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Nov 02, 2023

The Importance of Getting Full Knee Extension During Rehab

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Dr. Yoni Rosenblatt: Welcome back to the True Sports Physical Therapy Podcast. We got Dr. Timothy Michael Stone back with us piggybacking on our previous conversation on this awesome True Sports ACL rehab course, that we just launched. I wanted to dive in a little bit more clinically and talk about some of the import in getting terminal knee extension and why that is at times such a struggle and also why it's so important. So let's break it down a little bit. Why is knee extension so important after an ACL reconstruction? 

Dr. Tim Stone: So extension in general is important just because it's a normal function of the knee and in most cases, hyperextension is normal. And so restoring normal C in the knee or normal anatomy or normal range of motion should be of utmost importance after any postoperative rehab at any joint. So it's just important because it's what we're supposed to do. In terms of it being important so immediate after surgery, that is due to the difficulty in regaining it later down the track. And so it's important to regain that motion so early on because we only have a short window to be able to do that.

Dr. Yoni Rosenblatt: Yeah. When did you realize that knee extension is so important in ACL rehab? 

Dr. Tim Stone: Probably, I think I would say after my first experience having to send someone for a knee scope that wasn't regaining extension, that happened probably within the first couple of months as a PT.

Dr. Yoni Rosenblatt: It's worst. It's the worst.

Dr. Tim Stone: Yeah, it's the worst feeling as a PT because it's something that, I feel like in my soul is like my sole responsibility for a patient. If there's one thing I have to hold myself accountable is making sure they get full knee hyperextension back. And so I think having to make that call is tough, but in making that call and going through that procedure, you give that rehab new life and you give that patient the ability to get back on track. And so I think after doing that, I wrote that down. Don't ever let anyone not get full extension back. But secondarily, appreciate the fact that you're humble enough or that you're able to sort of like see when it's not going the way that you want it, make a change and then get them back on track.

Dr. Yoni Rosenblatt: Yeah. How do you define terminal extension in the knee? 

Dr. Tim Stone: So I think there's both passive and active components to the terminal knee extension. So if we're just talking about it from a sagittal plane perspective, it's basically as like far as the knee will straighten or go beyond straight. So most people have some level of hyperextension, in their knee, and so just regaining that full hyperextension is what we're talking about so important. So I would define that passively. So if you're grabbing the heel, pinning the thigh down, drawing that heel all the way up while the thigh doesn't move, it's basically like how much... How far you can go before you run into that, I would get classified that as a hard end feel. So once that what should be a hard end feel.

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone:
You know, so that's probably where I would classify it passively. Actively then it's what can your quadriceps do to produce the extension or hyperextension? 

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone: And I think lastly the tidbit would be like from an active perspective would be, you know, what role is the hamstring having in altering or not altering the ability to achieve hyperextension? 

Dr. Yoni Rosenblatt: Yeah. Okay. So as a disclaimer, we're gonna get super granular here about knee extension. Tell me what you want the kneecap to be doing during terminal extension.

Dr. Tim Stone: Yeah. So we really want that patella to glide superiorly, or up the hip. Okay? And so as you squeeze quadricep or even as you passively do that, the patella should slide up superiorly towards the hip joint to achieve full extension.

Dr. Yoni Rosenblatt: Okay. And then you were talking sagittal plane. Talk to me about the screw home mechanism and when you start worrying about that or how that plays into your interventions.

Dr. Tim Stone: Yeah, so I think typically that's the last few... Or it's not typically, it is the last degrees of extension or hyperextension. And so that's when the tibia from an open chain perspective is externally rotating through the last few degrees of extension. Okay. So if someone has a lack of extension, typically, like they'll go through a sagittal plane extension as far as it can, but you know, if they're missing a few degrees, it's really that like lockout mechanism or that external rotation of the tibia on femur that's lacking.

Dr. Yoni Rosenblatt: Yeah. And so when we're talking passively, we know that tibia needs to externally rotate on femur in order to achieve terminal extension. We know that patella needs to migrate superiorly to get out of the way of tib maybe, as it heads towards hip so that the knee can fully lock out. And then you have the soft tissue variables that could prevent it from reaching terminal extension. You mentioned hamstring. Perhaps it's too tight. Perhaps there's too much swelling in the knee that's preventing it from getting to that terminal extension. Anything else the clinician and therefore the patient should worry about in terms of preventing? 

Dr. Tim Stone: In terms of preventing...

Dr. Yoni Rosenblatt: Preventing terminal knee extension. Yeah.

Dr. Tim Stone: Yeah. So some other issues that can prevent it would be the development of scar tissue, like at that inferior pole of the patella. So if that occurs, and typically that occurs from a lack of motion frequency after surgery, that'll start to develop, that sort of binds to that inferior portion of the patella and then both actively and passively won't allow the patella to glide superiorly. So if you feel that stiffness, just medial and lateral to patella tendon after an ACL reconstruction, you're getting into that like danger zone of sort of developing too much scar tissue to then prevent that process of terminal knee extension.

Dr. Yoni Rosenblatt: Yeah. And it's important to highlight all these things because from this potential problem list is how we try to approach ticking those things off, making sure everything is functioning appropriately so that they can get terminal knee extension. So to sum that up, you need to have an external rotation of tibia on femur to get the lock home. You need patella to glide superiorly so that they can achieve terminal knee extension. That means the patella tendon needs to be free enough to allow the patella to glide superiorly, passively and actively. And that would get into potentially scar tissue formation or stiffness at that inferior pole, which is gonna prevent it from sliding up north superiorly. And then you got swelling and then you got hamstring tightness.

Dr. Tim Stone: I think there's one another thing we...

Dr. Yoni Rosenblatt: Hit it. What did I miss? 

Dr. Tim Stone: I add in there. The only reason why I didn't really add this one in so much is because this one's a little bit more out of our hands and that's the placement of the graft.

Dr. Yoni Rosenblatt: Fascinating.

Dr. Tim Stone: So you know, and the pathology that occurs when there's an inability to produce extension or terminal knee extension with a graft that's not placed ideally, is often what we call a cyclops lesion, which is basically like, every time you bring the knee into hyperextension, it sort of pinches the front of that graft. And so if you continuously do that over time, that tissue sort of like builds up around the graft and graft and then limits the extension more. So what you'll see in that case is you'll work really, really hard in a session to get a terminal knee extension. The patient's complaining of anterior knee pain when you're doing that. So it's not posterior stuff like capsule or hamstring. And then what you'll see is the extension actually like progressively gets worse off that. So maybe you get them off the table. You do a few exercises to get them back on the table and check it out again.

