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Jan 11, 2023

Rehab for female athletes - Post ACL reconstruction with Dr. Robin West

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Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. This is your host, Yoni. You are about to hear an awesome conversation with Dr. Robin West. She has done really incredible things with her career, most notably building one of the absolute best centers for integrative sports medicine care. She does an awesome job of combining physical therapy, strength and conditioning, as well as nutrition and other offerings with her sports medicine orthopedic surgical practice. The number one theme you're really going to hear in this conversation is her emphasis on collaboration, on communication, on really approaching the patient with humility. You're going to hear very interesting tidbits and techniques of how to relate to your patient, how to get patient buy-in, how to get an awesome subjective history and story out of the patient so you can provide the best diagnosis and plan of care. One of the things I really valued from the conversation was hearing when the doctor wants to hear from the physical therapist how we should communicate with the surgeon and then also getting into the specifics of adolescent female ACL reconstruction and then their return to sport and her really unique take on it.

Dr. Yoni Rosenblatt:
It's really a wide ranging conversation that's going to help you really get focused and as always, become a better physical therapist to the athletes that you want to treat. Without further ado, here's my conversation with Dr. Colish. Welcome back to the True Sports Physical Therapy podcast. Really excited to have Austin Colish with us today. Dr. Austin, we're going to talk about your niche in sports physical therapy. I want to know about your professional history before we start talking about your specialty in the profession. Tell us what brought you down to Baltimore and how you got started in the profession.

Dr. Robin West: You're going to learn about ALLs. You're going to learn about some meniscal repairs as well as graft choices, some things that I really found eye-opening. So without further ado, enjoy the co5nversation. As always, reach out to us on Instagram at TrueSportsPT. We'd love to hear from you and we'd love to hear who you want to hear from next. Welcome to the podcast, the True Sports Physical Therapy podcast. Dr. West, so happy to have you here. So excited to really educate the sports PTs around the world about some of what you're up to, some of your knowledge. In researching for this specific podcast, I was really excited to talk to you about the female athlete ACL reconstruction specifically in that female athlete population. But once I started learning a little bit about you and your career, I think there's so much more here that we can unpack in terms of professional and personal development. And I want to get into that first and learn a little bit about how you got to where you are, professionally speaking, and then we'll dive right into that clinical side, if that works. So with that being said, tell us your path to your current role and how you got where you are.

Dr. Robin West: Thanks for having me, Yoni. I'm excited to be on your podcast. Yeah, so I can start sort of from the beginning, that I grew up in Santa Monica, California. I came out to Johns Hopkins for college and I always wanted to be a physician. And I think immediately I was drawn to orthopedics just from playing sports. I actually got mononucleosis when I was at Hopkins and I was on the swim team. So I had to stop that season and I started working in the athletic training room. So I got to work with the athletic trainers, the physical therapists, and the orthopedic surgeons right at Union Memorial in Baltimore. And so I got to watch ACLs and I was instantly drawn to this whole thing. And I think I really love the whole aspect of taking care of the entire athlete, not just doing the surgery, but going through the, from injury through recovery was always really great for me. So even at that time I started thinking maybe I should be a physical therapist. And I started going down that path also because I loved again, treating the whole person. So anyway, I went on to medical school at George Washington and then did my residency there.

Dr. Robin West: And then I went to the University of Pittsburgh. And I think you had Jamie Dreese on a couple of weeks ago and Dr. Dreese and I were fellows together. And it was there that I met.

Dr. Yoni Rosenblatt: What star that guy is.

Dr. Robin West: What a small world.

Dr. Yoni Rosenblatt: What a small world.

Dr. Robin West: And I was at the University of Pittsburgh and Freddie Fu was our chairman. And he asked me to stay on after the fellowship. And I wasn't really looking, again, I'm a Southern California girl. I had a couple of job offers all across the country. But I decided to stay on at the University of Pittsburgh. And it was from there, it was a great opportunity for me. I started taking care of the University of Pittsburgh, all the teams, all the sports teams, Carnegie Mellon University. And then Jim Bradley asked me to stay on as a team physician with him for the Steelers. So that opened a lot of doors. I was the second female orthopedic surgeon at that time in the NFL. As you guys know, Leigh Ann Curl in Baltimore was a first. And so it was a great experience. And I was with them for 11 years as a team physician.

Dr. Yoni Rosenblatt: Doc, I feel like that's a theme. Baltimore Ravens just doing something quicker, better than Pittsburgh Steelers. So yeah.

Dr. Robin West: Anyway, it was great all around. And so then I came here to Inova in Northern Virginia. And Inova recruited me to come build their sports medicine practice. They did not have a lot of employed physicians, unlike MedStar where a lot of the physicians are employed. Inova was just a hospital system, had five hospitals, five ambulatory surgery centers. And they wanted to build a practice basically of physicians and build a sports medicine program. So I came to do that. So it's been really fun. So I came in 2014 and got to build the program from the ground up. So we had nothing. And now we are opening our eighth office. I think we have 26 physicians now. We've partnered with PT. So it's been a great experience and really fun to build and put the team together. And my model was...

Dr. Yoni Rosenblatt: What was that? That's so... Go ahead. Yeah. Yeah. Your model.

Dr. Robin West: No, no, go ahead.

Dr. Yoni Rosenblatt: I was going to say that's such an interesting shift because you're working for a team, you're working for the Steelers, you're in Pittsburgh, and Inova finds you and says, we want to build this thing. And so that sparks your interest in terms of building something. It's not something physicians always jump into. What was it about that opportunity that really excited you?

Dr. Robin West: Yeah. It was kind of mid-career. I guess not... I mean, I had young kids and I was either going to do something at that point or I was going to stay until my kids graduated from high school. And I felt like they were at this age where maybe I could take an opportunity. And I really admired what Dr. Fu had done. He had done this at the University of Pittsburgh and really built this comprehensive program, which was really unique in the country. And so I was really intrigued to build that. And I felt like this was a great area. Northern Virginia was untapped. There are a lot of great orthopedic surgeons, a lot of great PTs, but no one was really collaborative, I felt like, when I looked at it. And so I felt like, let's build this together and put something where we can really take care of the athlete from start to finish and injury prevention, nutrition, PT, strength and conditioning, this whole aspect.

Dr. Yoni Rosenblatt: And I don't know if you know the concussion world. The concussion program at the University of Pittsburgh was really on the forefront. And so I wanted to take that program and build that here. So I hired two of our neuropsychologists from there, one of the vestibular therapists and brought them over and that program's growing tremendously now too. So they see about a hundred patients a week.

