The Peter Attia Drive - #36 - Eric Chehab, M.D.: Extending healthspan and preserving quality of life

Episode Date: January 14, 2019

In this episode, Dr. Eric Chehab, orthopedic surgeon and sports medicine specialist, explains the measures we can take to live better and maintain our physical health through exercise and the avoidance of common injuries that prove to be the downfall for many. He also provides valuable insight for those weighing their treatment options from physical therapy to surgery to stem cells.   We discuss: Favorite bands, musicians, and concerts [3:30]; Eric’s upbringing, biggest influences, college life, and teaching overseas [12:45]; Eric’s training, fellowship with the New York Giants, and the risk vs. reward of playing football [39:15]; The knee joint: common injuries, knee replacements, and proper exercise [1:00:00]; Best exercise for orthopedic health and bone density [1:10:00]; Most common injuries: knee, hip, shoulder, elbow, ankle, foot [1:20:45]; Physical therapy vs. surgery, and the meniscus surgery controversy [1:28:30]; PRP, stem cells, sham surgeries, and the placebo effect [1:41:00]; Back injuries: when does surgery make sense? [1:54:15]; How to find the right orthopedic surgeon for you [2:01:45]; How to cope with complications and maintain quality of life through adaptation [2:09:15]; Dr. Bukk Teef [2:26:45]; and More. Learn more at www.PeterAttiaMD.com Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Atia Drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at pteratia-m-d.com.

Hey everybody, welcome to this week's episode of The Drive. I'm your host, Peter Atia. My guest this week is one of my best friends from medical school, guy by the name of Eric Sheaap. Eric is an orthopedic surgeon, specializing in sports, but overall knee and shoulder. He's an assistant clinical professor at the University of Chicago. We met obviously at Stanford, and he went on to do his residency in orthopedic surgery at the hospital for

special surgery or HSS as it's known in New York City. It's generally regarded as the best orthopedic facility in the country, if not the world. He did his fellowship with the New York Giants before settling in Chicago. He was also mentored at HSS by a guy named Russ Warren, who anybody listening to this, who knows a lot about or a little bit about orthopedic surgery will understand the significance of that. Russ has generally considered the godfather of sports medicine. This interview was also really informative for me because I, as you know, think about longevity through this standpoint of living longer, but living better and a big part of

living better is not getting hurt. And what I love about talking to orthopedic surgeons, especially people like Eric, who are just so cognizant of what the demise looks like at the end of life, is I think by understanding where people fail later in life, you can understand how to mitigate that earlier in life. So we get into a lot of detail around the common joint injuries. So what's going on with knee pain,

especially from incorrect form in a loaded fashion? We talk a lot about shoulder injuries, especially with weights being used overhead, elbow, wrist injuries, ankles. What's going on with the Achilles tendon? Obviously, we talk about lower back stuff, which for many people is also, I think it's almost impossible to get through life without at least one lower back flare up. We revisit sort of my injury, which I've talked about actually in the past. We talk about all the complications that can come from it. And we talk a little bit about how you

can decide when PT makes more sense than surgery, which unfortunately for lower back injuries is almost always the case. We get into some of the real controversy stuff like meniscus surgery, which some of you may be aware of. We talk about the origins of pain. So a lot of times people present with joint pain, but it's not really clear, is the pain matching the thing you see on the MRI. And again, I have an example of where that was not the case. We get into PRP, stem cells, sham surgeries, and all sorts of things like that.

The other thing that probably comes across, I'm not as much as I would have liked, is Eric is probably one of the funniest human beings I know. He's actually saying at my wedding and I think we even discussed that story early in this episode. Although I didn't get him to sing, so that's probably one drawback. Anyway, the show notes will be linked to a ton of awesome stuff that follows up and goes deeper on some of these things. And obviously, if you want to learn more about Eric, that's great, but the reality of it is this is mostly just a way to kind of help people think about orthopedic surgery and

More than anything else these types of injuries and what we can do to prevent them. So I hope you enjoyed today's episode and here we go Hey, man, what's going on? It's good to see you. It's been a long time. I feel like it's been two years since I've seen you in person and we did get to spend an hour Finding a place to record this so that that like here's been two years since I've seen you in person and we did get to spend an hour finding a place to record this So that that like here's a good chance to catch up Where are we sitting right now? We are sitting in my Wilmaid office for Illinois Bonen joint in Wilmaid We're like actually in a patient exam room. I think we're in a patient exam room Yep, just like the only room we could find that didn't have a AC unit blaring or something like that

Well Eric there's so much stuff I want to talk about. Mostly about orthopedic stuff, because in the spirit of trying to live longer, you've probably heard me talk about it. There's no point living longer if you're not living better and a big part of living better is your exoskeleton. And for a lot of people that you probably see, and certainly I see it to a lesser extent,

once that quality of life deteriorates, meaning once they don't have the strength, mobility, or freedom from pain to carry out the activities of daily living, for many people they don't actually care that much if they're going to delay their heart attack by four years or something like that. It's top smattering. So, let's go back to the beginning. There's so many goofy things I want to talk about.

Did you group in New Jersey? I don't think I knew this. Yeah. I grew up in New Jersey. I was born in Omaha and moved to New Jersey when I was three and Is Bruce Springsteen still probably one of your favorite singers? He's my favorite. Yep. There is this I think I put it up on social media a little while ago, but there's this awesome video It was from 2009 in Madison Square Garden where Bruce Springsteen was playing with Tom Morello and

My son when he watches the video thinks I'm Tom Morello He doesn't get that I'm not and it's like no, no, no, actually that he looks like him or he looks like that. But that's not mean. He's like, what do you mean? That is you. And he can he's like, why do you know how to play the guitar, but you never play at home? There's this one song which we'll have to link to the ghost of Tom Joe that they play together.

