Keeping Knees Healthy #219

Dr. Linc Avery:

How do you modify things and keep people going while they get to that goal? And then the other part is okay, if you've had an injury, how do we get you back?

Dr. Kirsten Buchanan:

The knee is just the unfortunate joint that is stuck between the feet and the hips.

Dr. Lisa Belisle:

Healthy knees are an important part of staying active. Known as hinge joints, they keep us walking, running, pivoting, shifting and bounding up stairs. Today we speak with orthopedic surgeon and sports medicine specialist Dr. Link Avery and with Dr. Kirsten Buchanan and Matt Kraft of the University of New England Physical Therapy Department about the newest happenings in the area of knee injury prevention. Thank you for joining us.

Dr. Lisa Belisle:

This next individual is a friend of mine that I've known for a little while and I guess first I knew him as my surgeon. He is Dr. Lincoln Avery. I call him Link, an orthopedic surgeon at Maine Medical Partners Orthopedics and Sports Medicine. He is the division leader of Sports Medicine. Thanks so much for coming in and talking to me today.

Dr. Linc Avery:

Well, it's nice to meet you here,

Dr. Lisa Belisle:

Lisa, and thanks for fixing my knee all those years ago.

Dr. Linc Avery:

It's nice to see you're not limping too much.

Dr. Lisa Belisle:

Yeah, right. Well, I know that's always the thing. If you're the person who does the fixing and then the person breaks again, then it kind of makes you not look quite as good at your job. Right, Exactly. Yeah, but. But I'm not limping. My knee has worked perfectly fine. So I'm interested in talking to you about knees. And in part, I know that this is one of your specialties is the knee, in part because it's. It really has been. It can be very disabling for people in my line of work. And I'm talking more older people. When I try to get people to be active and they say, well, I want to be active, but I have this knee injury and I can't do a lot of walking, never mind running. We can't even get to that next level of fitness. We can't even get to just the basic level of wellness. And some of these injuries started when they were younger. And that's kind of where you come in. You can actually help people with their wellness by helping stave off some problems as they get older.

Dr. Linc Avery:

Yeah, I mean, you know, there's a full range. You can have. A very common scenario I see are people that come in middle aged, they're very heavy and they're trying to lose weight because obviously they're working on their overall wellness. And the first thing they do is start to jog or go for long walks. And because they're heavy, their knees wear out sooner. And now you've got a bad knee and you're heavy and you can't exercise. And, you know, they see someone who's a surgeon says, okay, you need to lose weight and do this, this and that. And they're saying, well, how am I supposed to do that? So some of it is, how do you modify things and keep people going while they get to that goal? And then the other part is, okay, if you've had an injury, how do we get you back as good, if not better than before? And very often we can get you back better to let you get back to those activities that you love doing.

Dr. Lisa Belisle:

I have a special interest in, not only because I had my own knee issues, but in the knee, because my daughter had an ACL tear when she was in high school and she went through this enormous rehab process. And now they're doing work with ACL prevention, ACL rupture prevention. And I like where this is going. I like that we're actually getting to the kids before they end up having these catastrophic, potentially let's call it career ending even though they're in high school, but definitely life impacting kind of injury. Talk to me about that.

Dr. Linc Avery:

Well, you know, it's really interesting because there was a real epidemic of female greater than male ACL tears. And you know, if you look back 10 years ago, particularly in basketball, basketball was like 10 to 1 female versus male. Soccer was twice as much. I mean there were sports where women were clearly getting injured tearing ACLs specifically. And so, you know, everyone started to research this and going, oh, is it because their hips are wider or is it hormonal changes or different center of balance, et cetera, et cetera. And there are all sorts of theories and it looks like what's happened is that it's a neuromuscular control issue and partly related to the width of the pelvis that women have over men, but that their hips are weak and so that they set up bad biomechanics. And what you're referring to is that there's a program where you can actually prophylactically treat athletes to use their knee in a correct biomechanical way that drastically in the order of 80, 90% decreases the risk of an ACL tear and it can become motor memory and, and obviously very, very effective and preventative.

Dr. Lisa Belisle:

So where did this epidemic come from? I'm assuming that it's not like there's something different about biomechanics that shifted over the last so many years.

Dr. Linc Avery:

Yeah, I mean it's, you know, you look around, what are some of the things that are different versus when? Well, when I was growing up as a kid, number one is much greater female participation and number two is sports are starting earlier and, and particularly families are really devoting themselves to having their child get often year round coaching and experience in one sport to really focus on that. So the level of injuries are harder and higher for that age group than they were 10 years ago. And we've got a greater mix of female athletes.

Dr. Lisa Belisle:

So as I'm thinking about my own daughter who had her ACL injury, she had her injury in lacrosse, but she's a three season athlete. She was also a soccer player and a swimmer. So she wasn't. We didn't have her doing, except for swimming, which shouldn't have an impact on the knee. We didn't have her doing the same sport year round, but her father had an ACL injury. Does genetics ever play apart?

Dr. Linc Avery:

We're not really aware of that. There's an ACL tearing gene at this point. No.

Dr. Lisa Belisle:

Well, I think about knees in general because, you know, they are this big hinge joint. You can kind of injure your hip and get away with it. If you injure your foot, you can be put on crutches for a little while, but you can limp around quite a long time on a bad knee and just keep doing damage on top of damage on top of damage. What has your experience been with this?

