Dec 07, 2022
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Dr. Yoni Rosenblatt: Welcome to the True Sports Physical Therapy Podcast. As always, this is Yoni Rosenblatt. And today, I'm excited to have Dr. Dreese join us. We're gonna start just by learning a little bit about Dr. Dreese's background, and then we're gonna dive right into ACL reconstruction, but not just any ACL reconstruction, ACL reconstruction in the elite level athlete, but first we wanna hear about Dr. Dreese.
Dr. James Dreese: Well, thanks Yoni. It's a pleasure to be here with you. Thrilled to have a chance to sit down and chat with you. I'll go back to college. I went to college at Penn State, I majored in pre-medicine, which probably wasn't the best decision overall, but never the less, not that I don't enjoy what I do, but just that it really limited career opportunities from that point. I went to medical school at Penn State, I did my orthopedic residency at the Hospital for Special Surgery in New York, and then I spent a year at the University of Pittsburgh doing a fellowship in2002. So I started in clinical practice in Charlotte for two years, and I've been in Baltimore since that time, I've been at MedStar since 2013, so almost10 years now, and just taking care of athletes, and that's what I like to do. Recreational athletes, higher level sport athletes be they high school, collegiate, professional, club sport. Athletes have similar demands, similar interests. I think taking care of athletes at different levels, obviously has some different considerations, but for the most part, athletes all have a great motivation to return to play, and it's just a thrill to take care of them and try to help them to meet those expectations that they have.
Dr. Yoni Rosenblatt: Yeah. And I totally agree with you, obviously, it's one of my passions and our passions at True Sports. I'm all ready to jump into ACL reconstruction in the elite athlete, but I wanna back up one second. What would you have majored in?
Dr. James Dreese: I think if I could go back, I probably would have broadened out and majored in something like non-biologic, something like literature or history, or something that probably would have given me a very different perspective. I was actually an engineering major for three years, so I've always been sort of very based in science and math, and that's what led me to engineering, but then ultimately made the transition. But I think at this point with the ability to reflect back, it would have been really interesting to major in something completely different.
Dr. Yoni Rosenblatt: Yeah, I totally get that. I was kinesiology, and I think back and I'm like, what else would I do with kinesiology? I was kind of praying I would get into graduate school. I probably should have done business. I thought you were gonna say business.
Dr. James Dreese: That would've been good too. Yeah, I find that to be of interest as well, I've done some business class work since graduating and found that to be fascinating, so that would have been another good choice, for sure.
Dr. Yoni Rosenblatt: And the period in history that you would have studied?
Dr. James Dreese: Well, you study all of history, if you're gonna learn about history, you study all of it, so...
Dr. Yoni Rosenblatt: Okay, but one that interests you?
Dr. James Dreese: I would say the industrial revolution. Certainly the late 1800s, early 1900s.
Dr. Yoni Rosenblatt: I'm sure you could have gotten a degree in just that.
Dr. James Dreese: Yeah, I find some of those characters to be fascinating.
Dr. Yoni Rosenblatt: I feel like that's a whole another podcast.
Dr. James Dreese: It is, it is. We can talk about that for a long time.
Dr. Yoni Rosenblatt: Okay, well, let's talk about ACL reconstruction, 'cause I know way more about that than the industrial revolution. Tell me, is there any difference in the way you would repair an ACL in an NFL knee, an NFL athlete's knee versus a high school cross-country runner?
Dr. James Dreese: I think the answer to that is yes, and the reason that the answer to that is yes, is that I think there's... You have to be willing with ACL reconstruction, obviously using autograft is going to have better chances of success than using donor tissue. That raises the question of where does the graft come from. And that raises the question of what are you most willing to accept afterwards. So the risk of re-injury is the one, of re-tearing the graft is always the one that everyone mentions first, but in reality, when we look at ACL reconstruction and we look at the significant number of athletes that are not able to return to the same level of play, there's a lot of different reasons for why that happens, and I think all of those represent different modes of failure, it's not just the graft failing, it can be a lot of other reasons, and it can be anything from persistent instability to meniscal deficiency, to cartilage loss, to donor site morbidity, to loss of range of motion, lots of different factors that can figure into it. So all of those are potentially means of failure, and that's an important conversation and an important part of the decision-making process with athletes of different level.