Dr. Tim Stone: It's either gone back to where it was when they walked in, or it may even be worse because you're causing like inflammation and you're... You know, there's a painful response and things like that. So between sessions, every time they come back in, you just don't see the progress in that terminal knee extension sticking.

Dr. Yoni Rosenblatt: Then you're thinking potentially something intra-articular by way of a cyclops lesion or some other type of arthrofibrosis where they're laying down too much scar tissue due to the trauma in the knee. Okay. So lock home mechanism. Tibia has got to rotate externally. Patella's got to slide superiorly. Patella or tendon has to be free of any adhesions or stiffness so that it can glide smoothly north. Hamstrings have to have enough length to them to allow this to transpire. And then we got to hope the surgeon did their job appropriately, put the graft in the right place so that cyclops lesion doesn't form or more scar tissue simply put, isn't further laid down. Right? Those are all the things that could be affecting your terminal knee extension. And like you open the pod with, terminal knee extension is the number one focus of that beginning stage of rehab. It's something we obsess over. It's something a lot of the docs are stressing. And because of that, does that color when you want that patient to come in to you? 

Dr. Tim Stone: Yeah. A 100%. We typically want to see that patient pre-op for sure. Teach them what the home X program looks like.

Dr. Yoni Rosenblatt: Love it.

Dr. Tim Stone: Regain knee extension. I find those patients have, you know, as long as they go into surgery, looking pretty good. They have much less issues regaining the extension after. So that's a huge one. I think then post-op we're looking day one. Some docs aren't necessarily okay with that. What I'll find though, is if you have a doc that's sending them two weeks or even a week later, you can normally negotiate with them a little bit. And so if you see them within that like zero to three day scope, I'm usually not super terrified. Depending on how they've been sitting for those three days, but if you can, pre-op for at least a couple of weeks and then post-op day one's ideal, and that's exactly what we're doing first day post-op is just letting that knee sit in diver extension. See if you can squeeze quad and see if you can gain that extension actively.

Dr. Yoni Rosenblatt: Terminal extension. Okay. I'm gonna play the role of conservative surgeon. I'm gonna play the role of a surgeon who's doing the same surgery and same rehab protocol that I've been doing for the last 20 years. And I'm gonna say to Dr. Tim stone, the knee just went through massive trauma. Anyone who has not seen an ACL reconstruction in the OR, I highly encourage it. It is brutal, dude. They are ripping that tendon, that middle third tendon. And if they're getting a BTB, out of the knee, it's not brain surgery. They're not very subtle. They're not very gentle. They're ripping it out. They're cutting out a piece of bone from patella. They're cutting out a piece of bone from tibia. They're taking that graft, walking to the back of the room, cutting it up. Or in this instance, I'm cutting it up, sizing it appropriately and slinging it back through the knee. The knee is swollen. The knee is angry. They're on pain meds. Tim, tell me why I should send this patient into use so rapidly. I'm worried they're in so much pain.

Dr. Tim Stone: Yeah. So first of all, I think the relationship that you have with the surgeon is the most important part here. So spitting a bunch of facts from research papers, this and that, is just not gonna yield the response or result that you want because you're going into an argument with someone who's putting their guard up immediately that has been doing something for a long time. And quite often, feels as though maybe they have a better idea about how this should go than you.

Dr. Yoni Rosenblatt: Always. Yeah.


Dr. Tim Stone: Oh, yeah. Always. So the relationship building portion of that team approach between PT and surgeon is the best way to encourage the surgeon to let you see them earlier. If they trust what you've done with their patients in the late stages of rehab, they're also gonna be much more likely to trust you with their patients early. Okay? So that's probably first and mostly the only way that they're ever gonna agree to it. So develop the relationship first. Once you have the relationship, and you're trying to like broach that subject with them, I'll say like, we typically see them so they know that we're already doing it. We're not trialing this for the first time ever. And then two, what I'll do is kind of walk them through what that day might look like. So it's super low intensity, all we're gonna do is unwrap the knee, see how it goes into extension, make sure the brace is fitting well and see if they can fire their quad, answer any questions for them that you were not able to answer post-op and then send them on their way with a little bit of a homework program.

Dr. Yoni Rosenblatt: Yeah. I think that's really valuable. How about to the patient? I get a lot of nervous parents who are like, a bomb just went off in my kid's knee, can I allow them to recuperate at home for a week or two before I bring them in? 

Dr. Tim Stone: Yeah. So I think this has changed the more confident I get in this process. And two, I think the the greater of a reputation in your area that you get for doing this will help you broach that subject too. So I think early on, patients are coming to you just either from a referral from the physician, or maybe they found on Google, so they don't really... They might question a little bit more. I think now I feel like this for both you and I, for the most part, most people know somebody that came to us that and that's the reason why they're in here, and they already have a really positive like view of what we do.

Dr. Tim Stone: And so it's easier to approach that subject from a clinical perspective. So you can give them the tidbits on why it's important and this and that and they're open to that. Again, if you don't have the rapport, if you don't have that initial setup and they're new to you, I think you're trying to gain as much trust as you can in the first 30 minutes that you meet them if that's that's pre-op, or if you're you're on the phone, I think, again, saying we do this frequently, or we say that patients that come in to us earlier and regain that extension do better. But from a sales perspective, what I'm selling to them is, this is an opportunity to come in and ask all the questions that you didn't get to ask post-op because it's gonna feel so much different than whatever you thought it was going to prior to the surgery.

Dr. Tim Stone: And now you're you're going to have 10 questions. So come in, we'll just have a look at the knee. We'll see how you're feeling and then you can ask me 45 minutes of questions. And then basically, they typically will agree to that. Then when they come in for that, they ask questions and while they're asking questions, I'll start to like slowly approach the subjects of, "Hey, can we take a look at it?"

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone: "Hey, can you squeeze your quad?" Like, "Hey, can we put your heel up on here?" Sort of like go that route.

Dr. Yoni Rosenblatt: Yeah. I think also some of the things that I've seen that have worked have been talking about getting in early, but not just early getting in early and getting in often. And so I want those appointments scheduled before surgery. So hopefully you're talking to them before surgery and it's I want to see you post-op day one, you're probably not even gonna remember the session, because you're still somewhat recovering but we have seen time and again, that the quicker we get that extension, and hold it and maintain it, that we get a tremendous amount of success.