Dr. Linc Avery:

Well, you know, as you said, the knee's a very vulnerable joint. I mean, it's in the middle of these two long lever arms. So it's exposed, it doesn't have a lot of bony protection. It's all soft tissue holding it together. So between leverage or contact, it's very often the first thing to go. But because it's a weight bearing joint and, you know, hips and knee and feet injuries are, you know, can be just as debilitating. They're just not as dramatic because when someone limps in and they can't move their leg, you can see it across the room. But you really need, you know, that 98, 100% of your knee to really be competitive. And so it seems to be a very sensitive joint in terms of what it can tolerate and what it can't tolerate.

Dr. Lisa Belisle:

It also seems in the patients that I care for, that weight has a tremendous impact on the knee and even fluctuation of 10 pounds or so can change the, the way that somebody experiences perhaps an old injury.

Dr. Linc Avery:

Yeah, that's really true. I mean, it comes down to basic biomechanics. These muscles are pulling at well over body weight loads to make these legs work. And if, for example, going up and down stairs, you put three to five times your body weight across your kneecap. So if you're 20 pounds overweight, that's 100 pounds more than a little kneecap. That's only the size of a half dollar, seeing across the whole contact area. So weight is a huge thing. And very often I've had patients that, you know, it sounds easy lose 20 pounds. But if they're 250 and they get down to 230 and they say, you know what, my knee feels better already, you know, and very often that's motivating and really makes them not only hang in there, but take it to the next level in terms of what they're doing to drop their weight and get more active.

Dr. Lisa Belisle:

When we think of surgeons, and I actually have to talk my patients through this often, because when I say I'd like to refer you to an orthopedic surgeon, they automatically believe that I'm sending them towards the knife. But that is not true. What you're describing is, let's not have somebody go through surgery unless you absolutely need to. Let's try everything to get you to a place of better biomechanics before we go that route.

Dr. Linc Avery:

Absolutely. I mean, that's part, you know. Yes, I'm an orthopedic surgeon, but I'm specialized in sports medicine. Sports medicine isn't just sports medicine surgery. It's preventative medicine. It's performance medicine in terms of how can you make someone who isn't injured achieve a better level with sports? I mean, these are all aspects of sports medicine.

Dr. Lisa Belisle:

The sports medicine program at Maine Medical center actually came to be just after I went through my own residency with the family medicine program. And it is affiliated with the family medicine program, which I find interesting because it's kind of acknowledging that primary care doctors do have sort of a touch point within the sports medicine field. And you're working with family practice doctors and primary care providers as you're providing sports medicine care.

Dr. Linc Avery:

Oh, yes. I mean, Bill Dexter has been around for 20 years with the family medicine sports program, and he and I have literally moved into the same house at this point because of that interaction. I mean, we both are trying to get patients better, not necessarily with surgery, but with hands on care modification, physical therapy, medications, all sorts of new biologics that are being done in terms of injections and other treatments. So surgery's clearly the last resort. Now, there are times where it's very obvious that it's the only way to go with a dramatic injury. You know, as you said, an athlete with an ACL tear. There's no studies that really say you're going to do very well with that bracing or whatever if you want to stay the same level. But anything we can do to prevent surgery and to get people functional is clearly the right way to go.

Dr. Lisa Belisle:

With acls, there is the possibility that if somebody doesn't want to return to, say, a high level of play, if they don't want to go back to being a skier, you could decide not to repair an ACL if it wasn't completely ruptured, Is that right?

Dr. Linc Avery:

In that case, yes. I mean, the ACL is a stabilizer for sports that require plant and pivot, changing direction quickly, activities, jumping down on the knee, decelerating, those kind of things. I mean, my famous story is I've Patient who I met in the late 1980s who was a marathon runner and he tore his ACL with a fluke injury at home. That was unrelated, but all he does is run distance. And he talked to me about, hey, I don't want to do ball sports, I don't want to do agility sports. I'm not a big hiker, I just like high mileage asphalt running. And I said, sure, let's try it, see what happens. And I saw him probably five years ago for a different issue and I said, hey, would you mind if I get an X ray on your knee? I want to see what's going on and just update that. And he looked great. I mean, there were no arthritic changes. He hadn't had any instability. He was coping simply because he wasn't doing activities that he needed an ACL with.

Dr. Lisa Belisle:

So the acl, the anterior cruciate ligament, is one of four ligaments in the knee that can cause, potentially cause problems. There are also problems with meniscus, with the meniscus, which is also. Which is kind of a cushioning element of the knee.

Dr. Linc Avery:

Yeah. The menisci are C shaped cartilages separate from the joint. Cartilage that are like the lip of a dish. They support the edges of the joint, they take about a third of the load that each knuckle bears and weight bearing in the knee. And then essentially they're shock absorbers with a small amount of stabilizing function. But because they're shock absorbers, just like a shock in a car, they can wear, wear out, or rip or tear or get injured.

Dr. Lisa Belisle:

And again, this is the sort of thing that sometimes if there's a tear, sometimes people notice it, sometimes they don't. Sometimes you fix it and sometimes you don't. Kind of depending upon what type of activities people want to participate in and the severity of it.

