but apparently quite global. Previous imaging for a structural abnormality with the patella? No, no, that's all. What sort of thing? Anything visual, even just kind of a patella alter. Nothing objective wise. So according to Alan, who's the guy I've been in discussion with, it is me. There isn't anything really objective either you can pick up on. So I haven't asked him specifically about how high it's all positioned whether it's superior or lateral, but there's no swelling, no pain or hyper extension, no pain or full flexion. Not much really. So it's always, do you not know the outcome for this one? Oh, I've got my kind of thought about it, but no, you don't have to have an answer. Oh, okay, fair enough. So you mentioned obviously there's no previous investigations and you asked sort of what would be looking for? Yeah, what's the differential? What's the differential diagnosis for this type of pain? So it could be that chocolate and displeasure? What do you mean by that? So as in, it could be shallow, not very congruent, then it could lead to the diversity and pain. So I think we're chocolate, yeah, displeasure. It's in some images, so these looking at the correlation as like morphology and self-ferromal pain. Hasn't been strongly correlated. Oh. It is correlated with objective instability, but that feeling of instability probably not as much. Interesting, okay. Would that be the same with like the particular change as well? Obviously, Finn mentioned sort of signs of teller out to and those sort of things. Is that also strongly correlated or not? No, it's not correlated with self-ferromal pain in a usual population and in general population here. Hmm. Very interesting. Although if you ask some surgeons, I'll still do a tubularity rosteostiotomy and dyslization to treat kneecap pain. Yeah. And just probably before we go on to objective, so I'm assuming this person's generally very fit and well. No, it's a bit bad for the injury. Yeah, once the run goes to the gym, knees 40, no significant pass memory street or. And no, no, no, any night pain or anything. Sorry, sorry. Sorry. Sorry, sorry. You should have interrupted, sorry, you go ahead. No, if I can help me, it's my podcast, but you interrupt me all you want me. I just said, you were going down the, you know, I thought you were just putting on that hat. I was making sure everything's okay, mate. Like everything's an ACL thing, all right? Yeah, sure. That's his hip range emotion like that, yeah? And he blocks. Is that the interaction? Sorry, was that? Was that a new question? No, I was just, I was just, I was just mocking. Harder for like things that it won't be an out of me. So anything else to different choice? Well, fan pattern pinchment, potentially with the pain gone into extension and potentially the position. The teller tendon up, these seems unlikely because no, he's not kind of pointing to the area of the teller tendon. Am I correct in saying that? Sometimes it can be neck, like neck slip, teller tendon, but it's not truly distal pole, teller or anything like that, though. Yeah. And then the other one will potentially be ITB with the increase in low from not doing a lot during covert, lots of running. Yeah. What, with fat pad, what sort of things we look for, objectively? It would be, what's the special test called? Where you poke around the fat pad and then you bring it into hyper extension? Of whose test, isn't it? Of course. Of course. Yes, of course. My apologies. Please add it. That's fine. That's a bit difficult to do online, isn't it? Sure. Do you do objective tests? What's up? You've got what all the objective tests were. Yeah, I'm Jesus. Well, sorry, this is not the podcast, but I'm just reminiscing to Liverpool Airport when I was just talking about Jesus, I've descaled so much. All I know is how to treat ACLs and then someone's like, "Are there any first responders here?" I mean, you're on a run over and I'm just like, "I'm just saying I'm no, nothing of any medicine at the moment." I don't really have someone to need. Everyone stand back. Let me check his ACLs. Yes, have forgotten the last. It's amazing how much you lose. Well, very little information was there. That's quite a lot. Then, especially, massively upskilled in other areas, don't you as well. Anyway, sorry, we're going massively. Sorry, hona. I would have got the five Ds though. Let that be down. Oh, yes. Oh! Yeah. I remember my first year stuff as well, Finn. Yeah. You wouldn't have probably would have failed us to like the spot example if you didn't mention them. And I wonder how it was. I'm also like, you meant to be safe. Like, I think that's the first thing. You knew you don't do anything else. You meant to be safe at least. Scream for me. This is so hard because you got to be not into the family stuff. Yeah, I've got two people dicking on you. Okay. So, thanks a no pain on a pass of hyper extension or active hyper extension. It only comes on actively. I'm predominantly on the extension. So, you get a consistent click when he's getting into that end range. No confusion. No batteler tilt. No high ride and batteler. Nothing abnormal. We're looking about this knee at all really. And the extension you're saying it starts at 20 degrees. Yeah. And then closed chain when does it kind of hurt you? You mentioned it hurts when he squats and he kind of ranged and it hurts when he's squatting or lunging. I don't know. Actually, what would be what would make the difference for you there? So, what if I said it was in shallow any function? What would that mean for you? What does shallow mean to you Jeff? Sorry, only like 30 degrees. I mean, 25 degrees. 25 degrees. So, it's not. Yeah, so there's been a good bit of work, powers and song looked at the forces of the telephone moral joints during closed chain exercises. So, they really start to ramp up at around 45-60 and reach their peak at 90 degrees. So, it's a nice one to kind of differentiate between minuscultair and pfj or that pain. A minuscult could even be at 45 degrees, but typically you get worse. The deeper it goes where pfj usually in weight bearing. If they go into deep knee flexion, won't make it worse in a closed chain exercise such as squats or lunges. Right, cool. So, yeah, unfortunately I don't know the answer to that. If you had to hang your heart on a certain diagnosis right now, what would it be and why? I'll put it in half as. Fat bad? Yeah. Hey, a telephone moral pain. Cool. Yeah, I'm with the eye kind of concluded it's most likely to be surf animal pain. The other exotic things I was thinking of initially I didn't know is lateral pain when it was medial pain and he's getting this clipping I was thinking maybe it could be like a medial pica hypertrophic pica that's getting in the way but much less common with lateral side of pain. Do that more exotic thing would be like a discolored lateral meniscus. So your stimulus gets really fast not just at the rim but going all the way into the lateral compartments. Sometimes people can get tears of that and it looks like clicking or like sub-luxing. But with the absence of trauma that just from Instagram messages I'm kind of not heading down that way too much. Would you have more? Would you do a scan? I wouldn't scan now. Yeah. No. There's no talk where you're going to change management too much but I suppose what the advice it is on was like it doesn't help me but you know if it helps someone else it's reassuring. It's a surf animal pain diagnosis of exclusion isn't it? So if you scan it we're saying we're looking just for nothing to be here and it confirms our diagnosis. But yeah. No it's good that we've all come to an agreement on that and James isn't sweating as much as the previous bone stress injury. Oh yeah. Bill it's good we're getting in these little case studies. Would you do things like Clarks or like telecompression for these sort of things? For these tests as well? Would it help differentiate? How good is that? Yeah. Clarks is like Hawkins' candy in my eyes or for days. Like you do it and if it's not there it's more informative than if it is. So just for anyone who can't record Clarks as well you can do it inferior glide on the patella and ask the person to contract their quads. If I do do it I tend to contract very fucking slowly because if it's true stuff I'll pay like absolutely fucking rex. But although I do I look at I mean I don't think that I'd never use patella mobs as like to try and increase mobility as a patella but I still do it to assess is it painful? Try and push out laterally and feel