Dr. Yoni Rosenblatt: And that if we swing and miss or we give in to the fact that you're gonna wake up miserable and not want to come into rehab, we're gonna set ourselves back in month nine, in month six, in month three, because your knee isn't towards terminal extension. The last thing we want therapists, patient, parent, is to have to go through this again with a second surgery. And so the way we limit that, the way we we try to decrease that chance is by getting in post-op day one. I've seen that kind of work. Okay, so back clinically, you mentioned that it's awesome to see these patients beforehand and to give them a home exercise program of when they open their eyes post-op, what is that home exercise program that you think is so vital? 

Dr. Tim Stone: So it's really simple. If you're interested in the specifics and how and what to do it, it will be in our course that we've just put out so you can find it there. But essentially, it's a three step approach to regaining active hyperextension. So there's a progressive approach to the exercise. Phase one is using a strap to initiate passive terminal knee extension and then just squeezing the quad. Phase two is using the strap to get passive hyperextension, squeezing the quad, letting the strap go so that you can see if you can maintain that end range contraction.

Dr. Tim Stone: And then phase three is just without the strap all active hyperextension. So that's the active component of our homework. Our patients will do a variation of all three of those phases based on what they look like day one. They will do that 150 times until they're able to independently walk. And so that looks like five different sessions throughout the day of three sets of 10. So your most generic strength and conditioning piece because it's easy for patients to remember. And they're gonna do one, two or phase three based on what the appropriateness is for them right there. That's the active component. We talked about the passive component, which we actually do before. We do a thing called a heel prop. And so what that is, is just the patient laying on the table, or laying on their couch or laying on their floor, and then elevating their heel, but with nothing under their leg from the point of their heel to their hip. So that might be laying on the couch with your foot up on the armrest of the couch. So you kind of create this like slanted bridge.

Dr. Tim Stone: Or laying on the carpet with your foot up on a foam roller, or if you're in the clinic, laying on the table, the plinth with your heel up on the foam roller. So that is our low load, long duration stretch. We prescribe that also five times a day initially, and they're gonna do that for 15 minutes with a bag of ice on top of the leg. So gravity over time is gonna just stretch that posterior capsule out a little bit, stretch that hamstring out a little bit, and allow that knee to sink down in a very non-intense manner over that 15 minute period. It's super imperative that you do five times a day, because we need to accumulate a minimum of 60 minutes total, for a low load long duration stretch to really help. Now, if you've done it beforehand, like if you've done this program beforehand, and you go to it afterwards, you probably don't need to get anything out of the low load long duration stretch.

Dr. Tim Stone: The tissues haven't tightened up on you yet, and so you can have a conversation with the patient about maybe doing a little bit less there, but it's a easy exercise. There's no brain work or anything that goes into it. You can fall asleep while you're doing it. So we sort of keep both those things. So that's the passive first, and then we'll do the active components second. And there's one more that I'll throw in there right before you go ahead and do that active portion and right after you do the passive portion. So that's self patella mob. And so we'll teach the patients how to find the border of their patella. And then really in the first week, I think that it's quite difficult to self-teach inferior and superior glide of the patella just because portal holes are typically like right next to those lower borders of patella, where it's like you're just not gonna get them to squish that and then like shove it up their leg.

Dr. Tim Stone: So we'll teach inferior where you just cut the border of the superior portion of the patella and just kinda glide it down towards the ankle. And then probably most easily, this doesn't sort of like meet that directional preference like in terms of increasing extension, but just that medial and lateral glide at the patella is helpful in just, one, keeping things mobile, but two, like moving swelling around and all those kinds of things. And just sort of like freeing up that patella from any of that tissue that we kind of talked about earlier. So it doesn't develop any of that like infrapatellar scar tissue. So it's passive extension or hyperextension.

Dr. Yoni Rosenblatt: 60 minutes.

Dr. Tim Stone: Yep. 60 minutes minimum with the low load long duration stretch or the heel prop, then patella mobs. That one I didn't mention how long we do there. Also five times a day and we just do like 2-3 minutes there, followed by active hyperextension, which is our three phase approach to regaining full active hyperextension. And that's 150 quad squeezes a day.

Dr. Yoni Rosenblatt: So here's why I love that because it directly addresses all of the factors we opened with that can limit terminal knee extension, which are hamstring length, the screw home mechanism and clearing space between that patellar tendon and tibia, that is all accomplished with your heel prop. It addresses patellar mobility. Another reason we said you might be missing terminal extension that is aided with your patella mobs, obviously, is the antidote for that, as well as the active insufficiency. So using the quadriceps to pull that patella where it should be superiorly placing it there, and then if they get a good quad set that will also help with that screw home mechanism.

Dr. Yoni Rosenblatt: The prone prop will also help with that hamstring length issue we may or may not have. And now you're starting to solve for all of the problems we just delineated at the beginning of the conversation, right? And so that's why it's so important. It's super direct. It's three interventions. It's exactly how many reps, how many sets, how long you're holding it for. All of that is beautifully spelled out. Hopefully they get that and you have met them before visit one post-op. If not, they have to get it in that initial visit. And that's why that initial visit has to be so soon. That's why we can't wait 1-2 weeks because that sucker will bind down and then we're behind the eight ball. So that makes a tremendous amount of sense. Yeah.

Dr. Tim Stone: So the last thing that we didn't talk about in there that we spoke about earlier was the swelling or the inflammation portion. Each one of those drills or exercises or activities that you're gonna do five times a day will help reduce that. So the elevation portion of the heel prop...

Dr. Yoni Rosenblatt: And the ice. Yeah.

Dr. Tim Stone: Will help. Yeah. And the ice will help some of that inflammation, the patella mobs by getting things moving around. The shifting, the swelling, from a mechanical perspective or physically will help get that swelling resolved. And then finally that active muscle contraction brings blood flow to the area and will help clear that area of swelling. So that's a huge portion of gaining that knee hyperextension too, and a by-product of all the things that we're doing. And so going... To go back to your question about like, how can you sort of convince people? Everybody knows that swelling is bad. So if you're the patient or you're the physician, you wanna get rid of that quickly. These are real mechanisms in which you can do that without having to take medications and things like that. And so if we can decrease swelling, we're gonna decrease pain, we're gonna increase function. So that sometimes is a really good sticking point. Parents are really always concerned with like what the knee looks like and how swollen it is or how bad it is. So using that as a strategy to kind of convey why it's so important to do this exercise will also help.

Dr. Yoni Rosenblatt: Yeah. And stacking these interventions, I have found to be, really positive so that they're able to do the quad sets, let's say, while it's propped with a supine prop. Now you're teaching the knee how to function. You're increasing recruitment of quadriceps while the knee is where you need it to be. How do they usually cheat? 

Dr. Tim Stone: Say that again? 