It's like an eight minute thing with Morello doing like a three minute guitar solo at the end that is out of control. But there's something about Bruce Springsteen's voice that like he might kind of be the coolest guy ever. No, he's definitely the coolest guy ever. How many times have you seen him live? Five six times. First concert I went to was Bruce in 84 at Brendan Burn in New Jersey. And it was as he was kicking off the born USA tour. It was summertime. There were about five or six of us. We were in eighth or ninth grade and it was great, fantastic. And then I saw him. I lived in Milan for a

year. I was teaching high school and he was playing in Verona on Easter Sunday. And he was supposed to play in an amphitheater in Verona that guns and roses had played in like a month earlier. And basically nearly tore the place down. And one of these amphitheaters that had been there for 2000 years and sure enough won concert and no more concerts. So he played in the soccer stadium in Verona on Easter Sunday for about five hours. and I remember I was on a bike tour. I was taking my bike through Tuscany. I was by myself on a mountain bike. And it was Easter Sunday morning.

I was in Florence and there was the Easter parade and I had this one ticket to Bruce. And I'm like, how the fuck am I going to get to Verona? So I ditched my bike someplace. I get on a train of Verona, turns out there were a lot of Bruce fans on the way and there were translations of Bruce's lyrics into Italian, which I always wonder how like working on the highway and, you know, drinking warm beer in the soft summer rain translate into Italian. But anyway, and I get there and this show goes on as usual for about five hours and I get on a train at three in the morning from Verona head back to

Florence, pick up my bike around nine o' three in the morning from Verona, head back to Florence, pick up my bike around nine o'clock in the morning and then keep riding because it was so pumped up and jacked up from having seen this fantastic Bruce concert and just kept riding for the rest of the day. So that was one of my favorite Bruce concerts was that in Italy. I saw him in Oakland with my wife with Lynn when we were dating a medical school. And that was sort of tempered by the fact that she wasn't much of a Bruce fan. My good buddy, Mark Palmerance, was at that concert too.

Yeah, was that right? Yeah, we're up in Oakland, up in the nosebleeds. And then I saw Bruce most recently with Lynn, who now is a fan in Milwaukee on his River Tour. And he gives such a great show, The River Tour is fantastic. And so he plays the album, and then he goes on for another two or three hours with just great songs, and he's so good live.

I saw him in Riggly right after Clarence Clemens had died, and they had that tribute where they at 10th Avenue freeze out, they just stopped the music on when the big man joined the band, and they have a large shadow silhouette of Clarence from the Born and Run album. It's really moving. I mean, he must have done that about 50ce from the Born and Run album. And it's really moving. I mean, he must have done that about 50 times from his death to that concert, but it's still very genuine and very moving. And the whole place goes quiet. And then it erupts in sort of cheer and laughter and tears as it was really moving.

And that was what I think, I must have been four years ago when he played it regularly. And yeah, I'm sort of a JV Bruce fan compared to my roommates in college who go of my one roommate on, it had probably been about 100 concerts. And he tells a great story of punching. Is it the only one that I know? It's the only one you know.

Yeah, he tells a great story of punching someone out on the Brookner Expressway on his way to the Bruce concert. So I'll let him tell that story. It's not, it's not when you're he's at it., no, it's not like the guy had a coming. So I don't really have any problem. Oh, and was it like, wasn't he a Navy sealer? He's a marine, and he's now he's now an undersecretary defense for General Mattis. He's the special ops and very busy guy. Do you notice over time as you go to these concerts, like, does the fans seem older

to you? And so for me, Pearl Jam is the band that I've seen more than any other band. And I just saw them recently in Fenway. And I gotta tell you, it was the first time in a long time I've been in a concert where I had as much joy out of watching the other people there because they were older than me, some of them. But you could tell.

So when 10 came out, I was maybe 17 or 18, but you can tell there are people who were 30 when 10 came out and probably still found it amazing. And so now they're, you know, in their late 50s, and you can see the emotion in them when Eddie Vetter gets up there and plays something that from 91 or something like that. So it must be the same with Springsteen, but even greater because it's a greater time period. Yeah, no, that's another funny thing when you're wriggly and you see the fans to your left and you're right. And they're pretty old. And then you'll see some of them holding their 10-year-olds. And that's the fun part of it is that there's

a sort of intergenerational thing. You have these younger kids growing up loving Bruce because their parents love Bruce. And so, but yeah, no doubt the crowd is older. It's funny, I mentioned Pro Jam. They open for you to Inverona in 92. I was still in Milan, and I saw Pro Jam open for you to on the Zuropetour. And... So you ended up Pro Jam, you too, and Bruce Springsteen in one trip to Italy? No, no, well, I lived in Italy.

But who did this? Oh, you were there for a year or two. I lived for a year, but same venue, same, and fabulous venue, and I believe guitarist for Pro Jam was like in lived for a year, but same venue, same fabulous venue. And I believe guitarist for Pearl Jam was looking as picks out like he does. Yeah, Mike McCready. I've almost caught him.

Mike McCready pick once in DC. I was in the third row. I was like, that was my one shot at catching the pick. And I didn't. He also had a disposable camera. He takes pictures of the crowd. So I'd be creative if he still had one. That would be kicking in old school.

But the disposable camera out in the crowd. It was great. We could spend the next two hours talking about music, because we both love it so much. The last music story I do wanna tell though, is remember what you did at my wedding? I hate to tell you weren't the first. I still feel special.

You should, I mean, you're the first that I use the buck teeth for, but pretty much everybody's wedding. I've got up and sang with a band or whomever. And for whatever reason, let me do it. And I don't have any talent. I don't have a voice that's worth listening to. But I certainly think I'm great. And I have a lot of verve and energy.