underneath on the lateral facet. I don't know how much of it I'm getting but it tends to be quite consistently painful for people with anterior pain definitely. Okay. Yeah. I think for me working predominantly online and seeing lots of this you kind of get good at just using subjective history to diagnose us. We're being online and seeing this quite a lot and not being able to do any objective assessments and you get kind of quite good or in my opinion you're able to spot this based off subjective symptoms. Some of the big ones for me are introducing new loads to anyone's exercise activity so you said your friend did very little during COVID and then it's activity spiked. I think the big thing is is it exercise that's kind of spike anterior knee pain or patella tendon pain. So if there's lots of running and squatting and lunging that's going to obviously flare up and patella for moral versus someone's doing lots of jumps and hops. Patella tendon and the big one for me is the force on the patella during certain movements. So any squatting or lunging and particularly if you're making a quad bias any time where they're starting to get that pain at 60 degrees to 90 is a massive kind of that's potentially anterior knee pain or pfj and then on the knee extension as well the force is between 30 to zero degrees is when the force on the patella for moral gets quite high so anyone's doing any knee extensions from 30 to zero if they're really struggling that would be a big one and then even just day to day stuff anytime people have pain going downstairs he's kind of a big indicator that it's starting to rare its head if that makes sense so it's kind of the nice one to like a screening one to see if it's getting bad or if it's starting to become an issue. Yeah absolutely classic science. Do you hold much value in the cinema zone? Yeah I've probably seen a lot I don't like a diagnostic but you will have a lot of people when they're in prolonged knee flexion at around 90 degrees that it does make it worse. What about yourself? Yeah I mean see a quailo I never like say it's not a diagnostic thing. It's more people will freak out about us and it's kind of just explained that it's very normal because typically when people sit there at about 90 degrees where the pfj forces not force that's where it's aggravated the most in a closed chain pattern. So sorry the cinema sign is that literally be sat down for a long period of time with night degree knee bend or hurt is that right? Yeah. Okay yeah and that because there's most amount of congrycy is that right in that position so you've got most contacts in the joints. Is that why? I maybe but I also think it's because they spend a long time in one position with a bit of an irritable doing. Okay fair enough. Right so we do have a paper for today which is kind of around this topic of anterior knee pain as you've alluded to finished and that you see quite a lot on a day-to-day basis. The name of the paper is anterior knee pain after anterior cruciate ligament reconstruction. It was published in 2020 and the need author is Fabiano de Silva Marques from Brazil. So this was a retrospective study they looked at all patients who were in HL reconstruction between year 2016 at private facility. All the patients were operated on by the same surgeon and followed the same rehab protocol which apparently didn't evolve between 2016 according to the paper. So they had got nose with the 50-year-old animal probably balanced board and shit like that I don't know. They didn't get details on that. So they respectfully went through all of the cases that were done and they were looking for patients who'd undergone primary HL reconstruction with an Ipsilateral bone, petal, tendon bone graft or an Ips lateral hamstring sending graft. They had to be above age of 16 and 25 and then it's of a two-year minimum follow-up exclusion criteria where any other ligament injury such as post-racidual coroner, posterior cruciate, if they had an osteotomy for ligaments correction, significant condolusions but they did allow miscarapairs because that was in the same protocol. After exclusion they had 438 people that they can otherwise be the fault. What percentage of bone, tendon bone versus hamstring graft do you see? Fin over your plantar? It kind of depends on location but most people in America and Canada will have the patella. Most people in Europe who have come across all of hamstring in Australia and New Zealand usually patella as well. Probably a 60/40 split towards the hamstring. I don't really have you noticed any kind of difference in the two? Yeah, absolutely. The big one is kind of topical is that people would patella tendon grafts typically get anterior any pain more than hamstring grafts. Well yeah, I think we'll head into that briefly with this paper. The main things that they were looking at was whether graft type or an extension deficit postoperatively was associated with the presence of anterior any pain. So their primary outcome measure was very simple. It was did this person have anterior knee pain in the first year after their ACL reconstruction? The whole question around extension deficit comes from kind of previous research. I was having a look and it's a quite prolific author in the New Zealand world of I think it's K Donald Shelbourne. I think he's a surgeon over in America. He's published quite a lot throughout the 90s and 80,000. And they've kind of done some work showing that anterior knee pain may actually be preventable in kind of quotation marks. I don't know, we'll get onto your thoughts on that a little bit. But about this, if you actually can try and stuff an extension deficit from happening, then you might be able to reduce the rates of anterior knee pain. So I'll go straight to the chase of what they found. Essentially found that if you have a bone tertentine graft, you are 3.4 times more likely to suffer or a poor anterior knee pain in the first year postoperatively. And if you have an extension deficit, the 5.3 times more likely to suffer anterior knee pain in the first year postoperatively. And together combined extension deficit and bone tertentine bone did a linear regression and said that accounts of a 12.1% of the reason that people have paid enough to ACL reconstruction. Which is quite low really when you think about your total amount of time as a prevention. So Finn, do you want to run us through what are the potential reasons behind why an extension deficit might quote unquote cause anterior knee pain? Yeah for sure, but you've actually got me Jeff to be honest because I don't know why. I know deficit in hyper extension and lead to worse outcomes or poor outcomes after ACL but I don't know logically why it would. So I might have to put it back to yourself Jeff. Oh take that and put it onto James. So do you think I could piss go into your knee pain? Well actually I know exactly why. No, I don't think we do know, do we? Is that right? We know the links but we don't know the causation of it. Yeah, you know you absolutely right. Okay, right fine, let me read it. Why could extension deficit contribute to anterior knee pain? Try and wear your way out of that question. So why might? Why might take contribute? We've clearly seen that as a five four risk if you've got it. Well the big one to be your risk for potentially cycloplysions or scar tissue. So you're going to have pain whenever you're going into extension. Also as well if you're not getting your knee fully straight or you've got an extension deficit, your quad joint can be working as well as and the likelihood if your quads aren't working as well as they're short and you're not getting into that. that hyper extension and potentially you've got some scar tissue in there. Pain has gone ahead and hibisodes quite further. So we know the link between quad strength and patellar femoral pain. Again we don't know if it's the reason it's kind of like chicken in the egg. We just know a lot of people with patellar femoral often have quad weakness. That would be my kind of best guess. I don't know if you guys would have any other kind of ideas. I think I'd agree. I think we may be asking the wrong question. Is it not just a sign of the unhappy knee? So you can say that all of you more pain because they've got this issue but actually it could not just be a symptom of other things going on. In fact they have got, did you generally got more pain? The fact that they might have other issues like fin dys mention as well. Yeah I think absolutely right. If someone was discussing with