Dr. James Dreese: The high school athlete has a different demand than the college or professional athlete, just because we know it's really in our youngest athletes that the risk of re-injury is the highest. So I think those are the athletes where that risk of re-injury certainly is paramount. And as athletes get older, the risk of re-injury becomes less, and some of the other risks can become more. So I think a balance of the risk-benefit ratio there is important, and it varies from athletes of different sport and different ages.
Dr. Yoni Rosenblatt: Okay, that's such a far-reaching answer, I think it highlights a few things that I wanted to hit on, which are... Well, let's just boil down the answer to that question, what are you using to repair the NFL athlete's knee?
Dr. James Dreese: I think at the highest levels of sport, clearly the patellar tendon graft is by far the most accepted graft source for that, and that comes largely because of the implications of re-injury, and I think there's different factors at play there, but clearly the patellar tendon has the lowest risk of re-injury, maybe by 5% to 10% in some populations versus soft tissue grafts. But I think with patellar tendons, then you have to also manage more effectively some of those other factors that I talked about that can affect return to play. Most athletes at that level have the best physical therapy services available to them, so they're gonna be able to manage it better than maybe another athlete who doesn't have that as much, but I think that's what's important about True Sports and places that really focus on sports medicine is offering these types of high-level physical therapy to athletes of all different levels, but I think in many respects, the quality of the physical therapy... I tell patients all the time, the physical therapy choice you make and the quality of experience you get is gonna be as important as the operation in your success.
Dr. Yoni Rosenblatt: Well, we appreciate that. We don't hear that enough. So I think that's really awesome and telling. Let me push back a little bit, 'cause you said something interesting there, which is the NFL athlete has the best physical therapy at their disposal, and so that would lead you to possibly... Or more likely than not use a BTB, use the patellar tendon graft. I was gonna save this for the end, but looking at return to sport rates for the NFL, you and I had this conversation recently, share with us what you remember from that data of the chances of that NFL athlete tears an ACL and returns to the field.
Dr. James Dreese: The data that exists on that suggests that 30% to 40% of NFL athletes do not, in a sustained way, return to play for a prolonged period of time.
Dr. Yoni Rosenblatt: Chance of return is 60%.
Dr. James Dreese: Chance of return is about two-thirds; 60% to two-thirds. The chance of re-rupture of the graft is actually pretty low, that's in the 5% to 10% range. So that begs the question, well, why are so many athletes having a hard time returning to play? And that gets back to many of the other things that I mentioned earlier, which are all modes of failure, like those... If you're an athlete of any kind, and you can't return to play, that's a failure, whether your ACL graft feels like if you have a Stable Lachman exam or not, that's a failure if you can't return to play. So there's many modes of failure, and I don't think that any one of them is necessarily more important than the other to the athlete in terms of the fact they still can't return to play. So I think a deeper dive into why that exists is important.
Dr. Yoni Rosenblatt: So, let's talk about that. Why do you think it exists? Obviously, listen, they're trying to get back to this insane level, so the chance that they can return to such a high demand, you would think is a little bit less. What's the statistic that you hear most common in terms of non-professional athlete that returns to previous level of function would be what?
Dr. James Dreese: Well, that's a higher number.
Dr. Yoni Rosenblatt: It's a much higher number.
Dr. James Dreese: In large part because the demands are not the same, it's not because they get better physical therapy, it's because their demands are not the same. Many of those recreational athletes are gonna be able to return in some capacity what they wanted to do, some of them lose the interest in returning to the same sport, there's different reasons why they seemingly have more success, but I think the biggest reason is clearly that the demands just are not the same.
Dr. Yoni Rosenblatt: If we're looking at the NFL athlete, you said a number of things might preclude them from returning to previous level of function, one of which being the insanely high level of function. What else is on that list for you and what are we doing as a sports community to tick those things off the list?
