Sore Young Knees - Claire Robertson & Tom Jacobs - Chewing it Over

Today I'm Chewing Over sore young knees and how to help manage them with Claire Robertson & Tom Jacobs

CIO is a weekly lunchtime livestream with Jack Chew chatting about whatever is topical.

Usually healthcare and education, occasionally current affairs, always honest.

Episode Transcript

(00:27):
Good afternoon folks. Hope you're good and hope you're
tuning in now either on a Wednesday or you're getting this
after the fact. It's been nice to get back on
the chewing it over desk. I'm Jack Chu and today I'm going
to be joined by two esteemed guests, Clive Robertson and Tom
Jacobs going to talk about so young knees amongst other
things. We've just been guessing just
before we went live about many things that we, we care deeply

(00:51):
about in terms of the state of the industry.
And we think that this is a topic that really helps to
advance some of the reflections that we've been doing on this,
on this show, as well as in MSK mag recently about care quality,
about how we use evidence to inform practice and stuff.
So I won't say too much about itbecause they've got lots to say
and we'll, we'll discuss it all together.
And so I want to bring them in. Hopefully if a couple of clicks

(01:14):
of a couple of buttons mean that, then it, it works and the
technology behaves itself. So right, let me first get shut.
This is where I get this is where I get caught up in my, my
buttons, right? Let's take that off then.
Let's press this one. I'll get Tom and hopefully
Claire and then if I then do that, has that worked?
Are we there? Is it working?

(01:34):
Yes, you got it, you got it. Brilliant, right.
So one thing I've not been able to sort, and I said this when I
had Joe and Joe on recently, is I've not sorted out the
background so that it suits three people.
So I need to, I need to rememberto do that.
Jim, if you're watching, let's get the text sorted.
But anyway, before I start, I mentioned there at the intro,
we've been chatting just off airabout a few things that this

(01:57):
really gets us, gets us juices flowing, doesn't it?
And so I'm going to get stuck into the meat of of knees and
industry research, evidence based information.
But before we do, for those thatdon't know you each, shall we
just do a quick round of introductions?
Claire, could you go first? I know we've done a lot of work
together before, but in case there's any of our audience that

(02:18):
don't know about you and your interest and just tell, tell
folk a bit about yourself. Sure.
So hi Jack, thanks for having meon.
So I'm Claire Robertson, also known as Claire Patella and I'm
I'm a physiotherapist and I havea sort of triangulated working
life between clinical practice solely in telefemoral pain for
the last 20 years, research and teaching in guess what, yes,

(02:44):
telefemoral pain, anything to dowith telefat pad ITB on there.
So yes, but still very much a clinician at heart.
Brilliant. Thanks a lot.
And Tom Jacobs, welcome. Can't remember if I've had you
on the show before, but really good to have you.
Now let's talk a little bit about yourself.
So while clearly it's no introduction, it might be useful

(03:06):
for me to say a bit. So I've, you know, for Emma
Skiff is in 15 years and my areaof interest is in ACL management
and ACL injury prevention. I work similarly to Claire,
still clinically, a few days clinically and then I do some
teaching. I do some MSK teaching for GPS

(03:28):
on in Oxfordshire on the training GP scheme for second
and third year developing GPS. I do a bit of teaching and
prevention. Supply, which is.

(04:07):
Sorry, Tom, I'm I don't know if it's Claire, maybe you can be
help me verify this. Is it my audio We did Tom's
audio go off there or Tom? 'S audio went funny there, yeah.
OK, sorry Tom, we lost a bit of that then I thought it was me,
but if it might be, it might be.We lost you briefly, then just
talk again and now we've got a leg since it's still it's still

(04:31):
got a bit of a delay and stuff there.
I'm going to turf you off. Just reset your reset your
microphone for us, Tom, and see if we can get you back.
Sorry, Claire, just me and you. Pressure's on now.
Let's bring him back. Let me reset.
Let's say this is live radio. Does this doesn't it right?
Now. We'll bring Tom back in, of
course, as soon as we can. But one of the things that I

(04:53):
wanted to try and find out from you and you can start us off is,
is how it came about that you guys were planning to
collaborate. Because it's been really
interesting. I love it so much when some of
my favorite people come togetherand you guys really are our two
great thinkers when it comes to all things new.
So I'm excited to see, but I'm interested in, I know our

(05:14):
listeners will be as to how thatcame about.
Yeah, well, it's slightly scary to me, but I actually taught Tom
of his undergraduate course, notas not primary school
undergraduate. Course.
And so Tom very much stood out as some bright thinker.
And then we really had no contact at all until 2022 where