this, this with us clinically we wouldn't just stop at what's their extension deficit. We'd be like, have they gotten a fusion? Does it look scientific? I have much of an effusion I've got. I can't what's their flexion like, see, building this overall picture of, yeah, is this near a happy knee or not. My only kind of query which is like not really backed up by a lot at all is with an extension deficit. So the class that is, they've got, they're lacking more than five degrees off of extension in this study. Different people have different definitions and now some people say if you haven't got hyper extension, where you've got full extension, that's still a deficit. But if someone's got more than five degrees deficit, which is why wasn't this study. Again, I wonder if it's to do with the, during contact pressures as you alluded to before, different angles and effection affect different parts of the pterilla and actually when you're, when you're in a more flex position, you've that contact area between the troclear and the pterilla is quite largely spread. So the actual pressure going through is reduced but in more extension, then you've got less of the pterilla that's actually in contact with the troclear, which means that all the joint contact, the joint reaction force has to go through that small bit there. So I'm wondering if they just don't get a break and they're engaging over there in the constantly could that be a reason why it's like kind of mechanical overload? Yeah, interesting. Yeah, definitely. So I was a central option. It makes it makes sense to me. It's very logical. Yeah, for sure. Yeah. You mentioned a cyclopsiesion before Finn. For anyone who doesn't know what is a cyclopsiesion. Yeah, for sure. So it's a buildup of scar tissue in your knee. It's commonly called arthrofibrosis and it's called a cyclopsiesion because on an MRI scan, it looks like a cyclops eye. So I guess the the the correct term should be scar tissue in your knee or arthrofibrosis. So it's very painful whenever anyone goes into extension and typically people have extension deficits when they have arthrofibrosis scar tissue cyclops lesions. And so we've talked about getting extension, hyper extension back is a modifiable risk factor for these. Other than you other modifiable things like things we can do try and help people prevent getting these. Yeah, so one of the big ones is getting hyper extension or full extension before your surgery. So we know people when they don't have it the less likely to get a full hyper extension extension and thus increase the risk of getting a cyclops lesion. We know females are more affected. They're more likely to get cyclops lesions as well. So essentially, if you're a female before your surgery, get your knee hyper extended. But no, really after the surgery is the big time you need to do all the work to get your hyper extension. So one of the big issues that I see is a lot and from picking up people as well is that people don't control swelling. They get off crutches too soon. They progress the rehab. When the analogy I use to people is it's like your knee is a hinge joint and you've got a little sawdust in there and you're never going to be able to get your knee into hyper extension unless you get that sawdust away. So I think of essentially getting swelling out of that joint to get hyper extension. As well, I think it's the body's inclination to not want hyper extension because it's when your ACL is vulnerable and more of an extended knee and your body gives more once your quads to kick in straight away. So again, we know swelling inhibits your quads after the surgery. So really the big thing is to make sure you get this hyper extension back. It's control your swelling. Stay on your crutches until that swelling's down and really push to get that hyper extension. More about the people who have really seven effusions. So an idea where that advice would help people get the swelling down in the first couple of weeks. But you do have these people who've got persistent effusions like around six to eight weeks. So this is advice of the same front. Stay in the crutches and keep it off those and limit their walking and stuff like that or do you add some point you have to call it? Well, I guess it depends on what they're doing, right? Do they do that? Like some people have active jobs, some people have to get back to work, some people support their family. I would say if there's massive increases in swelling, so residual swelling is very common after ACL injuries. But if there's a big chunk or a big change in that swelling, I'd probably be de-loaded to get that back to kind of your baseline residual swelling. And how do you measure that? So again, online, that's one of the deficits. It's very difficult to teach someone how to do a sweep test. We just use circumference readings. It's not the most accurate, but people can do it. They can reliably see if there's differences between operated leg and non-operated leg and particularly for the big increases. If someone's done something that the knee's not happy, one of the first steps we'll do is can you give us a circumference reading? And they'll have their baseline readings throughout the day. So they'll kind of know themselves if the knee is ballooned up or if it has swelling. But there are flaws to it, but it's a very easy one, the patients can do or people can do. So I'm just laughing there, because I've just noticed that fit in your name has been changed slowly during the course of this conversation. I don't even realise that the actual change changes us to Dr ACL. Oh, you did that. Who was Professor ACL? When did that happen? That was called a medscare. The greater answer he's given, the more he's getting upgraded. If he gives you a pen, you're going to get downgraded and again. Then it will be Firmair, Fee BSC. Is he PC? Yeah, mate, that's a very good way to go about it. I think that's what, if people listen to this and see ACLs, then margin of fusion is such a big one. When it comes to yeah, movements and how happy the knee is. I remember listening to a PT Inquest episode, because Eric Meirin, J-Dubs, have been around for quite a while. I think they still remember the ACLs getting casted after the reconstruction. Apparently the rate of cyclops lesions was like through the roof with it just from there, and it had one static position for six weeks. So movement is what I'm saying from now is a care move and even if it's uncomfortable. I would even say swelling management, this is a bizarre approach, but I think it could not decrease PFL keyboard. The sooner you get your swelling controlled, the sooner that's arthrogenic muscle inhibition, which is essentially swelling basically puts your quads to sleep or turns them to sleepy quads. So when you can get rid of your swelling, you're also going to get your quads kicked in and you're not going to be able to get them stronger immediately after surgery, but you can prevent how weak they get essentially. And the longer swelling kicks around, the analogy I use is that after your surgery, your quads might be on the 10th floor. You have the surgery that drops to the 7th floor every time you're not controlling swelling. Those quads are just in free fall. So if you think of the two big areas is swelling as such a huge impact on getting hyper extension and getting your quads kicking back in, not getting them stronger, will hopefully preventing increased weakness. So I don't see many ACLs now at all. And just out of interest, do you ever find that trying to get the movement back is having a negative impact on this swelling and vice versa? How do you sort of manage that? Do you mean them trying to get off the crutches of them trying to rehab? I guess, I guess so if their movement isn't great after surgery, so they don't have that full extension, full hyper extension. And do you feel that actually we need to really start pushing this? But it's quite irritable and sore for the patient. Do you ever find that stares up the knee more and cause a more deem or those sort of things as well? Or does that not really a big issue? No, I think it depends what they're doing outside of the kind of traditional physiodexcer. So there's step counters, a massive one depending on the job, depending on what they're doing. That's usually one that can really ramp it up or also if they're kind of getting rushed back to do gym exercises which can flare up the knee. It's typically kind of the low level exercises one typically annoy too much or cause more pain or swelling. So