Dr. Yoni Rosenblatt: So it's so cool to hear. And so we just had our own Dr. Christie Chiesa on. She came out of the UPMC system. She's a PT and she does all of our concussion stuff. So that's been an awesome marriage between... I mean, it's like a rejoining of that Pittsburgh world down in Baltimore. And that has been really cool. So definitely up to date on that. What was the biggest difference in that role at Inova versus what you were doing up with the Steelers and UPMC?

Dr. Robin West: You know, I was very clinical and academic at the University of Pittsburgh. This was a little bit of a difference. I still, I wanted to be clinical. I didn't want to give up my clinical side, but I also wanted to have this opportunity to build something. So I took on a little more of an administrative role. But then also in that first year when I came here, the Nationals and the Redskins at the time reached out to me also. So within the first two years, I became the head team physician for both teams, which was really a lot actually. It was really fun, but it was hard because I was really building our program and then also functioning in that role and trying to build the program that we had also with those teams.

Dr. Robin West: They were also looking to build some comprehensive medicine and, again, integrating everything. And so we did that and it was really fun and great. So I still take care of the Nationals. I left the Washington football team last year, but it's been, it was really a great... It's been great.

Dr. Yoni Rosenblatt: Nationals, putting together all of Inova, treating and operating how many hours a week?

Dr. Robin West: It's kind of... I don't count them.

Dr. Yoni Rosenblatt: Endless. And then what was amazing was, Doc, I met you at the Mid-Atlantic Shoulder Conference, MASES in DC. And I remember meeting you and just like trying to talk shoulders and understand who you are and where you came from. And I remember you answering your phone, like in the middle of our conversation and talking about ACLs to your neighbor. And I'm like, how is she balancing all these things? Also, I thought we're at a shoulder conference. And when I reached out to you to do this pod, I'm like, let's talk shoulders. And you're like, no, no, I want to talk ACLs. I mean, it's so wide ranging. How do you manage all of these things?

Dr. Robin West: I think as a team physician in sports medicine you want to know everything, right? You want to... Because you take care of the athlete as a whole. So being a team physician I've got to know everything. Not that I have to be the expert in every aspect of everything, but I have to be able to diagnose and figure out something and then figure out how to help that person. And so that's always been what I have thought of myself as. But as a surgeon, I treat shoulders and knees. That's my specialty. But again, I'll treat simple ankle fractures or simple things that come through on my athletes, everything else. So my belief is you should get the best person and the most experienced and taking care of your patients too. So, but yeah, knees and shoulders are my expertise.

Dr. Yoni Rosenblatt: You're jammed. Okay. So, diving a little bit more into that, How is it that you have built this team and torn down all of these silos between rehab, sports medicine? What is your secret to creating collaboration?

Dr. Robin West: That's a hard thing honestly, because I didn't really appreciate all these little silos. I've always thought, oh yeah, everyone works together. And I never knew what went on behind the scenes. And when I worked with Dr. Fu, I remember in Pittsburgh, he said, it's so important. You have to take care of everything. You've got to have the athletic trainer and the physical therapist. You've got to have the nutritionist. And he really put that in my mind and I thought, oh, that's easy. Yeah, we'll get everyone together. We'll all do it. And then I started realizing, No, everyone wants to sort of own that patient. And not always, right? People who have not worked in that environment kind of feel like it's their patient. And so putting together the teams, that took a lot actually that first year or two and just saying, Hey, as an athletic trainer with the baseball team, you guys have... You've been here for 30 years. You guys know more than any of us. And when I bring in a new PT to work with the athletic trainer who's got experience, I've got to explain that this is how we work.

Dr. Robin West: Everyone has their own expertise. And we can all share and we can all be better if we work together. And so now I actually serve as a different role. So I serve as a chairman of Inova Sports Medicine, but I also serve as the president of the Musculoskeletal Service Line. I oversee all of orthopedics across our system. So there are about 250 orthopedic surgeons. I oversee the 200 plus outpatient physical therapists, as well as the inpatient physical therapists. So it all falls under musculoskeletal. So it's kind of nice now because now I actually oversee all the programs. So it really helps us to collaborate and to work because as orthopedics is growing I can work with a physical therapist and say, "We need more people. We need more of this. We need more expertise in this area. Hey, let's grow this area." So now it really helps actually because we really have a strong collaboration. And again, I love... Go ahead.

Dr. Yoni Rosenblatt: I love hearing that. I love hearing that because I feel like sometimes I feel overworked with what I do. And then I hear that someone's managing 200 physical therapists, not to mention the other things you do.

Dr. Robin West: Not directly. I got lots of good people. Yeah, we have to... Honestly, it takes a team.

Dr. Yoni Rosenblatt: I think that's a secret. It does. It takes a team and I think that's a secret. Yeah. And that's so great that you're kind of bringing all of those things together. With all of those titles and all of those accolades, it sounds like you have been insanely successful. I know that that doesn't come without some type of failure or setback. What is a failure or an apparent failure that has set you up for later success?

Dr. Robin West: Let me just tell you, first of all, the successes are also because of my team. It's not what I've done, but I think that letting, picking the right people and having them lead and letting them take the reins and lead, that's what makes a program successful. So it's really about my team from every aspect, from the medical assistants who room the patient to the administrators who are helping lead. So that's been key. And my partners have been terrific. As far as failures, gosh, there are failures all along the way. And I think my mom... My mom raised me as a single mom and she broke a lot of barriers herself. And she always told me, you've got to take a chance. You've got to step outside of your comfort zone and try something because that's where all the magic happens, right? You're never going to go and do these things unless you go try it. And if you fail, you fail, but then figure out why you failed. And so I think that stuck hard. And I remember her pushing me to go, and I wanted to be the commissioner of athletics when I was in high school.

Dr. Robin West: You know they're like, you have the president and this and that, and the commissioner of athletics, I thought was cool. My mom said, "Go run for it." And I went to a big LA public school system. I had 850 kids in my class and I said, "Mom, but when I do this I have to go and I have to give this talk at lunchtime and stand up in front of everybody and give my... " And she's like, "So what? Go do it." And I was like, this is really intimidating. I don't want to do it. And the kid who's running against me, he's the most popular kid in our school and the girls and the guys all love him. And she's like, "Just go run for it." So it was funny. I remember I ran and I looked around and there were like, whatever, 800, 1000 kids out there. And anyway, I wound up winning that and I was a commissioner of athletics and I'm like, how did that happen? And she's like, "Well, you tried and you went out there and you showed this passion for it. And whatever it was you took a chance."

Dr. Robin West: And so it was kind of from that standpoint. I thought, yeah, maybe I will start taking some chances. And if I fail, I fail. And I think in every little failure, if you look back and whatever it is you don't run your race fast enough. You don't win your game. You don't do all these things. You look back on in life and the failures of typically because you're not prepared because you didn't prepare yourself. If you're running marathon and you don't do as well as you want to do, or you wound up walking your last six miles. And I think those are the things that I look back on and say, "Yeah, I was not prepared. I took on too much." And so I think those are what I've learned from the failures. A personal kind of setback and not really a failure per se, but I was... I do half Ironmans and triathlons. And so I was out...