(05:38):
we met at Sheffield Kids Knee because we were both presenting
and we just got chatting on the stairs.
Actually, I remember very clearly.
And it was one of those like, OK, I've got a train to catch,
but actually I could just chat to you all day because there's
so much common ground here. So we're really thinking along

(05:59):
the same lines. And we've kind of stayed in
touch and I've been interested in the work that Tom's been
doing and his character play conference.
And again, when I spoke at that last year and then had more
discussions and then it was like, OK, we need to collaborate
because there's just so much of interest here.
We're totally thinking on the onthe same wavelength, although

(06:21):
obviously coming in with our different biases, but
holistically and how we approachthe world, if you like, there
was huge commonality. And was he hanging from the
ceiling like he is now tight down?
Tight gymnast, yeah. I'm going to say this is this is
amusing. I don't know.
Stop. He's turned it around now.
This is good. Now, Tom, can we hear you though

(06:44):
now? Hopefully.
Oh, no, I've got a well, it seems to maybe won't be working,
but it's a lag, so I don't know.Tom, I think you're back with
us, you know, the right way up. But Claire's given us a bit of
insight into how it how it came about.
You might have heard some of it.Tell us from your side how this

(07:04):
collab turned out. Well, yeah, I think, you know,
Claire stopped me in the in the corridor.
I think it was a Sheffield kids knee conference, wasn't it,
after a presentation that I'd done about ACL injuries and ACL
prevention stuff through the through the charity work.
And it was a pretty random conversation.

(07:27):
It was more talking, I think a bit about you kind of hit me
with like the industry is is very divided in in and physios
are, I think possibly veering to1 ditch or another.
And I know you've talked about this a lot, Jack passionately
where people are either becomingquite partisan around evidence

(07:49):
based practice and and almost almost reductionist in saying
this is the way it is. Anyone is is clearly either
stupid or or just interested in making my and then taking taking
advantage of people in our in our industry.
It's potentially of of being disinterested or not being up to

(08:12):
date laziness. Maybe different different things
that lead people to perhaps justmy enough.
And it's hit such a chord with me that I thought, you know, we
need to stay in touch about this.
And and that was I don't 3-4 years ago, possibly Claire.

(08:33):
And then we've met at a few new conferences since and from
different angles, Claire from Patella perspective and me from
an ACL one. And, and, you know, I just felt
there was an immediate understanding and people often
talk about, I don't, you know, Simon Sinek and about it's more
the why is more important than the how and the what and, and

(08:55):
the why was so on point and sortof like, right.
I feel passionately about physiotherapy being and, and
muscular rehab being delivered in a really bloody good way with
the clinic, with the patient being at the heart of it.
And then their understanding of the human body being healthy and
also us aiming for the best possible outcome.

(09:17):
And before I became a physio, I was, I was predominantly a
scientist. I love science, and I heard a
piece recently around scientistsabout curiosity.
It's not about being sort of belligerent about a belief and
being inflexible. It's about curiosity.

(09:39):
And before, before you come to any sort of hypothesis, you need
to have an observation. An observation is not evidence
based at all. It's an observation.
So that was my why and it resonated with Claire's why.
And so we thought, right, we must do something in our
sectors, which is knees really. And we, we both love teaching

(09:59):
and and continue clinical practice.
And so it seemed a little bit. Yeah.
So Claire, tell me a little bit about the because I think you're
right, an observation is is where things need to start.
But I've said before, including the affair just earlier, that
that that people that are commentators in our space, I
find them the most important thing is keeping a finger on the

(10:20):
pulse of the industry, understanding how what it is
that patients are coming in with, with regards to concerns,
especially those of us that start to see second, third,
eighth opinion work, start to realise where the sort of mood
music is in the industry and, and what what trends and fads
are coming and going. Some rigidity or lack of
flexibility that's sometimes in there.