a lot of your standard ones that you see in booklets are actually in my opinion are actually really good, they're basic because you're not doing more advanced stuff than what you're ready for. Did that answer that question or did I just run? That was brilliant, that was really good. So sorry Finn, it's like we're having any questions here. As your name is now Professor ACL on our chat, I feel like you know the year after these levels of questions. When do you call it so we're assuming here that anterior knee pain is plan it's you know it's related to loads there's nothing else going on the knee. I am, I had a patient recently at Watt Siu actually, you've come through that I've had quite raging anterior knee pain. So the point with like I'm really struggling to walk or you know getting into the gym is impossible as can do it. And it's being quite interesting both of those cases have been from overseas kind of East Asia it's being people who've been in the NHS. Here the time for surgery is a while and haven't seen that as an opportunity to pre-habit as best they can or try not to rehab but they've they've just kind of gone. Now I'm gonna go back home and get done. very cheap and so it's probably not common occurrence when we've got like surgeons who do high volume surgeries both of these people actually had their tubular tunnel that was far to anterior so they were getting kind of impingent of the graft itself anteriorly and I mean that was associated a little bit with their extension deficit it wasn't gross it was about five degrees or so one of them that was it and they just had a really anterior graft and it was really difficult it couldn't wait for an extension because the pressure was just too much for them. The other one was similar to anterior tunnel position but actually the screw would come right into the joint surface as well and caused so much scarring of the fat pad and massive author fibrosis so by far not the most common cause of anterior knee pain but yeah exercise caution with A1 who say in a their pain severity is really quite big especially if they're from a low volume ECL surge and I'd recommend you know get back into the ortho clinic and you know ask them is this right? Yeah I source stories were for remembering isn't it there can be like a like a pure biomechanical reason where they've been by the struggling so much you know we can't forget that. Yeah I think contrast as well if you've got someone who's having really I know it's isn't that the topic is available so he's having quite a lot of pain on kind of way bearing and getting an end range new flexion you can get posteriorly placed two built tunnels and they get some roof impingent in the notch seeing one of them recently as well but yeah kind of off topic a little bit there but I thought quite interesting. That's really interesting yeah. But these aren't too many pains in ACLs have you ever had anyone that's just been so incredibly stubborn with it that was in the pain's been incredibly stubborn? What's your sort of like like after you've looked at all those things like the overall load, the age of movement, the strength, what other things have you got to go to if they're not really working at that time? We probably say I didn't mention area of the typical patients we'd see we would get a lot of people were raging anterior neapine words very very bad and it's kind of it's having probably my experience when it's raging in that sense it's having a discussion with them there's the light dealers is kind of doing certain things that are going to benefit the ACL rep are ultimately going to piss off this anterior neapine more so it's probably a lot of education and saying explaining things that are going to make it worse and then trying to eliminate it as much as possible and in the short term for them taping I've kind of seen I know the evidence is kind of a bit mixed on it I've seen probably 50% so people get really good results with it and I can really help the pain and Ben was the one who kind of said like try it and I was kind of like that there's no real support for the sport is kind of low level but like clinical I've seen really good results 50% voodoo floss as well I don't know if you guys have come across that no it's essentially just rapid therapy around the round your knee it's just really grippy therapy band really good for getting a range of motion back but when people have raging ones it kind of just give them a different pain stimulus they can help and then in souls as well can just give a different stimulus but I guess the key thing is educating them that we need to get this something you've been doing if it's not by mechanical as Jeff talked about something you've done on your rehab has just flared this up massively and we need to de-load this and it's one of that people get frustrated with it because you can't necessarily train your way out with PFJ and a lot of people struggle without that they want to do stuff and they want to help you you can do other stuff well I kind of don't think it has a positive effect on the PFJ I think it just keeps them busy and the big one for me is education and de-loading it and getting pain under control and then trying to progress the rehab. What about pain relief and those sort of things do you recommend people saying a lot of pain relief all the way through or do you try and wean them off that first or would you put them to be on that for a long time if they need it? I think if they're like in the in the rehab this is kind of out of the post-op stage if they need painkillers to the rehab I think PFJ is raging then and you need to back off from rehab but if you want to take painkillers take painkillers but I wouldn't recommend people push true pain with PFJ because in my kind of the analogy I use it it's like I'm sure well I've done this for you guys before but it's like eating sculling hot pizza we all know when it burns burns your mouth if you kind of keep eating that sculling hot pizza it's usually just gonna keep getting worse it's not gonna magically get better and kind of the PFJ analogy I use it just let that pizza cool we need to get it settled down and then stuff your face once it's cool as much you want I love that, Audrey I'm gonna steal off your music tomorrow probably. We had lots of pizza and palma we definitely stuffed our face for piping hot pizza. Say you let that pizza cool and you know you can't just ask people just to kind of like wait there and they're cool down and pick it back up or do things around that while they can't work any. Yeah yeah cool question so yeah you have to keep it busy because obviously they're they're paying for us to rehab the race and they're not gonna want to just sit idle for a few weeks and the big one to be seeing what death is there of other areas so lots of type people hamstring grass I kind of use as a positive spin and I say right for the next few weeks we're gonna get after your hamstrings and glutes massively most people as well the calves aren't you know kind of where we want them to be so you put a huge focus on getting after some deficit that they have and you kind of spin it as a positive opportunity where hamstrings can often take a long time to get normal if there's a hamstring raft and this is a really good opportunity as well typically the good leg and it's gonna be at your feet and it's not gonna be at the level they need it to be so really good chance to just really get out of the good leg hamstring calf and glutes and just avoid irritating that knee in quite dominant exercises and a lot of people get good by in from that because things still really get after certain things and targets it's a bit harder admittedly with patellar graphs because the hamstrings want to take the hit so it's tough to kind of flip that on them but they still likely will have hamstring deficits glute deficits calf deficits and the good leg as well is probably going to be weak so it's just not as easy to kind of put a positive spin on them for a patellar graph when you're when you're doing like pre-hub like preparing for the post-office stages how do you frame self-immolary up self-immolary do you kind of raise as a possibility and say like you know I don't know how to go about saying most people get it if you look at your avoid it or you say then you need to look out for this it's the enemy where it's just trying to avoid as much as we can how do you go about those conversations yeah and it's it's the big benefit of online physics because I can record videos some I can speak to them