Dr. James Dreese: Yeah, if we look at studies and outcomes, clearly the status of the meniscus and the cartilage are the two other areas that are most often cited as impairing the ability to return to play. So, meniscal deficiency, either on the medial or the lateral side and chondral damage, clearly having more significant chondral loss within the knee impairs the ability to return to play. Those are the two things that I think are most often cited. I personally think that some persistent rotational instability of the knee plays not insignificant role there as well, and that it also leads to higher rates of further meniscal damage, higher rates of meniscal repairs not healing, and by the same logic has to affect the ability of chondral lesions to have successful outcomes too.
Dr. Yoni Rosenblatt: I think it's also interesting. Those are great points. How many surgeons, ballpark, are operating on these NFL knees on the regular? How many surgeons...
Dr. James Dreese: I think it's a relatively small number. I think the community of the NFL, I think has a relatively small number of providers that take care of these athletes, and there's a lot of reasons for that. Experience is a big part of it. I think past success in those athletes is obviously an important part of it, it's just a different decision-making process, I think when your career is dependent on having successful outcomes versus folks in the community or at lower levels of sport that maybe are not as dependent on that. Everyone wants to do well, obviously, and we want everyone to do well, but I think when your career is dependent on that, it's a different decision-making process.
Dr. Yoni Rosenblatt: Do you think because of this lower return to previous level of function in the NFL athlete than I would have expected, do we start to see more or different procedures being implemented, like the ALL, like meniscal repairs, like cartilage transplants? Do we start to see more of that with that initial ACL rupture?
Dr. James Dreese: Well, I think over time, we've certainly seen the interest in meniscal preservation increase in high-level athletes, so historically, I think there was a belief that repairing the meniscus led to prolonged recovery times and a longer time to get back on the field at an important point in an athlete's career. But over time, we've seen those meniscal removals lead to shorter careers, less capacity for sustained return to sport, and now more and more interest in preservation, that has certainly been one really big switch.
Dr. James Dreese: In terms of ACL reconstruction, I think the patellar tendon has largely been the graft choice in high level athletes for a long time, and it has stood the test of time with respect to that. The anterolateral ligament conversation really pertains more to the pediatric and adolescent population historically, because that's where it's been used the last five years or so, there certainly has been more and more clinical data that suggests that in adolescents and maybe even in some athletes who are beyond adolescents into young adulthood, that if their knees exhibit certain features that they would likely benefit from that as well, just from the standpoint of controlling rotational instability of the knee.
Dr. James Dreese: And certainly, I've seen that clinically in outcomes, in patients, just in terms of the stability of the knee and the way in which it stands up to rotational force of the knee, that that makes a big difference, but it certainly is not the standard of care at the highest levels of sport. But I think we hear and we see more and more reports and discussion about potentially translating it to that group as well. So I think, I personally believe that we will see that become more of the standard of care moving forward, but at the highest levels of sport, I don't think we're quite there yet. But certainly in the adolescent population, we are there, that is the standard of care in our patients who are most at risk, who are largely just having reached at skeletal maturity and just beyond skeletal maturity, so those are largely our high school and early collegiate athletes.
Dr. Yoni Rosenblatt: Tell us a little bit about the ALL because I finished graduate school... I always get this wrong, I think '08. So apparently there was no ALL in 2008. I just looked it up earlier this week, it was discovered in 2013. So tell me what the hell the ALL is, what it does and how you repair it.
Dr. James Dreese: Well, the contribution of the lateral side of the knee to controlling rotation has actually been a part of knee reconstructive understanding for a long time. Largely in the pediatric population, the iliotibial band has been used for decades really, in either isolation of reconstructing, of dealing with ACL insufficient knees or in the augmentation of other forms of other strategies of ACL reconstruction, so it's been around in that population for a long time. I think in terms of defining the specific ligamentous structures in the capsular, the Kaplan fibers, the anterolateral ligament on the lateral side of the knee, that's been a more recent, I think better understanding, and that results from some anatomic studies and some biomechanical studies looking at what effect it really has on the knee, and clinical studies as well, showing its effect on the pivot shift and rotational instability and how reconstruction of those structures, either when using iliotibial band or a free graft can actually help to control rotation better, which is now translating more into clinical studies showing less risk of ACL re-injury, the graft rupture, better chance of meniscal healing.