Dr. Yoni Rosenblatt: Only half. You're only doing half. Okay. Yeah.

Dr. Robin West: I was out riding one morning and I got in a bad accident and flipped my bike and I'm having a four-part proximal humerus fracture, a bunch of broken ribs. So I had three surgeries on it and it's been a long haul, and I think that happened early on, that happened when I first started here a couple of years in. And I think I learned at that point, it wasn't a failure, but it was really my first big setback that I had. I felt like here I am building this program. I just got my role as the head team physician with the Nationals and the Redskins. And I'm super excited about hiring my team, and then this happened to me. And I was like, wait, wait, I've never had this. I felt like I was on this trajectory up and I was doing everything I wanted to do, and all of a sudden everything was let down. And I'm like, I can't do anything. I can't operate, I can't ride and run and do all the things that I like to do. And so what am I going to do? And that to me was a really big learning experience. I'd always believed in this leaning in thing that Sheryl Sandberg always says, 'Lean in." And as a female leader or whatever you need to lean in and put yourself out there.

Dr. Robin West: And that's how I always felt like, but all of a sudden I couldn't do that anymore. And I had to lean on and I had to get people to help me and I had to call my physical therapist that I work with and say, "You've got to help me. You've got to do this." And I wasn't a great patient, but all of a sudden my partners, I relied on my partners to help me, my family. And so I think that to me was a big learning experience. You can't burden it all. You can't shoulder everything.

Dr. Yoni Rosenblatt: Yeah. I think that can be tough. I mean, as such a high achiever, sometimes that's really hard to say, Now I cannot do everything. How do I lean on those around me? And it sounds like you've built an awesome team to do that. That's really an awesome lesson. As far as lessons go, what lesson do you want to teach your physicians? What do you wish orthopedic surgeons were better at?

Dr. Robin West: I think better at listening to their patients. I mean, that's the most common thing that I hear from my patients. I went to this person and they just said, I'm okay. I'm okay. You're okay. It's fine. You're going to be fine. I can give an example. I even saw a patient yesterday, a young 16 year old girl who was sledding and hit her knee. And she had seen several orthopedic surgeons as well as several physical therapists. And everyone said, Oh, you have patellofemoral pain. You have patellofemoral pain. This happened four years ago. She's miserable. And she came to see me and started listening to her and you're like, you probably have a pretty bad cartilage injury. You start hearing her story, get an MRI and she's got entire... Her entire cartilage has gone under her patella. She needs a osteochondral allograft to her patella now. And she's 16, but she's like, "Oh my, you're the first person who actually listened to the story and told me I need to get further imaging." And so I think that's what we have to do. This is why we went into it.

Dr. Robin West: I mean, I'm a surgeon. I love to operate. That's fun to be in the operating room. But the fun part is also getting people better. So listening to them and you can often just pick up... You often don't need an MRI. You can hear the story. I often, just by listening to the story before I even touch the patient I'll make a diagnosis in my head because you can almost always make that diagnosis. You see that too.

Dr. Yoni Rosenblatt: I love that. And I definitely see that. I think listening is something we talk a lot about on the pod. Sometimes it's so hard to listen to your patient just because of the construct of a practice. Things are so busy. And how do you carve out the time to one, listen to the patient, but also carve out time for all these other things like taking care of Dr. West or keeping up on the literature or staying current? What is your secret to time management?

Dr. Robin West: Yoni, that's hard. I wish I had the answer for that.

Dr. Yoni Rosenblatt: I'm not going to ask you easy ones.

Dr. Robin West: That's a tough question. I think you have to make time for the things, right? Like you, I mean, we all have busy practices and we're all trying to squeeze patients in. And that's to me hard when you have somebody, a complex patient come in and they have a long story and they want to tell a long story. And how do you sort of guide them through the story, but not rush them. And so I think there are simple things that you learn, like sitting lower than the patient does. I always sit down with them. Either you're putting your hand on your shoulder, whatever, whatever it is. And trying to make them feel... And then maybe helping them guide through the story. If it's a long story and, Hey, like let's do this. And Hey, why don't you lay down and trying to start at least the exam as they're talking. If you have somebody who's long-winded, but how do you manage? Time management's always hard. There's never enough time.

Dr. Robin West: And I think that depending on, you have a family, you have a practice, you have, your own personal health and how do you make it? But I think you have to sit down each week and figure out, Hey, where... For me, exercise is a big deal, but where in the week? Maybe it's not going to be every day this week because I'm super busy. But if I can squeeze it in three times, maybe I'll leave at five in the morning and go to the gym and work out, or maybe I'll do this or whatever it is you try and plan it, so you can make sure you're getting what you want.

Dr. Yoni Rosenblatt: Yeah, it's about seven o'clock in the morning in Baltimore. Have you been to the gym already today?

Dr. Robin West: I have not actually today.

Dr. Yoni Rosenblatt: Be honest, doc.

Dr. Robin West: No.

Dr. Yoni Rosenblatt: Okay.

Dr. Robin West: I usually do, but...

Dr. Yoni Rosenblatt: Thank you for being human. I appreciate that. Of course you do. Of course you do. I appreciate that. In the last few things that you said, things that really resonated with me were those tricks of getting down to the patient's level, maybe even below the patient, having an understanding of where you want to get to in the story and coaching them along. I love that. I also heard you say you have an idea just from reading the story, hearing the story of what's wrong with that patient. I always like to go into that room and say, I know it's a knee pain. I know it's knee patient. Here are the things, here's the list of things that could possibly cause pain in that knee. Let me just start ticking them off. It wasn't really traumatic. There was no pop. Okay, let's take off ligaments. Or they don't have problems with deep squatting or there's something... Okay, let's take off meniscus or whatever. And then you're left with something. And now you jump into your tests to try to prove it. But already you've ruled out so many things.

Dr. Yoni Rosenblatt: And so I think those are three awesome tricks that sports PTs, that docs can do. You walk in with that list, you start ticking things off as you hear them, not necessarily examining. You sit down with a patient, maybe you make physical contact with a patient if appropriate, obviously. Is there anything else that sticks out to you that will lead you to get an awesome interaction?

Dr. Robin West: I think it's helpful to have somebody with them also. If they're not alone, if they have a friend or their mom and dad or whatever it is. And someone will often mention something else and say, "Hey, I watch you." I had a patient yesterday, same thing. The kid said, "I'm actually fine. I'm okay." And the mom said, "Listen, every time you get up, I see you. You're limping. You're doing this." And so having someone else's input is also helpful because you know how it is when you go to see a physician, you start to forget exactly all the details unless you wrote them down. So I think that's fair.