all the time and I'm in the rear so it is something I can plant the seed early doors and Paul Reed our header performance he is big theory of ACL rehab is reverse engineering so you start from the back of sport and you go all the way back to surgery and you think of the biggest thing that's going to stop them or slow them down and if it's not sinister like scar tissue it's going to be pfj right so you have to then go back up to check how do you eliminate people getting pfj so the big one is we've kind of touched on earlier as explaining to them what it is essentially and what aggravates and what to look out for and if you can kind of flag it up early and you reduce it it typically settles down very very quickly if you just plow into it and you keep pushing and a lot of people particularly men are like pain is good and rehab I need to push through this that's when it becomes raging pfj where a lot of times if you can just nip it at the boat weaker to off things settle right back down and you can carry on you just just the load you might modify some of the exercises and people can typically carry on with no issues but if you allow and just push into it that's when people come into issues and raging pfj takes so long to settle down I think that idea of backwards design is is important and you know that that's on that anyone listening who who doesn't do that I'd say that backwards design is too huge and I have the key for everything opportunity because unless you know where you go and you can't plan your next short term steps and yeah I think is it a rate limiter is what you're kind of reading to like what's going to stop you it's called a rate limiter in complex systems yeah and then it's even stopping you going into things that we know will annoy the pfj so kind of that risk towards so we know the extension full range is going to flare up pfj 30 to zero so you know I typically get people doing the extensions 90 to 45 for a long period I know it's kind of like the it's been debunked as like a risk on the ACL I use it more as a risk on pfj and we know quads are strongest at 60 degrees so between 90 to 45 it's a very safe zone for your pfj and it allows you to get a really good stimulus for your quads the other thing as well is that as we all know a lot of times ACLers compensate massively so they'll use hip-domin strategies I guess our job is he's see all physios or physios in general it's to get people using their quads the problem is though when you start using your quads you also start wrapping up the stress on the pfj so if you're using very quad bias lunges as bogear in split squats you're going to be really putting the pfj under great a load even with front squats if you're using a staggered stance or you're putting the non-up leg on a plate that force you're going to be getting the quad going but you're also going to be getting the pfj going and it's a very kind of the advantage I use is like dancing with the devil because you're trying to get the quad going but you're also pissing off that pfj so a good strategy as well as every two weeks you introduce a new stimulus into the rehab and it's something that could piss off pfj and then once you know that it's going to tolerate things you add another one and you add another one and if it doesn't tolerate it you just back it off you modify certain exercises and that's the key thing is when it flares up you just modify straight away so let's say they might be doing staggered gobblet squats so you put the operated leg back we just got to bias the quad lot more which is brilliant but if that PFGA is flared up, you just get them doing a neutral stance or you can just bias the upgraded leg for a period. So the still training, they're still getting stimulus but they're not just, you were just letting that pizza cooler sense away. I was just interested how aggressively and how quickly do you intervene with that sort of stuff. So the example I think going in my head is someone who's just saying, actually I'm just getting this very, very mild little niggle, put on my knee when I'm doing some of that. Do you guys straight in really hard? Like right, let's ramp it down, let's just get on top of that straight away or do you do a little bit of time to see why you're just adapting to the new exercise. Yeah, typically a lot of people I've found I don't have to do any basis. A lot of people have anterior pain at the start of the session. So they might start letting them leg presses on them, they say, after the fourth set, it's okay, I'm good. If it's kind of the second exercise, the third exercise, they're still feeling it. I'm modifying it straight away. And it's kind of, it's a vested interest for me because I have the ability to modify things. People also have contact with me and PFJ is very difficult to treat. So it's a vested interest to kind of make sure it's settled down, you know, because it is ultimately just going to stop them from re-having. So, yeah, usually some have rambled there. First exercise, kind of normal to be a bit of pain, as long as it's kind of tri-altern and gets better during the session. I'm all good then. But then I very much clear, if you start noticing going downstairs, things like that or other things that will load it up, I'm like, tell me and we need to get this under control. The thing that's kind of standing out for me through all this is kind of communication, which is obviously what you've got a lot of. It's that staying in touch and we'll change the plan like that. Like, you know, it's not, not a big thing, we sort of like becoming a big thing. I hear that's where we can fall down on, you know, big or clinics where you can't, you don't have that, but it's just staying in touch. It's kind of like, go away for a week in the best case scenario, like you're wearing a witty. And also like in class environments or, you know, how much can you really communicate and get these messages across. So I'm kind of thinking in my head now, I've developed an idea of how do I even look at this. And try and see, you know, what I'm interested in is like, what are rates of anti-reunee pain, post-ACL at the moment. I have feasibly what's going to help with that exercise programme, probably, but it's probably staying in touch and like having that kind of that help plan almost like, what do we do? Because that's what you keep on going back to. It's like, use time, use time, use time, you know. Well, what we have quite well is every coach is kind of different. I see a real online board. We typically structure where you'll have a quad dominant day, twice a week, and then you'll have a hip dominant day. Once a week, and it's such an easy thing if PFJ's flared up, it's like, stop quad, modify quad, let's do hip dominant days. And that could be an option for any, and if he's there even for yourself, do you have to have people around with a safety workout they can do? Do you know what I mean? So like they get the symptoms of this is what you do. So you're still training, you're still working your good leg, you're still working hamstring graft calves, you still get an afterstuff, but you're not annoying mini, and it just will naturally settle down. Yeah. I really like that. That's what preempting that situation happening and we've got a plan in place. I mean, that's really good idea. Plan B. And so easy for the business because a lot of kind of what I've seen of NHS or tradition, we have to kind of throw everything into every session, right? So it's a bit of everything, right? Which is fine, like both if PFJ's there, and even if it's a less quad dominant session, it's if it's a less quad dominant session, it's still going to flow it up. Have you just had interest because you know, throwing at squats, so front squats, front loaded squats typically low quads, PFJ more, plaques squats, so particularly low bar backs squat would load the hip more, but still loads that different than any. Do you have it, you know, is it as linear as saying you've got anteriorly pain, and you do in a high bar back squat, go to a low bar, does it ever work, is it simply as that, or is that just kind of works in biomechanics mindset, but it doesn't really, or does it have some ground? I guess it depends how irritable it's being, usually when they're getting back to stuff, I usually do back squats and then progress back into front squats if that makes sense. So I don't I think in the acute stage it doesn't really matter, it's still hitting quads, but when I'm weaning them back in, more so I would say split squats or Bulgarians will