And so at your wedding, I sang a verse. Yeah, fire. Yes, fire. And I had my teeth in, so I was listening pretty badly. Those buck teeth that make me... Yeah, we're gonna explain what these are in a moment, at the listening. So anyway, those Dr. Buck teeth in

and sang fire to you and Jill. And I could tell there was kind of like, what the hell is going on here among the whole wedding crowd. And but hey, we were all in and it was great. And you had to, I remember that. It was incredible. I remember that wedding also talking to Conti

because he was driving from Was it then that he was driving from he had just driven from Jason Piles wedding in Los Angeles To Boston in 30 something hours, right? So he was planning to do it without stopping right his wife Or I wasn't his wife yet. He'd taken Provisional,, which is that. I gave him 400 milligrams of ProVigil, 800 milligrams of IB Profen, and he said he was gonna be fine. And I was like, that's crazy. And she finally made him stop in Cleveland.

Yeah, yeah. And it's was 36 hours to get to Cleveland before she made him stop for eight hours before they finished the drive to Boston. I asked him, I was like, you must have suffered like 24 hours. I was like, no, eight hours got to drove the rest of the way. Yeah, when you sang fire at our wedding, it was one of the most amazing things because it was kind of like camp of a blank note. Same as a

Dan Flarety, you know, the Dan band. Yes. It was that experience because like at one point, you threw in a couple extra fucks. Like it was fucking fine. Yeah, yeah, I did actually think of it. So that's the part I love. Yeah, I wish I had done something more with it to be honest with because obviously it's been a great career for that guy I actually got to meet him at a party two years ago. I see you summing the selfie. Yeah, yeah I just glued myself to him the whole night That's like I can't freaking believe I'm sitting here with this guy. It's incredible So where'd you go to college? So I went to a little school back east. Oh, whereabouts? That's east of Mississippi.

Oh, what city? Oh, I can't go city so quickly. Oh, what city? It was a Massachusetts. It was an Eastern mass. Oh, so in your Boston. In your Boston's a little school outside Boston. Boston College?

No, that's in the city. No, no, no. Harvard. So you were the first guy I met that took that to another level in terms of the complete buffoonery of the the too cool to say Harvard. Yeah, no, I'd always struck me as odd when people couldn't say that they went to Harvard. And I remember being in the backseat of a carbon-dunkin and his brother Hunter and this dude is there with me and I'm like, oh, so hey, we're in school.

And he starts out with Massachusetts. And I'm like, oh, so hey, we're in school. And he starts out with Massachusetts. And I'm like, oh, my god, you gotta be kidding me. So I play along with it. I'm like, oh, wearing Massachusetts on the west side of Massachusetts or the east side of Massachusetts. He's like, east side. And so he's so happy he's not coming out with it. And then finally, we will there down to Boston

and then Cambridge and then Harvard. He finally lays it on me. I was like, I'm a thirtue. And then I've got to admit, very lucky to go. And there's not a chance in hell. I'd get able to a place like Harvard or anything like that these days. As my 16 year old is going through this,

it is a different world for college admissions. And all the breaks that I had to get there, you know, the door was still much wider open than it is for kids today. It's just a different world, more international kids and highly more competitive. They're much less wed to schools that they've used to admit to. They're much more open and for kids all over the place and all the words. I think it's a great thing, but it's just not the same. I mean, there's no chance in hell I'd be in a school like that little school back east. If I were flying today.

Well, we used to joke about this so much that it stayed with me forever. So even when I left med school and wound up, anywhere I would go thereafter, now I became, I was always looking for the person who went to the little school back east. And so finally, so fast forward, maybe 10 years after we're done with medical school,

I've got this friend, his name is David Bataro, incredibly talented artist, could have be talented at everything basically. And he went to that little school back east and he thought that was the funniest shit on the face of the earth. And I said, David, I need you to design little school back east t-shirts. So I want the sort of the Harvard shield, but I need you to find the exact font that it normally says Harvard, but you have to just say little school back east. And of course, David, because

only David could do this, he probably spent the next, I don't know, three weeks designing the font to make the t-shirt that I sent you. So he made 10 of them because I had 10 friends who had gone to Harvard or whatever, at least who I thought would appreciate the joke. There were some who I didn't want to piss off too much. So do you still have your little school back east shirt? Yeah, of course I do. Yep, that's so great. I showed a warrant at doing a reunion just a couple years ago. That would have been good.

Would have been good. So did you know when you went to college, you wanted to go into medicine? I had a pretty good idea. My mom is a nurse, my father, who I'm not, I didn't grow up with my dad. When my mom and dad divorced, he went back to Lebanon and I really didn't hear from him until I was 16, 17 years old. Caldary you when they split?

Three. But he's a physician and my grandfather was a physician and so I always grew up around medicine with my mom being a nurse and the doctors that she worked for were terrific people. I had a bunch of injuries as doctors that she worked for were terrific people. I had a bunch of injuries as a kid. So I saw Dr. Taylor, I remember like it was yesterday in his office for some of the knee injuries I had as a kid. So I was exposed to medicine probably more frequently

than most people. And so I had a pretty good idea, but I took a little bit of a securitus route after college where I taught chemistry and physics in high school. But I did it overseas. I spent a year in Milan. That's where I saw the great concerts.

And it's a ton of an American school there, which was a terrific experience. And then came back to the States for a year to a private school in D.C. called St. Albin's at all-boy school there. It's a very prominent, great, preparatory school. And then went back overseas to Bulgaria of all places and taught at an American school there. So these three years that you're teaching kids in high school, did you still think you were gonna go and do medicine?