Dr. Linc Avery:

Activities and the tear itself. I mean, these tears can occur in any conceivable geometry and location on the meniscus. For example, a horizontal tear, which is a tear like you're slicing a bagel and just literally slicing a portion of the meniscus. So it's almost like a mouth. Very often patients can tolerate that and go on with life with no change in arthritis and no significant change in function. Now they're not playing for the NBA, but they're doing recreational sports, they're working out, they're active, they can ride a bike around the world. I mean, there's lots of activities you can do and never have symptoms. So those are the type of People that we try not to operate on unless they're having pain, that's, and that's frustrating for the patient in terms of not doing the things they want to do.

Dr. Lisa Belisle:

When we think about the knee, we have to think about the other parts of the body. We have to think about maybe whether the muscles, maybe the hamstrings aren't quite right, maybe the gluteus muscles aren't quite right. How do you, when you're doing an exam on a patient, walk me through your kind of mental process?

Dr. Linc Avery:

Well, the mental process actually backs up to the history. So taking a good history and listening to what the problem is, how active was the patient, what is it they're trying to do, what are they really describing? And you know, it may be a knee symptom, but as you listen to it, it's clear that maybe something else could be going on. So you watch. I'll have a patient walk down the hall and just watch. How are they using their feet? How are they using their ankles? How are they using their hips? We test their joint mobility, we test their joint strength above and below the knee itself. Just because these all can be a big factor. And just like we were talking about with the ACL and hip weakness and lack of hip control, very often standard old kneecap pain, housemaid's knee, or very common sort of teenage girl malady where you knees track a little bit abnormally and get pain in the front of the knee. Hip strengthening can make a huge difference and in those symptoms. So it's just one example of how the knee bone is sort of connected to the hip bone, et cetera.

Dr. Lisa Belisle:

What I've noticed in my own experience with physical therapy is that and other modalities is that orthopedics and sports medicine have increasingly been borrowing from various other practices. The physical therapist that I have seen, it's not just exercises, it's not just flexibility work. She's actually doing some hands on manipulation of my joint. So this is interesting that there has been this evolution that you're able to say, oh well this works over here, so let's bring it in and use it over here to get the patient better.

Dr. Linc Avery:

Yeah, I've seen that as well, that the good therapists now are very hands on and it seems to make a difference. It makes a difference in terms of appropriate mobility of all the tissues in a complicated joint. It makes a difference in terms of flexibility, preventing injury. It makes a, a difference in terms of, you know, particularly for me as a surgeon, the cases that I send to a Physical therapist, they're at risk for scar tissue. And scar tissue very often can be prevented by a knowledgeable physical therapist that can sense when that's working, when it's happening, and loosen that up with hands on work. And there's a whole subculture of there are all these semi medieval smooth metal tools that are used to really literally distend and stretch out some of these tissues very aggressively. That is a real science and it's made a real difference, particularly with soft tissue injuries like it band tendonitis, which is a common running malady, the kneecap we talked about, Achilles tendonitis, et cetera, et cetera. But yes, I think that certainly is a field that has grown within the culture of physical therapists.

Dr. Lisa Belisle:

They're also using things like ultrasound and electrical current. And I mean, it's really been amazing to see what types of things are being brought in to accelerate tissue healing, which is kind of different than, I guess, when I was first a medical student, the whole idea was Rice. It was rest, ice, compression and elevation. Some of which seems like it still works in some situations, but not always and not in every situation.

Dr. Linc Avery:

Yeah, I mean, that's sort of the mantra for an acute injury, but 10 days later, okay, where do we go from here? And rice isn't really going to be as helpful for that. And that's again, that's where a good therapist can be invaluable in terms of recognizing how hard to push a patient, how, you know, what's a good pain, what's a bad pain, what, what mobility is going to be a step forward and what pushing and pain mobility is going to create enough pain and inflammation that's a step backwards and going to lead to scar tissue, for example. So it's a tremendous art. I don't really understand how they do it as well as they do it. And I really appreciate it just because it is a little bit of a mystery to me. But I can tell you that I, you know, there are a number of really qualified people in this town and in this state that make a huge difference in terms of, you know, you take the same patient with the same malady or the same surgery and you can get totally 180 degree different results based on how they're treated, recovery. And I'm a huge utilizer of physical therapy. I know there's doctors that with routine, for example, knee arthroscopies, they'll give the patient some home exercises and off they go and they never see them again. And some of those people do do great, but I get to see the people that didn't do great who come to me and say, hey, what happened? And, you know, I find just anecdotally and in my own experience that PT is invaluable.

Dr. Lisa Belisle:

I have two siblings that went into orthopedics, which, of course, you know, I have nine brothers and sisters, and many of us are doctors, but two of them happen to be orthopedic doctors, which I find fascinating because one is a shoulder specialist and one is doing a sports medicine fellowship. Fellowship. It's a remarkably difficult field to actually get into. It is a very competitive field, and it has just blown up over the last, I would say 20 years or so.

Dr. Linc Avery:

Certainly in the last 10 years. I mean, it's been so popular that therefore it's become so competitive. The good part for me being on the other side that I'm in it is some tremendously qualified people are making it through and really bringing a depth of knowledge and integrity, which is really nice to see. But, you know, sports, as I said earlier, are much more ubiquitous now, it seems, particularly through the ages. Younger patients, but also older patients. You know, you can kid and say weekend warriors or whatever, but, you know, people are doing more activities much later into their life. And this is all part of sports medicine. And so it's easy to understand the appeal.

Dr. Lisa Belisle:

What was your appeal?