flare it up more, where reverse lunges will really settle down and you really emphasize that negative shenangle, if that makes sense, so you're not going into as much knee flexion where with a Bulgarian you're going to a lot more. Could you just elaborate on wanting to be able to shenangle and what's positive and what's negative just in case anyone's not familiar? Yeah, sure, so I guess imagine if you were proposing to a girl, so you run a knee and then imagine just bringing your knee further forward as if you're trying to knee your fiancé. So that would be a positive shenangle, or think of if you're in this position and you're proposing, your shin is vertical, so it's pointing towards 12 o'clock and you want to try and point it to 11 o'clock, would be a positive shenangle and if you want to make an a negative shenangle, you pointed to 1 o'clock. So imagine she said no, you'd recoil and that knee would go into less knee flexion. Is that not as good as the pizza now? How would you describe it, Jeff? I'm sorry, I know, I'll try to know. I'll try to know. I'll try to know. I'll try to know. I'll try to know. I'll try to know. I'll try to know. You have to understand, they see so many videos of people split squatting with a negative shenangle, so we can draw on the screen, so we can just pause them and see them when they're a negative, we're going to be like pointed to 11 o'clock, or want to try depending on the position of the rest. I would perhaps say that the positive shenangle is knee towards toes and negative is knee behind angle. I'm an idiot, yes, knee's on toes. That is the dumbest thing I've ever said. Damn, Greg, please. Yeah, yeah, currently ACL God. Before you start, Danny God. I think also get lots of ACL advice from Finn, but you're not getting proposing advice about me and your partner. Finn, are there any questions that we haven't asked or any topics we haven't mentioned so far that you think really would be quite valuable for us to talk about for listener? Yeah, probably two, Jeff, so I've kind of talked a lot about avoiding any quad bias stuff, but there are some things you can do like when it's settling down, and then as well, PFTN, the later stages, so when you're just introducing lots of running drop jumps, more plyometric, that's kind of another key stage where PFTN kind of start to come at you again. And then another one, which I want to get your thoughts on as well, a kind of preventative based on cohorts or individual people. So three things to discuss if that's okay. Yeah, I'm here. It's great for me. Let me start with the first. So training around it, some really nice ones that when it's settling down, as I said, keeping knee extension 90 to 45, a lot of people will be concerned because they're not getting that kind of 45 to zero knee extension strength. We know lots of ACLers have deficits there. I can't quote the research, but Paul Reed is amazing and he's told me reliably, isometric knee pushes. So you rack the bar, ridiculously heavy that you physically can't lift the bar, you stand underneath it, you get your knee in about 15 degrees of knee flexion, you just try and stand up and straighten your knee. It gives a quite a really nice stimulus. It's not going to annoy PFTN because it's a close chain exercise. So you know, it's kind of that safe zone and you try and you build up the bar and you try to stand up and straighten your knee. And again, I don't know the research list, but Paul says there's a 15 degree transfer of strength gains when you're training in specific isometric ranges. So if you're training in 15 degrees, you're in theory going to get stronger in zero degrees and 30 degrees. The knee, eyes are pushed. Alex Natera is big into it. A really nice one to do is to start. You rehab as well. A really nice one. The people get their quads really pumped up and they can really feel it during this exercise. Another great one is track bar deadlifts. So in a quad dominant fashion. So typically the knee is around 45 degrees. A lot of people can train track bar is really nice and get a good stimulus on their quads when they're doing track bar. It's also nice to stagger as well. A lot of people with PFTN really tolerate track bar deadlifts and that's a great one as well that it works your quads between 45 to zero degrees and knee flexion. It's going to be safe. It's a close chain exercise. As long as you're constructing it to make it quad biased or keeping your chest up and increasing the shin angle, you're going to get a really good stimulus on the quad and not annoyed the PFTN. The other thing as well I'd say is that when it's resolving what I've seen is typically people will have one area that they don't like. So it'll either be open chain, knee extension or hamstring curls or it'll be closed chain. So I haven't found a way to predict it, but some people just will not tolerate knee extensions. Some people will but they won't like any closed chain stuff. So that's a good sign when the two of them are a bit grumpy. You back off the mall and as you're introducing it back into the program, you kind of see which one they're tolerating first and then you start working on that one and then you slowly start introducing either open or closed chain. Nice. So just going back to what you said about the trap bar split squat and constraining it to keep an upright trunk position. Yeah. With the people you work with, it's probably quite tuned in. They've got the program there on their phone or whatever they can just look at. Do you ever use any environment or constraints to try and cue body position or is it mainly kind of available and so we want to do it? For the trap bar for every exercise. Yeah for any exercise, are you trying to cue, keep an upright trunk position? Yeah well we use the classic end of one where you're against the wall for front squats. It's kind of a really unique situation. We've kind of all thought about this on the team that you know they're sending videos to us. We're giving them feedback and then they're also recording themselves next time and they're almost getting the stimulus straightaway. So they're coming to us saying I'm doing this incorrectly. Now what impact that has on ACR/REA port? It is quite a cool thing that because when they go to the gym, they can just watch us giving them feedback on specific exercises. They can then execute it, record themselves doing it, and they can almost compare straightaway. This is what I did last time, this what Finn said not to do, this is what I'm doing now. Okay, that's what Finn said not to do. I'm going to try and do it like this. So it's not constrained but it's kind of a different, you get very real-time feedback in their own environment where I think why constraints are very important is because you set people away to do it, right? So you're kind of not there to correct them or kill them. But having that for us is such an advantage but for anyone that doesn't have that support, constraints are massive but we wouldn't typically use it a lot because we're able to give that feedback straightaway. Yeah, you hit the nail on the head. I'm so big on constraints with the FI of IC because I don't have that control. So the only way I can kind of say on how they do stuff is to just give them in the own like they need to work it in the only way that I want to. It can be quite convoluted sometimes but it directs the stress exactly where I want it to go. So yeah, the analogy I know I've done some bad analogies track bar, I tell them they want to do quad bars, they need to pretend they're trying to take a shit in the woods, we're doing a hip hinge and they're trying to close their car door with their ballmen, they're holding heavy shopping bags. Because I want people squatting down if that makes sense. What was the last thing that you said you had three points for the first one was the isometric, because that it was the. It was about later on in rehab because it's kind of PFA is usually associated with strength and running when you go back. But also Song et al in 2023 I think put out a really cool paper where I don't know how we did it but Jeff he might find some flaws on this. But if you actually ranked 35 exercises on how much load goes through the PFA and if you look at it, it's essentially the pathway of ACL rehab. So it'll be like walking, double-exquoting, lunging, then it goes into running, drop jumps, plyometrics as you go on into different aspects. So it's another area that when you really start ramping up running volume because it also is known as runners knee and