(10:41):
So you guys are absolutely doingjust that.
And so from what Tom's describing, it sounded like you
were your kindred spirits in this space.
What are your primary concerns just following on from what Tom
said about some of that partisannature or the way in which some
of the tribes are forming in that in in MSK right now?
Well, I think, look, I think theundergraduate education is

(11:04):
understandably and quite rightly, much more evidence
based than it used to much my house around literature, more
academic, which is great, but I think it gives people such a
strong construct of this is how I am, this is how I operate.
But then the sort of ability to perhaps think more inductively

(11:28):
with a patient goes out the window because it it pushes, I
think the physios to a more a sort of hypothetical deductive
approach, right. I've got my hypothesis.
I know the background of the, ofthe literature says this and I'm
going to introduce this, this orthis.
And actually, they've forgotten to listen to the fact that the
patient with knee pain in front of them has just said how

(11:49):
traumatic their divorce has beenand how they're actually in
complete overwhelm. So it doesn't really matter what
the literature says. You can give them, you know, the
best exercises, but they're not in the place to do them, you
know, so it's, it's having that evidence base as as part of the
richness of what we do. And I also think, to be honest,

(12:10):
if we're a slave to the literature, we're losing a lot
of the fun of what physiotherapyis about.
And you know, I've been qualified like 30 years, over 30
years, and I still really enjoy it.
And you know why I really enjoy it?
It's not because I've read another 5 papers this week.
It's because I love the narratives.
I love the patient's stories andI love trying to be creative

(12:34):
with this patient given what they've just told me.
And it's really interesting. There's something like a model I
really like from the psychiatry literature of not know.
It's called not knowing. And you basically start as a
blank canvas as the clinician and you listen with curiosity.
And I love that word curiosity that Tom's just mentioned.
And then from what you're listening, yes, of course I'm

(12:56):
going to use my understanding, the literature and my
understanding when asked me bio mechanics.
But it's that richness that should make us excited about
getting up in the morning and seeing yet another patient.
I, I we're going now, interestingly.
Yeah, she's got it. I love it.
Yep, juices are flowing right now.
I have a regular listeners of this show are going to be

(13:19):
irritated by having to hear thisthis phrase again.
But I said, unfortunately we're seeing a number of graduates
that are coming out that can muse, muse over the shortcomings
of an RCT but can't do a Lachman's.
And that adage is irritatingly coming true.
I think I first said it maybe six or seven years ago, and
it'll be documented because I always said it online.

(13:40):
And it's irritatingly coming more and more true.
Different universities have got different versions of that.
In a sense, some are applying practice better, but there's
been a decrease in some of the practical work, some of the
clinical reasoning that's been centered.
And so instead people are, it's almost like the flow charts of
yesteryear are back, right? It used to be that we would just
administrate orthopaedic protocols.

(14:02):
We moved away from that and rightly so.
And it's almost like we've been dragged back now from some sort
of protocols that were informed by guidelines and supposedly
empirical. But one of the things I wanted
to interrogate a little bit withregards to this, because I know
that the risk is that it sounds like we're harking back to a
cluster of anecdotes, that the research can't inform our

(14:24):
practice. And that we necessarily need to
get back to the good old days where you could put a wet finger
in the air and kind of understand therefore what you
might do and that anything kind of goes.
And whilst I know full well thatyou're not saying that, Claire,
one of the things that was interesting when you were
speaking then is that you're excited about your work and your
job. Not because you read 5 papers

(14:45):
this week, but because you like to then apply your curiosity in
practice. Now interestingly though, I know
you, you will have also read 5 papers this week.
Yeah. And that's and.
So I want to understand then where you feel that meets right.
So where, where is it that you feel we can use a full plethora
of evidence to really inform ourreasoning without feeling like

(15:07):
it's a slide back to a Wild Westthat we all kind of moved past?
Yeah, I mean, I think we I thinkwe should try and remain on top
of the literature because ultimately there is some great
literature that is informing ourprofession really well.
But it's still, you know, massively in my views in the
infancy of, you know, of this asa profession.

(15:31):
And also, you know, there are elements that you might people
might not think about as evidence, but like anatomy, you
know, let's just know our anatomy really well.
Let's know our bio mechanics, our exercise, exercise
Physiology. I mean, wow, that's scenario
that we don't necessarily need to be over every single paper
coming through, but let's let's do our exercise prescription

(15:52):
well and let's try and blend. And I think it's back to this
curiosity. And this is where Tom and I are
on the same page. If you remain curious, then you
want to keep evolving. And I would be horrified if I
was still treating the same way as last year.
So what's changed in that year? It's papers that I've read and
things that I've seen and heard from patients conferences.