Dr. Linc Avery:

The greatest satisfaction for me, you know, number one, I understood it because I was an athlete or am still sort of an athlete. But more importantly, the satisfaction of helping people. You know, getting somebody back into the level of competition or even at a higher level than they were before they were injured or before they develop symptoms. The smile on that person's face, you know, shake of the hand at the final visit and the gratefulness. I mean, that's what makes me go to work every morning.

Dr. Lisa Belisle:

So you describe yourself as was an athlete. Maybe you still are an athlete. What was your past and what is your present?

Dr. Linc Avery:

I was a big skier. I was a collegiate ski racer. Wintertime was important for me, but, you know, all that I was baseball, football, I did a lot of cycling. And some of these things have just taken. I'm still active with skiing and on ski patrol and things like that, but obviously I've got a real job, so I can't do it anywhere nearly as much as I. As I want to, and I probably need to.

Dr. Lisa Belisle:

You also have worked with the US Ski Team?

Dr. Linc Avery:

I do.

Dr. Lisa Belisle:

So tell me what that's like to be living here in Maine and also working with the US Ski Team. What types of. Well, first of all, are there different injuries at a lower level than there are at a higher level of competition?

Dr. Linc Avery:

That's a complex answer. And again, I've seen some huge. I've been traveling with the US ski team since 1989, and the level of science has increased to the point that these athletes are just in tremendous shape when they used to be just kind of getting in shape by skiing. And I'm exaggerating a little bit, but the conditioning, the workout, they're working year round, they take it seriously. You don't have to tell them at the end of the day when we've been up on the hill for six hours that they then go to the gym and lift and just incredibly motivated and in incredibly good shape. And, you know, male and female across the board, there's been a huge increase in interest in that. And that's frankly why the US has been such a power in skiing in the last decade. I mean, there have been some real stars that have worked through the science of performance in terms of skiing specific conditioning, and, you know, it's been fun to watch that. So the problem with that is they're now competing at such a high level of, you know, speed and efficiency that when they do get hurt, when they do crash, it's usually a bad one.

Dr. Lisa Belisle:

We've also had some success with Olympians coming from our state, which is kind of interesting considering that, you know, we have a relatively small population and we're relatively high up on the coast. What do you attribute that to?

Dr. Linc Avery:

Well, well, with skiing, obviously the mountains, so that's an easy one. There's a lot of exposure. Skiing is difficult in the East. A lot of ice, a lot of conditions that are very similar to what racing is like all the time. So we've seen a lot of New Englanders. I mean, currently there's a girl from New Hampshire on the team. Kirsten Clark was from Raymond May, who you may be referring to. So I think part of that is just being exposed to some really good performance related mountains locally. But it depends on the sport. You take a summer sport like baseball, we have a hard time with that versus teams that are playing, you know, 365 outside down in Florida all year. But the winter sports, I think we tend to do well. Water sports, we tend to do well. And then any indoor sports, it's a wash.

Dr. Lisa Belisle:

I remember when we brought Julia Kluge in and interviewed her, she essentially was kind of alone in her sport. She came down and did a tryout thing here in Portland for the luge and she got the bug and she really had to be very independent and go off and her family supported her and basically this became her life. And I wonder if there's also some sort of work ethic that also Maine is familiar with that even if you're not, you don't have a big mountain of skiers to ski with you. But maybe there's some frame of mind,

Dr. Linc Avery:

you know, I think that may be true. Just New Englanders tend to be sort of just because you're dealing with adversity and weather and conditions, you know, there's a little bit of chin up hardness to drive that. But I do see that the whole family commitment that you referred to, you know, that it's not just the athlete, it's the whole family saying, okay, we all need to get behind you to make this thing happen. Not just financially, but in terms of emotional support and time and, you know, every weekend going to tournaments or going this, this and there. And I think that that's some of the main spirit, you know, the sort of family unity and the sense of really protecting what's around you and trying to achieve your goals.

Dr. Lisa Belisle:

So you have, you've been in the business for how long now?

Dr. Linc Avery:

A long time.

Dr. Kirsten Buchanan:

Long time.

Dr. Lisa Belisle:

Okay, good, we'll go with that. And you'll probably be in the business maybe another.

Dr. Linc Avery:

Another ten years anyway.

Dr. Lisa Belisle:

Ten years, anyway.

Dr. Linc Avery:

God willing. Yep.

Dr. Lisa Belisle:

What do you hope to see happen over that period of time?

Dr. Linc Avery:

In terms of what?

Dr. Lisa Belisle:

Well, I guess you can answer the question any way you want. I was thinking about sports medicine, but, you know, how do you hope that things will move along?

Dr. Linc Avery:

Well, my first response to that is, okay, what about in my field? And there is just so much exciting research that's going on with what we call biologics, where you're recreating structures either through stem cells or viral engineering. And instead of us using, for example, a cadaver graft to replace an ACL using a form of silk that is then impregnated with a virally engineered collagen producing virus. And you make an ACL without having to rob Peter to pay Paul that, oh, by the way, it's stronger than a native ACL and has all better qualities. And meniscal transplants right now are all we have to try to replace a meniscus. But in the lab, there are sponge scaffolds that can be impregnated again with the appropriate cells to grow a meniscus within that structure. So, you know, I would not be surprised that, you know, in the next 20 years just as we've seen in cardiology, where things have got progressively less invasive, that who knows, I mean, there may be a shot that you get to create a new acl, you know, regrow joint surface, total joint joint replacements may be a thing of the past. This is where all the really exciting stuff is in terms of my field.

