Multiligament Knee Injuries with Jill Monson - Episode 43 - The Sports Physical Therapy Podcast

Episode Transcript
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(00:00):
On this episode of the sportsphysical therapy podcast.
I am joined by Jill Munson.
Jill's the lead physicaltherapist for the complex knee
injury clinic and the practiceof Dr.
Robert At twin cities,orthopedics in Minnesota, she's
done a bunch of great research,but also shares her knowledge on
these complicated cases all thetime at national meetings and

(00:21):
publications.
In this episode we're going todive deep into some of the
thoughts she has behind thesemulti-ligament as knee injuries
This was a really great episodeand almost like a masterclass
from Jill herself.
You're going to really enjoy it.
Welcome to the Sports PhysicalTherapy Podcast.
I'm your host, Mike Reinald fromMike Reinald.

(00:42):
com.
Hey, Jill, how's it going?
Welcome to the podcast today.
It's going great.
Thanks so much for having me,Mike.
Yeah, I've been excited aboutthis for a little bit.
Um, obviously, you're somebodythat I've looked up to in this
field, uh, for physical therapyjust in general, but obviously
for the topic today, it'ssomething that you've published
a lot on.

(01:03):
It's something that I've heardyou speak about, um, and it's a
really exciting topic for mebecause unless you see a lot of
people a specific injury.
It's, you know, it's, it'susually a daunting thing when
you, when you get a new case onyour schedule that may be
complex.
So, um, I'm really, reallyexcited to, uh, to talk to you
about this stuff today.
Well, and right back at you,because I remember early in my

(01:26):
practice when I would get Trickythings, or I had a cartilage
case and nobody had greatinformation on cartilage.
I remember something that youand Kevin Wilk wrote on
following cartilagetransplantation procedures.
And that was, you know,essentially my manuscript, my
Bible for how I was going to goabout it because there wasn't
content available that wasclinically practical.

(01:49):
It may have been really, um,scientific, but as a clinician,
you need examples of what to do.
So thank you because your typeof work that you did in your
career was kind of foundationalfor the type of work that we
strive to do with our group.
Yeah.
And you're, and you're doing itright.
Like, so you're, for example,like your multi ligament is knee
injury paper.
I mean, that is, that's the samestyle paper that we always write

(02:10):
about the things that we're, youknow, that we see a lot.
So, um, yeah, you guys, you guysare kicking some butt with that,
but, um.
I want to start with this,right?
I mean, you have this, uh, Idon't know if unique's quite the
word, but it's a very strictniche, uh, of expertise around
these complex injuries, right?
Multiligamentous, things likecapsular meniscal involvement, I

(02:31):
think that's a little bit morecommon, but we're talking about
the multiligaments, the nerveinvolvements.
These are some of the most.
daunting things that nobodyreally wants to see on their
schedule.
Unfortunately, um, why don't westart with this?
How do you get so muchexperience in this area?
Because, uh, you know, to me,that's the tricky part, right?
Somebody might see a complexknee injury once every, you
know, 234 years, right?

(02:52):
So how do you get so muchexperience here?
That's, that's very true.
It's a scary population and it'sscary for the patient mostly.
Um, but the clinician should beadequately scared as well.
And, um, you know, my practiceearly on, I was fortunate to be
partnered up, um, with some verygood nationally and

(03:13):
internationally acclaimedorthopedic surgeons at the
University of Minnesota, where Iwas part of Fairview, and they
were with U of M.
And I was with Elizabeth Arndt,Dr.
Elizabeth Arndt, and Dr.
Rob Leprad.
And Dr.
Arndt did a lot of complexpatellofemoral procedures, and
then, you know, my, myrelationship developed with Dr.
Leprad during my time at theuniversity as well, when he was
first doing his research onposterior lateral corner.

(03:34):
And so everybody did sports.
Everybody did ACL was patellafemoral was dr.
Aren't niche.
And, you know, people weredabbling with meniscus when they
weren't just taking it out.
Right.
And so dr.
LePrade was a big fan ofunderstand the native anatomy
where, where do things.
Sit in the joint normally, whatdo they normally do?

(03:55):
Because what he would end upseeing was failures of ACLs that
had this profound rotationalinstability.
And he started to do hisresearch on posterior lateral
corner.
And of course I was two years,three years out of PT school.
And I'm like, the who?
Like, what are we talking abouthere?
I didn't, I didn't learn thisstructure.
Nevermind three or morestructures combined.

(04:16):
And so I felt very naive.
And exposed like I don't evenknow what language you're
speaking right now.
And so I really just botheredhim and lurked around his region
of clinic because I was curiousabout this.
And when, when a surgeon or aclinician gets known as seeing
the.
Other everybody sends the otherto that person because they

(04:38):
don't have to do with it.
And so he started to be thislightning rod for the other.
And he was meticulous enough inhis study of the joints and his
awareness of the anatomy anddeveloping surgical techniques
that were His language isanatomical reconstruction.
So the goal is to reconstructthings as close to back to their

(05:00):
native state as possible, butdefend your technical choices
with a significant body ofbiomechanical literature.
And so he was doing that.
I was slinking around in thebackground, very curious about
this and asking a lot ofannoying questions.
And, and as a result, he startedto say, well, she's obviously
curious and started to send methese complex cases.

(05:21):
And I would shadow in the OR andhe, his answer to my questions
in the OR was usually we'll readthese three papers I wrote.
And I'm like, so I would go backand I would Google words.
I didn't know.
And I would read papers that,that were written and I would
try to dig up whatever I could,but there really wasn't much.
So you ended up kind of going tothe, um, kind of bench work,

(05:43):
like the biomechanicalliterature to start to just
understand, well, what does thisligament even do?
And then, like, Kevin Willickand Ralph Escamilla's work on
here's what happens when wesquat and when we do certain
exercises, and you just try topiece it together, but I think
the important thing is theexposure over and over again,
and, and having a sufficientlevel of fear early on.

(06:06):
And then as reps come along,then you start to learn where
you can let go a little bit.
Do you regret this?
We have a lot of fun justtreating isolated ACLs in our
clinic.
I mean, do you, do you regretshowing this much, uh,
excitement over these complexcases?
Because like you said, now I'msure your caseload is jam packed
with complicated people, right?