Dr. Yoni Rosenblatt: Yep. Yeah, no question. I think that's great. I think writing them down is awesome. I know I get nervous talking to the great Robin West. So I'm sure people walk into that room and they're like, "That's her. I saw her online." Okay. So we work a lot with Hopkins athletes. We do a ton with lacrosse. Just by chance, as I start talking specifically to these Hopkins athletes, I start hearing about what they want to do for a living. I start hearing about who their inspirations are. I've had three different Hopkins students say, "I want to be Robin West." What would you say is most inspirational about your career and path to date?

Dr. Robin West: That's funny. I hear different things. I get a lot of emails from students, college students, high school students. And I think that there are a variety of things. I think a lot of young boys will reach out to me because they're like, It's so cool. You take care of the... You're a doctor in the NFL or the MLB or whatever. So I hear that. And but then I hear from some of the young women who will reach out and say, "I've never had a role model like you. There are not a lot of women that I see on this side," and, "Hey, what did you do to get there?" So I think it's a variety of things that people reach out to me for. And so I don't really ever think of myself as that inspiring. But I guess to some people, everyone's got different role or goals in life. And maybe they look at it and they see something that I've done.

Dr. Yoni Rosenblatt: Yeah, I heard an awesome story where I think you went in to talk to some of the Hopkins students and it might have even been specifically Hopkins athletes. And I think they sent out an email saying, Dr. West will be here to do whatever. She made it her business to come to that lecture speech and she went up to you afterwards and she was amazed at how much just time you gave her to talk and interact. And I think that really resonates with everything you're saying with the patients is, give them the time, listen. You never know how far that's going to take someone. You never know how much impact that's really going to have. I think that's an awesome lesson. That's something that I think is inspirational about your career. It's like it's those little interactions. It's the interpersonal skill. That's what leads to those accolades and those high positions and your ability to build a team. But it's that ability to connect one on one that's inspirational to me. So next time you're on a pod, doc and someone asks you what's inspirational about your career you should say it's my ability to connect and interact one on one. There you go. I'm gonna give you the lines.

Dr. Robin West: Actually, the most fun is always getting a little note from somebody, somebody who I interacted with 10 years ago and they're like, "You inspired me, and now I'm doing this." When I get those, I'm like that made my entire day. So to me those are the most inspirational to me. That's what keeps me going each day. The days that you're having a hard day and things aren't going well, and then you get something like that. Like, wow. So you have the same thing, where your patient comes in and you're like, you helped me. You did this.

Dr. Yoni Rosenblatt: It's unbelievable. And it's really making that patient or that next generation of practitioner. The center is absolutely what keeps me going. Let's change gears a little bit. I want to get into clinical specifics, specifically with ACLs because you're a Freddie Fu prodigy. These rates of ACL tears are skyrocketing. I saw it's going up 2.3% annually and that's true for the last 20 years. Why are we seeing such an increase in ACL injuries?

Dr. Robin West: Yeah, I think there are a lot of reasons. I think one of the reasons we know that females have a much higher ACL tear rate than males do and there are a lot more female athletes. Now, if you look at Title IX, ever since Title IX, that rate of female athlete participation and ACL injuries has gone up dramatically. So that's probably one of them. The other thing is we're playing year round sports. People are specializing earlier. So if you look at that and we see it in a lot of sports. I take care of these baseball athletes and they're like, this is all they play all year round. And so I think that just the same thing, this very hyper focused on one sport, not being a multi sport athlete. So biomechanically, I think you're setting yourself up for some injuries. If you look at in the NFL and you look at the draft picks, 89%, 90% of them are multi sport athletes. And this is what's made them successful. So when you're taking care of these young kids who all they're focused on is one sport. I always say, "Hey, look at these professional athletes. These guys played many sports and this is what made them a better athlete." So trying to push that. I think those are probably the reasons we're seeing them.

Dr. Yoni Rosenblatt: Yeah. Okay, so female athlete unfortunately ruptures her ACL. She walks in to see Dr. West. What grafts are you using to fix that ACL?

Dr. Robin West: Yeah, Yoni, it's tricky. I do a very individualized graft. I don't just do one graft. I look at the patient. We talk about what their sport is. We talk about the graft choices. In my hands there are four graft choices. There's the allograft to cadaver. That is not an option for me. I rarely ever do that.

Dr. Yoni Rosenblatt: I was going to say that's a choice? Okay.

Dr. Robin West: That is not a choice. So it has a 25% failure rate under the age of 25. So that's not a choice. So then we have quadriceps tendon, patellar tendon and hamstring. To me, a female athlete is not going to get a hamstring autograph because if you look at most female athletes, 70% of their injuries are non contact. And why do these happen in female athletes? There are a variety of reasons. There are hormonal reasons, biomechanical reasons. Female athletes are typically more quad dominant, especially our soccer and lacrosse players. They have stronger quads and weaker hamstrings. So why would I harvest their hamstrings and put them at higher risk for a re-injury? So in my hands they're not getting a hamstring autographed. So now we're down to the patellar tendon or quad tendon. So and that's where we go. And then we start talking about the graft choices and the benefits of each one. If you look at two years out, they have similar outcomes, similar failure rates. They both have a low failure rate. So now we talk about complications. So patellar tendon grafts are a great graft. It's kind of the gold standard.

Dr. Robin West: It's been around the longest, but it's an incision in front of the knee. And so kneeling on that knee is going to be... You're always going to have some symptoms. Numbness is very common. Most people will have numbness around that incision and down their their leg from a patellar tendon harvest. And the chance of anterior knee pain, you're a PT, the anterior knee pain of the patellar tendon.

Dr. Yoni Rosenblatt: A hundred hundred percent.

Dr. Robin West: Yeah. I mean, everyone has it at some point. And probably 20% of people have a lingering pain up to about a year. And it may even extend a little beyond that. So that's an issue with patellar tendon. Quad tendon pain is really uncommon. Actually, pain is not a common complaint actually, after a quad tendon, numbness is not a complaint. The skin nerves are not... There are not many up there. And so you're not really going to get a lot of numbness that travels down the leg from the infrapatellar branch of the saphenous nerve. That does not go by there. So you don't get the numbness and the kneeling pain isn't there. So what's the downfall of it?

Dr. Robin West: The downfall and you probably have seen this, but the downfall is getting that quad strength back. That active hyper extension back early on is hard. And it's six months. If you look at the quad and patellar tendon, the quad tendon lags behind the patellar tendon for quad strength. So but again, at that year to two years out they're very similar. But it's just in that early rehab and we're taking care of high level athletes and they want to get back at nine, 10, 11 months. We have to think about all those complications, anterior knee pain, quad weakness.