Or is this a part of deciding if you still wanted to do that? No, I was pretty sure I was gonna go, but it's interesting, the teaching was fun, but I felt like there was more that I could offer, I guess. And I was basically a high school chemistry teacher and enjoyed the kids and loved working with the kids. But I just felt that medicine would be a better fit because I'd still be able to teach

and still be able to help people. But it was a little bit more challenging, I guess. It was just more up my alley. And I think it was sort of a calling to go and do it. But the teaching was a great experience. It was a great way to see the world. It was a great way to learn how to become an adult from college to earning a living, getting a paycheck, paying your bills, paying back your

student loans, and then directing your life in a way that, you know, geez, I really want to make something of this. And so then you go back to school. So that that time off between college and medical school, for me, was invaluable in terms of maturation. And it's hard to imagine. I mean, knowing me in medical school, I don't think I was the most mature dude on the black, but believe it or not, I was still maturation. No, you know, Conti and I actually did a podcast a while ago, which I just actually just came out.

And we talked a little bit about this, that there was just a group of us that became very fast friends. And I think we were viewed externally as sort of these testosterone knucklehead guys, but we all had this thing in common, which we said all kind of taken a bit of a winding path to get there. And I think on the surface, while it looks like we were just a bunch of idiots, I think there was probably more to it.

Do you remember the last time you and I interviewed? I sure do. It was me interviewing for med school. Yeah, I was your student interview. Yeah, that was my first interview. So I was beginning like the circuit and doing all that, but it was also my first time in California. So I'd never been to California until that interview. And Stanford was the only school I applied to that was not in the Northeast. And I remember leaving there, and I think I went either Duke or Hopkins or Hopkins Duke

and sort of worked my way. But I remember thinking, you know, in part because I met you and I really connected with you. And in part because I remember it was February and it was 76 degrees out. And I, having grown up in Toronto and going to school outside of Toronto, it didn't occur to me. Even though intellectually I understood

you could live in a place in the winter where it wasn't freezing. To see that, I was like, wait a minute. This is a different place. But when you went to med school, my recollection is you, we kind of thought you were going to wind up doing internal medicine or ortho.

There was a bit of a toss up there, right? Yeah, that's right. I was undecided pretty much until the 11th hour between internal medicine and orthopedics. And the appeal to internal medicine was the idea that you'd have these long-term relationship with patients. My guess is most people who are struggling between ortho and something that other something is not internal medicine was the idea that you'd have these long-term relationship with patients. My guess is most people who are struggling between ortho and something that other something is not internal medicine.

It's generally surgical, for sure. I don't know, maybe I shouldn't be admitting this among my orthopedic colleagues. Well, there's a joke, and I remember when I was going through my rotations, you had sort of the attending and the senior resident of the fellow and the senior resident, all the orthopedic team walks into the patient's room, you know, post-opt day one. And the nurse says, you know, I think so and so might have broken out into a fib last night and says, you know, so I'm going to call the cardiology consult and the attending says, come on, we're doctors here.

Like you're not going to call a cardiologist to tell us our own patients in a fib, give me a stethoscope. And he reaches in his pocket, doesn't have one, he looks back at the fellow, the fellow doesn't have one, he looks back at the chief resident, doesn't have one, but all the way down, even the med student for the ortho rotation, not carrying the stethoscope. So then he's like, yeah, just call it cardiology. That's all right.

Well, there was a sign in the general outside of the weight room that said ortho library. So. And there's a stereotype, right? I mean, all the jocks go into ortho. Yeah, no, it's a definite stereotype, but it's sort of an unfounded stereotype. I mean, obviously, there's some of it that's true. I mean, most of the guys in orthopedics are athletes or have been athletes at one point, but it's a pretty thoughtful, especially.

It's not simply bone broke me fix and that's that. And I'm really glad I made the decision I did. I mean, I really can't imagine not going to the operating room, not seeing patients, not seeing sort of the fruits of my actual work. I think being an internal medicine is for some people. It's great. For me, I think it would have been ultimately a poor fit. So I'm very happy with the decision I ended up making.

I remember you let me read your essay for residency, and you talked a lot about Bill. Yep, who was Bill? So when my mom and dad split, we moved back, my you say move back. My mother's from New Jersey, we moved back to the town where she grew up. And it's a beautiful town near the shore called Rumson.

Very well to do place, similar on par with Crenish, Connecticut, some other places that people hear about. And when we move back, we moved on to a smaller street. And across the street was a guy, Bill Hensler, who was living with his aging mother. And he was a longshoreman. He had worked on the docs. He'd been a caretaker. He'd been married three times, had kids, but had been estranged from his daughter for a while.

But anyway, he was our neighbor. And he took a liking to my mom and my family and sort of ended up being over time a father figure to me. And like I said, I didn't really have any contact. I really had no contact with my biological father for between ages three and 16. And Bill was that role. He was that father figure.

So the real turn of the relationship actually happened in I think 1978, close to there, where my older sister, Karina, we were all out playing in the street and Bill at that time was an alcoholic, he was a World War II veteran, and I think he had PTSD, and like many other World War II vets basically suffered in silence to some degree.

And his family, they were brewers in Newark, there was Hensar Beer, that was Bruton, Newark. And Bill passed out. And I think my sister was like trapped under his leg in the middle of the street. And I mean, it was just a whole scene. And my mom said, hey, enough. And she took him to a place called

Carrier Clinic in New Jersey. And he sobered up in 28 days. And that's the last time he had any alcohol to drink. And he was sober since. He came to all my popcorn or football games. He would drive up to St. Paul's in New Hampshire. I went to boarding school and come to some of those games there and he got remarried in 87 and I was his best man and that was you would have been what 18 years all the time and

it was the honor of a lifetime to be his best man. And you know, we were very, very close and part of the reason I a lifetime to be his best man. And, you know, we were very, very close. And part of the reason I had chosen to do my training in New York and leave California was so that I could be closer to home and closer to bill. Because by that time he was in his late 70s, his health was failing. He'd had a cabbage.