(06:28):
Yeah, it's, it's a mix, but youknow, I love them.
They're, they're, I like to makepeople feel safe and normal
because what you don't want tobe is the one person that
everybody in clinic comes overto see, like, Oh, you got to
check this out.
Oh, I've never seen anythingthis bad, like, kind of, but,

(06:48):
but also like, is that theresponse you want as the patient
to be like, okay, so I'm yourend of one.
No, I don't regret it because tome, it's, um, it's like the
island of misfit toys where, youknow, people don't understand
them and you created reallypowerful connections with
patients when you say things tothem that demonstrate that you

(07:09):
understand, like, I get tears alot in, in our practice because
people are like, Oh my gosh,you're the first person who you
know, we had that a lot withpatellar instability patients,
but with these multi legs, youget a, an 18 year old coming in
with their nerve out.
And three ligaments out andeverybody around them has been

(07:29):
like, Oh my gosh.
Oh my gosh.
Oh my gosh.
And, and we just sit down and wesay, it's going to be okay.
Here's what we're going to do.
But I need you to understand,like, things are going to be
different.
This is not cute.
This is not a cute ACL, likewhat your friend had.
And it's not just a sportsinjury, like it's a medically
traumatic situation and, and itallows you to create

(07:50):
connections.
You know, I just had a patientof ours send us a video of her
squatting the bar in, in theweight room with all of her
softball teammates around her,like screaming at the top of
their lungs.
Like she was maxing out withlike three 45s on, but she had
the bar and it was just like.
I was like, like weeping openlyon zoom with her because it was

(08:11):
such a moment because her nerveis still out and she's she had
three ligaments out and likethat does not make me regret it
for a minute.
In fact, it's like my calling tobe on this little special island
with these people.
I love that.
And that's, that's what makesyou special about that too.
But that it definitely feelsgood to help these people
because they are complicated andthey know it's complicated,

(08:33):
right?
They, they know that.
So, you know, it's, you know,we, we always joke and say that
we deal with blisters and crackfingernails and baseball and,
and that's why we didn't getinto the NFL.
But, um, you know, I, I, I cansee that, right?
Like we've, we, we've had a lotof these complex patients just
over my career.
And they're so challenging toget over both physically and
mentally.
So I can see where thatemotional reward comes in.

(08:56):
That's, that's pretty special.
Uh, athletes, it's everydaypeople who really just want to
be able to go back to work andtake their kids to the park.
And, you know, so it does groundyou.
Because, I mean, don't get mewrong.
We see plenty of ACLs and Lordknows, we've not figured that
out.
Right.
But, you know, the expectationsand the demands in terms of, um,

(09:19):
what are people getting, whatare they getting back to how
soon it's kind of refreshing tohave a degree of appreciation
for just the simple things whenyou're working with someone
who's, you know, truly complexbecause they don't take the
little things as for granted.
Well said.
I love that.
Let's dig in a little bit here.
These, again, complex cases,often multiple structures.

(09:41):
Why don't we start talking aboutthat a little bit?
Um, obviously, there's sometrauma involved, oftentimes.
Maybe some high velocity, thosetypes of things.
But let's talk about themechanism and some of the
anatomical considerations forthese types of injuries.
Because, like you said, as anearly career professional, at
one point in your career, youdidn't...
You know, respect this probablyas much as, as we, we probably

(10:02):
need to.
So I'd love to hear yourthoughts on how these injuries
happen and anatomically whathappens like during these
complicated cases.
Yeah, fantastic.
So as you'd alluded to, youknow, there's these different
velocities of injury and youknow, you can have a high, a lot
of times it's a high velocitytrauma sort of thing where
patients, you know, what patientof ours was bouldering and fell

(10:24):
from a height.
There's a good example, oryou're in a car accident or, or
some type of an ATV.
You know, we get people who ATVthrough the woods up here in
Minnesota, and, you know, thatcan result in a high velocity
trauma.
And there's also low velocity.
And actually in this world,sport is considered low velocity
by comparison.
So a sporting injury, or you canhave instances of someone with a

(10:46):
high BMI that will do somethingbenign in daily life and their
knee will dislocate underneaththem.
We don't see that as often, butit.
Over the last five to 10 years,though, you're definitely seeing
more of a sporting injurypresentation.
You know, you think about thefreakish progression of football
athlete in terms of the speedthat they get up to on the field
and the type of collision thatthey have with other players.

(11:07):
And you can certainly have, um,multiple structures involved.
I just saw a guy fall into aflex knee last night and I
thought, oh, there's a PCL.
Um, but sporting injury isrepresenting more and more and
younger patients, you know, thisis, there's an inverse
relationship between age and thelikelihood of a knee dislocation
because young, brave men inparticular, um, will sometimes

(11:29):
find themselves doing sillythings.
you said BMI and I thought thatwas an interesting take here
because I've actually seen, um,just for the listeners here,
I've actually seen, uh, verylarge, but super athletic people
have multiligaments thatligament is like complex knee
injuries with some things thatyou and I may consider.
You know, a benign event, right?
Just a typical thing that youwouldn't expect that had that

(11:52):
big of a, an injury, tibialplant, toe fracture, stuff like
that.
Like just from having a six footfour, 254, you know, pound
athlete.
Um, so, you know, it's, youknow, the velocity spectrum's
there, but I think like yousaid, it's, it comes down to our
athletes getting bigger, faster,stronger.
right?
Are they putting themselves inmore disadvantageous positions?

(12:12):
Um, you know, it, it, it makessense.
Um, so it's very scary whatpeople have to get back to,
especially, you know, at, at thelevel of professional sport.
Yeah.
All right.
So tell us about the anatomicalconsiderations here with this,
because again, I think an areathat's probably not like
physical therapy, one on onethat you learn in PT school,
necessarily like the complexityof the posterior lateral corner,

(12:33):
stuff like that.
Talk to us a little bit aboutwhat you typically see in these
complicated cases.
Yes, there's going to be avariety of things.
I mean, there's differentgrading scales for multi
ligament knee injuries, and Ithink it's important that we can
distinguish between a kneedislocation versus multiple
ligaments because a kneedislocation where the entire

(12:54):
joint completely disarticulates.
is different.
It's more traumatic.
You can have an ACL MCL and thatcan be considered a multi
ligament injury, but it may nothave actually been the result of
a true knee dislocation.
Certainly there'll besubluxation involved.
You have to have a degree ofsubluxation in order to have the
ligaments rupture, but a truedislocation like those pictures

(13:15):
you see where the femur is overhere and the tibia is over
there.
That's.
That's uglier.
That has that has morechallenges.
I would say those patientsstruggle more postoperatively.
And so when you're followingsomething like a shank
classification, you go fromhaving a cruciate plus a
collateral to then I believeit's it's both cruciates out

(13:36):
plus one collateral, bothcruciates plus both collaterals,
all of them plus a fracture.
And so you see this progressiveand progressive involvement of
more structures.
Um, it's important to, torecognize like for our
colleagues that do on the fieldcoverage, when you see that
gross deformity of the limb, orwhen you do see what's Suspected
as a dislocation.