(16:16):
So it's blending it. And I think it should be
acknowledged that's that in itself is a skill.
And it's, it's hard, I think, asa new grad to do that.
And so I think, you know, we're certainly not saying all these
new graduates, you know, they don't know what they're doing.
But I think the thing I would encourage any new graduates is

(16:36):
to stay curious, stay wanting toevolve and never have that sense
of, you know, oh, right, I know it now.
I've I've read all these papers,you know, and in fact, it's the
opposite, isn't it? The more you know, the more you
don't know. And I think that's what Tom and
I are trying when we are going to be collaborating, we'll be

(16:59):
talking more about that in a minute.
I think it's talking helping people, empower them to say,
actually, you know, you have so much knowledge inside you from
what you've been taught, but also your rich experience.
Let's help you facilitate you really making that come out so
that then you, you know, you useall of that rich experience and

(17:22):
knowledge perhaps better becausepeople often don't realise how
much, how much they have in there.
Yeah. And I talk a lot about the what
I consider a warranted variationacross practice.
And some of this sort of crossesover with what we're talking
about a little where some of thevariation in, in, in especially

(17:44):
variation in care that patients will sometimes carry with them
to, to 2nd opinions and stuff. So tell me if I could just bring
you in on the fact that when you're trying to, as I said,
feel the pulse of the industry and, and thinking about the
patients that you, you see, do you feel that they are noticing
these sort of what seem to be niche in industry disputes?
Do you think that it, it does actually affect the way that

(18:07):
we're perceived the things that patients get confused about and
things? I just wondered your your
thoughts on that sort almost social level.
The Sean answer is no, I don't generally think that.
They do make observations of sort of schools of thought
within the therapy space, but they they do see a difference in

(18:28):
how the NHS is being operated inSouth of England.
In my opinion, there's a lot more of a swing towards, pardon
the phrase, paint by numbers or hit the minimum targets and then
push people away to be to be more self managing.

(18:50):
And I think there's a, there's a, there is a fair amount of
outcry from the patient populations that we serve about
that. But I mean, coming back to the
point, if I may around, I'd really like this idea of
richness to what informs our clinical decision making.
And Ed Brown, my colleague who I, who I work quite closely with

(19:10):
in clinical practice, he talked about patient mileage being
really important. And of course, you can't buy
that when you're less experienced you there's a
certain amount of just having togo through that.
But then the more experienced colleagues who've been around
the block a while perhaps sometimes undervalue patient
mileage more than they perhaps should.
And to your point around, shouldwe, are we swinging too far away
from evidence based practice? Well, fundamentally, I really

(19:32):
hope not, because evidence basedpractice papers and so on should
be foundational. It shouldn't be a nice to have,
it's an absolute necessity. But what I made an observation
from, I was up in Edinburgh an ACL conference a few weeks ago
and I've noticed that this really isn't a physiospecific or
MSK clinician specific challengethat we're facing here.

(19:55):
Andy Williams, surgeon, ACR surgeon to the stars.
He stood up and he did a presentation, really good
presentation around what he was lamenting around the lack of
clinical hands on skills and assessing acute knee injuries.
And he went back and brought outtests that I'd never seen
before. And I was like, OK, he's using
those all the time. And an experience that I'd had

(20:19):
some while ago, actually now is shadowing an orthopedic
consultant and seeing how he tests for PCL injuries, which
are not, in my opinion, particularly easy to assess.
And he used a test that I'd not seen before.
And I practiced quite a lot subsequent to that, which was
one of the tibial palpation, tibial plateau palpation tests.
Now through that test, I picked up two PCL injuries in a private

(20:42):
practice, you know, operating largely on my own.
That had been that the, the, thesurgeon, the orthopedic and
surgeon who was seeing the patient at the same time
concurrently disagreed with me on and said, well, we'll get an,
we'll get an MRI scan. But I think he's wrong.
And then it came back, both of them came back as PCL injuries
just because I've taken the timeto go and try and upscale on the

(21:04):
hands on stuff. And of course, that's only one
element in my toolbox that I need to be thinking about.
And evidence base plays an enormous part of, of, of good
clinical practice, but it needs this richness.
And I, I think patients going back to original point, I think
they pick up on this lack of absolutism, this sort of open

(21:25):
mindedness curiosity. When I say to patients, funnily
enough, I really not too sure what this is.
Normally I'm pretty good but I don't know what this is.
It doesn't fit nicely into a boxand sometimes that happens.
Let's let's just see how it develops over time or let's get
some more investigations done inorder to inform that.
So you demonstrate a bit of humility and open mindedness and

(21:46):
they love it. And my, my mum, I spoke to my
mum and she'd had that experience from her GP.
It put more confidence in her inher GP because the GP was
willing to acknowledge their ownlimitations and I think that is
a fundamentally healthy attraction.
Verbalise, verbalising your reasoning, I think is something
that is just an increasingly important part of our work and