you also are doing lots of plyometric and you're doing lots of strength stuff. It's another time where PFA can rear it's head again. So it's about that careful. The streams I say is the things again that reverse engineering. Three things are going to annoy PFA, strength work, particularly quad-buy stuff, running as we know and then plyometrics stuff as well. So when you're introducing that into programs and I've made this mistake, you might introduce all three at the one time and that PFA just gets so annoyed where what I would recommend is you focus on one area, make sure they're tolerating and then start topping up the other areas. So think of that as the load versus capacity CSEL. If you give them all three running, running strength work, plyometric work, it's like the big show just jumps on the CSEL for PFA where you want to kind of stack up. It's slowly make sure they can tolerate an adapt to it. But I think that's an important one when they get back to more high level stuff. Yeah, I really like that. I know I do have a CSEL and transbalance. Transparency, the excise that you give in the consequences that it has. Yeah, I'm doing it. Tongue paper is brilliant because it lists them in a really nice infograph even if you just google it, a song about PFA loads. It just ranks them really highly on the different ones. And if anyone has PFA, if you have ACHL or work on my own, just look at that. Like this if you just remove all the painful stimulus, it has a good chance of settling down. Yeah, I remember I saw that and I think I've posted lots of last year because it is really good looking at that kind of biomedical pressures going through it. My only question is I wonder, you know, you typical kind of PFA I'm not paying person that you get, but they don't necessarily have to be active. Yeah, it's not a whole mark. So I wonder if there is a little bit of difference between you and you can hypothesise, hypothesise, there's more of a load component in a postoperative knee compared to someone who just gets insidious on set of PFA I'm not paying. So yeah, I think with those binary kind of call studies from song, well, that kind of graph that he gives, are more willing to kind of use that to guide the treatment, but I think that it could also drive people down the wrong path of it's too linear. Like you can't make linear assumptions, I just reduce load. It will use pain and so on. It's got insidious concept of our pain. So yeah, I think I think I'm more willing to accept that in this kind of contact sport generally for our pain at some people, just rang a few of our bells of like missing sanitation for me, but within this say, in some sense, I'm definitely with you. Yeah, completely great for AC Allers or people getting back to after a trauma, but you're kind of non, you know, you're non-sporting environment getting PFA, I don't think it holds much weight. I don't think just reducing stuff for them because they're probably not doing a lot and it will help. But yeah, very specific AC Allers, I think it's a good resource, but maybe my last point was and I know you alert me to the paper, it doesn't matter which, whether it's postural, hip strength training or sorry, postural lateral hip strength training or anterior medial hip strength training helps PFA. So a lot of people used to think it was postural lateral where they compared the two of them and the showed similar effects on PFA, but this is my question because what I'm noticing is a lot of people who get PFA in rehab aren't people who do running or aren't super people who expose the PFA to huge amounts of load. So in my assumption, I would have thought runners would have got PFA after ACL because they wanted to get back running and they would do a lot of running. What I found a lot of the times, it's surfers, snowboarders, jiu-jitsu, who get it because their sport doesn't entail a lot of things that will annoy the PFA. And I'm wondering if the PFA load even though like before the surgery, obviously the capacity of the PFA will be a lot higher than someone who doesn't expose it to stuff, right? And I kind of come across them now where two people who had hamstring grafts, my most recent people who have PFA, hamstring grafts, surfer, snowboarder, and they shouldn't have got it, like I was very conservative, like not. Like I, the analogy is I dad's with the level devil a lot to get quads gone, but with these, I very much respect, I didn't want to hear any pain. And they got it. Whereas lots of people will not listen to me go and huge runs, smash the rehab runners, rarely get PFA after ACL in my experience. That was really interesting. It's like saying they've conditioned themselves so much before the surgery that actually afterwards they can tolerate this force as anyway. Yeah, because the snowboarders gear, maybe if they lifted weight and did some recreational running, they would have some not resistance, but they have some capacity, right? Actually, interesting. I thought, especially like a snowboarder, I would be with the jumps and the impact and you sort of always in that sort of squat position. I always thought that would be quite high PFA load, but obviously. I guess it's, I guess she's a seasonal snowboarder. She does not all the time, right? Oh, okay. I see what you mean, though, if it was every day or even surfer every day. And then my next one was I thought about what my Gigi2 guy because he wanted to do loads of, he actually has a bit of PFA, it's just a niggle, but he loved all the doctor work. And I was like, of course, you're Gigi2 guy is going to have unreal doctor strength. And I was also thinking people have huge hip strength. I know we don't know, but what ACLers do we think it could help at all? What do you guys think? It's chicken and the egg, but if someone has such, because we know they're going to have quad weakness regardless, but a Gigi2 person is going to have huge a doctor, and glue me in strength, right? Like, it's going to be true to the roof because of their sport. Would that be a preventive for a PFA? Because it's going to get quad weakness, he's got a patellar grafts compared to someone who wouldn't, do you know what I mean? Yeah, I think generally someone who's higher trained and generally stronger than our LEM would be with our polyg last chance of getting it. So that's what I'm coming across. Do you think there's away from the grass we're talking about? Is there a sport or training history prior to surgery that could predict the FJ? I wouldn't be surprised if it did. Yeah. Yeah. Yeah, so I'm probably not, I'm waiting for a thought to come to me, but it's not really happening. I think I'd be genuinely surprised if it was to do with kind of like joint reaction forces, trying and stuff like that because I just think that it's so task-specific and even in studies I've looked at increasing strength. It doesn't necessarily change the kinetics of what's happening to me, even if you do strengthen higher up. So I need probably a lot to persuade me on biomechanics altered by training history and I got to control this. I don't even know how you go about studying that, but I think there is a lot to be said about training history. It's probably a bit more meat on that bone, but as to what exactly, I'm really not too sure. And I wonder as well as how much they did before the surgery, if they'd good rehab and prepared and they were back running and doing not like their sport, but they're still active versus we all know the people who do nothing after their injury, right? And just wait for the surgery. Like I know they're going to have a lot more quad weakness, but let's say two groups, they both build up their quad strength really well, but one group does lots of running off, does lots of things that annoy the PFJ. Because actually, would they be at less risk? Because the capacity of the PFJ is going to be used to more load even going into surgery, you know? Yeah, there is that. I know that it's been challenged quite a lot by, is it Franco in Pellizariat, that acute chronic work load ratios? I mean, what you said there is just to and Snowboard and but sees on Snowboard. So you could assume that sees on Snowboard that waits to have the operation then begins rehab and you just see you're not going to do that, it wasn't unstable me. I was on a drive to people wouldn't. And so yeah, how they just stuff, whereas we're running, it's very linear, like unless you're doing those change directions. So if you're in yes and yeah, to track their activity levels in the months prior, because