(13:57):
That's not just an orthopedicathletic training moment.
That's a medical emergencybecause the vessels and the
nerves can be involved.
And when the vessel is involvedin particular, it's life
threatening.
And so having your medical teamaware of that, that you're doing
a proper on field workup to, torule in or rule out concern for
it, but most of the time,they're going to advocate for

(14:18):
advanced imaging with thesepatients to look at the vascular
system and to make sure thatthere's not some sort of
popliteal artery injury.
And, you know, that, that, thatcan be a concern at the time of
surgery as well, but certainlyacutely when these injuries
happen, you have to treat themwith more of a, of a trauma
medical emergency eye than justa, okay, let's see, come over
here.
Let me see what ligaments arehurt and get you back on the

(14:39):
field.
Um, so that's an importantdistinguishment, but certainly
the cruciates are going to playa role.
And then you have, you know,simply your collaterals, your
medial or lateral collateral,but then we have this kind of
emerging concept in the last.
10 years or so of the posteriorlateral corner.
Well, certainly posterior butposterior medial corner where
you're talking about MCL, butalso you go deeper, you've got

(15:03):
superficial and deep MCL, butthen you have the posterior
oblique ligament, which isessentially a capsular expansion
and thickening.
That's a little more posteriorat the lateral side of the knee.
The posterior lateral corner isthree structures together can be
more.
But it's the FCL or the LCL.
It's the popliteus tendon, andthen it's the popliteal fibular

(15:24):
ligament that comes off of thetendon of the popliteus and goes
over to the fibula.
And those three structurespartner to, to control against
varus and recurvatum the tibiaand the femur.
And so when you get thesecombined injuries, oftentimes
there's like, hyperextensionplus verus, or I'm going into
velgus and my tibia is beingrotated underneath me because my

(15:47):
foot was planted.
So when you see guys go downwith their foot planted and you
see their foot rotating,probably ACL, probably MCL, and
if it rotates far enough, youknow, they might bring on that
lateral side as well.
And then if they have forcecoming down through their tibia
as they land, well, goodbye tothe PCL too.
So you, you can kind ofappreciate this progressive

(16:07):
disruption depending on the.
The angle, the angular movementof the injury and then the
rotational movement of theinjury.
And, you know, I think the, thetake home with that for me is
it's, it's short sighted tothink the knee flexes and
extends and, you know, sometimesyou can have a medial lateral
torque.
It's a three dimensional joint.

(16:28):
Right.
And sometimes young cliniciansdon't, don't comprehend that as
well, or maybe they're justoversimplifying in their mind.
But this is a, a 3d type injurythat is going to involve a lot
of different structures.
And that's going to really notonly add to the complexity of
it, but something that we haveto appreciate during the rehab
process.
Right?
Absolutely.
And that's The type offoundational thinking that you

(16:51):
want to have.
I will tell you, having tried togo into a DPT program and give a
lecture after I just came backfrom talking to a group of PTs
who are in practice, smoke likestarts to come out of their ears
when you start to talk about allthese structures.
And we, so you kind of, you haveto start with that, that single
plane, like, what does AP, andthen what does Veris Velgus.

(17:12):
And now let's start to talkabout what controls the
rotational elements of the kneebecause you're exactly right.
And that's what you think aboutwhen you start to tackle your
post op rehab is like whathappens natively, which
structure is primarily and whichstructure is secondarily
responsible for stabilizing thismovement at the knee.
And those are the things that wemight want to show some caution
for early on in our rehab.

(17:33):
I love it.
That makes sense.
So big, big injury, obviouslywe're going to have a big
surgery.
Right?
This is, these aren't nonoperative cases, right?
So, big surgery, I'm surethere's going to be a bunch of
factors that lead to better ormaybe less optimistic, we'll
say, we won't say pessimistic,we'll say less optimistic

(17:55):
outcomes perhaps.
But tell us a little bit aboutsome of these surgical factors.
Like what, what is it in yourexperience that you've seen lead
to better or worse outcomes?
Just so people are aware as youknow, anything that you've,
you've seen in your practice, isthere anything you've, you've
picked up on?
Yeah, I, you know, I've beenvery fortunate in my practice
because I happen to be by theforces of the universe aligned

(18:18):
with someone who's the worldexpert in this domain of
surgery.
So I'm very fortunate and thatmakes my job so much easier
because The surgical job isbeing done so precisely.
Um, so I would say first, uh,someone who's technically
expert.
This is not a a dabbling area ofexpertise.
So if you don't know who the goto is in your region, you know,

(18:42):
it's as simple as asking aquestion of a few providers to
say, hey, Who is the person thathandles the most complex?
And so getting patients into thehands of somebody who is
technically expert is reallycritical here because graft
placement, graft fixation, eventhe, the order in which the
grafts are fixed, the angle atwhich the grafts are fixed is,
is going to influence thisbecause it's not just, Oh, my

(19:05):
ACL was tensioned a little bitoff, or we got a little too
forward on the tibia.
Well, Now three other graphs aregoing to be impacted by the
placement of that other graphand certainly that's not what
we're doing.
But as we can appreciate you geta misplaced ACL graph and now
we're banging away trying to getextension thinking what am I
doing wrong.

(19:26):
Well, sorry, you're not the onewho did something wrong here.
And so I, so technically expertis important because that just
makes it so much easier forthings to, to be logical with,
with our observations.
Most operatively someone who'scapable of doing the surgery
efficiently is helpful becausethe less time the patient's on
the table, the less blood loss,the less infection exposure,

(19:49):
the, just the morbidity of thesurgery is down.
If they're not full open on thetable for three hours.
You know, if they're there foran hour and 15 minutes,
fantastic.
You know, Dr.
LePron's incredibly efficientbecause he's very organized,
surprisingly, in his approach.
And so they have everythingready to go and they complete
these surgeries very quickly.
But I hate using the word quickbecause that seems medically

(20:11):
irresponsible, but it'sefficient.
And, you know, timing ofsurgery, I know that that is,
that's an area where you say,okay, is it's hotly debated in
the surgical literature, you'llsee some big review papers say
earlier surgery does better.
You'll see some big reviewpapers say, you know, later
surgery does better, you know,there's, there's a greater risk

(20:32):
of stiffness or, you know,they'll have all of their
outcomes that they're comparingand you'll see.
Two papers within two years ofeach other, even sometimes in
the same journal come to adifferent conclusion on that.
And so with our patients, whatwe like to do is, well, first of
all, if they have like a tendonrupture, if the biceps femoris
is off or, you know, thegastroc, the lateral gastroc can

(20:52):
even be off sometimes, orthere's like a fracture or some
sort of impaction fracture, youmight bring that patient to
surgery sooner.
If there are certain things thatare just going to retract and
become problematic with a delay.
But we usually like to get ourpatients into some rehab ahead
of time, get the knee quieteddown a little bit.
They'll have a lot of kneeswelling and also a lot of limb

(21:13):
swelling and bruising.
And so we want to resolve someof that.
And then we also want to get thequad woken up a little bit so
that it can find itself at allpost surgically and start to get
range of motion coming on.
But also critically, it gives usan opportunity to sit down with
the patient and their family andtalk about what happened and
give them that, that permissionthat.
Hey, this is a little bigger.