(22:09):
of, of actual expertise is to tonot have to sort of front
something up or to masquerade asif there's more certainty in the
situation than there is. And I think that that's that how
how vague is safe. But I think it.
Was just interestingly though, we can actually pull on some
literature over that because there is quite a lot of emerging
literature on patients making sense of the reality of their

(22:33):
injury. And you know, I'm particularly
interested in this because obviously most of the
patellofemoral patients, it's insidious onset.
So they can't, you know, why is my knee suddenly hurting?
And so if you are open about your clinical reasoning and
okay, and right, I've listened to you, I've looked at you and I
think that you've got telephone pain because of this, this and

(22:54):
this. And then you moved house and
you've got more stairs, you've changed job and you're wearing
heels or whatever. It helps the patient make sense
of it. And as and you know, and it's
back to this richness of listening and evidence.
Actually, that is a really good example of saying the evidence
tells us this is what patients wants.

(23:14):
And that's where the listening skills and listening to the
narrative really comes in. Yeah, I've I've got just because
I'm going to move us towards these really specifically for in
a moment, but I've got somethingthat I want to invite you both
to disagree with if you like. But something I've been
concerned about on this topic ofof of kind of a lurch towards a

(23:36):
narrow empiricism implying that MSK practice can be treated like
pharmacy. I think there's a spy.
I don't. I was going to try and use a
word there, but I've never used before spinalification.
It's not, it's not a word, but that we are centralization would
probably be more make more sensewhere we're at risk because the

(23:57):
the the low back pain was such primary and still is a Primary
Health concern. And there was a lot of funding
that went into research there that some of the nonspecific
chronic low back pain literatureand the mindset we got into over
recognizing, you know, de prioritizing anatomical findings

(24:17):
found on scans and much of it rightly so in terms of some of
the specificity that was being implied in spinal care was
something that didn't affect care as much as and shouldn't
have affected care, certainly shouldn't have then led to
interventions that didn't have good backing etcetera or or
rationale. I've a concern that knees and
shoulders are classic examples of which and improved anatomical

(24:40):
specificity, improved clinical testing as well as then more
tailored rehabilitation then youwould be able to really or need
to deliver to the spine for anatomical reasons, right.
So we're not talking about necessarily other personal
factors of how you might adjust and should still adjust spinal
rehab, but I'm meaning those anatomical factors or the

(25:00):
testing specific testing like you've just described on special
tests set on orthopedic tests ofthe knee.
I feel like we've been at risk of them just applying more valid
spinal concepts to the periphery.
And I think the knee has been a victim of that.
So I don't need you to have to bandwagon in agreement with that
in case you don't want to. But that's something that I

(25:22):
think has happened. And I think that one of the
reasons I'm excited for you guysto collaborate is because I feel
that you will unpick that not risk over lumping and getting
category errors that I'm describing there because I think
the specificity matters. So I just wondered if I could
get your, your, your reflectionson my hot take as well as what
you, how you think this whole thing we've just been talking

(25:43):
about applies most to the knees.You got Tom, you got either of
you go first, I suppose. You go, Tom.
I think that the interesting thing because you're dead right
about the the non specific lowerback pain guidelines over the
over the years and I think we all celebrate the fact that that

(26:04):
those MRI studies in the 90s came out and clarified the
picture for us. I think that the first way I
introduced this to patients who have mechanical back pain, which
we know is probably about 80% ofall back pain, is historically
over the years I've just said that the medical world doesn't
understand back pain particularly well.

(26:25):
And that's the opening gambit just to lay the foundation and
that is the truth. And I'm also not close minded to
the fact that research may well inform our understanding to make
it much more specific. In years to come, we may look
back on this period as the doldrums where we didn't
understand back pain very well and it was always a bit like,
well, it doesn't really matter too much what you do as long as

(26:46):
you do this and the other. And then it suddenly might get a
lot better and much more specific, who's to say?
But what we do know is that shoulders and knees are actually
quite different. And there's a huge detail as to,
you know, how do you manage an acutely presenting teenager
who's got posterior knee pain versus someone who's got
anterior knee pain in their 30? Immediately your possible

(27:09):
differential diagnosis are hugely different.
And this comes back to an interesting point which I know
is lurching again into a whole new topic, but subjective
information and history taking I'm extremely passionate about.
And I, I developed this thing through my teaching called the
Maddock principle, which is MADDOC, which is mechanism of

(27:32):
onset, age, duration of symptoms, diurnal pattern,
offered information and comorbidities.
And I, I present this idea that with that information, you can
come up with a much smaller listof differential diagnosis just
from what you're hearing and theage of the person and so on.
And then, you know, your objective examination is really