Dr. Yoni Rosenblatt: I'll tell you, I love that quad tendon compared to patellar tendon. If those are my two options, I'm leaning towards quad. As long as the surgeon has done a million of them and they're equally as comfortable. I love that quad tendon. When you talk to me about lagging and quad strength, quad versus patellar tendon grafts, I think some of that's on us on the PT. We need to be loading appropriately. We need to know the strength and conditioning principles to load properly. If quads behind patellar tendon, I think patellar tendon often sucks at that because that front knee pain is so pronounced. So if we can live in quad tendon and doc, you can get your colleagues to get better at that harvest and fixation. Let's just go all in on the quad tendon if you're robbing me of the ability to do hamstring. I love a good hamstring because that rehab is so easy, but I totally hear what you're saying.

Dr. Robin West: It's so easy. It is really easy. I still do. Again, I probably would have a hamstring if I had mine done. But I think that I've been doing quad tendons for probably about 10, 15 years now. I've been doing them a long time and I do a lot of them. And you're right. I mean, it's a very... You have to be perfect on your harvest. You have to have good fixation, great fixation, because that was the main issue early on. We didn't have great fixation options. We have great fixation now. So but the rehab is important. And so I really put it on the patient, on the PT and on myself. So my part they always say, "Oh, doc, you fixed my knee." I'm like, "I didn't do anything. It's you and your therapist. My part is small. I took an hour. We did your surgery and now you're moving on. But even in the preoperative holding area, I tell them, I say you have to get your quad activated post-op. I want you in the recovery room. I want you getting that terminal active hyperextension. I want to see your heel pop off the table. So even after surgery, I walk out and I make sure I'm like there and they do it typically because we do have a nerve block and we do just a saphenous nerve block.

Dr. Robin West: So we're just doing... Not a motor nerve block. So they can do that actively. And then I have them again go to therapy within one to two days after surgery and immediately start getting that activated. And like you said, Yoni, it's such a difference in the therapist, because some therapists aren't comfortable doing that and are like, Hey, I don't want them to get hyperextension. I want you to have that active hyperextension. If you can get that heel pop for me week one I am thrilled. It doesn't happen usually, but...

Dr. Yoni Rosenblatt: I love that. I think I say the words heel pop more than any other words in the English language. So I love hearing them from the doc. That's totally true. Talk to me about that fixation because the sports PT or let me rephrase that. I don't know a ton about that. Tell me what's better about the fixation, what you're doing now that you weren't doing 10 years ago.

Dr. Robin West: Yeah, it's an all soft tissue graft. So we always think about how do we fix soft tissue? We can put screws in. And if you have a patellar tendon, it's bone to bone healing. It's quick healing. We know in six weeks the bone is going to be healed. The graft may not be ligamentized. It's not mature, but the bones healed in the tunnels. With the soft tissue we're putting a screw, or we're trying to... Whatever we are trying to fix it that way. But now the soft tissue has to heal to the bone. And we know that can take three months. So we need to have really good fixation for those first three months. Otherwise, we're going to start to get some slippage. And the graft is going to lengthen. So there are all kinds of options now. There are all kinds of button fixation and suturing techniques and they come up with all kinds of... And every company has a different product. But there are a lot of different options and whatever the surgeon is comfortable with. We have to make the graft in the operating room. So we have to be efficient. We have to have a great well-fixed graft. And so the options are broad.

Dr. Yoni Rosenblatt: So I'm going to get a little bit granular here. So you're drilling through your femoral tunnel. And when you try to get that piece of quad tendon to grow into the femur, what are you doing to bolt that tendon down? I'm just thinking about like a piece of paper shredding over a screw as it gets tugged. So tell me what prevents that.

Dr. Robin West: So there are options. So I don't use a screw on the femur. So there are, you can put a screw in and there are different kinds. There's bio composite, which are like calcium triphosphate screws. They can turn into bone. There are plastic or peek screws. And so those are options that you can put that won't shred the graft. You can put them in and kind of push that graft in. You can also use a button fixation and where you sew, it's a little button and this button sits on the cortex of the femur. So what you do is you drill a blinded tunnel in the femur and then you make a small little drill hole through. And this button passes through the drill hole, pops on the femur and then holds the graft in place. So it's suspensory fixation, it's called.

Dr. Yoni Rosenblatt: And so that tendinous tissue grows into the femur.

Dr. Robin West: Into the femur. And so then you've got the circumferential graft in there. And you have... The problem is when you put a screw and you put the graft and then all of a sudden one side of the tunnel is a screw. One side is the graft. With suspensory fixation the whole tunnel is filled with graft. And if you have good fixation and it's not moving and bouncing around you're going to get good at bony ingrowth.

Dr. Yoni Rosenblatt: Okay, so that's super interesting. You learned that technique when?

Dr. Robin West: Early on. That technique's been around a long time, but not for a soft tissue graft. For patellar tendon it's been around. It's been around for hamstring. Hamstrings are easier because you can loop the hamstring over a button and fix it that way. But the quad tendon is just a one singular graft. So how do we attach a button? We can't loop it around. So that's where these techniques have changed over the past couple of years, trying to sew the button into the graft.

Dr. Yoni Rosenblatt: Gotcha. Okay, that's really interesting. It makes me think about part of your origin story coming from Pittsburgh. Because you mentioned it's one singular graft. I want to know what a double bundle procedure is. When's the last time you did a double bundle procedure? Why don't more people do it? I just want to talk about double bundles for the next 40 minutes. So how's that? Tell me about... Break down the double bundle and the history of it as an option.

Dr. Robin West: Yeah, I'm trying to think of when it was, probably in the mid-2000s, mid to late or 2005 to 2010. In Pittsburgh, Dr. Fu started doing double bundles and he had learned the technique in Asia. And really the goal of it, and Dr. Fu is always thinking outside the box and he did not jump on techniques early on. He always put a lot of thought into it. And so his thought was, let's try and make the ACL even better. We know we have good results as surgeons. We say, Okay, the failure rate is 5% or 10%. It's a pretty low failure rate. But when you look at the return to play we know it's like 65% return to play after an ACL. And so that's a very low percentage. And why is that? Is that because they have an unstable knee, because they have pain, because they're psychologically not ready? What is it? And also when you look at these ACLs 20 years down the road, 10 years down the road, most people have bad arthritis in their knee. And so Dr. Fu said, well, there's something going on, and is it the biological response in the knees and all those bad enzymes that are released?