Dr. Lisa Belisle:

Well, I'm hoping that my brother and my sister, the orthopedic surgeons, will be able to put a few more years in after you're done. And we'll see some of those changes take place.

Dr. Linc Avery:

I'm sure they will.

Dr. Lisa Belisle:

Link how can people find out about the work that you're doing with Maine Medical Partners Orthopedics and Sports Medicine?

Dr. Linc Avery:

Maine Medical center has a website, obviously where we're listed. We're everywhere. I mean, we're on the sidelines covering games, we're doing performance labs, we're setting up a concussion clinic. So there's all sorts of resources that are available to high school kids and colleges very easily, but certainly the website or good old phone book and Google can do it.

Dr. Lisa Belisle:

Well, I appreciate the time that you've taken to come in and talk to us about sports medicine and the work that you're doing. I especially appreciate the work that you did on my knee because I will say it was, this was a cartilage transplant. So this was no easy and short fix. This was something you and I worked on together over the course of maybe 18 months.

Dr. Linc Avery:

I think it was unique. You were the first person I remember that we did as an outpatient. So it was usually a two or three day stay in the hospital. Yeah, you did great.

Dr. Lisa Belisle:

Well, so did you. And I'm not limping, so that's good. We've been speaking with Dr. Lincoln Avery, who is an orthopedic surgeon at Maine Medical Partners Orthopedics and Sports Medicine, also the division leader over there. Thanks so much for keeping us all active and healthy here in the state of Maine.

Dr. Linc Avery:

Thank you, Lisa, for having me.

Dr. Lisa Belisle:

Listeners of the show know that the University of New England is doing great work in the the healthcare field and specifically in the field of physical therapy. Today we have with us two individuals who are representing the physical therapy department at the University of New England. The first is Dr. Kirsten Buchanan, who is an assistant clinical professor in the department of Physical therapy at the University of New England, and Matt Kraft, who is a third year doctor of physical therapy department student at the University of New England. Thanks so much for coming in.

Dr. Kirsten Buchanan:

Thanks for having us.

Dr. Lisa Belisle:

Thank you so much. I love the idea that I recently heard you've been engaged in and that is preventing ACL tears in young soccer players and I think specifically women. But I could be wrong on this one. So, you know, tell me about that. If that's so your ACL is your knee. It's the anterior cruciate ligament. I have seen in my own practice increasing numbers of ACL tears. My own daughter was a soccer player and lacrosse player who had an ACL tear. So it's kind of, it's become a little bit of a public health issue, actually. If we want to keep young athletes fit and healthy and active, we need to keep their knees in good shape and we need to keep them uninjured. So how did you, Karesten, Dr. Buchanan, how did you get interested in this?

Dr. Kirsten Buchanan:

Yeah, well, I think that, you know, as you probably know, girls are two to eight more times more likely to rupture their acl. And so this is something that there are programs out there, preventative programs that, that can help to decrease the risk of this acl. And so they're warm up programs. And so that's. We decided that this would be a great community outreach program through the University of New England to try to get the research that's out there and bring it to the community.

Dr. Lisa Belisle:

And Matt, what's your relationship to this research project?

Matt Kraft:

To this research project? Well, I was a soccer player growing up. I've seen many ACL injuries working in some of my clinical placements through this program. I've seen a lot of ACL repairs and, you know, it's a preventable injury. And we see way too many injuries of this kind. And I think any work that we can do in the realm of prevention would be fantastic.

Dr. Lisa Belisle:

So back me up a little bit because obviously I know more about this than perhaps many people do. But I'm not sure everybody out there knows exactly what an ACL does and why it's important in the knee and how it actually gets torn.

Dr. Kirsten Buchanan:

Right. There's four major ligaments in your knee that helps to stabilize your knee. And your anterior cruciate ligament, or the ACL is one of the cruciates. So one of the ones that crosses in your knee. And it helps to, like we said, to stabilize. And it can be at a risk when people land in a more stiff way or place more pressure on that knee. So the way you move can really depend on how much pressure is going to be going or force is going to be going through that acl. And we're trying to help people move in a way that decreases the risk that it's going to be injured.

Matt Kraft:

Yeah, ACL injuries are usually a non contact injury, like a plant and pivot sort of thing. People will hear a pop and then their knee will go out. So the anterior cruciate ligament is responsible for preventing forward translation of the tibia, which means like a sliding forward of the tibia on the femur. And it's responsible for a decent percentage of that prevention. So we can strengthen the surrounding musculature and supplement that with good body mechanics. Hopefully we can take a lot of that load off of the acl.

Dr. Lisa Belisle:

So when I'm thinking about possibilities for ACL injuries, it would be if you're on the soccer field or lacrosse field and you stop suddenly and shift in a different direction than your body was originally going in.

Dr. Kirsten Buchanan:

That's exactly right. It's that pivot, plant and change direction that oftentimes, just like Matt said, it's you hear a pop, before you know it, they're on the ground.

Matt Kraft:

Yeah. It's also a very common injury in Basketball as well.

Dr. Lisa Belisle:

And what about skiing?