(27:53):
trying to confirm or deny those that short list.
And that isn't the case in back pain.
Back pain is much more, there's a much smaller list of potential
causes for someone being in pain.
So I think that's why it's it isso different.
No, thanks. Thanks for that, Tom.
Just so if I can throw the same question to contestant #2

(28:15):
Claire, because I'd be interested in in your thoughts
and and again, dragging us to tothe knees.
Well, I think. You've got to remember the
context of the patients that I see.
So, you know, presuming that they've not had a misdiagnosis
or a misdiagnosis. So with the patellofemoral pain
patients, we are then actually saying, OK, well, there's this

(28:39):
huge umbrella term, but I'm lessinterested in structure and I'm
more interested in load and I mean load and it's very broad a
sense. So that could be intrinsic to
them. So asymmetrical loading pattern
that could be extrinsic load in terms of, you know, running
volume, shoes, whatever. It could be psychosocial load,

(29:00):
depression, anxiety, overwhelm, belief system, whatever.
And so, you know, I guess I'm sitting somewhere between what
Tom's saying like, OK, I've got some of them acutely injured
knee, what's going on? So ACLPCL combined injury and
then our back pain sort of non specific, let's move right away
from structure and I guess I'm kind of plunged somewhere in the

(29:24):
middle. And so, yeah, I mean, you know,
there's a there's a place for all of these different
approaches. And again, it's that, it's that
back to that richness of what wedo.
If I was one of the things that say you've got someone that from
what we can hear about or we might deduce from an assessment

(29:45):
that they've got some tension through their QL in their back,
but they also have a facet arthropathy that we might know
of or be deducing. Then the management of those
things or the concurrent management of those things.
We wouldn't need to try even if we could to focus in on the
differential diagnosis between those or see which was more
relevant necessarily to them forthe care that we deliver.

(30:05):
Whereas a fat pad irritation at the knee compared to a let's,
let's say there was let's go, let's go posterior for the sake
of, of making it even more overt, right?
If you've got actually a peasantsurround issue and that's where
they're sensitive, right? So you've just got this

(30:27):
opportunity where or even if I was to say you've got a more
PFG, your PFG dominant in a sense of having an arthropathy
compared to a fat pad issue, which I know that they can
coexist and but the management would be different in terms of
how they did. It wouldn't just be based on
function, but the zooming in on the anatomy or caring about the
behaviour on the anatomy would matter more there than it would

(30:49):
in the spine. Yeah, absolutely.
And actually fat pad PFJ and Patella tendon is a really good
example because you do get people that have had treatment
for one and it's actually just revved up the problem.
Because, you know, if you put someone on a decline A slant
board and get them to do eccentric loading for a tendon

(31:10):
problem and they've actually gotfemoral pain, well, you'll
probably just wind that up. So, yeah, so your starting point
should be 1 of I, I absolutely believe diagnostic accuracy, but
then we're going to be looking more broadly to what is feeding
into that. What?
What Tom, what do you think are the primary issues affecting

(31:34):
young knees at the moment? Then if we think about you'd be
that examples on pathology or some of the work that you guys
have been doing with power up toplay with regards to making sure
we we do as much prehab as we can to avoid sort of large
significant, you know, ruptures and the like.
So just wonder if I can get because you're closer to that
than most people. What's your general take on that

(31:56):
side of the industry? Well the starting point would be
that most MSK physios have a sort of a minimum age that
they're comfortable with, and that'll often be adults or maybe
into late teens. But the the mid teenage group is
not such typically such a comfortable zone for most MSK
physios. And paediatric physios will

(32:16):
often learn more unless they've got a real special interest in
MSK to developmental conditions or people who are specifically
younger. And that specialty often doesn't
exist very much in private practice.
It's much more in, in hospitals or pedic and the like.
So there is this natural black spot, if you like, I think in
clinical practice, which Andrew Jackson, among others is doing

(32:38):
great work to try to rectify. And I support that
wholeheartedly. I think in, in the for, for me,
the concern is around misdiagnosis.
So structural things that are going to have long term impact.
So Apophis CLA voltions is 1, Osteosarcomas are very rare, but
occasionally can can present with issues.

(32:58):
And if people are told that, oh,you've got a torn hamstring, but
the person is 14, I mean, the likelihood of that being the
case is tiny, but the chance of them having a sudden apophyseal
avulsion is quite high. So it's that niche knowledge, I
think that doesn't doesn't raisethe amount of input just to
upscale a bit on, on adolescent stuff.