Dr. Yoni Rosenblatt: How do patients usually cheat the prop exercise.

Dr. Tim Stone: When you're propping up on the foam roller? 

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone: So there's a couple ways, and I think which patients will do that, they'll sort of like roll their foot out to the side or to the inside. And so now that like direct line of gravity is not really going through that, like posterior capsule might be going like that posterior lateral side or that posterior medial side, or it's only hitting like one group of the hamstrings there. So that's probably the biggest way from a passive perspective that that will happen. The only other thing I could think of is, and I'll see this sometimes, is when you show them how to do this, like a lot of people will use that like triangle bolster to do this and they'll say like, yeah, my foot's like elevated and it's straight. But that surface and having like the calf and hamstring on top of that surface really doesn't give the same sort of force down through the knee. So whilst that might help with swelling, that retrograde effect of having the heel elevated, it doesn't really help produce like the mechanical stretch in the capsule or the hamstring. So those are two biggest pieces I see there.

Dr. Yoni Rosenblatt: Yeah. So I always coach, you want those toes facing the ceiling. Make sure they don't fall out. Make sure it's not coming from the hip. So that they can really live in the knee and explaining to the patient, you're not gonna like this. It's not comfortable. Push through it. There is no damage that is transpiring in the knee joint. It's also an important point to the doc. One of the things I say to patients and to the doctor is, whatever we're gonna ask your knee to do over the next few weeks, your surgeon did to you before you opened your eyes and woke up. So they slammed you all the way into flexion. They pulled you all the way into extension with way more force than we're gonna provide over the next few months. It didn't bother your ACL, this won't bother your ACL either. And that's why you need to see us right away.

Dr. Yoni Rosenblatt:
Some of the other things that I'm seeing far more readily accessible is use of a intermittent cold compression. And so, while game ready is out there, we've worked closely with a company called Preventice that will allow you to, number one, use your insurance to get a home compression unit, and two, cycle on and off of that cold so that you can actually sleep in this device while it's extended. Keep the compression. So just food for thought. Look into that. Another piece is getting them a home stim unit before surgery is the ideal, is the gold standard because I don't wanna waste your time in the clinic doing things that you can do on your own. If you can get this home stim unit, let it run, it's gonna help your quad contraction, it's gonna help with swelling, it's gonna help with a million different things. Insurance covers it. So put it through your insurance if that's a concern. See if you can do that extra legwork for your patient. It's gonna help you, the therapist. 'cause now you have so much more time in clinic to work on them. And so that brings me to my next question. When they come in, what types of manual interventions are you doing to try to achieve terminal knee extension? 

Dr. Tim Stone: Yeah, so honestly, if it goes the way I want it to go, not a lot. Not a lot. Like I'm just checking to see if things are going the way that I want it to go. So like, as soon as they come in, I find the easiest way to like doff a brace or take the brace off is to put their heel up on a foam roller anyway. So I'll just do that. And then as I'm undressing the knee and taking the brace off, they're getting a good three minutes of sitting in that extension. And so that's kind of how I kill two birds with one stone there. And then if we look at it and it's symmetrical to the other knee, I might test the infield a little bit. But that's really about it because it shouldn't be this like process where it's not like the surgery's reducing hyperextension, right? It's the postoperative care that reduces hyperextension.

Dr. Yoni Rosenblatt: That's a really important point.

Dr. Tim Stone: Right. And so if you don't... If you get them doing it early enough, you don't have to do anything really, except for coach on like making sure it's still there. Same thing with patella mob. So that's what I'll go to next. I'll then put their heel down onto the table and I'll just check the mobility of patella. Again, if you've been doing it frequently enough, there's nothing to do from a manual perspective except for check that it's still moving. So again, like the thing that's gonna reduce patella mobility is that like infrapatellar scar tissue or swelling. So if you've done it right and you're reducing swelling and they haven't developed that infrapatellar scar tissue because they've been moving it or because you moved it the day before, again, you don't have to spend 20 minutes on patella mobs.

Dr. Tim Stone: It'll just say like, yes, it goes left. Yes, it goes right. Yes, it goes up. Yes, it goes down. Move on. And so really, those are the main manual pieces. Now, if you get someone that is...

Dr. Yoni Rosenblatt: Two weeks post-op or stiff.

Dr. Tim Stone: Yeah. Two weeks post-op, still in that window where you can still achieve it, but they haven't achieved it yet, here's where we get pretty heavy with this stuff. So we're doing something that we call... And I would say, this is just like a mechanical, like from a manual perspective, it's more of a passive exercise, but we're attaching like weights to the knee or applying manual over pressure to the femur for the most part to try to increase that hyperextension.

Dr. Tim Stone: I just don't like getting in that portion if I don't have to, if I get it early enough. Another reason to get them in early enough. Secondarily, we may flip them on their stomach, have them come down the table and into that prone hang position. Now, whilst I don't love these postoperative initially because there are so many ways to cheat, we mention those. Rolling so it's going through your hip or rolling. So it's not going like directly down through the leg. I do like this post-op for someone that's having some issues with that, like that posterior capsule that's tightening up or a little bit that hamstring. So I'll sort of like, straddle their heel and then squeeze it between my... Their heel between my knees and I'll apply some down pressure. So basically I'll just squat down while I have one hand up on their lower back so I can prevent that hip from popping up when I push the heel down. From there, with my other hand, I'm just using my fist to kind of like glide through all those posterior structures. So capsule and hamstring basically, with some lotion to try to like increase some of that extension. So that could be a really good way to increase extension for someone that's having like some guarding.

Dr. Yoni Rosenblatt: Yep.

Dr. Tim Stone: So if they have some hamstring guarding that's going on, I find that really helps a lot.

Dr. Yoni Rosenblatt: And what I think is important there is you need to be more like a sniper here than a carpet bomber. In order for you to pop them on their stomach, you need to know, or at least come up with a reason why you're doing that. And if you think it's posteriorly mediated, so it's hamstrings or it's posterior capsule, that would be when you do that and you pop them on their stomach, it's a great opportunity to use Graston. Maybe you're needling hamstrings, stuff like that. But you have to be sure that it's coming posteriorly. Otherwise you're wasting your time if their issue is patellar mobility, you've just wasted your whole session.

Dr. Tim Stone: Right.

Dr. Yoni Rosenblatt: And so you need to assess in the entire conversation, and as you unwrap the knee, like you said, that's your assessment portion to try to figure out, what am I going to use my time most effectively to address? Because you've assessed it appropriately. So I think that's great.

Dr. Tim Stone: I can't tell you how many times someone will change PTs, come to us and they've had an extension issue and like majority of their homework is like hamstring stretches. Well, I'm like...