Matt Kraft:

Skiing, definitely. Although there are a lot more factors involved in skiing. But yeah, since your foot is fixed in that boot and the rest of your body moves, yeah, the ACL is definitely at risk there.

Dr. Lisa Belisle:

So it's not just the kids who are playing sports in Maine. It's also the. Anyone who's out there really being active, possibly on the slopes.

Dr. Kirsten Buchanan:

It's true. I think that in the, the group that we were really looking at and targeting are the girls because the girls are more likely. Yes. In skiing, I think it's not necessarily just girls who might get injured because you do have like Matt was talking about sort of this, your foot in a boot and a long lever arm of your ski that can cause a great deal of force coming up and put a lot of pressure or force on that acl. What we're really looking at are the soccer athletes and the lacrosse athletes and the basketball athletes. So that if we can help them move in a way that can prevent it or better alignment, that's going to help prevent this sort of injury from happening.

Dr. Lisa Belisle:

What is it about the way that girls bodies are formed that causes them to be more at risk?

Dr. Kirsten Buchanan:

It's a great question. They've looked research wise to see if is it something about a girl's body that is, is it, you know, a hip width situation or do they tend to have flatter feet that cause this problem or is it a hormone piece of things or what is it? And there's really no conclusive research that shows that it's one of those things. What the research has shown is that the way they move can make a difference. So there was research that was, like I said, it was done 15 years that looked at if we can get girls to land from a jump in a more absorbing, more shock, being able to land without so much of a stiff knee. That is something that can. They did a prospective study and showed they took thousands of girls in California, in Southern California and they had one group who they just did a traditional warm up. They went ahead and ran around the field and did some jumping jacks and things like that. And they took the other group and they did this injurious prevention program, this PEP program, which stands for prevent injury, enhance performance. And it's a combination of strengthening plyometrics flexibility and it's a 20 minute warm up type of a thing. And it's fairly basic exercises that you can do, but it's about landing softly and absorbing shock and teaching them about good alignment while they're Doing that. And they found in this study that of the thousands that they, that they studied, the ones who did the PET program were significantly less at risk for this ACL injury. So we thought everybody should be doing this.

Dr. Lisa Belisle:

And so who are you working with now? I know you're working with Yarmouth High School because my daughter's been working with your program and where else?

Dr. Kirsten Buchanan:

So right now we are working with the JV University from the Yarmouth team and also with the U13 girls, the travel team, the Yarmouth Colts. And we figure that's a target group if we can really get that U13, U14 girls to start moving in the correct way by the time they're in high school. Hopefully you don't see anybody that has any kind of an ACL tear.

Dr. Lisa Belisle:

And I understand that as part of this program, you actually came in and you evaluated the biomechanics of each girl. Describe that process for me.

Matt Kraft:

Well, in our motion analysis lab at une, we had the girls do some jumping tests. So we'd measure with a force plate and surrounding halo cameras, just basically the direction of force on the ground going through their legs and just how they moved, when they jumped, how they landed. And then we also took some, some measurements of, well, some strength tests, some foot drop tests just to see if they have flat feet or if they have fixed arches, that sort of thing, how far they could squat down to the ground without lifting their heels off the ground. Just very basic physical therapy assessment

Dr. Kirsten Buchanan:

data. And the hope is that from this we'd be able. UNE has this really incredible motion analysis lab, and it's one of the only ones in the state. It's just this really, like Matt was saying, it's got these great cameras all around and you can get 3D motion. So they put these reflective markers on them. It's how they do animation. And the girls, then they jumped off this box onto the force plate, like Matt was saying. And we can get a snapshot of what they look like in 3D. And then we couple that their static evaluation. And from that we get a sense of like, okay, what do they look like coming in? And then the hope is by adding and doing this PEP program, that maybe some of the forces that they land with, or maybe some of the malalignment sort of situations, that they maybe drop their knees into the inside or that they flex too much at the hip or something, once going through the program, perhaps they'll be able to bring them in again at the end of the season and have them jump again. And the hope is that we See some changes, that there's less force and that we always tell them to land softly like a ninja, and so that hopefully we're seeing softer landings and more shock absorbing and things like that.

Dr. Lisa Belisle:

I know that when I see patients in my office, I evaluate the entire chain. So it's if you have somebody with some knee problems that I'm also looking at their hip and their ankle, I'm looking at their lower back and even to some extent, sort of the upper part of their body. And it seems as though that's a real focus in physical therapy is not just to focus on the part of the body that is damaged or not working as well, but to look at the entirety of the person.

Dr. Kirsten Buchanan:

I think that's vital. I think you hit it right on the head. I think you have to look at the strength of the hip. The hip strength is so huge for these girls to be able to have that hip strength. When you look at some of the ACL injuries that take place, they take place more often in the third and fourth quarter of a game or the second half when fatigue is starting to kick in. So having that strength from the hips on down and then also having stability from the feet on up is important as well. So both of those. The knee is just the unfortunate joint that is stuck between the feet and the hips.

Dr. Lisa Belisle:

So, Matt, you were a soccer player?

Matt Kraft:

I was, yeah.

Dr. Lisa Belisle:

And you played actually at a pretty high level in Massachusetts, where you're from?

Matt Kraft:

Yeah, yeah, up and up through high school.

Dr. Lisa Belisle:

So tell me, what types of work was being done when you were a soccer player as far as biomechanics and strength, flexibility, endurance. What types of work was being done to protect knees?