(33:20):
And also I think in terms of management like managing ACL
injuries in that group is complex and the orthopedic world
is still wrestling with this about how do we manage these
people. There is such an international
divide. Have we lost him again, Claire?
I think we. Might have done.

(33:40):
He's frozen. Yeah, he's had enough.
Oh, he's back. Sorry, Tom, we lost you for a
couple of sentences. Sorry, I was just saying that
that, that there's internationaldivide about how we manage ACL
injuries in this in this group as well where, you know, we've
got the Americans who are very interventionalist and doing more

(34:01):
surgery and then you've got the Scandinavian.
So a lot, lot more hands off. So it's an evolving picture as
well, very much in the orthopaedic world, which is nice
for us I think to stay abreast of and stay up to date with.
So I think the next few years isthings are really going to
involve evolve and then you're throwing cross bracing, which is
just an infancy. There's some really interesting
work for what's happening. The ACL space for adolescents,

(34:23):
100%. Brilliant.
And so over on to PFJ for these sorts of patients or you know,
don't do you use the term anterior nepen as an umbrella at
all anymore, Claire? I don't know.
No, I. Really dislike it and I'll tell
you why, because so many of the patients don't have any
anteriorly located pain. So I kind of think it's

(34:43):
misleading, yeah. Fair enough.
Want to what, what, what do you feel are?
I can't remember my question, but I know the general gist of
it was kind of like applying what we've been describing to
young knees, particularly at thePFJ.
What are the sort of things thatwe need to make sure we keep an
eye out for? I think this more and more
understanding that adolescent telephone pain is not the same

(35:06):
as adult telephone more pain andhence doesn't shouldn't be
treated in the same way. There's no evidence at all that
strength is part of the picture or strength deficit in our
adolescence. Now it might become a secondary
issue, but in terms of the driver of the pain, we need to

(35:27):
be looking much, much more at load management and again,
getting loads, quite a sort of trendy term at the moment.
But what do we mean by that? Getting really good at, how do
we assess load? You know, it's not just about
how many hours you play a week. Yes, OK, that's useful.
But the distribution that are there any rest days, the surface

(35:47):
they're playing on, the positionthat they're playing on, on the
network or whatever, there are so many elements to load.
And I think as I'd like to see physio is getting better at
assessing, knowing how to assessthat and understanding that that
is where their buyers should be in their, yeah, their teenagers
with Patella from all pain and. It can sometimes for those that

(36:09):
might have moved away from biomechanical rationale towards
a more macro load approach to thinking about that.
Sometimes they're a bit intimidated to think, yeah, I
might get an understanding of how much they're moving and how,
how much they're running. But then how they're running
really matters to the focal loads through their Patella.
And then comparing that and, andso and how much to take with a

(36:31):
pinch of salt with regards to someone's gay and not.
And so people sometimes they're away from zooming back in on
things like that because they think it's going to then be away
from their general style of practice.
But I think it's completely compatible.
It's just that we need to realize that in this in this
demographic, it is perhaps more important than in, say, an older
person with, with patellofemoralpain.

(36:53):
I mean, there are circumstances,of course, where it can still
be. And we see making alterations to
people's sort of limping behaviours even in, in older
life can be surprising for people that have moved away from
what they think of biomechanicalinterventions.
But in, in, in youths that mightwell be much more relevant.
And we know that their Physiology is just, it's so much
more active. It can go off really badly and

(37:14):
it can then respond really well.So it can be an incredibly
rewarding population set to workwith.
And so again, I repeat, I'm excited to see what you guys
have in store for us, Which brings us on to you maybe
hopefully giving us a few teasers.
So you guys are are collaborating on, on a course
together. Tell us a little bit about what
that's going to be. And and also when we might get

(37:35):
first glimmers of dates that hopefully we can we can be
first, first to know about, of course.
Do you want to go, Tom? Well, if my technology holds up,
I can make a start. Yeah.
So, so we are putting together A1 day course, which is going to
be a mash up of ACL and Patella femoral pain prevention and

(38:03):
management. So we're trying to give the most
bang for your buck in that that course and the dates of the
first course will be released some point soon.
We're still nailing down a few details, but but yeah, it's
going to be hopefully giving people a sense of taking these

(38:24):
philosophies that we've talked about now and delivering is a
really specific usable information.
So when people go on the Monday to their first clinic back and
they've got a patient in front of them, they'll be thinking
right, that's. All ages then as well.
Yeah, all, all. I'm presuming you're not talking
about the delegates, yeah? Yeah, I didn't expect you to to