Dr. James Dreese: So those things, I think are... It's an important part of the evolution of our understanding, and it just simply goes back to what I talk about a lot, which is that we have to evolve as clinicians, and we have to be better, so we learn from these experiences, and I think we adapt our practice to best incorporate that knowledge. I think the anterolateral ligament in the last 5-10 years is without a doubt the best example of that. I think going back before that, it was the transition from a trans tibial technique to an anteromedial portal, and ACL reconstruction of being more anatomic with the femoral tunnel, all those things represent an improvement of our technique and ultimately of our outcomes, and without a doubt the anterolateral ligament, I think has shown that to us in the last few years, and we see the results clinically now as well.
Dr. Yoni Rosenblatt: I think it's really telling to the sports PT to hear that because if you picture me coming out of graduate school in '08 and rehabbing ACLs for the first two, three, four years, let's say, before anyone's doing these reconstructions, like you're describing, certainly with the ALL at least, we're racking our brains to figure out "Well, why did this one retear? Or why did this patient not get to the level we thought?" We don't have all the access necessarily that we should to the OR, and what is happening in there. And that's why I think these conversations are so important because a PT is just not gonna hear of such things or the way that doctors are evolving in the OR, it's so important for the sports PTs to hear that, so one, they can make the right recommendation to their patients, but also to say "Maybe this is why it's failed, and this is how we're gonna get better about it." There's so much of that that has happened in our world clinically, how do you stay abreast of those changes in your world? Because there are definitely people Dr. Dreese that we know that are not learning about fill in the blank, ALL, meniscal reconstruction. They're doing the same type of procedure they learned in 2000, in '95 or whatever. How do you stay up-to-date with these things?
Dr. James Dreese: It's important to stay engaged in the learning process. I serve as a co-director for our fellowship, I'm involved very much in research, clinical and biomechanical research, but it's just a commitment to, I think, learning and evolving, adapting, like I said, it's just a matter of being involved in that process, and I don't think anyone can look at historically ACL reconstruction and say that we're doing the best job possible. I think clearly, when you really sit down objectively and look at the data, you say to yourself, we need to get better. And I tell athletes all the time, you know it's not a good thing to tear your ACL, it's just not, that that's not a positive predictor for your athletic career, but it's not necessarily something that you cannot get past and succeed and move forward. What's important for us is that we continue to improve in ways that helps that process to take place. But the concept that somehow you tear your ACL and you come back stronger than you ever were before, that's a really high bar to try to set for anyone.
Dr. James Dreese: But I think particularly for young athletes who are at a stage in their career where they're starting to look at college and looking at playing sport at a higher level, it can be a very challenging time to deal with the injury and the recovery, and ultimately if there's disappointment that exists, it's really difficult. So I think that it's just a conversation that is a lengthy one with athletes, for, you would say that a physical therapist doesn't know what happens in the operating room, I would say that an orthopedist doesn't know what's happening in physical therapy. So I do this operation, I feel great about it, we feel like we did a great job, and then the patient goes to physical therapy and I don't see them again for sometimes a week or more, and then it'll be a month, every month after that, but there's so much that happens between those visits that I don't have access to, that I don't know a lot about. And that's where the line of communication is important.
Dr. James Dreese: But I think we both see it from different perspectives, and the more sort of cohesive that experience is for the patient... Between the therapist and the orthopedist, I think it gives them the better chance of success for sure, but we both have a view of it from one side of the experience, and the more that we can do to try to bring that into a more mutual experience, I think the better.0
Dr. Yoni Rosenblatt: Yeah, I think as sports PTs, we stand to learn a ton from your side, from the orthopedic side, the medicine side, I would also say the other way, not just you learning from us, 'cause I know you thought that's where I was going, but I was gonna say from the strength coach side, really getting better at our craft, sports rehab, from looking and learning from outstanding strength and conditioning specialists, how do they teach movement, how do you teach change of direction? How does that play into what we know from the pathology side? That's been a game changer for us at True Sports to better our field. I bet you there's a ton there from the sports medicine side as well, that can look at that and understand that performance enhancement. Just worth thinking about. So if you thought about the ALL as the most recent addition, would you say or enhancement?