Dr. Robin West: Or is it that we can make the ACL better? Can we do a better job at putting the ACL in? And so his thought was, let's try and do an anatomic ACL. Let's put the ACL exactly where it belongs and let's try and reproduce it perfectly. Because at that point, everyone was doing transtibial tunnel. So you would drill your tibial tunnel and go straight up and drill your femoral tunnel. And this was not normal anatomy. So you got good anterior-posterior support, but rotationally, the knee was just rotating around the graft. So at that point this double bundle was developed really in Asia and then was brought over here and Freddie brought it over here to the United States. And the goal again was to control the rotational stability, to reproduce both bundles of the ACL. And so making two femoral tunnels, two tibial tunnels.

Dr. Yoni Rosenblatt: And using what? What would you use? What do you use as the grafts?

Dr. Robin West: You could use a hamstring, you could use a quad tendon and you could split the graft. And so, we had a big study that we did with quad and we looked at the biomechanical differences. So functional differences and then biomechanically having them run on the treadmill six months, a year out and seeing if there are biomechanical differences. And that study showed us something. That study showed us that the clinical outcomes were the same, basically. Biomechanical, maybe slightly better with a double bundle, but not like we saw in the lab. In the lab when you looked at it, this was so much better, the double bundle, but clinically, it wasn't showing up. And there are a lot of issues with these double bundles. Two tunnels on the femur, two on the tibia. And if you do happen to fail your ACL and all of a sudden you've got these big expanded tunnels you're dealing with, then revising them can be difficult. And it's a very technical procedure.

Dr. Yoni Rosenblatt: And we see a ton of stiffness. There aren't a ton of double bundles coming out, but for whatever reason, I can come up with a few. I can make a hypothesis as to why they're tighter just because there's so much more being packed into that knee, but they are so damn tight. Like getting extensions tougher, getting flexions tougher. Is that possibly why they're not as done frequently?

Dr. Robin West: I think that the reason you're saying that is probably because biomechanically, probably the tunnels aren't placed perfectly. You're going to see that because if you get two anterior of a femoral tunnel, you're going to lose flexion. And if you have two anterior of a tibial tunnel, you're going to lose extension. So it's a very, very technical procedure. You have to have these tunnels perfectly placed because like you said, there's a lot of graft and you've got these two big tunnels. So the quad tendon is the same too, Yoni. I don't know if you see that too, but extension loss is much more common with a quad. And I think again, it's a lot of tissue. And if you're off a millimeter or two, you're going to lose extension.

Dr. Robin West: And so I think that's something else as well. Like you said, you've got a lot of collagen in there. But again, you have to be really perfect in the OR and getting these tunnels perfect. And I think that the problem with double bundle is too many people started doing it and saying, Oh yeah, this is great. And not really understanding the anatomy and how to get these tunnels perfectly placed. It's difficult. It's not easy.

Dr. Yoni Rosenblatt: It does not sound easy, especially to the sports PT. So I can certainly understand that. Talk to me about the ALL. How often are you doing any type of ALL procedure? Where do you see the future of the ALL?

Dr. Robin West: Yes. The anterior lateral ligament is that that's almost always injured with ACL tears. If you look in the literature and you look at biomechanically and we look at these MRI studies, between 60 and 90% of standard ACL tears have an injury to the ALL. And the ALL is just that posterior capsule. Just that anterior lateral capsule. My light fell. I had a light up here.

Dr. Yoni Rosenblatt: I was wondering.

Dr. Robin West: What's that noise? And so it's an anterior lateral capsule that gets injured. And the question is, How important is it to fix? Do we have to fix all of them? We've never have in the past 30 years since we've been doing ACLs until more recently. But again, it's trying to perfect that, make that anatomic ACL. And does that control some of the lateral rotation, some of that that pivot shift phenomenon? That's how this injury happens. So I do a modified technique. So I do a iliotibial band tenodesis and I'll do that only on a revision case. So somebody who has had a failure, they have a very unstable knee, they're super hyper lax, got a lot of hyper extension. I consider adding in an ALL or IT band tenodesis. The problem with the ALL is it's a little bit like the double bundle in the sense of it's being done a ton right now. And if you're not anatomically perfect with your tunnels or your graft is too big, you can over constrain the knee. You can lose extension. And if you follow these patients and you look at the studies coming out more recently now, you're getting a lot more lateral compartment wear because, again, if you're over constrain that lateral compartment.

Dr. Robin West: And so I think there's you know, are we going to go to doing them always? Maybe. But this has to be perfected first. Again, what kind of graft, what kind of fixation, what flexion angle do you fix it at? If you fix it in 30 degrees of flexion and over constrain the knee, you're never going to get the extension.

Dr. Yoni Rosenblatt: I think that's what I've seen. I've seen it... By the way, early on, I felt like I saw it with hamstring grafts where docs were so leery to do hamstring grafts because they're like, Hey, we haven't figured it out yet. We're not sure. Maybe the graft, maybe the harvesting isn't as tight or as specific. And then slowly I just felt like it started getting better clinically. And now all of a sudden, at least in my snapshot or my outcomes, hamstring is just as good as patellar tendon. It's not like I'm seeing hamstrings come back being like, Oh, we ruptured because it was hamstring tendon. I just don't see that. I would say the same thing with the ALL. Even in the last like three years where I'm seeing docs are doing it, first of all, as the primary and second of all, they're not as stiff. We're not losing the extension and flexion like we used to. And I guess and this is why I love having MDs on this podcast is because we start to hear that side of things where you guys are getting better about the placement. Oh, that's why the flexion is no longer so adhered, or that's why they can get the terminal extension when they're getting an ALL. Because you guys are getting better at it. So I love hearing that.

Dr. Robin West: It's a combination. And you guys are also rehabbing... You guys understand the rehab process or you can, Hey, I can push through this. I think initially when we're trying these new procedures we're often like, Okay, let's go really slow. Let's not move them. But actually it's the opposite. You really do want to be in a hyperextension. Yeah.

Dr. Yoni Rosenblatt: And that's the must. That's the must for us. We preach that like crazy. Obviously you preach it like crazy. What's one other must for your patients during the rehab process, specifically ACL?

Dr. Robin West: First of all, the hyperextension is really a must and getting that quad activation. I am a fan of weight bearing as soon as possible. The thing that makes me absolutely bonkers is when somebody comes in still wearing their brace and they're at four to six weeks out from surgery. I saw a kid yesterday. He's wearing his brace. He had a standard simple ACL and he's six weeks out and he said, "My PT said I have to wear it." I'm like, I would like you out of the brace on day one if I could. And I said, the only reason you're in the brace is because your quad is shut down. Until you get good quad activation, I want that brace off. So to me, I want them out of the brace. I want their gait normalized. The problem is they come in in that brace and they cannot get that hyperextension. They can't get that heel to toe gait in the brace. And so as soon as that brace comes off, it's a mess.