Matt Kraft:

To protect knees specifically? Practically nothing. It was very old school, you know, just regular warm up run around the field, just drills, mostly soccer related drills. And there was not a huge focus on proper mechanics.

Dr. Lisa Belisle:

And so what types of injuries were you seeing?

Matt Kraft:

All manner of types. I was. I would mostly break bones. Like I broke my toe three times. Fortunately, twice it was my left foot, so I could. I could still play pretty well

Dr. Lisa Belisle:

and.

Matt Kraft:

But I did see a fair number of ACL injuries. Lots of. Lots of sprained ankles, some. Some torn ligaments around the ankles and concussions too, which is a whole other discussion, but I think some more, more work is being done in that realm.

Dr. Lisa Belisle:

So the things that you were seeing when you were playing soccer versus the things that you're seeing now as a physical therapy student, have those changed?

Matt Kraft:

Not tremendously. I don't think that a lot of preventative Programs like the one that we're implementing now are really in practice. So we're still seeing a lot of preventative injuries out there that, you know, with proper body mechanics, proper stretching, strengthening, and just general awareness can be prevented, but they're, They're. It's not happening.

Dr. Lisa Belisle:

Kirsten, you also, you're a runner, and you've worked with the Boston Marathon and you've worked with beach to Beacon. Are you seeing similar types of preventable injuries in runners? Maybe not as an ACL injury, but maybe overuse injuries?

Dr. Kirsten Buchanan:

Yeah, I think that there's, you know, certainly in runners, there's all kinds of flexibility programs that you can implement. Preventative medicine, I think, is just. It is the future of medicine. And so I think that in physical therapy is one of those areas that we need to look into preventative ways to do things. And I think in running, there's all kinds of things. You look at flexibility programs, it's very similar, quite honestly, to some of the ACL things. It's about strengthening things that are weak, and it's about stretching things that are tight. And when you're younger, you get away with a lot because you have a lot more flexibility. And then as you get older, you, you know, you start having problems where you never used to have problems before, and you wonder why that is. So, yes, gait analysis is one of my backgrounds or one of the areas that I've looked at, and people start to break down a little bit and they wonder why that is. And so if you can do more preventative things, whether that be strength, whether that be focused flexibility, you can do something to help yourself.

Dr. Lisa Belisle:

Isn't part of what you're talking about getting even kids in, or maybe adults, if they're, if they haven't already had this exposure. But getting kids used to engaging in activities that are not sports specific, but are really body specific. And right now I wonder if we have enough youth coaches out there who are aware of the body mechanics that you're talking about.

Dr. Kirsten Buchanan:

I think Matt spoke to this a little bit before, but I think that's exactly right. I think that we have a responsibility almost to some degree to be able to provide girls with this information, to be able to help them stave off these injuries, because, yeah, I think that once their knee is injured, they're more likely to develop osteoarthritis. They're more likely to have a total knee at a very early age because of all of that. So if we can do things earlier, preventive wise, then I think that makes a Huge difference. And helps them obviously down the line.

Matt Kraft:

Once somebody has an ACL injury, they are at a much higher risk for injuring that same ligament and the contralateral, the other knee. That's just what the data says.

Dr. Kirsten Buchanan:

Yeah, the research shows that. So if we can help them to decrease again decrease that risk, that's going to be huge. But I think that exercises like you talked about a little bit exercises they can do, it's a lot of core stuff, you know, things that, and there are other things that they don't have to necessarily be doing a plank. I think that getting kids to do exercises that are, you know, paddle boarding is a great core exercise.

Matt Kraft:

Any kind of anti rotation exercise would be fantastic.

Dr. Kirsten Buchanan:

Longboarding is a great core exercise. These are exercises just getting kids out there and active and doing multiple different sports as opposed to always. The specialization of just one sport is important for them, important for their health, I think.

Dr. Lisa Belisle:

Matt, what is an anti rotational exercise?

Matt Kraft:

Okay, so your abdominal muscles are in three groups. You have your rectus abdominis, which is the six pack, the beach muscles that everybody loves. You have your transversus, which kind of looks like a cummerbund. It just kind of keeps everything tucked away in there, keeps your guts in place. And then you have your obliques which kind of go off at an oblique angle, which, where they get their name and they, they allow you to twist. But really their most, their main function is to keep your core steady while a rotation force is being put on your body. So paddleboarding, as Kirsten said, is an anti rotation exercise. You're keeping your trunk stable while you're paddling away from you off to the left or the right. So that force is trying to provide a torque on your core, but your obliques are resisting that. So it's an anti rotation exercise.

Dr. Lisa Belisle:

I'm interested in general, in why physical therapy seems to have gained such momentum. It used to be, I believe that physical therapy could be an undergraduate degree and I think it still is possible to get an undergraduate degree in physical therapy. But Matt, you're getting a doctorate in physical therapy and UNE really has put a lot of emphasis on their doctoral program. Why is this?

Matt Kraft:

Well, for one thing, many states are now doing direct access to pt, so you don't need a referral from your physician anymore. You can just go directly to your physical therapist to receive treatment. And in that instance it's preferred that your provider has a doctorate degree. And there's, you know, there's a lot more information coming out. PTs are doing a lot more work doing wound care, which PTs have been doing for a long time. But just the scope of practice is broadening so much that the amount that we're learning in school really merits this doctorate level degree.