And a cabbage for the listener is a bypass surgery of the heart coronary artery bypass graph. So he, you know, he was aging and I just wanted to be closer to home. And then he died my fourth year of residency, about five days before my youngest son, JJ was born. And those last six months were rough for him, but I was very happy to be there. He actually broke his hip, which is an end of life injury for many, many people.

And it was for him. So he broke his hip in March. And it was actually right after we had come back from Key West, Florida, where his daughter Annie lives and works and his daughter and he had been estranged for a long long time but his wife Jay who I had stood up for at the wedding she had gotten Annie and Bill back in touch and they were close and they were, they had reestablished their relationship. And so I had a week off from residency and Lynn and I decided to go to Florida and our plans had fallen through at the last minute to be in a place near Palm Beach. And

so we said, let's go to Key West and let's bring Bill down to Annie and so we did. And then he ended up staying, planning for a weekend, up staying for about six weeks. And then he came back to New Jersey and then shortly thereafter he broke his hip. And I went down to see him immediately in the local hospital in New Jersey and they had and so medicated that he couldn't talk. He wasn't him and I said, this is not going in the right direction. So I brought him up to New York to special surgery. And Matthias Bostrom, who's one of the greatest guys at special surgery, did his hip, did his M. And Matthias Bostrom, who's one of the greatest guys at special surgery, did his M.I. Arthoplasty. And then the nursing staff really took a liking to bill

and everyone really, you know, he's a hard guy not to like. So he ended up staying for about two weeks in the hospital after his M.I. Arthoplasty. For another reason that people like hanging out with him, which is unheard of, right? I mean, and then, you know, when I was on call over the weekend, we used to take call basically from Friday to Monday and being overnight. And so we would go up on the roof on a nice day. And this was now in April, whether it was turning nice and we went up on the

roof on the sunny days and I'd hang out. My picture would go off. I'd bring them back downstairs. And then whenever we had a minute, we'd go back up to the roof, it crews around. And then he got out of rehab. He went to home. He was on his own, but he just got scared. And then I forgot to mention this. He ended up having a liver cancer at HEC. So he had a patellous cellular carcinoma. So he was becoming kick-cack-dick. He was losing weight and he was just becoming scared. And so the summer was sort of miserable for him. He was on his own at this point. Jay had died about a decade earlier. And he went in the hospice, and about two days later, he died.

But Bill was probably the most giving and nicest person you could meet. He was always quick with a laugh. He was a ton of fun. When he'd come up to St. Paul's, he'd make fast friends with all these other people. And again, they'd be like, are you his grandfather? He's like, no, he's just my friend. But he was that father figure that I otherwise probably

wanted to have had. And he made all the difference in the path that I was able to take. And so, I did write my essay about Bill partly because I just wanted people to know who he was. If I'm applying to be a part of your medical school, I mean, I didn't want to just list my resume. That seems sort of stupid.

I just wanted to give an insight. So I would talk about, I think on that time, if it was my application for residency, Jay had passed. It was about two months after she died and I was at home for the summer. It was between my second and third year of medical school, so I was in New Jersey. And I wanted to take him on a, just wanted to get him away. So we went up to New Hampshire, like we had done when I was in high school.

And we drove, and we drove, he called it a sponge tour when he was younger. He talked with his buddies. They would go on a sponge tour where they go from house to house and place to place and sponge off their friends or their friends parents. And so we kind of did that. We stopped in a few places and then we went back to Cancad. We were joking in the car, Concord, New Hampshire, but the way the folks in Concord say Concord

is Cancad. So that was something I'll never forget. And then we went to Winnipez Sake where Mike Love, who's one of his family friends, who was one of my first bosses, I bust tables at Mike's restaurant in New Jersey, and Mike moved up to New Hampshire and opened a restaurant named Montenborough on Lake Winnipezaki. And then he opened another restaurant in one of the other lake towns that often went a Pasaki called Love's Key. And so Bill and I saw Mike, Mike, insist to be staying with him, and we really were sponging

from place to place. And so by the time I got back to New Jersey about 10 days, two weeks later, you know, we had gone on this nice ride and just had a chance to kind of normalize his life again. And that was in the late 90s. And so I think that's what my essay was about was this sponge door that I have with a guy who had just had a big loss in his life in a way of sort of healing through time and healing through laughter and healing through laughter, and healing through just normal, daily activities.

That's what struck me about it. I remember this because, you know, I remember going through, because you were a year ahead of me and I'm sort of putting that stuff into my own thought at the time, which was like, what do I want to write about? You don't get a lot of space to tell your story when you're making these applications.

And I remember thinking this isn't what you'd expect for a McGuy applying to orthopedic surgery. And there was some stuff in there about ortho, right, which was like returning functionality to people and things like that. But I was very touched by this story of Bill. And yeah, I had forgotten until you mentioned it again, but that you were his best man at the, you know, at the ripe old age of 18. I love that story. And your old son is named after him. Yes. So my will, we call him will, is named after Bill Henser. And he was tickled pink about that. He would have loved to have met JJ. I mean, sort of a hell-raiser character like Bill was.

And I think about life as somewhat serendipity. And it is serendipitous that we happen to move into a house across the street from this man. And that we took such a liking to one another and it was really awed by chance. And I sometimes think would it happen in a day and age like we have today where everyone so suspicious of people becoming close. Anyway, the bottom line is, it is a great stroke of fortune to know Bill. And I did write about him an awful lot because he was probably one of the most

meaningful influences in my whole life. Are you close to your dad today? No, no. I've seen my dad probably total of about four weeks. And you know, it's funny you mentioned that because he's recently we are here in the office right now doing this interview. And so he's been sort of raising hell through the office because I get calls from the hospital page or I think your dad is on the line and then I get calls my secretary. I think your dad is on the line and we don't we don't talk very much and he lives in Spain. He's he was in Beirut for the majority of the Civil War during the 70s and 80s. And he refuge from Beirut to Spain in the mid-80s and in 86 was when I saw him again. And he was in a small town in Anteniente, now lives in Alicante, which is a beach resort town, about five hours south of Barcelona.