(21:33):
This is a little bigger deal,and it's pretty traumatic.
And, you know, we even talkabout, you know, bring in mental
health.
If you're somebody who hasstruggled previously with mental
health, this is going to be anexacerbation, certainly.
Um, if you're, if you've neverhad a mental health issue, but
now all of a sudden you're inthe middle of a traumatic
medical situation, it can be,and not everybody is like that.

(21:55):
I mean, some of our cases aretruly athletes who have,
ligaments out, the nerve isfine, it's ACL plus territory,
but you get those biggerinjuries where you get two or
three ligaments and the nerve isout and that's, that's got a
different feel to it.
So it gives us that opportunityto sit down with the patient and
kind of process the situationand lay out a roadmap for what

(22:15):
they can expect in the recoveryperiod.
And do you, do you have likecertain criteria that you want
them to fulfill prior to goinginto surgery?
Do you ever have to get intosurgery just because it's taking
too long, but there are certainlike KPIs that you want to
achieve before you actuallyproceed to the, to the operating
table?
Yeah.
You know, ideally we want to seethat they're getting a strong

(22:36):
volitional quad contraction.
Um, you know, if the nerve isout, it's, it's going to be out
and typically there'll be sometype of a neural lysis done at
the time of surgery to free upany scar around it and hopefully
relieve it a little bit, butwe'd like to see that the
patient can get a strongvolitional quad contraction.
Full extension is nice.
Um, sometimes these have.
full extension plus a whole lotof recurvatum if the PCL and

(22:59):
posterolateral corner is out.
So we're not going to be hanginginto hyperextension with those.
But you know, getting flexion,if we can get up to 90 or
beyond, that's great.
If ideally, if we can get closerto 120 and beyond, that's even
better.
Um, you know, a lot of times theeffusion is limiting the motion,
but what limits the motion a lotis fear.
These patients are really,really, really gross and weird

(23:20):
just happened at their leg andnow they feel terrible and so
educating them, putting them inpositions where they feel
supported and confident to moveand then giving them permission
on how to move in a way that'ssafe because oftentimes they
will move in a very simple wayand their knee will sublux, they
can visually and physically feeltheir knee sublux and so
understandably they're not superexcited about moving it.

(23:42):
And so just showing a goodfeeling, like here, we're going
to place this on the groundsthat your foot's on the floor to
mitigate the weight of yourtibia, I gotta say, I've done a
lot of podcast episodes.
There, there hasn't been anepisode where I've made that
like.
Remus kind of face more oftenthan, than, than we've done so
far in this episode.

(24:03):
So kudos to you for that.
You've, uh, my stomach, mystomach's upset already, but I
can, I can only imagine, butyeah, you know, you kind of
started talking about this alittle bit, but like there,
there's a lot that goes intothese, right?
So.
As a therapist, we have toreconcile all these different
structures.
They all have uniqueconsiderations, right?

(24:25):
They're, they all have theirown, own things that we should
work on, things that we should,we should avoid, right?
Like you just brought up areally good example of ACL and
PCL.
But, you know, we, we want toget full knee extension back,
but you're right.
Is that stressful for, for PCLand posterior lateral corner?
So, you know, how do you, how dothese surgical factors, how do
all these things involve?
Go into your decision making forhow you progress somebody like,

(24:46):
how do you put all of thattogether and make sure that
people are going as, as fast,but more importantly, as safe as
possible through the process.
Yeah, absolutely.
And we, you know, we getpatients who come in from all
over the country and all overthe world for surgery with Dr.
LaPrade and the scariest thingis sending them home.
And, but also I want to respectthat my peers and colleagues

(25:08):
throughout the country areThey're skilled, they're smart
people.
It's just that lack of exposure.
And so I always send my emailhome with our patients and say,
send an email to your patient,to your therapist with me cc'd
on it.
Because I want them to be ableto type in JI and Outlook and I
pop up.
And then we can easily talkabout, like once people get it.

(25:30):
It makes sense.
And let me do the brain work foryou because I tell you what,
even like when I was firstlearning these things and going
through periods of relearninglike smoke would come out of my
ears.
And I want to shortcut thatprocess for my colleagues who
don't see a lot of it because ifwe have a 15 minute phone call
on my commute home, you'll belike.

(25:51):
Oh, okay.
That makes sense.
So structurally, you know,again, you're thinking about
natively, what happens, youknow, we all think about the PCL
is the dashboard injury, that 90degrees of flexion.
And the PCL is, is a monster,you know, it's, it's Newton's
load to failure is significantlyhigher than the other structures
in the knee.
And so when the PCL has beenreconstructed, you really want

(26:13):
to make sure that the, the graftintegrity is sound and that
we're not.
Doing things that create a lotof elongation stress, um, at the
PCL when it's first healing,because I'll tell patients that
the PCL is kind of like thatcenter beam for the knee.
And if the PCL is healed in theright length and the knee is in
the right alignment, the rightneutral alignment when it heals,

(26:35):
all the other structures aroundit are going to be functioning
at their ideal length as well.
Whereas if the PCL Doesn't, andthe tibia has sagged back.
Not only is the p c L in anon-ideal length, but so are the
other structures inside of theknee and, and your articular
cartilage loading pathways havebeen changed as well.
So now you're stressing adifferent part of the tibial

(26:55):
femoral compartment.
You're slinging the patella backagainst the trochlea with a
little more tension, and that'swhere you'll see these long-term
changes in articular cartilage.
Where in PCLs that are.
that are um, continuously lax.
And so the PCL, yes, you thinkabout flexion, but
hyperextension is important, isanother important structure,
function that the PCL helps tomanage.

(27:16):
Same thing with theposterolateral corner, it helps
to block recurve bottoms.
So we're careful, but we're notso careful that we create a
flexion.
a flexion contracture at theknee.
And so it's about giving peoplea little clearer guidelines of
we don't want to hyperextendinitially, but we do want to get
to zero.
So please make sure that yourcalf and the popliteal space are

(27:36):
able to touch the table, but Idon't want you.
Hanging your heel on a coffeetable with your knee hanging
down freely and, you know,rotationally thinking and, you
know, various and vulgar stress.
Okay, we can start to work onhip strengthening, but I'm not
going to put you in sideline.
If you had a posterior lateralcorner or an FCL reconstruction,
because I don't want variousstress through this knee.

(27:56):
When the graft is just trying toget its bearings and heal
sometimes into a bony tunnel,sometimes with a suture
fixation, right?
And so, you know, we have a lotof bony tunnels in our world,
but different surgeons aroundthe country will have different
fixation techniques.
And so you need to be aware ofthat.
So you're, you're thinking aboutthe native function of the, of
the ligament itself when timesare good.