(38:51):
to have that would in fact, I'm pretty sure it'd be very illegal
for you to have some sort of age.
But no, I I meant the. I meant gap because we.
I was just admitting that we were using young, sore knees as
a means of explaining some of the wider points about
empiricism. But the your course that you're
doing together is going to be about all age categories across

(39:12):
MSK. Yeah.
Absolutely, Yeah, yeah, undoubtedly.
And and it's going to be very practical as well as theory
based and cases as well. And we're very keen to empower
people so that we're not standing there.
We're the big cheeses. We know everything.
You don't know anything. It's the, in fact, it's the
opposite of saying, right, well,if I've got, if we've got to

(39:34):
say, you know, 30 people in the room and they're on average of
the qualified 10 years, think how many hours that of
experience that is. And actually, you know, let's
draw on that richness again and help people understand that
there is value in that patient mileage.
And really the dots are probablymostly there.

(39:54):
We're just helping them join up and maybe just adding in a few
specific tests. But really it's, it's helping
them reason through that all those dots that they will
already have there. They just often don't realise
that. That's my view on on education.
So really empowering people. Super.
I love that. I think sometimes where the
magic really happens at those sorts of events, it's discussing

(40:17):
the trade-offs and saying, right, let's just tweak 1
variable and reflect on how thatwould inform your reasoning
differently, how that might deliver it.
You know, that might be the perfect prescription and then it
turns out that's not as compatible and likely to be able
to be complied with for whateverreason.
How might we make adjustments tothat?
And so having that real open forum round table style style
courses is great. And also some of the feedback

(40:39):
I've heard about from yours and Claire's 36 postures and Claire
Mitchell's courses that you've got that that atmosphere, and I
have no doubt that it's going toflow into this course as well.
Tell me if I can just come to you as we wrap up, tell the tell
folk a little bit more about where they can find more info
from you. Obviously we'll be sharing out
information about the course as much as we can, but where can
people find out? And what other projects have you
got that people might be interested in?

(41:03):
Yeah. So there's some interesting work
going on in ACL prevention at the moment.
And we're trying to work within the industry with those who who
are trying to lead on this to improve ACL prevention through
the charitable work is trying toget the FIFA and the RFU and the
big bodies to embrace that more.So there's some really
interesting information coming out and hopefully that will lead

(41:25):
to a white paper. So I'll keep you informed on
that front for people who like free stuff.
I know physios love free stuff. We, I'm going to be launching
very soon an ACL specific podcast.
I'm very lucky in the position with the charity to be able to
go to quite a lot of these orthopaedic conferences.
And what it's taught me is that a lot of people within the

(41:49):
industry, orthopaedic consultants, sports medicine
consultants, physios, SNC coaches who are passionate about
this topic have lots of information to share.
And we should be making the mostof that.
It shouldn't be a therapies echochamber.
I believe passionately about that.
So I want to interview those toppeople and I want to share that
information on a podcast. So the different platforms,

(42:11):
YouTube and whatnot. And that will be launching very
soon. So I'll share that info with
you, Jack. Superb.
Look forward to that and Claire.Yes.
So if people want more Patella stuff, it's Claire Patella
website, soclairepatella.com. And I've got my courses in
there. So that's my own courses.

(42:33):
I've got courses with Claire Mitchell still coming up.
And there's I've got a podcast tab, so back copies of podcast.
There's loads of stuff for patients as well.
So yeah, anything Katella. Yeah, Claire katella.com.
And something that I can't, I don't think we've, we've oh.
By the way, the ACL podcast is is going to be called ACL Wise

(42:55):
Jack ACL. Wise, right?
We'll make sure we're making outof that.
But Claire, we, we haven't announced it yet, I don't think.
But you are now a staff writer for MSK Mag, and we've got a
piece in the next month's issue in that as well, which I'm
looking forward to, which is definitely on this theme.
Yeah, absolutely. Yes.
It all fits very neatly, obviously all planned out, yeah.
Absolutely best mate, best laid plans.

(43:16):
Thank you both so much for your time.
It's been fantastic to get to know a little bit more about
what you've been scheming. I've been hearing about it and
knowing about it, but to now to hear a bit more meat on the
bones. We will absolutely be linking
the notes to, to how you can getinvolved in these courses and,
and follow these two closely Formore information.
And we will be sharing that liberally once once we know

(43:38):
exactly when the dates are. So thank you both so much.
Forgive the blaring music, but we'll just go wave awkwardly as
my closing credits blare out. So thanks guys.
Bye. Thanks, Joe.
Thanks, Tom. Bye.