And I think he also suffers from PTSD. I mean, he was living in Warzone and he's a nobi guy. And, you know, he tells a story of having a woman on the table who he's doing Caesarean on and then someone comes in with a machine gun asking to save his brother's life and you know, he became someone of a trauma surgeon as an obstetrician and that's a big leap. And you know, I just think it got too much and he misses being at home. He misses Lebanon, I'm sure of it. But the fact is, he's sort of anxiety riddled guy. We never really had a meaningful relationship.

So he got in touch with me again when he was hounding the office. I called him and we talked for an hour, but I think the bottom line is, is at a point in his life where he's not gonna change very much, I'm probably not gonna change very much. And it's hard to bridge the gap. I wonder sometimes whether I want to expose my kids to that type of relationship with their father. So I go back and forth on that. And then I did make a point of seeing

him. The last time I saw him was when I was engaged to my wife Lynn and I told her, look, you've got to meet the gene pool before you come into this whole thing. Because he's a little nuts. So that was the last time I saw him physically face-to-face. My sister, Rand, and my oldest sister went to see him, and it was a real brutal visit. He's starting to lose a little bit, and he's just not fully there. So it's tragic. It's very sad because I think... Well, he was at Hopkins. He trained at Hopkins. He was one of the four medical grads. He had gone to the American University. I didn't know that. think well he was at Hopkins he trained at Hopkins He was one of the foreign medical grads. He had gone to American University I know them. Yeah, he was at Hopkins. He did his old began was that where he met your mom He met my mom and Roosevelt hospital in New York where he was training

I think he was doing some of his residency there or Somehow he they met there. I'm not sure if it was during his residency afterwards But they met New York my mom was working as a medical assistant slash nurse anesthetist at that time. She worked as a medical assistant her entire group. But I think about him in his mid 20s. He's got his whole life ahead of him. Everything's very promising. He's a young medical student. He's becoming a resident and becoming a doctor. He has his family. And then fast forward 10 years. It's all falling apart. Like he's lost his family, he's back in Beirut, he's with his, you know, his four kids, his wife gone back in New Jersey, he's in Beirut. And then he basically gets burned out in Beirut during the war. And since then really hasn't done much, he's taken care of a few people locally in Spain as a obstetrician for some

of the community that are refuge there essentially, but not really doing much. It's a derailment of his life at a time when things were really looking very promising. And when I see him and meet him, I can see how that can happen. And then I just don't want that for myself sometimes. So maybe I'm just turning a blind eye to it. Yeah, again, I probably a deeper discussion that we could have off my... But I have so many thoughts about this, right?

I think that, you know, on the one hand, I have found myself more and more empathetic to sort of the situations people are in that on the surface might look like, well, you know, that's a cut and dry case of, you know, he left his family and X, Y, and Z. But you start to realize that there are other bits of baggage that people are carrying with them that, you know, you can make a wrong decision in a moment and that decision can, you know, two people can make the same sort of wrong decision, but one comes with far greater consequences. You know, one of the other people I had on this podcast was named Corey McCarthy, and it was a really, really interesting discussion

about his life and how he wound up in prison. And it made me reflect even more on how close I could have come to going to prison too. When I was in eighth grade, the kid I looked up to the most in high school, and he took me under his wing. I mean, he really liked me. And he was the toughest kid in the block and blah, blah, you know, by the time I'm in 10th grade, he's in 11th grade,

he's in jail for armed robbery. And I've always thought like, what if I was out with him that night that he decided to do this really dumb thing and hold up a liquor store? Like, you don't have enough of a prefrontal cortex at that age to sometimes go wait a minute. This is a bad idea. Like in the moment, that can seem like this is a great rush. Like we're going to get some money. Now that said, you've brought up Lynn a couple times, so I got to get one story out of you this, probably. If I had like top 27 Shea Habs, stories this one's on the list.

So do you remember your first date with Lynn? Now Lynn was one of our classmates, so you knew Lynn, but you finally figured out a way to get her out on a date. Yeah, our first date was a real winner. So I finally sort of mustered up the balls that asked her to out on a date. We were gonna go out to dinner someplace. It was over Thanksgiving break.

And my buddy Josh Edelman was at the Ed school at Stanford at the time. And he called me up as like, he said, some of my friends called me sit for Sid Walskip from Old Budden Rising Rushmen. He said, he said, totally forgot that. He's like, her mom sent you one of those hands. It's half time at the mental aftertune game. I'm wondering if I can come over and have some of it. Okay,

Josh, I'm sorry, man, I got a date with this guy. I really dig her. I take her out to the dinner. He's like, dude, dude, come on. I'll be over in like five minutes. Like, all right. So I call up Lynn. I say, Hey, Lynn, I'm sorry. I got a cancel dinner. I've got, I got Josh coming over here to eat my ham. like, all right, so I call up Lynn, I say, hey, Lynn, I'm sorry, I got a cancel dinner. I've got, I got Josh coming over here to eat my ham, but, you know, maybe we can meet at the goose. Jesus. No, no, no.