Dr. Lisa Belisle:

And Kirsten, why was it important for the University of New England to begin offering this program?

Dr. Kirsten Buchanan:

I think it was. It's just. It's being able to provide the students and the population with a degree that is going to match, I guess, what their needs are. So just trying to stay abreast with the national trend. And, you know, like Matt was saying as well, where the needs are going to be for direct access, that's where we need to be as well.

Dr. Lisa Belisle:

Each of you has an interesting background that wasn't necessarily PT related. Kirsten, you graduated with a BA in German from Colby, and Matt, you actually ended up having a degree in media studies or a minor in media studies and an English major. Can you explain that a little bit?

Dr. Kirsten Buchanan:

I think that you can. It just goes to show that you can. You can come to physical therapy from a whole bunch of different angles. Mine happened to be a German background and I was able to take a true liberal arts education in the way that I was able to take a couple of semesters and go to Austria and to Germany and to have this wonderful education and take other classes while I was also actually doing sort of pre medical classes. But I didn't have to concentrate in that. I wasn't a bio major. And so for me it was a wonderful undergraduate experience. Took a year off afterwards and took a couple of prerequisites before PT school, but I knew that physical therapy was always the direction that I wanted to go in. So German hasn't necessarily been handy in physical therapy. I use it perhaps occasionally, but not so so often. I'm not practicing physical therapy in Germany at this point anyway. I could, I guess, but. But yeah, it gave me a great broad liberal arts background, which I loved.

Matt Kraft:

Yeah, I think mine was a little bit more of a circuitous route. I had no idea that I was going to be getting into physical therapy when I was pursuing an English major. But medicine has kind of been a passion of mine. I think my Latin background definitely helped me out with anatomy.

Dr. Kirsten Buchanan:

Yeah,

Matt Kraft:

I don't know. I had toyed with the idea of med school. And then I took some time to just sort of travel around the country. Went to Ecuador, came back and hiked the Appalachian Trail. And I think somewhere around Pennsylvania, I decided that med school wasn't for me, but found my way back to physical therapy because I'm really interested in body structure and function. And I think this is a good niche for me.

Dr. Kirsten Buchanan:

It's a wonderful profession. You get a chance to chat with people while you exercise with them. At the same time, it's just a great way to be.

Dr. Lisa Belisle:

It also seems as if what you were talking about, things like biomechanical analysis and gait analysis and the technology that's now available to do these sorts of things that it used to be we would do just by visually. When I see patients in the office, I analyze their gait by watching them walk down the hall. And to have the availability of the next level up of tools must really be increasing the likelihood that you will be able to help people.

Dr. Kirsten Buchanan:

Yeah, I think that that's one of the things just being able to. Like we said that the motion analysis Lab has these 3D. So we can do the 3D evaluation of somebody's jumping or walking or running in the lab. One of the things I do actually is see patients for runners primarily, but it's mostly a 2D analysis. But we just by getting a camera on people and being able to slow it down, you can really start to see the biomechanics. And with, like you said, the advent of all this technology out there, you can get your iPhone on somebody and be able to slow it down well enough and really start to see these movements both in walking and running and help them, help them be able to say, I can see this might be an area of weakness. Or this might be, do you see how you're sort of bringing your foot out in this direction? Maybe we can correct that in a certain way that will keep you from irritating your knee or whatever it might be. So all this technology is wonderful to be able to use.

Dr. Lisa Belisle:

After listening to this, I'm sure that people will have some interest in the work that you're doing with ACL rupture and other sorts of injury prevention. So how can people find out about the University of New England program?

Dr. Kirsten Buchanan:

Certainly if they have interest in having us help them with an ACL prevention program. Not sure exactly how to get it started or what to do. Emailing me is the best way to do that. That's the K. Buchanane. Edu. Happy to help bring people in the right direction. There's some great things online that they can look at, you know, sort programs that might be all that they need, or it might be such that they want one of the students to come out and help them with a program for whether that be a practice or two or a whole season like we were doing with the JV varsity. We're happy to do it. So that's probably the best way to get in touch.

Dr. Lisa Belisle:

And the University of New England website, Matt, is une. Edu well, I appreciate the work that you're doing in this area. Obviously it would have been great if my middle child had had access to the ACL prevention program, having rehabbed herself through an ACL rupture. But, you know, you have to. We keep learning as a medical profession and we keep moving on and we keep offering more to the next generation. So I think it's great that you're doing this and I thank you for doing this for the girls in Yarmouth. And hopefully this will continue to spread out with rippling effects throughout the state of Maine. We've been speaking with Dr. Kirsten Buchanan and Matt Kraft from the University of New England. Thank you so much for coming in.

Dr. Kirsten Buchanan:

Thanks for having us.

Matt Kraft:

Thank you.

Dr. Lisa Belisle:

You've been listening to LoveMain radio show number 219, Keeping Knees Healthy. Our guests have included Dr. Link Avery, Dr. Kirsten Buchanan and Matt Kraft. We'd love to hear from you, so please let us know what you think of lovemain Radio. We welcome your suggestions for future shows. Also let our sponsors know that you have heard about them here. We are privileged that they enable us to bring Lovemain radio to you each week. This is Dr. Lisa Belisle. I hope that you have enjoyed our Keeping these healthy shows. Thank you for allowing me to be a part of your day. May you have a bountiful life.

Matt Kraft:

Ra.