Dr. James Dreese: I'd say improvement, certainly, of our understanding of successful outcomes.
Dr. Yoni Rosenblatt: Okay, if you're looking down the road, what do you think is next with this ACL reconstruction surgery in the elite level athlete? Do you have any idea?
Dr. James Dreese: Well, the other thing that deserves a mention here too, is sort of revisiting the whole concept of repair of the ACL versus reconstruction, so we're talking about success with reconstruction, but obviously repair has some enormous potential upside if we can have success with it.
Dr. Yoni Rosenblatt: How close are we? How close are you?
Dr. James Dreese: I think that the data shows that there certainly are some ACL tears that are amenable to that conversation, and I think in moving forward, we'll find that probably more and more patients acutely are candidates for that, and the benefits of that are not insignificant from the standpoint of not having to harvest the graft, potentially having a ligament that works in a more physiologic way, potentially just having a ligament biomechanically that does more as well, there are some big potential benefits to that. So my sense is, in moving forward that we will see that that has more application to what we do. It's never gonna be applicable to everyone, probably, but what we find in looking at different tear patterns is that many of these tear with similar patterns, they're largely proximal injuries. And for some of those, giving some thought to repair is a reasonable thing. The data from decades ago that suggested 50% or more failure rates, that's not what's necessarily being encountered now, so I think there's some thought to be given to it, I don't think we're at a point where it applies broadly to the ACL tear population, but...
Dr. Yoni Rosenblatt: I think we're close.
Dr. James Dreese: Now compared to 10 years ago, I think there's much more reason to be optimistic about that.
Dr. Yoni Rosenblatt: Talk to me about partial tears. First of all, are those a thing? I've heard that being an argument that either it's ACL deficient knee or not, so have you seen partial tears in high-level athletes return to previous level of function? Let me stop there and let you answer that.
Dr. James Dreese: Well, the concept of partial tear really refers to the fact that the ACL has two bundles, and in some athletes, people in the population in general, they may tear one of those two bundles. Now, for me, it comes down to whether the knee is stable or not, so if your knee is stable, then certainly observation and rehab is the right choice for that, if your knee is not unstable and typically it's gonna be rotationally unstable, then you're gonna still be at high risk for having further injury and difficulty in return to play.
Dr. James Dreese: It's very difficult on... I think people try to evaluate that on MRI all the time, it's very difficult to reliably evaluate that more completely on MRI. I think, obviously, you can make some conclusions based on MRI, but I think more important is the functional status of the knee and whether or not the ACL's functioning more normally, both in translation and rotation, and whether or not with that we can predict whether the knee is gonna be able to perform at a high level with just rehab there.
Dr. Yoni Rosenblatt: Do you think in the next five years, 10 years, we're dealing with situations where you will be able to repair a torn ACL and have that athlete return to previous level of function?
Dr. James Dreese: I think for some, we probably will... The tears that are most amenable to that are the tears that are simply peeled off the femur, so the ligament is essentially normal, it's just peeled off the femur, there's actually no portion of the footprint that remains on the femur and reducing and repairing that with some healing capacity has shown some promise. Now, how those are gonna perform longer term, I think is open to debate, we don't know the answer to that for sure. But certainly there have been examples of athletes who have returned to play following amenable repair of those types of tears. So it's not to say that there is no clinical evidence to support that, but we just don't have longer term data that suggest that it would function that way, but to be determined.
Dr. Yoni Rosenblatt: Yeah, do you ever think that there is a new gold standard for reconstruction, replacing the BTB?
Dr. James Dreese: I think in terms of reconstruction, probably not. The BTB has just proven to be the most effective, so I don't see anything on the horizon from a reconstruction standpoint that would largely replace that, there's other options for sure. But there's a couple of trends that I think are really undeniable. First and foremost, the use of allograft leads to higher rates of failure in young and middle-aged athletes in particular, lots of studies have shown that the definitively.