Dr. Yoni Rosenblatt: That's not the problem.

Dr. Tim Stone: You're... It never got tight.

Dr. Yoni Rosenblatt: Yeah.

Dr. Tim Stone: Like, how is it getting to a shortened position? You're not in over 90 degrees in knee flexion, so it never really got shorter. It's, more related to that like stiff deal.

Dr. Yoni Rosenblatt: Yep.

Dr. Tim Stone: The front. Like you have this ginormous like ball of tissue, so like next to your patellar tendon that's limiting it. So any amount of hamstring stretch...

Dr. Yoni Rosenblatt: Doesn't matter.

Dr. Tim Stone: Is not going to address that.

Dr. Yoni Rosenblatt: It's not gonna address that. And that's why I thought it was interesting you didn't mention, yep, three rounds of 30-second hamstring stretches if that's not the problem. So you gotta figure out what is it that's limiting this patient. I can't tell you how many times I've had patients come in and tell me, yeah, I've been doing quad sets, I've been doing straight leg raises. Well, the issue isn't quad recruitment.

Dr. Tim Stone: Right.

Dr. Yoni Rosenblatt: It's posterior. Right? And so like, you're not addressing the problem that they're showing you. One last piece that I think is important, let me go.

Dr. Tim Stone: You go.

Dr. Yoni Rosenblatt: Is we just mentioned patellar mobility and patellar mobilization. Number one, remember you're trying to get the patella to move and the structures around the patella, the retinaculum to elongate. So just floating it, flipping it back and forth, that is not addressing a stiffness issue. You want to put that patella at end range and hold it there. You want to hit various angles of your mobility and mobilization and hold it there so you can force that tissue to change. Don't just flip that patella back and forth. And don't forget, the patellar tendon itself has to move. So maybe your thumbs aren't placed on the lateral border of the patella. Maybe it's placed on the lateral border of the patellar tendon. Let's make sure that that's gliding appropriately too. Remember, it just went through hell and back by having the middle third of that belly ripped out. So the patellar tendon also has to move. That is worthwhile utilizing your time in session if you have deemed it to be hypomobile.

Dr. Tim Stone: So I think that was along the same lines of my question is those two scenarios that we just gave either hamstringing flexibility or it's posterior capsule stiffness or anterior knee stiffness. How do you check which one it is? I think you gave a good description on basically how you check through the treatment of, on the anterior side. So how do you check for hamstring if it's a hamstring issue? 

Dr. Yoni Rosenblatt: Yeah, great question. So if it is a hamstring issue, in my mind, they're gonna have a lot of trouble getting towards knee extension passively because the tissue is just tight. And they're gonna feel that restriction posteriorly. So if I'm slamming them into knee extension, so I've got my superior hand placed superior patella, or maybe it's just inferior patella encouraging a posterior glide as I pull up, like you described on distal tibia, if they're not able to get terminal extension there and they feel a massive tug in the back of their knee, I'm thinking hamstring. Okay? And if they have good patellar mobility. It's very... It's akin to, and I see this time, and again, if they don't have passive motion, they're never gonna have active motion.

Dr. Tim Stone: Never.

Dr. Yoni Rosenblatt: Right? It doesn't make any sense.

Dr. Tim Stone: Impossible.

Dr. Yoni Rosenblatt: It's impossible. So very similarly, if I'm pulling them into that terminal extension and they can't get it, and the restriction is felt posteriorly, there's not pinching up front, there's not stiffness felt inferior to patella, but it's all posteriorly, then I'm thinking, okay, this is hamstring. If I pop them on their stomach and they're in a severe amount of flexion, again, what's being tension there? It's the posterior knee, I'm thinking hamstring. Did I miss anything there?

Dr. Tim Stone: No, I think you hit the nail on the head. I would just say on top of that, it's just a harder thing to check, I think. So that answer stiff is easy.

Dr. Yoni Rosenblatt: Yep.

Dr. Tim Stone: To see if it's that. Right. Just place your fingers on there. I think that that hamstring is a little bit more difficult to check. But all those things are super helpful. The other things that I'll cue into is, what's their resting position? So if they're like, I don't know for some reason, occasionally we'll see someone come in with like a brace that's been...

Dr. Yoni Rosenblatt: A lot. I see that a lot. Yeah.

Dr. Tim Stone: A brace that's been locked to 30 degrees. It's that...

Dr. Yoni Rosenblatt: Or locked to 30 degrees? 

Dr. Tim Stone: Right.

Dr. Yoni Rosenblatt: Yes, you're absolutely right. Or the brace just isn't sitting right, or they're falling asleep with an inflection. I mean, those braces do not hold them in terminal extension. It prevents flexion. It's not holding them in terminal extension. The athlete is gonna die to find that slight knee bend. So just make sure that it's placed appropriately. That's why the supine hang is so important.

Dr. Tim Stone: I'll tell you one thing I feel like that has helped me regaining hyperextension, is the ability to effectively manipulate and fix a brace that's not fitting properly. I think it's like an underappreciated skill to have, to get someone into a... Not just grab the front of the straps and just rip them across so that the joints end up on top of their knee, but to be able to tighten it evenly from the back, and then evenly from the front so that it's like firm and snug, but those like, the joints or the center points on the brace sit right at the center point of the knee. And then also on top of that, I'll occasionally add a folded up towel at that last strap underneath the heel, which will elevate them within the brace into a slight bit of hyperextension. And I'm locking their brace at -10 degrees of hyperextension.

Dr. Yoni Rosenblatt: Yeah, at the video.

Dr. Tim Stone: Not zero degrees.

Dr. Yoni Rosenblatt: And they never come in like that.

Dr. Tim Stone: No, never come in like that. Usually they come in and their brace's at zero and they have an ice pack that's strapped to the leg on top of all of this material that they have surrounding their knee and none of the straps fit because when they got home, they hurt. So they loosen them up. And every time they put on and take off the brace, they don't unclip it. They change the length of the strap. So being able to communicate how important it is to only take off the unbuckling portion of it. So the length of the straps remains right, but then also being able to execute a really good brace fitting has really helped prevent some of those flexion issues. There's nothing worth getting your session. You've talked about all this stuff, put the brace back on the crotch out and you can just see them crutching out with 10 degrees of knee flexion is awful.