they're acute to chronic workload ratio would be not as drastic a change as if you were've done fuck off. And then most most most runners who have telegraphs, I am on them like crazy because I do not want them to get in PFT and runners as we all know, don't listen and they're just going run and I'm like, you fucking idiot, you're going to get PFT and it's going to be my problem. No issues, they're like, why am I doing full training? I'm like, we're just trying to modify those precautions and they're just running and smashing everything, which is bizarre. I don't get it. Maybe there is something to that. It's kind of just something I'm kind of just in anticipation for today. I was kind of wondering or thinking of the people who have had PFT when working together and telegraphs definitely more. We meet a lot of people who don't have extension and then get raging PFT. But it's the ones that shouldn't and do. That's the ones where I'm like, yeah. Maybe it's something you can track me because you guys see however a lot of ACLs, maybe just stop Roman, be like, just if you have no pre-ad with me, just have interest. What have you been doing before the operation? Or I don't even know how you do. Obviously self-reported activity levels and the levels of activity people were doing. It's going to be very accurate but it's just art. Yeah, it's a link between it. I think that's right. Inactivity before rehab, I think that'll be definitely one where even if they get quad strength up. Like if you don't get quad strength, not that it's essential but if it's really, really weak, again, nothing I can't base this off, it's just you have to be at risk of PFT, right? If your quad is 50% symmetry, right? Yeah, surely. That much of deficit at 50%. Before the surgery, before the surgery, I mean, once you get that person doing anything for ACL rehab, surely that's not going to be happy. Yeah, I don't know. I can't back this up like there's no way I can back this up, it's just around them thought. And as you've all known, I'm wrong a lot of the times, just thought. Oh, me, it was too, no, I'm not. This is a safe speech to spit for me. I don't know, it depends what you kind of mean but I don't think the ability to produce newtons for a quad has a direct link to to that final pain. And if someone doesn't come producing much force, then presumably gets at the risen as high during the action forces because there's not as much force pulling that tolerance to the chocolate. So I read it, I read it now. I don't, I probably couldn't get on board with the statements if you've got a few cent quad steps so you're like you're much more likely to have PFP after the operation because I just, I struggle to kind of connect the dots in my head, but it could, it could also be a, have they not got a good quads index because of something that's happening that we can't see on a scan or an x-ray or any of my data, you know, some chemical because me and James were talking, I think it was on the, on the cheque-story, about different ways to imagine when we're talking about gadolinium enhanced MRIs and stuff like that. And atty shows Articular cartilage degeneration or metabolic processes differently, like they, they blow up on the scan on and on, all right, it just looks normal. And I wonder if there's something going on that we can't quite see, that's why they can't produce the force, if you know what I mean. I see. So you're saying that if someone had 50% deficit in a, it's likely, they'll have pain, but mainly because of other processes, not because the can't produce force. That'll be my guess, yeah. But guess is just as much as, you know, I guess we can do that. I guess we can agree with that. As well Finn, we're reading, not like, I suppose the thing is trying to say is is the mediator's strength, that's the whole thing isn't it, is that the thing that's going to change the pain? I'd be purely changed that what's going to happen. Yeah. And I guess it's a modifiable, what's a potentially modifiable factor as well, isn't it? That's all we argue over it because if it is something going on, then we don't know about you. There's nothing we can do about that. So you may as well focus on the stuff that you can try and modify. I guess well, if they're kind of not going to correct rehab, they might be exposed to things very early when they have their massive strength deficit. And then is that the thing that causes potentially PFJ being slowed up? Yeah. Yeah. Huge spike in what they're saying. It's an envelope of function essentially. Hey, any of that, um, towels of wisdom you want to unload on us? Of PFJ or life in general? I think that's covered most. I think it's very, I think you're right, Jeff, then animal listens is I think PFJ is very different. ACL wise to PFJ you might see in the normal population. I think that's a lot of my advice will make normal populations PFJ significantly worse or won't help us. We know there's a big psychological component to, or there can be it's kind of non ACL PFJ things. So I would take everything I'm saying in an ACL concept. But I think the best piece of advice is, de-load, keep them busy with other things, slowly introduce things back into the program. Don't be afraid to take them away. And typically, when they're getting back, open chain or closed chain will tolerate one of them really well. Get after that, modify ranges, and then introduce the other one back in. That's great advice. Great summary there as well. We could have just started with that, couldn't we? And save ourselves down a half. And so, taping, I wouldn't under a spare table. Honestly, I've had really good results with it. And Voodoo Fluss, people really like it and get good results from it. So sometimes to try, as a general fit, so people really really like it. Brilliant. Yeah. Those sort of things are great out there. I think they put into the back context. I mean, ultimately, no medication, no side effects. Helps you to pain. Great. And even like, they might be able to do split squats or, but maybe get some tape on, they can do reverse lunges, okay? They're not getting their quad gone. They still get some quad activity. They're still feeling good about themselves. And they don't know that it's not really necessary hitting their quad, right? They think they're just doing a lunge, but you know, things like that, they can just modify the pain to keep them training, but not annoying, but still getting some quad. Pearl. Yeah, honestly, it's been great having you on. I feel like we could talk about this for hours. And we'll definitely get another ACL people. How to get you back on to get your thoughts on it. I think, I think, probably because, like, in essence, he's a strength and conditioning kind of in port and ACL rehab. I think that'd be classed out. Yeah. That would be really useful. Yeah. That would be a good perspective. Are you just trying to take over our podcast here? We outnumber, but I'll agree. I'm trying to upscale massively. This is restoring single XCMJ and single drop jump. I think that'd be an area that's if anyone cares, but that's a very niche market, of course. That would be one I'd be willing to jump out of. Cool. Yeah. That was good. We've got a weekly podcast. We struggle to come off with things sometimes, so definitely. Well, thanks for having me, guys. Yeah, great having you mate. It's been great to hear the discussion too far. I feel like I'm just being a bit just watching from the sidelines, which has been really interesting to listen to. Yeah, so we'll definitely get you back on fin. And I see that you've finished the episode as ACL demigod. But I think we can put it up to ACL God. I think you made up for it at the end of those nuggets of information. Yeah. The word analogy took you back a little bit. That's what gave you the hint of the notion from God to demigod. I would say I do have a lot of experience in PHA, but a lot of it is self-inflicted. So I've learned a lot along the way. So it's, I've learned the hard way, but ultimately that's how you have to learn, right? Yeah. Do you want, we've not even spoken to you about your own journey. Maybe that could be another one for a future podcast as well, but yeah, great having you on mate. I have never had PHA in my own journey, but I don't know, a lot of other stuff I've never had to. So yeah, thanks a lot mate. That was fantastic. I will speak to you again soon. Yeah, thanks a lot, guys. And I do have to see you soon. Hornor, I'll see you when you're back on number four. That's wrong. See you later, bye-bye. See you guys.