Dr. Yoni Rosenblatt: When's the last time you used an allograft
Dr. James Dreese: I just simply don't unless if it's a multiligamentous knee injury, and we just simply don't have enough graft sources. But in young athletes, I will typically go to the other knee if they've already failed in the same side, so I'll typically take grafts from the other side and there's good evidence to support that that leads to better outcomes. But I think the use of allograft in my practice is really reserved to patients who've suffered ACL, PCL, lateral-sided injuries, instances where there's just too many ligaments that are damaged to be able to use all of your own tissue.
Dr. Yoni Rosenblatt: Okay, so talk to me about quad tendon, talk to me about hamstring tendon, what populations are using that, and will you put those into elite level athletes should they ask for them?
Dr. James Dreese: Yeah, I think those are both soft tissue grafts. So just from a biology standpoint, soft tissue grafts rely on soft tissue to bone healing, which is less predictable than bone to bone healing, which you get with patellar tendon grafts. So historically, that's been believed to be the reason why we probably see higher failure rates with those types of grafts. They each have their own challenges. I use hamstring grafts on a regular basis in people that are at lower risk, or even with people who've had bad patellar tendinitis or had some real anterior knee pain issues before, because no doubt those will get worse after harvesting a patellar tendon graft.
Dr. James Dreese: The quad tendon is a soft tissue graft as well, there's certainly studies that have shown some levels of success with it, but it still biologically is a soft tissue graft, and each one of those grafts obviously has its own potential downside, upside. It's a balance with them, but I think essentially, you're either getting bone-to-bone healing, or soft tissue to bone healing with different graft types.
Dr. Yoni Rosenblatt: Okay, changing gears a little bit, but touching on something that we said previously, which is that PTs have a limited knowledge of what happens inside of that OR. And I think it would behoove all of us to spend more time in that OR to learn from you guys as to know exactly what's transpiring. But for some reason your ACL reconstructions seem to do better than other surgeons. I'm gonna submit that because I see all of them. Tell me why you think that is.
Dr. James Dreese: Well, I think you have a more interesting perspective on that than I do, 'cause I don't largely see a lot of ACL reconstructions from other providers, but I think some of the things that I do differently, I really minimize tourniquet time as much as possible. I do not like using tourniquets, I personally think that it has a negative impact on a lot of different factors, but for patellar tendon grafts for instance, I try to really limit that to 15 minutes just in terms of harvesting the graft itself.
Dr. Yoni Rosenblatt: So remember, we're novices in the OR. Tell us... Define tourniquet, like what goes into that? How hard is that sucker gripping the leg? What is normal tourniquet time?
Dr. James Dreese: So, tourniquet is basically applied to the upper thigh before the case starts, and when it's inflated, it's typically inflated to 300 or 325 millimeters of mercury, and tourniquet times can be... The historical literature and belief is that anything under two hours is acceptable, I would say for most ACL reconstructions, it's probably an hour or maybe a little bit more than that, if you're keeping it up for the entire case.
Dr. Yoni Rosenblatt: Just so there's no blood... What's the purpose?
Dr. James Dreese: The purpose is just to facilitate viewing arthroscopically.
Dr. Yoni Rosenblatt: So, why don't you need it up for an hour?
Dr. James Dreese: I think if once you really gain experience in arthroscopy, you can control visualization without a tourniquet up.0
Dr. Yoni Rosenblatt: How do you do it?
Dr. James Dreese: You need to manage in flow and outflow, you need to manage the amount of fluid that's being taken out of the joint by the use of the shaver, which removes torn tissue, but you need to be able to manage that in a way that it doesn't. Bleeding is dependent on several factors, it's dependent on the pressure of the inflow, it's dependent on the amount of outflow, but it's also dependent upon the patient's blood pressure. So if they have an elevated blood pressure, they're going to, in general, have more... You're gonna have more difficulty viewing without a tourniquet up, that blood pressure is controlled by a lot of different factors, one of which is pain, and the use of regional blocks can help to manage that as well, some of it is dependent on underlying factors, patients with underlying hypertension. Other factors like that are going to negatively impact your ability to control that better. But the ability of the anesthesia team to keep the blood pressure at a manageable level near sort of normal systolic blood pressure is certainly gonna help from a visualization standpoint.