Dr. Yoni Rosenblatt: No question. And so those blood sore joints that you described, it's not a great measurement. So it's definitely not -10 degrees. And zero is probably 10 degrees of flexion. And so putting them there and making sure that that brace fits appropriately. And if there are any MAs or PAs that are listening to this, please put that blood cell at -5, I think it's five, maybe it's 10 -10 degrees. So at least it's trying its best to hold it in terminal extension. That's the only purpose of the brace. Okay. When are you pushing the panic button and calling the doctor to say, hey, this is too stiff.

Dr. Tim Stone: Yeah. So I think I'm communicating once a week with the physician. I might even just drop at the end of the email, like no need to reply just so you're not blowing them up and having them think you're the most annoying PT ever. But I'm just giving them an update on what they hit. Okay. So by two weeks, if they're not getting it, then the doc knows that this is gonna be... It's a little bit slower.

Dr. Tim Stone: But there's some pretty good research out there that says, if you don't get it by six weeks at 12 weeks, you don't have it. And at 12 weeks, if you don't have it, you're never gonna get it. So at six weeks, I'm sending the email saying, hey, look, we're gonna carry on, but I just wanna let you know like, I'm probably sending this person back to you within the next like week or so for you to assess it, maybe try something or we're ordering a low load, long duration device that will hold them in that for that extension position for a long period of time, but most likely this is person... I don't even know what the research is. If you don't have it at six weeks, like you're not getting it, you're just not getting it.

Dr. Yoni Rosenblatt: You're not getting it. And if I've seen them from day one, I would say... I would do it sooner. That doctor needs to hear from me that I'm really worried about it at three weeks. And then let me ask you this. What are you hoping the doc does? So they're gonna order a splint. What else can they do? 

Dr. Tim Stone: Scope it.

Dr. Yoni Rosenblatt: Scope it, get in there before it's too late. So we've seen a ton of success with airing on the side of a scope. Other things that I've seen work, I don't know if it worked, but the patient made it out was prescribing a Medrol Dosepak. Maybe that helps. I've seen some doctors inject a knee with cortisone. I recently did an awesome interview I thought, with Dr. Bassett up in Jersey, where she talked about draining the knee almost routinely and at their first follow-up visit. So you're talking like a week post-op. They go back to the doc. She's pulling all the fluid out so we can get to the terminal knee extension. I haven't seen any other doc doing it, but she had a crazy statistic of, I think having zero...

Dr. Tim Stone: Yeah, I thought it's awesome about that.

Dr. Yoni Rosenblatt: Lysis of... Yeah. And so that is just awesome. When you're waffling, "Oh should they go back in?" I know you said how painful it is for you to send the email saying they don't have terminal knee extension, but it works when they go back in and they do a lysis, it works. And so do it sooner rather than later and fight for your patient. That's what this whole thing is about. I just had this conversation with a PA where his patients were suffering because he was waffling. We need to take the ego, throw it aside, get your ass back into that knee and scope it if necessary, or some type of intervention, don't just let them flail and hope it gets better. I think that's fine for your gen pop, it's not for the athlete.

Dr. Tim Stone: Yeah. I would say, yeah, we're hit... You're trying to get the littlest neediest grittiest things back 'cause it's going to make a massive difference for them. So I would say on top of that, don't be surprised if the doc wants to wait for like 10 to 12 weeks for things to just settle down and for that knee to heal. I don't know if like it's more appropriate or not to go in earlier. Some docs I talked to say yes. And then some docs say that they don't wanna do two surgeries in a short amount of time, just due to like the same reasons why you don't wanna send them into surgery with an angry knee, you want a nice quiet knee. I don't know, in my opinion, like it's angry if it's not hitting extension, there's a lot of inflammation going around. There's a lot of scar tissue developing. It's not gonna get less angry. But I would say too, like if you make that email and you send that patient back, you better have done what we had talked about before in prepping the family and prepping the patient and prepping the surgeon that you're gonna see this person the next day and you're not even going to see them the next day, you're gonna see them five days a week until they get that motion back because there's no third surgery.

Dr. Tim Stone: There's no antidote after you use that option, particularly, right? Maybe there is, but chances just go down and down. Now you are getting to this space where you're just...

Dr. Yoni Rosenblatt: In trouble.

Dr. Tim Stone: Doing too many surgery, so you got to... One, hold yourself accountable to get it there in that first week, possibly the second week. Two, if it doesn't get there, be humble enough to reach out and send them back. Three, if you make that call, you better freaking know what you want to do afterwards so it doesn't happen again, because if it happens again and you just sold the parents and you just sold the surgeon on doing this for the patient. You f them. You didn't really leave them many options after that.

Dr. Yoni Rosenblatt: Yeah. The good news is after a lysis, the protocol and the program is exactly the same.

Dr. Tim Stone: The same.

Dr. Yoni Rosenblatt: It's the same, except you got to see them that day. And then you got to see them five days in a row. Quick shout out to one of our favorites, Dr. Dries, because he really taught me that. And he called me, I remember after he had just gone in back into a girl's knee, she was struggling elsewhere in rehab. He called me on a Saturday night and said, "Hey, right before sundown on Friday, I went into this girl's knee. What's as soon as you could see her?" And I saw her that Saturday night, that's not me being heroic. That's the doctor saying, I'm sending her to you. You have to see her within 24 hours because this is our window. And so get ready for five days in a row of rehab. And only if she has achieved terminal knee extension do you then start cutting back on rehab. I think that's... Yeah, that's super important and often missed. This pulls me back to the idea, and there's some good literature on this with the shoulder and how to...

Dr. Tim Stone: What is that? 

Dr. Yoni Rosenblatt: Shoulder.

Dr. Tim Stone:
I've never heard of it.


Dr. Yoni Rosenblatt: Shoulder. So when you're dealing with a shoulder, there's some studies looking at tendonitis and comparing one cohort of therapeutic exercise, manual therapy, and their outcomes. This is following tendonitis compared to therapeutic exercise, manual therapy, and ultrasound. And the ultrasound group did worse than the other group, but why is that? The reason we think is because it's how you're using your time. If you're wasting 8-10 minutes waving a wand on someone's shoulder, you're not doing what you should be doing. I say all that to say, as it pertains to the knee, don't spend your time doing clamshells and doing straight leg raises and doing lateral band walks when the problem is extension. Because if you spend time doing things that are not extension, you're not spending time doing extension. And that's what they need.

Dr. Tim Stone: If you can't develop glute med strength in a nine month period for a joint that hasn't been affected...

Dr. Yoni Rosenblatt: You'll be fine.

Dr. Tim Stone: And you need to start week one to do it, you got to reassess the way that you're going about this thing. Right? 

Dr. Yoni Rosenblatt: Yeah. Yeah.