Dr. Yoni Rosenblatt: And it glues like this and they sit in that brace and they're still sitting in flexion. That drives me bonkers. So I love that it bothers you as much. Now, once they're glued in that flexion, God forbid, but we've all seen it. They have trouble getting that terminal extension. When are you considering doing something about that? When are you worried about that?

Dr. Robin West: Yeah, early on. I mean, Yoni, that's something... I like them by six weeks to have that full range of motion, active hyperextension, full flexion. If I don't see it at that point, we start to really say, "Hey, we're going to need to do something. If I don't see you get better in the next two weeks." So at that point I start watching them very closely. So there were six weeks out. Let's say I say, I'm going to see you back in two weeks. You have to do this. And we start talking about prone leg hangs, active quad sets, putting something under their knee to get that active hyperextension, maybe using something like the ideal knee brace to get hyperextension. So we're trying to go down that road and I say, "Listen, if I see you back at eight weeks, we're going to start talking about the manipulation if you're not better." And so I'd say by 10 to 12 weeks, if they are not where they need to be, then we're going to get an MRI first of all, because that can be caused by two things really by either a cyclops lesion, right?

Dr. Robin West: The tibial tunnels to anterior and you get graft impingement. Or is it because they truly have arthrofibrosis? True arthrofibrosis is a big, big problem, but they're typically going to lose extension and flexion with arthrofibrosis. They're going to have a swollen knee. It's going to be very stiff and fibrotic, no patellar mobility. And that patellar mobility is something else I push hard to. I like them getting that patella mobilized immediately.

Dr. Yoni Rosenblatt: I love that. Okay. So this is this is very similar to the interview process when you come in to be a True Sports PT. This is exactly what we walk through. So that first question is when do you push the panic button with that extension? You said six weeks when you really start honing in on them. And by the way, you scared the hell out of me when you said we're going to have to do something about it. So I guess that's one tactic that you do, right? It's six weeks. You scare the hell out of them. Eight weeks. You hope that they're already there. When are you doing manipulation? When you pulling that?

Dr. Robin West: Before three months, so 10 to 12 weeks, I'd say.

Dr. Yoni Rosenblatt: Before three months. Okay. So before...

Dr. Robin West: After three months, you've kind of lost that window of opportunity.

Dr. Yoni Rosenblatt: Do you go manipulation or do you do a lysis of adhesions?

Dr. Robin West: Depends on what it is. We get that MRI and we see, right? Is it arthrofibrosis? Is it a Cyclops lesion? It's a Cyclops lesion and that's all they have, then it's a knee scope and debridement. If they have arthrofibrosis, significant arthrofibrosis, loss of flexion and extension. Sometimes it's an open procedure. Actually, sometimes you have to do an open release. It depends on how stiff they are. Are they going to go on a Medrol dose pack first? So there are a lot of different ways to treat that, but it's usually not just the bend your knee and that's it. It's usually putting the scope in and doing something.

Dr. Yoni Rosenblatt: Okay. So that's what I was going to ask. Do you ever put them to sleep and crank them into flexion and extension or that is gone? We're done with that.

Dr. Robin West: If someone's missing flexion I would do that, but not extension. You can't do anything on extension. There's a reason they're missing extension. So the camera goes in if they're missing extension.

Dr. Yoni Rosenblatt: Okay. And that has to happen before three months?

Dr. Robin West: Mm-hmm.

Dr. Yoni Rosenblatt: Okay. And you mentioned Medrol dose pack. Are you ever injecting these knees?

Dr. Robin West: No, I'm not a fan of injecting. I mean, not with a steroid. I'll inject hyaluronic acid sometimes if they have a little bit of stiffness, or we'll consider something like that. But no, sometimes we'll use Toradol. So you can use Toradol intra-articularly.

Dr. Yoni Rosenblatt: Now you sound like an NFL doc. I'd love to hear that. Okay. So let's say that doesn't happen. This young female athlete's doing great. She passes by that three months. She has her full motion, her strength's coming along. When do you start talking about return to sport and how do you, Dr. West, clear these athletes for return to sport?

Dr. Robin West: Well, that's up to you guys actually. So it's a combination of things, Yoni. I lay the crepe kind of early on. So I see the patient who initially tears her ACL. I say, listen, their return to play is nine to 12 months in my mind. I'm not going to release you before nine months. And typically it's that nine to 12 month window. It may take you a year and you look in the NFL now, players are taking a year, a year and a half. And there's talk in our world about even extending it. Do we now start talking a year and a half to two years? Because as you know, athletes aren't normalizing until that point. So I say nine to 12 months is our plan to return to play. And it has three things. The graft has to heal. It has to mature. So we know that's going to take nine months basically for maturation to happen for an autograft. And we know you have to be functionally ready. So my point is mine's easy. I look at your knee. Do you have any swelling? How's your range of motion? And then your PT now is going to take you through all this functional testing.

Dr. Robin West: So that's a functional part. And then it's a psychological readiness. We talked about that 65% return to play. But we also know that the reason most athletes don't return to play is they're not psychologically ready. And so we're assessing that the whole time, from the time they walk in the door with their injury and getting them involved with a sports psychologist if necessary or just talking to them and making sure, Hey, this is normal. Everyone is like this. Everyone's not ready. But to me, that whole functional training and having a great PT helps them prepare and helps them get over that being scared to return. Because every test you do, and I tell them every functional test you go through and you pass, your confidence is going to increase. And that's going to get you more and more excited and ready to play. So I think the PT plays a big, big role in that aspect.

Dr. Yoni Rosenblatt: That supports my notion that PTs are great medical providers. They're great strength coaches. They also have to have this psych component to the way we interact and the way we encourage. So they really need to be great coaches. And I think that makes an awesome PT. I love your outlook. It's so holistic. It reminds me of what our dear friend Dr. Dreese taught me, which I think I've mentioned here previously, which is equally as predictive is the patient's range of motion, the patient's strength and the patient's psych, and their confidence in returning to the field. That blew my mind because as a PT at first I was thinking it's all physical. Like, how do I get this quad massive? How do I get these hamstrings and glutes to kick on? How do I get this motion? But so much is above the neck. That was really eye opening to hear, especially from Dr. Dreese, who lives in the world of orthopedics, how important that piece is.

Dr. Robin West: Yeah, I mean, that's not normal. A lot of orthopedic surgeons don't think about that. But that... We're like, oh, yeah, we fixed ACL. And like, I did it. But that's actually not the part, the part is to get them back and be successful back on the field.

Dr. Yoni Rosenblatt: Yeah. Yeah. But keep in mind, you still have to fix that ACL. We can't get them back on the field unless you fix the ACL.