Dr. Yoni Rosenblatt: And you have that conversation with the anesthesiologist, say, "Listen, I need you to keep it here?" How does that work?
Dr. James Dreese: We use blocks routinely. Patients get two blocks, they get an adductor canal block and they get a popliteal block, so that really helps to control their pain, it limits the amount of anesthetic that's required, the pain medicine, the narcotic that's required, so it has tremendous benefits, and it's an ongoing conversation with anesthesia throughout the case to make sure that our visualization is good, and that's a partnership in and of itself that just helps to manage that.
Dr. Yoni Rosenblatt: That's fascinating, 'cause I never would have known about that. Are those nerve blocks standard issue?
Dr. James Dreese: Pretty standard now. Yeah, I've used them routinely for 10 or 15 years at least. They're pretty standard with ACL reconstruction. And they're safe, they're reliable. They're definitely a standard of care to use regional blocks for ACL reconstruction.
Dr. Yoni Rosenblatt: And so you think your tourniquet time, you know your tourniquet time is a quarter of some other doctors?
Dr. James Dreese: Well, I think for people that keep it up for the entire case, it would be probably an hour, but for just keeping it up during the... I'm not doing the entire case, I'm just taking the graft out, which is the beginning of the case, so that generally is gonna take about 15 minutes. So I believe that helps in managing quad recovery, the negative impact of what having a tourniquet up can imply. If you put a tourniquet up on yourself and wait for 15 minutes, tell me what that feels like. And then leave it up for another 45 minutes and tell me what that feels like.
Dr. Yoni Rosenblatt: That 300 level that you're talking about is, we do blood flow restriction and we're living in the 120-150s, and patients are like grabbing at their knee trying to get out of that tourniquet, I can only imagine what double is. That's something that we would never know. I can definitely say that your ACLs come to me the next day, so that's one. First of all, you make sure they come to me the next day, within two days for rehab. Two is, they are able to get terminal knee extension with their quadriceps, almost fully engaged 24-48 hours later. I have to believe it has something to do with that tourniquet time. Is there anything else that you're doing differently to allow for a better outcome?
Dr. James Dreese: Some of it, I think is probably pain control, too. I think trying to manage the pain at the surgical site is important also, and pharmacologically, there's different ways to do that, that plays a role, but I think also just really counseling people about the important features afterwards of getting elevated, get some cryotherapy on your knee, get terminal extension. Those things just make, I think everything less painful and help you to progress faster, so no doubt... There's a lot of different factors that figure into pain and recovery, some of which are controlled by me, by anesthesia, but some of which are patient factors too, and I think all of those have an effect.
Dr. Yoni Rosenblatt: Yeah, I will say that patient comes in, the quicker they can get to passive terminal extension, the less anterior knee pain they have when they engage their quadriceps, and I think that's another vote for, get those patients into us early and then to the therapist, and the PT is listening to this podcast, do not be scared to push that knee into terminal extension so that that quad can hopefully be fully engaged and take pressure off of that patellar tendon graft site, I think goes a long way. I think that's something you do differently, too. I know we've touched on in the past, but kicking your patients ass to get into therapy is super helpful to them in the long run. They might not love you in the short term, but certainly in the long run, I think that's gold, that's totally worthwhile to double down on. I think there's so much there to chew on, I think you've done a really good job of highlighting what it's like to surgically reconstruct an elite athlete's knee as it pertains to the ACL, so I appreciate that and the knowledge that goes on in there. What is it that you wanna share with the sports PT community when rehabbing the elite level athletes knee specifically?
Dr. James Dreese: I don't think that the rehab itself is necessarily that different. I think communication becomes that much more important because there are a number of different players that communication is important with when you get someone at that level of sport, so you just have to have good communication. And I don't think that the goals are necessarily, that the timeline changes at all, it's largely... It's biology, which is not any different. It's rehab, which having good access to really good rehab makes a huge difference, but it's really just like having open lines of communication and making sure that everybody understands the treatment, the expected timeline, and what needs to happen at different stages to kind of move forward with things, I think that's the important thing.