Dr. Tim Stone: Contrary to what I think sports PT was saying before is that we wanna make them work out and feel like an athlete again. Well, guess what? They don't feel like an athlete when you rub it in their face on the first week, trying to get them to do these sweaty exercises at their hip when it has nothing to do with their knee, you just increase a confusion about what's going on. You certainly increase their confusion about where they're at in their process and where they think they're at in the process. "I'm killing it. I'm sweating. I'm working hard. I'm doing everything I can." You haven't moved the needle from day one on the extension. You haven't gained anything. You haven't worked your way towards those goals. So, yeah, drop that crap out of there. We don't need that hip stuff early on.

Dr. Yoni Rosenblatt: We don't need it. You're exactly right. And you're hurting your patient. Okay. That's a huge amount on the extension. I feel like we could do another hour on the extension. By the way, we jumped to hip to say, hey, don't spend so much time on the hip. It might be even more poignant to say, don't even waste time on...

Dr. Tim Stone: Flexion.

Dr. Yoni Rosenblatt: Flexion. Stop working on flexion. I've heard orthopedists question our profession to say, I don't know why these therapists are so focused on flexion when you'll get flexion, we need to get extension. Don't spend your time on that, which isn't their problem. Do you have an idea as to where this flexion bias came from? 

Dr. Tim Stone: I think to me, it's just from a broad visual sense at what the knee does. If zero degrees of extension is nothing, like you just think of it as nothing, it's not moved anywhere, that's the resting place of the knee, then anything that you should be moving in this, in the direction of improvement should be in the bending category. Because your...

Dr. Yoni Rosenblatt: Knees bend.

Dr. Tim Stone: Yeah. Your knees bend. Exactly. We don't think of knees as starting bent and having to get straight. So I think that's maybe predominantly where, just from a face value that came from, I think. And the reason why I think that too, is patients think that. Patients feel that it's important to do flexion and think that that's important. And that's just like somebody that doesn't have an understanding of how this thing goes. So I think that's probably all I can... Maybe it came from the total knee section, but those people also still benefit mostly from regaining extension. Functionally as humans, we can live without some flexion, but we can't really function well without full terminal knee extension or has drastic implications for the knee. So I think that's where it popped up, but I don't know. I haven't...

Dr. Yoni Rosenblatt: But we're gonna change that. We're gonna change that.

Dr. Tim Stone: I think that's been debunked. I think it's been changed. I think that shows many times in research, I think the practical application of it hasn't met what those case studies and research has kind of shown. And I don't think we... I think we value extension, now, I think the lay PT for the most part now values hyperextension, maybe not hyperextension yet, but they value extension. But I don't think they understand the scale at which you should work on extension to flexion or what, so the ratio in which you should do that. So I'm a firm believer of all range of motion should be a lot early. So I do think you should work on flexion a lot, but if someone were to say like if I have 24 hours in a day and you wanna split that out, how should I split it up working on extension versus flexion? I would say you should work 20 hours a day on extension and you should work four hours a day on your flexion. That's probably a good ratio right there. I don't think in a 45 minute session or in a 15 minute session, depending on what PT cleaning you're at, we're appropriately dosing it.

Dr. Yoni Rosenblatt: Weighting it.

Dr. Tim Stone: Yeah. Which one we do more of.

Dr. Yoni Rosenblatt: Yeah. Yeah. I think there's a huge amount of value there. Okay. If you don't know how to get extension after this conversation, [chuckle] find us on Instagram, we'll show you or download our course 'cause we'll definitely show you. And there are even some more nuances and tricks that you'll get from taking our course as to how to get extension, because it's not always smooth sailing. You have to have so many tricks to get that athlete where you need to get them. But just make sure that that home exercise program is 100% extension early on. Okay. The Eric Cressey lightning round. What rehab pods are you listening to, Tim? 

Dr. Tim Stone: Ooh. Rehab pods...

Dr. Yoni Rosenblatt: Rehab Pods.Dr. Tim Stone: I'm listening to right now. I actually stepped away from the rehab pod.

Dr. Yoni Rosenblatt: What are you listening to? 

Dr. Tim Stone: You put me on Huberman recently.

Dr. Yoni Rosenblatt: Okay. It's an amazing one.

Dr. Tim Stone: Trying to regrow my hair.

Dr. Yoni Rosenblatt: I got that from [chuckle] I am too. Don't let that make you think that Huberman's not good at what he does. Okay. So Huberman Lab podcast. I learned about that from Cookie Carr. Another Stanford resident, so that's where she found him. What book are you in the middle of?

Dr. Tim Stone: The book that I am in the middle of on Audible right now. I think I just opened a new one.

Dr. Yoni Rosenblatt: Yeah. What was it? 

Dr. Tim Stone: It's $100M Offers, I think it is. Alex Hormozi.

Dr. Yoni Rosenblatt: Sure.

Dr. Tim Stone: So that's more on the business side of things.

Dr. Yoni Rosenblatt: That's good. I will take that.

Dr. Tim Stone: Leisurely, I just finished Greenlights by McConaughey.

Dr. Yoni Rosenblatt: Was that good? 

Dr. Tim Stone: Great book.Dr. Yoni Rosenblatt: Really? 

Dr. Tim Stone: Awesome book. I like it.

Dr. Yoni Rosenblatt: Here's my struggle. He's an actor. So what's he teaching me? 

Dr. Tim Stone: I don't know. He's the narrator in the book. I don't know if I learned a lot of life lessons from the book.

Dr. Yoni Rosenblatt: So what did you learn? 

Dr. Tim Stone: I was doing it from a self-help.

Dr. Yoni Rosenblatt: So what did you learn? 

Dr. Tim Stone: He's a baller.

Dr. Yoni Rosenblatt: He's a baller? 

Dr. Tim Stone: Yeah.

Dr. Yoni Rosenblatt: Okay.

Dr. Tim Stone: He's the man.

Dr. Yoni Rosenblatt: Okay. So I shouldn't judge him by his profession, although he's at the top, very top of that profession. He's got a good life lessons and he has lived a good life. I should read it, is what you're telling me? 

Dr. Tim Stone: Yeah. For sure. For sure. On the clinical side of things I think if I were to rate my favorite podcast from a rehab perspective, contrary popular belief, this would not be my favorite.

Dr. Yoni Rosenblatt: Go.

Dr. Tim Stone: Just 'cause I can't listen to you anymore. I've already listened to you all week. But I think my favorite one is a Journal of Arthroscopy podcast.

Dr. Yoni Rosenblatt: Cool.