Dr. Robin West: Yeah. We have to do a good job at it and we have to really, again, stay on top of our literature.

Dr. Yoni Rosenblatt: Right. So I love that. And it sounds like it's really evolving. You also have a hand in selecting the physical therapist at Inova or hiring them. It's a piece of the puzzle. How do you find a great physical therapist? What are you looking for?

Dr. Robin West: I'm not the person who does that. We have leaders, we have physical therapy leaders at each each of our locations. And so but again, working directly with them and saying what I like, what I want. And I have told, and I really stress the importance of working collaboratively. So having our team, every time I see an athlete who I have concerns about, I always make sure to call the PT. And I want the PT to call me too, because open communication is important. So that's what I always say. When you're hiring someone make sure they understand that we have to work collaboratively. I have to know if there's an issue. I don't want to have someone come back six weeks and be like, Oh, yeah, for the past four weeks I've had this problem and no one ever called me about it. And same thing I would hope that they want to hear from me and say, "Listen, I'm concerned, you need to do this a little harder, or push this more or whatever it is.

Dr. Yoni Rosenblatt: How can we phrase that as PT's reaching out to the doctor? I think the patient needs X. How do I relay that to you appropriately?

Dr. Robin West: Everyone is going to want it differently. I like being people calling me or texting me and telling me this is what I'm worried about. Hey, Doc, I saw this. I'm concerned about this and this is what I think is going on because you're the ones who are seeing the athletes, two, three times a week. And so I really value your input. Everyone's different. Every surgeon is different and wants different input. Some people don't want that. I mean, I have some colleagues who really don't want to hear, but you have to hear. You're not going to get the person better unless you're working together.

Dr. Yoni Rosenblatt: Yeah, okay. Awesome outlook. It really is. Now, looking forward, what do you think the future of ACL reconstruction for this adolescent athlete is?

Dr. Robin West: I think we're reaching. I mean, I think we've come to the... So far we're doing this anatomic ACL. We have good graft choices now. We have the BEAR implant. We have the ACL repair techniques available. And where are we going? Right now, I think the ACL repair is on the forefront. It's something that I'd like to see long term where it's going. We know the early results look okay. But are we ready to use them on on these high level, these collegiate and professional athletes? So I think that as time goes on we're looking at more biological opportunities as opposed to drilling tunnels and taking a graft and reconstructing, potentially taking more biological approaches. But we've been down this road.

Dr. Yoni Rosenblatt: How often are you doing that? Yeah.

Dr. Robin West: I'm part of the clinical trial. So it's being offered to our patients. The hard part is when you have a 16 year old girl who wants to go play Division I lacrosse and their parents say, "What's the gold standard?" And then that's the question. The gold standard in my mind is not yet the repair technique that we don't have enough data. We don't have enough long term data. The gold standard is still an ACL reconstruction. So I'm not doing a ton of them. The patients I take care of aren't the appropriate ones. Again, if I tore my ACL, I would raise my hand for a BEAR implant. But I'm not at that level. So I think that... Yeah. So I think that there's so many great things happening.

Dr. Robin West: We've been down this repair technique for a long time, though. I mean, I remember in residency and putting in the Gore-Tex ACLs and then seeing them in my practice and seeing all the failures. And so we did repairs early on and had a lot of failures. But again, we had fixation issues. We didn't have all the biological options that we have now as far as inserting different various implants that are soaked in blood or PRP or stem cells or whatever they are to stimulate healing. We've got a lot of great things on the horizon.

Dr. Yoni Rosenblatt: Yeah, it was exciting to see I went into the lab with local orthopedic surgeons. So while they were learning that their implant technique, a few things were fascinating. One was just some of the signs, like you mentioned, the biologics behind it and the way that that bridge is really soaked in those biologics and how well that can constitute a healing repair. That was fascinating. It was crazy to see orthopedic surgeons struggling in the in OR because I talked to orthopedic surgeons and it sounds like they're God until I see him struggling. Not that I wouldn't have struggled. It was interesting. But I think that it was really promising. It was promising to see that that could be the future. And then BEARs beginning to focus on the athletic population. How do we put this in athletes?

Dr. Robin West: Yeah. You know, the problem they'll tell you the main problem for our clinical trial, which we're doing is that rehab portion, Yoni, is that you have to really immobilize them for those first four to six weeks. And when you have an athlete I can't do it. I can't have someone not moving their knee. And so to me, as soon as we can do the BEAR implant or do a repair, whatever we're going to be doing and allow them to do the same rehab that the ACL reconstructions are doing weight bearing ASAP range of motion ASAP. Then I think we start to look at comparable outcomes and seeing where it goes.

Dr. Yoni Rosenblatt: I think you're probably right. I think it could be that. I think also we could get better at our game. Like 10 years ago we didn't have this blood flow restriction concept where we fight atrophy and we promote hypertrophy. I think something else is going to come along that maybe allows us to immobilize the knee for four to six weeks, let it heal. But we can still gain muscle mass or prevent atrophy. Maybe that's a game changer. We'll see. We'll see what that future is. If there is one thing that you wish sports PTs knew, it would be what? And we'll close on that.

Dr. Robin West: Oh, no. You guys know everything.

Dr. Yoni Rosenblatt: No, we don't know everything.

Dr. Robin West: No, it's so... Again, it's so variable. I think to me, not not knowing, but just the communication is what to me makes a great relationship. And so not being afraid to reach out and like we we talked about, not every surgeon or physician wants to hear from the PT, but they make that effort and reach out. If you have a concern, raise your hand, call them and say, "Listen, this is an issue and I'm concerned about this." And if that surgeon opts not to listen to you, then that's their problem. But I do think that it's very important the communication because you guys are the experts in this rehab. I'm certainly not. And it always makes me laugh. My partner's like, "Well, I want them to do this and limit this." I'm like, "They they know. They know more than we do." I can tell you I put the graft and I did this, so we have to rely on each other's expertise.

Dr. Yoni Rosenblatt: Well, that's a great summation and really refreshing to hear if we just rely on each other's expertise and utilizing and listening to the patient feedback to understand where they are. I think that hopefully decreases these retail rates, increases return to sport. And then if we really all put our heads together, it'll decrease that rising trend of ACL tears. I think we can get a little bit more preventative.

Dr. Robin West: That's where we have to go, Yoni. Yeah, we have to prevent them.

Dr. Yoni Rosenblatt: Yeah, exactly right. Dr. West, what a freaking pleasure. Thank you so much for getting up early with us, although it's probably late for you. And thanks for being so open to collaborate, to discuss. It's really been eye opening. Thank you for your time. I can't wait to do another one.

Dr. Robin West: Thank you. Thanks so much. It was great being on here, Yoni.

Dr. Yoni Rosenblatt: Absolutely.


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