(28:18):
Um, what happens when the kneeis moving through range of
motion, what happens when thequadriceps and hamstrings are
pulling to create that range ofmotion.
And then finally, what happenswhen we get up on our sticks and
we start walking and doingsquats, what are the normal
sliding and gliding forces atthe knee, and which structures
usually control that because youdon't want to You don't want to

(28:40):
all of a sudden vault the kneeinto a position where it's
trying to control a lot.
You want to, you want to drop,drop, drop a little bit of that
medicine of load onto thoseligaments gradually over time.
And let's back out.
And then remember, what about ameniscus repair?
Because it's not that often thatwe have three ligaments go and
the meniscus is sitting in theresmiling at us.
You know, you usually have sometype of meniscal involvement,

(29:01):
which is going to bring on adifferent You know, it's not
necessarily going to intensifythe precautions because you
might already have a lot ofprecautions on, but it'll make
the joint a little angrier.
It'll make the joint stayswollen a little bit longer and,
and then you have a nerve out,you know, so you just kind of
layer it on and you take it oneat a time and you think about
which of these precautions kindof fit with each other.

(29:23):
Some of them kind of gotogether.
So now my precautions aren'tanymore because the same
precaution is going to coverboth structures.
And again, that's, that's whereI think you said it very well,
there are professions, a bunchof smart individuals around this
country.
Um, it's about putting togetherall these little pieces of the
puzzle and then just knowingwhich factors, uh, way more than

(29:46):
other factors.
And what you just said about thePCL and, and that being kind of
like the starting point there, Ithought that was amazing.
That was a great, uh, pearl foreverybody.
So, um.
But people are going to want toknow specifics.
I know that because, you know,we're, that's, that's us, right?
In the, in the PT world, we wantto know specifics.
So let's, let's take some of thebig chunk, uh, topics that we,
uh, tend to talk about PT and,uh, kind of hit your thought

(30:10):
process for each one, but let'sstart with weight bearing, you
know, when you're going throughyour range or, um, your rehab
process, like how do youdetermine when does somebody,
when does somebody safe toprogress their weight bearing?
How, how cautious are you withthat after surgery?
Yeah, that's a very goodquestion.
And that is something that weare currently investigating.
Um, because I pride myself onkind of being a squeaky wheel.

(30:33):
And if something doesn't makesense to me and there's not
great literature to say yes orno definitively, I will
continuously ask why and why andwhy.
And, um, you know, an ACL can beweight bearing as tolerated
after surgery, which ligamentmanages the tibia most with
gait.
It's the ACL, you know, it's theanterior translation, you're in

(30:55):
that shallow angle of kneeflexion.
You've got tibial slope working,you know, to bias toward the ACL
and that's the one we let weightbear.
But we don't want to make sense.
Right.
Um, now, now with that said, um,certainly when you're talking
multi leg, um, you with, withthat traumatic subluxation,

(31:18):
you're going to have bonebruising, you're going to have
meniscal pathology.
So, so a lot of our patients arenon weight bearing and for
multiple reasons, but we'recurrently investigating
different weight bearingstatuses.
So we're looking at non weightbearing versus.
partial weight bearing with allof our ligamentous structures.
Now, before, right when Dr.
LaPrade was transitioning backto Minnesota from Vail, he had

(31:39):
just wrapped up a trial lookingat an ACL, FCL, pardon me, ACL,
FCL and FCL by itself, lookingat non weight bearing versus
partial weight bearing.
And looking at stressradiographs where you stress the
knee into varus and you look fora difference in side to side
gapping of the lateralcompartment.
And they determined thatoutcomes were very good.

(32:02):
It was safe.
We weren't seeing graftelongation at the FCL in
patients who were allowed to bepartial weight bearing.
So then you push pause there andyou back up and you say, well,
wait a minute, besides the ACL.
Which other structure should bethe loaded, loaded most with
gait?
There's a varus moment throughthe knee.
There's an adduction momentthrough the knee at mid stance
with gait.
So the, likely the second mostproblematic structure for gait

(32:25):
should be the FCL.
And our, his research on thatshowed that partial weight
bearing after an FCL.
Was not problematic in terms ofgraft elongation and patients
had very comparable outcomes.
In fact, better in terms of painand swelling and, and some of
their patient reported outcomesearly on.
Um, so when he came home withthat, I was like, well, looky,

(32:47):
looky, what about these?
Yeah, exactly.
Certainly, you know, the MCL,unless someone's limb is in a
malalignment position, the MCLshould not be stressed
significant with significantlywith straightforward gait.
PCL is is big and important, um,but the weight bearing portion
of gait theoretically shouldn'tstress it too much.

(33:10):
Now there's some literature andit's all very experimental
design looking at PCL stresseswith gait and squatting and
things like that, and and theoutcomes are a little bit mixed,
but for the most part it When inthese computational models, it
appears that the load issignificantly below load to
failure for PCL, but the thingyou do have to keep in mind when

(33:33):
you're talking about GATE iswhen you let somebody walk, what
else do they start doing?
They start to pivot, they startto go up and down the stairs,
they get up and down from thechair, and so that there is A
space for being cautious withweight bearing because weight
bearing to us means forwardambulation.
Weight bearing to our patientsmeans a whole variety of other

(33:54):
things.
And when you have this big of asurgery, is six weeks really
that big of a deal to hold yourhorses for the long term
outcome?
Right, right.
And let the knees settle down alittle bit and you know,
probably get your quad back aslong as you're doing the right
rehab and you're not, you know,falling behind.
But yeah, I, I, I see it.
I mean, you convinced me to behonest with you.

(34:15):
I had everybody weight bearingimmediately after our, after the
beginning of your conversationthere.
But yeah, but you're right.
Sometimes, sometimes we settledown, but, um, how about range
of motion?
Are you similar with range ofmotion?
I mean, how do you progress thiswithout getting tight?
Because I think that's, that's.
The biggest complication I wouldassume that most people are
afraid of here is that they'regoing to get a stiff knee and

(34:37):
that's going to be a problemdown the road.
How do you, how do you reconcilethat?
Yeah.
And let me clarify too on weightbearing.
So right now we are seeing ifACLs and FCLs and FCLs can
tolerate weight bearing istolerated.
And we're looking at our otherligaments that do not have
meniscal involvement.
We're looking at them withpartial weight bearing right now
and our preliminary results lookvery favorable.
And so I think the next leg ofour research will be taking that

(34:59):
cohort from partial weightbearing to weight bearing is
tolerated.
But again, we don't have goodliterature that specifically
follows an outcome that looks atjoint laxity to tell us that
yes, it's safe or no, it's not.
We don't have that in the non A.
C.
L.
World.
So, you know, flipping to rangeof motion, we start range of
motion day one post up 0 to 90with everybody.