Dr. Tim Stone: I think they... To give some critical feedback, it's a little dry. It's not an entertainment show particularly, but I've learned so much about the nuance of particularly ACL surgery, it's not just sticking a graft into the knee. Like, there's so much going on in terms of like the meniscus or different techniques to doing that. As easy as different graft selections, how ELLs will implicate the rehab of a knee and all those kinds of things. So, I just learned a lot from a... I think you gotta go back as far as you can to kind of move forward, understand like why things are happening in our world. So that one I think is my favorite medical podcast.

Dr. Yoni Rosenblatt: Yeah. Okay. That's awesome. I gotta spend more time on that. What's the biggest difference between US and Australian physios? 

Dr. Tim Stone: I never practiced as an Australian physio, so, I would be taking...

Dr. Yoni Rosenblatt: But you are an Australian physio.

Dr. Tim Stone: Oh, no, I'm American.

Dr. Yoni Rosenblatt: You're an American? 

Dr. Tim Stone: I'm an American.

Dr. Yoni Rosenblatt: Okay. But you're also Aussie.

Dr. Tim Stone: I think...

Dr. Yoni Rosenblatt: Did you have to renounce your citizenship? 

Dr. Tim Stone: Absolutely not.

Dr. Yoni Rosenblatt: Absolutely not. Okay.

Dr. Tim Stone: Allies.

Dr. Yoni Rosenblatt: Okay. Allies. [laughter] I like that. Yes. Fighting the good fight. So what would you say the biggest difference in terms of the way PT is practiced here versus down under?

Dr. Tim Stone: Yeah, so I think from what I see, I think it's model based on their healthcare system a lot. So, it's more of a socialized like medicine approach. So, for one, it's quite difficult to get in to see a specialist. You have to wait quite a long time to do that, or you can go privately, but then the price has increased a lot. So I think that's one. So we're talking about like the timing and of all this stuff, that's a massive implication for how they're gonna rehab their patients. I think secondarily, I don't think they see the frequency of visit that we do with our patients. 

Dr. Yoni Rosenblatt: A lot of education.

Dr. Tim Stone: It's a lot of education. It's a lot of one time a week, a lot of, like two times a week at max. I don't think their insurance, because it's so broad of everyone allows for the benefits that our private payer insurance is doing. And that's not a plug for our private payer with your insurance at all. But because our premiums are 30 times the cost of what it is to live in Australia. And then I think the last point of this is the access to the type of patient that they're treating. So I think we're really really fortunate to have a college-based sport system here, which results in a massive amount of ACL test for one, but competitive athletes that are willing to come in four or five days a week that wanna do that. So I think we get a lot of reps and there are a lot of sports PT businesses in the field, so there are some really awesome sports physios in Australia. They're amazing and in the top of their class and I would, and argue also like the best in the world, but I think it's just a smaller pocket of the ability to be able to work with like those, that caliber of an athlete on a day in day out basis. So, I've heard that as a feedback too. I think too, they only really do hamstring recons there for the most part. So they're rehabbing a little bit of a different ACL than what what we're used to more often than not, but...

Dr. Yoni Rosenblatt: Very interesting.

Dr. Tim Stone: Conceptually I think their strength and conditioning is unbelievable. I think from a research standpoint, they're also batting well above their weight in terms of the size of the country and the dollars and cents are able to put into research and things like that, and the quality of the PTs is really good. I think it's favorable to be here to do it because it's just so much more access. Like, it just seamless.

Dr. Yoni Rosenblatt: Interesting.

Dr. Tim Stone: I never would've imagined being able to treat 10 lacrosse ACLs in a row in a day. And I do that a lot. I do it a lot.

Dr. Yoni Rosenblatt: Yeah. That's pretty wild to think about. I mean, what I learned from like my sport and society class in my undergraduate studies was how active the Australian population is. There is a tremendous amount of sport. I think the color you give behind socialized medicine and how that dictates their interventions is really interesting. It's worth studying. Well, what was the toughest question on your citizenship test? 


Dr. Tim Stone: I already blocked that out of my mind.

Dr. Yoni Rosenblatt: Come on.

Dr. Tim Stone: I got super lucky and three of the responses out of the six that I had, that I got all right.

Dr. Yoni Rosenblatt: Hell yeah.

Dr. Tim Stone: Where the president was the response, so...

Dr. Yoni Rosenblatt: Just the president? 

Dr. Tim Stone: That was the response. I almost started second guessing myself like this is...

Dr. Yoni Rosenblatt: How can this be? 

Dr. Tim Stone: This is a trick questions.

Dr. Yoni Rosenblatt: What'd you get on that test? 

Dr. Tim Stone: Six out of six.

Dr. Yoni Rosenblatt: It's six questions? 

Dr. Tim Stone: So yeah, so I think, and I might be saying that there's a total number of questions that they can pick from. I wanna say it's like in between 100 and 200 questions. And so basically if you can go ahead and learn or rope learn all of them the response flashcards, being back in anatomy class...

Dr. Yoni Rosenblatt: Did you do that? 

Dr. Tim Stone: 100%.

Dr. Yoni Rosenblatt: You sat there with Les and you went over flashcards? 

Dr. Tim Stone: 100%.

Dr. Yoni Rosenblatt: Did she know all the answers? 

Dr. Tim Stone: She actually was very, very, very good at them without looking and then she has just an incredible ability to read and digest information and pick it up the first time. So I'm sitting here like an idiot, looking at the same five cards that I keep getting wrong. Just again, look, write, turn it down, repeat, she's one time.

Dr. Yoni Rosenblatt: That's amazing.

Dr. Tim Stone: Every time she can kinda get that stuff, so.

Dr. Yoni Rosenblatt: Yeah, my wife's the same way, which is why she was my tutor in undergrad.

Dr. Tim Stone: Yeah. [laughter] Exactly.

Dr. Yoni Rosenblatt: That's pretty wild. Okay. How do you feel about sci-fi movies? 

Dr. Tim Stone: Terrible.

Dr. Yoni Rosenblatt: You feel terrible about them? Dr. Tim Stone: Yeah, I'm more into the darkness and...Dr. Yoni Rosenblatt: It's really sick.Dr. Tim Stone: Of serial killers.Dr. Yoni Rosenblatt: You like serial killers? Dr. Tim Stone: I love that stuff, I hate fantasy. I think this is a running joke within our clinics.Dr. Yoni Rosenblatt: Lord of the Rings. Aren't you a big Lord of the Rings guy? Dr. Tim Stone: I hate dragons, I hate fairies, I hate wizards and emperors.Dr. Yoni Rosenblatt: You just hate fun.Dr. Tim Stone: No, I'm like, "Bring me back to the real world."


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