Dr. James Dreese: I don't think in terms of when you run, when you cut, when you twist, I don't think that is all that different though, between the two, and I always tell people too, if you really try to push those timelines and try to accelerate things, you're gonna really increase the likelihood of taking a big step back or potentially having a more significant kind of complication, so you just gotta give it time and be patient, and that comes with understanding upfront how the process is gonna work and at what time points we're gonna try to be doing different things.
Dr. Yoni Rosenblatt: Yeah, sometimes this is an insurance thing, but when I get a professional athlete that comes in for rehab, if they're a workers' comp patient, and so that means workers' comp is covering their rehab, and that means that that patient is coming in every single day for rehab, and that's actually the conversation that I have with patients that are not NFL athletes. I give them a response when they say, "How much should I come in for therapy?" I say, here's the ideal: I see you every day, I see you every day for nine months, and that will ensure that you have a better outcome, in my experience. That's not really reality. And so early on, I wanna see you X amount per week. And when it comes to post-op, specifically ACL, it's three times a week to start because I need that extension.
Dr. Yoni Rosenblatt: But I think that's one difference in our world of how we deal, let's say, with the elite athlete versus your recreational athlete. The other thing is, you and I spent a lot of time just now talking about surgical intervention and then talking about early acute care, and how important range of motion and muscle re-education, which we didn't get into a ton, but it's so important early on. Once I start taking weights off the rack to challenge these individuals, I think that's where my game changes a little bit, where I know that I need a certain amount of load to go through that quadricep hip, glute stabilizers, and it's gonna be more weight for that guy than it would be for a guy like me. And so I'm just increasing how much weight I'm grabbing to begin to load them and then sport specificity, position specificity. What does this athlete need to do every single Sunday? In the case of the NFL, does he need to cut, does he need to be able to bear a tremendous amount of load as he back pedals, like an O lineman?
Dr. Yoni Rosenblatt: Their exercises, after you get through that acute phase, should begin to mimic that somehow, and that I think is really the difference between sports PT and gen pop PT, your general population, where everything is directed and goal oriented, 'cause you know exactly what they need to do for a living. So for us, it's a little bit different, but for you... Correct me if I'm wrong. It's the same repair, you're not like tightening it extra tight or anything like that when you put it in there, is that correct?
Dr. James Dreese: Yeah. I think there's not really any differences. Now, there may be some differences with regard to graft choice, potentially the idea of how you treat the meniscal tear, it can affect some of those types of things, but in terms of the reconstructive technique, it's based on anatomy, it's anatomic principles of where a ligament originates and inserts and it's gonna be the same, but what you do in addition to that, there may be some extra augmentation and high risk, and the lateral side of the knee is a good example, just in the highest risk individuals that potentially has some big advantage versus maybe in folks who are at lower risk.
Dr. James Dreese: But I couldn't agree more about the need to really tailor the physical therapy as you get more out of the initial phase and more into strength and agility, that that really needs to be focused on the athlete, not just at the professional level, but even in our every day patients. For someone in their 40s who wants to get back to moderate activity, and is having some instability in their knee and undergoes reconstruction, their rehab at that point is gonna be different than a 17 or 18-year-old that's trying to back to play volleyball or basketball. That older athlete really doesn't have a lot of... There's not a lot of reason for that athlete to be doing high-impact activity early on, particularly if they have a meniscal problem or... We take all those things into consideration. So it's gonna be specific to the athlete. But I agree in the early stages, it's pretty similar, it's motion, it's all about motion, edema control, getting the quadifier, that's gonna be the same for all those different athletes.
Dr. Yoni Rosenblatt: And extension, like you mentioned before, right?
Dr. James Dreese: Exactly.
Dr. Yoni Rosenblatt: We gotta get extension early. So the good news is, to the sports PT population, they're gonna be able to learn a ton through our new continuing ed seminars, which Dr. Dreese is gonna be really highlighted in from the surgical procedure side, and also on that rehab side, really highlighting exactly what you need to do day one, all the way through month nine. I wanna thank you so much for your time, this has been awesome and really eye-opening, I look forward to learning way more from you in the future.
Dr. James Dreese: Thanks, Yoni, it's been a lot of fun.
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