(35:21):
Um, the Exception would be, youknow, if somebody had a huge
patellar tendon reconstruction,in addition to this other work,
we might gate them to 45 degreesthe first couple of weeks.
Um, but typically ourligamentous procedures and even
our meniscal repairs are 0 to 90day one.
Now, there's different things.

(35:42):
And so, you know, Dr.
LaPrade published a cohort of194, 197 ish single stage multi
legs.
Um, in 2019 AJSM and thosepatients, the protocol they
followed was they were nonweight bearing at that time, but
they were range of motion dayone, zero to 90 and the graphs
do not stretch out.

(36:02):
Now that's his graphs with hissurgical techniques.
And that's a physical therapyteam that sees these patients
often.
So, you know, it's notnecessarily generalizable across
all surgeons and all therapycenters, but we follow.
A structure specific and surgeryspecific framework for how we
approach range of motion and thethings that are important to

(36:25):
keep in mind is again, whatmovement stress the structure
natively.
And so we want to beconscientious of that who
normally blocks hyper extension,what structure comes into
tension and length as we godeeper into flexion, you will,
but you also want to think howwas the ligament fixed in the
joint.
Was it a bone plug was it softtissue fixation was it suturing,

(36:48):
where was it fixed you know wasit in the big beefy tibia or
were they fixed into the fibularhead where it's a little.
Smaller zone of bone.
And then you also wanna thinkabout where was the graft taken
from?
Was the graft an allograft orwas it an autographt?
And if it was an autographt,where did it come from?
Because that's going to be anadditional source of trauma for
the patient, especiallyhamstrings.

(37:09):
Um, you know, additional softtissue trauma is not unusual in
this patient group.
So the biceps femorals being offis not unusual.
And so in that situation, wemight start passively for the
first couple of weeks and thenthen kind of trickle into active
assisted and then trickle intoactive, we, we trickle a lot
where we are.
Um, the precautions we mightsend out to a center outside of

(37:32):
ourselves might be a little morerestrictive because sometimes
how people have people rangingthe knee.
requires a lot of hamstringpulling.
We have our patients seated,their foot's on the floor, they
use a strap underneath theirthigh to kind of lift the thigh
up, and their foot comes slidingback with no effort at all.
Now, PCLs are going to be pronefor the first couple of weeks

(37:53):
after surgery, because if you'veever seen a PCL that's out, What
does it look like?
It like droops back and looksweird and you're like, why does
it look like a ski jump?
Because just the weight of thetibia, the fibula sag back when
the PCL is out.
So the PCL injury makes gravityand the weight of the tibia

(38:14):
Stress that.
And we don't want to have thatelongation during those early
healing phases just because it'ssuch a big, beefy ligament.
And so we really want to makesure that it's healing in the
ideal length.
So we put them prone, as much asit's a pain in the butt, we put
them prone because thengravity's not sagging their
tibia back.
Because if I'm in long sitting,or even sitting with my foot out

(38:35):
in front of me from 0 to 60degrees, Gravity is going to
catch the tibia and sag it back.
And if I'm doing that four timesa day for my therapy exercises,
that's going to be problematic.
So we flip on their belly, theyhave a partner help them with
range of motion, so they'redoing it passively.
Because the other thing that weknow is if we're pulling hard
with the hamstring, because myknee is stiff, so I have to pull

(38:57):
hard, or 40 degrees of kneeflexion, creates posterior
shear.
Might not be a lot, but if we'redoing it 30 reps, four times a
day, every single day for fourweeks, that might not be great.
So in the first two weeks, thepatients are prone doing partner
assisted passive motion.

(39:19):
And then after that, we havethem continue with passive
motion, but they can go into aseated position with their PCL
brace on, or they can have atherapist providing just a
little bit of a manual anteriordrawer support at the tibia.
Might that be overkill?
Perhaps I don't know.
But what I do know is that ouroutcomes in terms of posterior

(39:39):
um, tibial stress x rays, PCLstress x rays look better than
most people around the countryand internationally.
And the reason people wouldn'treconstruct PCLs historically is
because they stretched out.
And they say, well, why bother?
They're just going to stretchout.
We can demonstrate that oursdon't stretch out.
And so then the question is,would, what, why not?
Is it the masterful surgicaltechnique of Dr.

(40:02):
Leprade or is it the fact thatwe're passive or is it the PCL
brace they wear?
Or is it that they're non weightbearing?
We don't know.
So my job is to kind of slowlypull down some precautions that
might be heavy and see, makesure that we can preserve our
really good outcomes so that wekind of get to that place where
we're not creating moremorbidity.
By being so restrictive postoperatively, you know, think

(40:24):
about their bone density.
ACLs have bone density loss andtheir weight bearing is
tolerated.
So I'm horrified is what, whatthese non weight bearing folks
look like.
So with our PCLs, we're alsoprotecting against
hyperextension.
That would be the same with aposterior lateral corner.
You know, your FCLs and MCLs,you're being thoughtful about
varus and velgus stresspositions.
Um, you know, if the posteriorcapsule is involved like the

(40:48):
posterior oblique ligament orthe posterior lateral corner,
you're going to be cautious withhyperextension just like you
would with a PCL.
And so like when I first starteddoing this at TCO, I built a
little table that just had eachstructure.
And the things so thateverybody's heads didn't
explode, including my own.

(41:10):
So you can kind of go throughthis little checklist of
understanding, what does thestructure do?
And as a result, what are wecareful with?
And we might be too careful,right?
Um, but if somebody has hadtheir semi tendinosis harvested
and they've had a posterolateralcoronary reconstruction, do you
want them pulling, pulling,pulling with their hamstring?
Probably not the mostcomfortable thing.

(41:30):
And if they're not comfortable,they're not going to be
successful in recovering therange of motion.
That's that that's amazing.
So how do you progressstrengthening exercises now on
top of all this right becausethe blend from you know Active
range of motion to now actuallyadding some load to it.
How do you progress throughthat?
Yeah, absolutely.
So it's kind of taking thoseconcepts because again, range of

(41:52):
motion, you could say, well, theliterature looking at sheer had
a load of, you know, 10 poundsat the distal tibia when they
were doing that.
And so that's what we thinkabout when we go into our
strengthening and you want tocome back to like these larger
tissue based concepts,mechanical load.
Once we get into that remodelingphase, you know, so early on, we

(42:13):
have this big bomb of aninflammatory phase.
And then we go into thisproliferation phase.
That's very delicate.
And, and you're creating thisframework of structure that your
body fills in over time, butit's kind of delicate initially.
And that's two weeks, threeweeks.
And then we start to get intothat remodeling and maturation,
which goes on and on and on.
And we can't forget that duringthat phase, mechanical load

(42:35):
helps.
And so we want to use mechanicalload.
But again, you think about theeyedropper where you want to
drop, drop, drop mechanical loaddelicately more, more, more onto
the tissue based on the tissue'sreaction to it.
And so we start off with weightof the limb, just doing the
motion actively.
And then we start with a lot ofisometrics.