Like that again, I mean, like what is going through your mind in that moment? I'm just thinking I want to give him on my ham to Josh. And so anyway, and so she goes, are you kidding me? I'm like, no. And then she goes, okay. And I'm like, well, do you want to meet at the good? She goes, we're not meeting at the goose, you can pick me up when we go to the goose. I'm like, okay, the goose was the dive. But you've been there really time for those who don't

know, it's a dive bar outside of Stanford. It's still there, it's still up and running. Is it still there? Yeah, same first place I ever ate when I came to Stanford. Yeah, no, he'll never forget it either. It's probably still working its way through you. And so Josh did come over, he ate most of the ham and then I picked up Lynn and we went to the goose and we were talking and chatting across the table. And I don't know if I should talk about this part of it, but I had gas and I was just trying

to sniff it one way and blow it the other way. I'm just trying to divert it from getting near her nose, but I don't know. She says to the station you know exactly what I was doing. I thought it was very subtle. So after that, I drove her home. And my car at that time was this was 96. And I had an 83 Honda Civic semi station wagon with where you could see the road through the floorboards I had sheepskin on the seats because they had worn complete through there was no radio and there was no air conditioning and this thing was a you know, I bought it for like $1,300 and there's a story about selling it to so anyway I took Lin back and I've were sitting in the car on the sheepskin and and I asked her, hey, can I give you a kiss?

And she's like, I want to get on a UKtting me. I'm like, what do you mean? I'm like, kidding you. She's like, why do you have to ask? I was like, I don't know, I thought, and so anyway, we kiss very awkwardly and she bolts out of the car good night and she leaves and I'm like, oh, Jesus Christ,

I really fuck that one up. And so I get in the car in the car because you're sort of three strikes at this point. Yeah No, I'm really on that blowing off the dinner for the Ham and three Strikes and no I'm like 27 ounces like a no-hitter So I'm leaving and I'm driving and literally like about I don't know fourth the way home like Fuck you. Have you idiot? So I turn the car around.

And I, This is the story. Yes, this is the best line. This is, so guys, if you've listened to nothing else in this story, this is the recovery. This is the money line, yeah. So I knock on the door and she looks, she opens the door, she looks me and like,

Hey, Lynn, I'm so sorry, I got halfway to the safe way and I'm like, fuck, should I have you edit it? And so I turn around and I decide, I just gotta tell you how I feel. And she goes, well, how do you feel? I'm like, I think you're hotter, shit. And I said, and I don't, I have to say to myself, if I don't care if I have to sleep on the couch or in your bedroom, but I'm not going home.

She goes, well, you can sleep on the couch. So strike, strike 10. And then to be honest with you, things just sort of happen from there. So I mean, I mean, I slept at home that night. We did kiss and was much better kiss. And then, you know, things just took off and lucky me. But that's the line. I mean, I think you have a shit. You have a shit. We're in a new era now. And I still think that your hottest shit is not going to get you a MeToo offense. I don't know.

I shouldn't. I can't imagine why. It could. I think it's reasonable. Yeah, no, it's objectifying. It's authentic. It's objectifying. It is authentic and it's sincere, but it's objectifying.

And it's using swear words and stuff. So there's certainly something that could be MeToo to do about it. That's, I just love it. So you've alluded to it already, but just for those who don't know what HSS is. So the hospital for special surgery in New York is the APEX facility for training orthopedic surgeons. I mean, even though I wasn't interested in orthopedic surgery, even I knew what HSS was from the first year of medical school because if you wanted to do orthopedic surgery, you wanted to go to HSS. So you end up there.

But I mean, just for someone listening to this, what the heck made HSS so special? They had some giants in the field of orthopedics. And so number one, it was an all orthopedic hospital. It was all orthopedics. And so they were a think tank of orthopedics and they were... I'll let the oxymoron there slide on the think tank of orthopedic Yeah, so but the development of joint replacement that was a big they played a big role in that Some of the giants in the field of joint replacement chip ronowat Tom Skolko

Philip Wilson were part of it the spine surgeons I mean every every field within, or every sub-specialty within orthopedics, HSS had a player in that field. And again, it's just a really unique environment where the reputation of the hospital is well-earned and well-deserved. Patients come from all over the tri-state area

to get their orthopedic work done at special surgery. The hospital will work now. We have 20 operating rooms for all the sub-specialties. There were 20 inpatient operating rooms alone, all for orthopedics. So just through that incredible volume, you can't help but learn just through osmosis. And they were very dedicated to resident education. I remember one conference that we were getting a little bit scolded because not everyone was showing up to conference. Obviously it's funny when people scolded people are actually there for not showing up, right? But anyway, I remember one of the guys saying,

look, we don't we don't have to do these teaching conferences every morning. We'd be just as happy to crank up the RS at 730 instead of 830. But they did do that. They would have these conferences every day from 730 to 830 about some topic of orthopedics. And by the end of four years, again, simply by as most as you'd absorb so much knowledge. And then the operative experience was second and none because the operating rooms were humming all day long. And sometimes, well into the night, it's not unheard of to do 10 joint replacements and be doing your last one at 10 in the evening.

And they just, that was the ethic of the place was you took care of people you did. There was no sort of end to it. And they had an endless demand and an endless volume. And they still do. And they still have the same giants in the field. They've developed some really young talent and influencers in the field.

So who were your mentors when you were there? Well, there were several mentors, but Russ Warren, I would consider a mentor. I'm probably the, not his pride and joy. Keys had several, he's trained half the NFL team physicians and he's been, he still is prolific as he ever has been. And he's got to be pushing in those mid-70s now. And he's a Vietnam war surgeon. It seems like all those, and you probably met him at Hopkins, but these old-time Vietnam War surgeons were just incredibly gifted,

balsy. They were just great surgeons, and they really knew how to take care of people. And I think their training in wartime was a big part of that. So Russ Warren for sure. What did he specialize in specifically with the North Island? So he's one of the Godfather's of sports medicine. And one of the earlier developers of ACL reconstruction and he was a pioneer in arthroscopy and arthroscopic reconstruction. And he's written more papers than any orthopod alive and probably more papers than all orthopods combined. I mean, he's been, he, he never stopped moving and working. If he wasn't seeing a patient, he was reading a research paper.