(42:56):
Isometrics are great because youput that knee at 60 degrees and
you do a quad kick out.
They're not going to get.
A significant amount of anteriornor posterior shear, you know,
don't forget deeper in kneeflexion.
You can get some posterior shearwhen you're doing resisted quad
work, you know, from say ahundred degrees up towards 60.
And then of course, you know,the dreaded 40 to zero debate

(43:17):
of, of don't post this anywhereon social media.
We'll never, so appreciatingthat you're going to get
anterior and posterior shearwith resisted quad.
You're going to get posteriorshear with resisted hamstring.
So resisted hamstring comes onslower for us with patients with

(43:37):
structures that are tensionedwith posterior shear.
So we're going to beparticularly slow with our PCLs.
We might ease into it a littlebit with our FCLs and posterior
lateral corners because thatposterior shear touches on that
a bit.
And, and again, if they've had ahamstring autographed, so open
chain, we're thinking about whatsort of shear is being created.

(43:58):
And we start with an ISO at midrange and we work into it.
When we start our hamstring ISOsdown the road with our PCLs, we
started a really shallow angleof knee flexion.
So, you know, stand up, put yourheel against the wall with your
knee bent to about 30 degreesand engage your hamstring there.
And then you start to work intosome active motion, and then you
maybe do some fixed angles, isosat different angles, and then

(44:21):
you gradually progress into yourresisted arc.
You can hit the hamstrings withhip hinging, um, you know, and
standing with a little bit of adeadlift movement.
Um, so you want to be creativein the different ways that you
can hit the structure ofinterest.
You can create a lot ofintensity at a fixed angle ISO
for the quad in at zero degreesat 60 degrees.

(44:41):
You know, we use a Tindex, um,that, and the patients look at
an iPad and they can see howhard they're pushing out over at
the training house.
We've got Kaiser equipment.
So patients, you know, canpneumatically adjust it and know
how hard they're kicking out.
And so you're using thosedifferent sources of feedback to
modulate intensity while youstill have the patient's knee in
a position that doesn't put alot of stress on the ligament.

(45:03):
So creatively create muscularintensity without the joint
being in a position that createsstructural intensity.
And, and then over time you openit up and now I'm doing an arc
of motion, but I'm doing it withlightweight.
And now I start to progress theload and maybe I start to play
with tempo.
So you're thinking about sheer,you're thinking about, you know,

(45:24):
rotational stress as you moveinto squatting, you know, we
move into squatting and you godeeper, deeper, deeper.
The hamstrings start to come onthe hamstrings, create that nice
posterior pole, which is greatfor an ACL that might not be
great for a posterior lateralcorner.
And so we're going to modifysquat depth in the beginning,
and then we're going togradually open that once we get

(45:45):
further down the maturationroad, kind of four months and
later, we feel a little bitbetter about going deeper and
introducing more shear at thejoint.
So how do you get somebody nowto get more to a return to sport
type progression and assumingthat not all of these people are
going to be athletes, they justmay have to get back to just
general orthopedic, right?
But how do you get them back nowto, to the advanced stages?

(46:07):
You talked about the maturationof, of the surgical procedures.
I think that's obviously goingto be important, but does this
look pretty similar to, to anACL down the road?
It's just further down the road,or is this something where you
have some unique pearls that youthink are helpful for them?
Yeah, I mean, I really thinkit's once you get out of the
first four to six months, it'snot as scary, you know, we have

(46:30):
this somewhat nebulous timeframeof four months where our
heaviest precautions lapse, andthat has more to do with like
histology.
And the healing of the tissueand having some confidence that
we've had good bony integrationin the graft tunnels, we've had
a period of time where where thetissue has been able to kind of
go through its ligamentizationprocess, and it's getting a

(46:53):
little more mature.
It's not fully mature, but it'sat a point where we're not
worried about something smallbeing problematic.
And In some ways, yes, Mike,where you get beyond that, it
starts to look and feel like anACL may where all right now,
what are what are our primarygoals for returning your high
level activity?
It's not any different.

(47:13):
It's the same goal.
So you need those foundationalelements.
If you don't have great range ofmotion, don't just leapfrog over
that step and try to look cooland sexy by doing other things
like training.
You're very not sexy for a verylong time in this world.
And so you just have to staytrue to the basics and clean
them up.
Like I'll tell people the visualof you're walking through a
series of rooms with doors inbetween them and you have to

(47:36):
look back at that last room youwere in and make sure you didn't
leave it a mess.
Otherwise you have to go backthere, clean up your mess and
walk into the next room.
And so range of motion has gotto be solid because if you're
going to sprint, you need yourknee to flex.
If you're going to be a gymnast,you need your knee to straighten
out fully or they hate it.
Um, you have to get goodfoundational strength at all of
the muscle groups.

(47:57):
And as much as we have cool waysof.
Testing athletic performancewith different gadgets.
Now you can't athletes will beathletes and they will cheat
tests.
If you just let them move,they'll figure out a way to get
it done.
And what, how many seconds doyou want me to get this done?
And cool.
I can do it.
And my 60 percent LSI to bodyweight, but I managed to get

(48:18):
that done in 3.
5 seconds because I'm anathlete.
So you have to demonstrate thefoundation of strength at the
large muscle groups.
They have to have goodfoundational movements.
You know, we run through, um,kind of your standard, what do
we have in the literature toguide us?
We have our performance testingthat's specific to ACL, but it's
not specific so much to ACL,it's specific to getting back to

(48:40):
being athletic.
And yeah, it just insert themost popular surgery.
And so ACL gets the associationwith testing, but what does
somebody need to be athletic?
That's what we want to test.
And that's what our trainingshould be addressing.
And, you know, we're fortunateat our center that we have a
biomechanics lab and a greatsports biomechanism, uh,
biomechanics team of scientiststhat run it.

(49:04):
And so we're able to look atkinetics and kinematics so you
can kind of pull the curtainback and see what their
strategies are, because whenyou're looking at it clinically
of them squatting, okay, you'redoing your one legged squatting.
We put you on the Y balance testand we have a side to side
comparison.
We compare that to your limblength.
But what's the strategy?
Like how did they manage to getdown there?

(49:25):
What happens when they have tomove faster?
What's the strategy that theyemploy there?
So the progression is verysimilar, but what you're going
to find is that each phase takesa little longer because their
joint is generally moreirritable.
It's going to take you longer toget full range of motion than
with an ACL.
It's going to take you longer toget the quad up and running
because they might be more soreat their knee.

(49:46):
And so you have to modulate thetraining a little bit and your
hamstrings are going to bedelayed.
You can't have a hamstringprecaution for four months and
then at six months have fullhamstring strength.
I don't care who you are.
Right?
Exactly.
That's what I'm like, really,really?
And so, but all of those sameparameters for, I want you to
achieve X, Y, and Z before I letyou run.

(50:09):
Are going to be in place, butthey're probably not going to
meet those goals until, youknow, seven months instead of
maybe five or four.
I don't know how much fasterpeople's ACLs get better than
ours, but I've, I call BS onsome numbers that I see
sometimes.
You've seen so much.
I'm sure, you know, but, uh,Jill.

(50:30):
OMG, that was a master class onmultiligamentous knee injuries
right there in what, 45 minutesor so.
Um, that was a very, veryimpressive episode that is going
to be very, very helpful for somany people.
So, uh, thank you for takingtime out to do that.
Um, I'm going to put a link to,um, at least one of Jill's

(50:50):
papers on this topic so you guysCan kind of dig in a little bit
deeper and have a reference togo back to as well.
So check that out in the shownotes.
And then Jill, before we let yougo, we're going to do high five,
uh, five quick questions, fivequick answers to learn a little
bit more about you, um, and whatyour brain does, which I think
we're, we already get a goodsense of from this, uh, amazing
episode, but, uh, first questionis what are you currently

(51:13):
working on for your own contentor your own professional
development?
Yeah, you know, that tends tofollow what I've managed to get
myself signed up for in terms ofpresentation lectures.
And so it's nice, though,because I'm not I wish I were,
but I'm not the type of personwho can just dial it in and.

(51:35):
Like represent something Ipresented three years ago and
call it good.
So I tend to do, my husbandwishes I was that person.
I always do somewhat of arefreshed and up to date lit
review on whatever it is thatI'm, that I've been asked to
give a talk on.
And the reason I commit to doingthat is because every time I do

(51:55):
that, I end up changingsomething in my practice because
I'm like, Oh, dang, I didn'tthink about that.
Or that's great.
Yeah, I mean it's just becausewe can get lazy and just do what
we do and then defend what we doand then there I am like 70 like
and then you'll do this and solike I want to evolve.

(52:15):
So, you know, we've, I look I'vebeen talking about return to
loading after meniscus injury soI dug into that, and you know, a
little bit on knee stiffness andthe relationship with quad
insufficiency and.
And there's just some cool stuffin that.
And so I kind of immersed myselfand, and always have one or two
things I changed in my practicebecause of it.
That's awesome, which leads usinto the next question.

(52:37):
Then what's one thing thatyou've recently changed your
mind about?
Yeah, I mean, I don't know aboutchanging my mind.
Um, maybe kind of coming back toit a little bit.
Um, Lane Bailey did a reallygood job of, of speaking at our
OSET meeting about, um, EMG Inaddition to thinking about NMES
for quad, like the value of EMG,I was kind of an EMG purist

(52:59):
early in my career.
And then I got on the NMEStrain.
And I like the concepts of whatEMG can do.
And I think it has a space andvalue.
And, you know, focal cooling isnot something I did a whole lot
of.
You know, we always hadeverybody ice after their
treatment and we do a lot ofconversation about inhibition of

(53:19):
the quad after surgery and we doa lot of strategies to overcome
but I've started, you know, justgetting my little baggie ice and
sticking it on the knee andwhile my patient's working on
extension and then we go intoquad work once they've been 15
or 20 minutes.
Brought that on and that kind ofrelates to that deep dive.

(53:39):
And then, you know, anotherthing is just holistically our
center has a lot of, um, kind ofmultidisciplinary resources.
And so I talked to my patientsjust a lot about recovery and
nutrition and sleep andwellness.
And those are things that I tryto weave into our practice more.
So those are things that I maybe doing differently now than
what I did, you know, five, 10years earlier.
That's great.
I love it.
Uh, what's your favorite pieceof advice that you love to give

(54:01):
your students?
I challenge them to understandthe why behind things.
Don't just nod your head and sayyes.
Um, don't memorize protocols.
Figure out why is thatprecaution on the protocol.
And if it's on there with nogood reason, or it's maybe
because you don't understand thereason, and you need to ask why.

(54:22):
So, ask why.
Because if you understand thewhy that opens you up to be
creative and think aboutproblems in a new way and maybe
be the one who kind of creates anew and different strategy that
no one else thought of beforebecause you're not limiting
yourself to just followingorders.
Awesome.
That's a great one.
Uh, what's coming up next foryou, Jill?

(54:44):
I got a couple of things.
I'm apparently I'm a mentor withASBT's virtual teammates.
That's coming up here inNovember.
Um, so loading in cyberspacebetween various rooms, I think,
our team is presenting at CSM.
We've got an educationalsession.
We're on the, we're the, we'rethe grand finale, baby.
We're on Saturday, the lastsession talking about the

(55:06):
collateral ligaments and rehabafter collateral ligament
reconstruction.
And we're also going to bepresenting, um, In the research
platforms for our preliminarydata related to PCL and we've
got a couple, you know,projects, research projects in
the hopper that are kind ofnearing completion, specific to
meniscus.
And, um, again, weight bearingwith our ligament

(55:28):
reconstructions.
Awesome.
Sweet.
So where can people find outmore about you?
Is there anything that, youknow, are you prolific on
Twitter or Instagram or anythinglike that?
Where, where do you, where canpeople learn more about some of
you and your work?
I'm prolifically boring and nonconfrontational on social media,
I'm sorry, I'm not, I'm veryconfrontational in real life, I

(55:49):
just, I just want to be, like ifI want to be able to reach out
and grab you if I'm going to beconfrontational, um, so, I'll
have to remember that next timeI see you at a meeting, by the
way.
So if you see me with Mike andI've got him in my hands, so
Twitter, Instagram, LinkedIn,I'm on all of those platforms
and I can give you my, My littlehandles for those.

(56:09):
And then, you know, my TCO, um,Jill Munson.
If you type in Jill Munson TCOand it's Munson with an O, not a
U.
Um, my, my page within the TCOpage has, I've got some little
educational resources forpatients and just my bio and
some of the, some of theliterature that I've been a part
of.
So that's probably as good aresource as any, nothing more

(56:31):
attractive and appealing thanthat.
That's fantastic.
I'll put links to all that,including Jill's socials in the
show notes, so you guys cancheck her out.
But Jill, again, sincerely, thatwas a masterclass.
Thank you so much for such anamazing episode.
Thanks for nerding out with meon Complex Knee.
I love it.

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Multiligament Knee Injuries with Jill Monson - Episode 43

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Multiligament Knee Injuries with Jill Monson - Episode 43