He was coming up with an idea. And I remember one night, his driver, he had, I worked with him as a fellow with the giants when he, and he's still their team physician. And he had a driver Ernie who would take him every place. And we had a late West Coast game. We got back to Newark at three or four in the morning and Dr. Warren would spend the night above his office and then start seeing patients at 8 a.m. and Ernie, he asked me if I want to lift back because it had to be great

thank you because where I live was two blocks down from the hospital. And Ernie dropped off Dr. Warren and then I was in the car with Ernie. I said, Hey, Ernie, and how does Dr. Warren do it? I mean, he's always working. And I'm like, how do you do it? He said, well, Dr. Warren takes very good care of me, but he once told me all I got his time and I'm not wasting it for anybody. And when I heard that, it put everything in a perspective of the way Dr. Warren worked, the fact that

he never let a minute go wasted, he would, it's constantly either taking care of patients or thinking of research. I remember on a West Coast trip, he met with some engineers at Stanford for a type of bracing. He just was constantly thinking orthopedics research. I remember on a West Coast trip, he met with some engineers at Stanford for a type of bracing. He just was constantly thinking orthopedics and advancing the field. So he's obviously a huge influence and anybody who's ever worked with him will tell you he's the number one

guy. And then Dr. Pileci, Paul Pileci, he's a joint replacement surgeon at a sports medicine surgery. Surgeon was the most gifted joint replacement surgeon I've ever seen. He could do a total hip replacement 45 minutes to an hour. What do you mean skin to skin? Yes. And he just put in a perfect total hip every time. And he was the doctor's doctor. He did anybody in the area, anybody in the hospital needed a hip replacement was getting in from Pilece. I mean, he was just a very, very gifted surgeon and everyone knew it. He's also one of the funniest people you can possibly meet, a big Bruce fan as well. And a Bon Jovi fan and turns out Jovi played it, you know, honorary dinner. And Bon Jovi was his, you know, was playing at this dinner for in his honor, the Pileche

terrific guy. And Wickelitz, Tom Wickelitz, who is the director of our fellowship, again, super good guy, Scott rodeo, who's the head team physician for the Giants now, who's in a phenomenal research clinician, and they're hard to find the clinician scientists are sort of a dying breed, but Dr. rodeo certainly embodies that and he takes terrific care of people including my mom. I don't know, I can go down the list. I mean, well, before we talk about leaving New York, you spent a year with the Giants,

you did your sports fellowship. What did you learn there? I mean, it strikes me as an interesting crash course of sports medicine because you're really seeing the finest tune machines under the greatest destructive forces. Yeah, that's a great way of putting it. So with the fellowship that Dr. Warren had, he, Dr. Warren's fellowship, he picked two guys and you would alternate a week of training camp. And so once the Giants opened training camp, that was also coincided with the beginning of our fellowship just by just by chance.

And I grew up a Giants fan like a rabbit Giants fan and Bill Henser was a rabbit Giants fan. L.T. the greatest linebacker of all time. Yes, without question. And one of the greatest people. I mean, so Bill and I used to go to Giants games. That that was our thing. And one of my first Giants games was with Bill in 1983 when Scott Peruna was the quarterback. And any Giants fan will remember this when Giants scored in our end zone and they went up by three points against the Redskins. And it was pissing rain. It was 32 and a half degrees.

I mean, I've never, you can't really be much colder than that. And then the Giants kicked off and they squib kicked it. And so the Redskins got great field position with 40 seconds left. They get in the field goal position. And Mark Mosley kicks his record tying consecutive field goal. Then the Giants lose the coin toss. The Red Scenes get the ball.

They drive into field goal range. And this is like, first score is gonna win. It's 83 hit and Mark Mosley kicks his record breaking consecutive field goal. And we go all home, so disappointed. And I think that was a game that Phil Sims heard his name and out. But anyway, Bill and I would go to all these games and actually the night before Bill died,

there was a Giants game on and we had talked about it. And we always did. We'd call, you know, when I was in New York or California or wherever, we talk every Sunday, talk about the Giants game. And I remember talking about that game with Bill. And then, and he knew something was up because that following morning, he, that's when he died. And we were crying on the phone, and I love you, and you know, after talking about the

game. And the game was again just another vehicle. So anyway, I had a, and Bill had taken me to Giants training camp when we were driving up to St. Paul's, I think, one time. And I was going up early for my own football camp as a junior in high school. We stopped in Albany for the Giant's training camp where they would have it. We hung out there for the day and watched practice. I remember that training camp.

Now I'm coming back about a year and a half after Bill died to Giant's training camp. It was a bizarrely emotional time. I never spoke with the trainers, Ronnie Barnes, and Byron Hansen and Steve Cannelli about this. I mean, there are three of the greatest guys. They're unbelievable practitioners and caretakers of these athletes. But it's kind of an emotional moment where I'm in training camp. Having all these memories of Bill, thick and man, he would be, he would love to do this. You imagine the pride he would be. He would be so happy. But okay, all that aside, the first thing you do

realizes that these guys are freak athletes, like beyond anything you can imagine there. So physically gifted, it is beyond belief. I remember I had a poster in my bedroom when I was a kid of Jerry Rice standing in the end zone and he's holding the ball up. And at his feet is a player. I think it was someone in the Bengals and he's like, God, his ankles, but he's completely like laying out and obviously failed in his attempt to stop Jerry Rice. And I remember one of my best friends in high school who was himself a fantastic athlete. We were like sitting in my room one day sort of shooting the shit and he said one of the

most astute things ever. He looks up at that poster and points to the bangle laying prone and he's like, do you realize that guy's a better athlete than we'll ever be? Like the dude at the feet of the guy you're worshiping? Well, the guys in the league are freak athletes. The guys trying to get into the league are freak athletes. The guys at the top of the league are freak athletes. And it is a razor thin margin that separates the guy who's a superstar in the league and the guy who's not in the league. And again, it is such a narrow margin of, you know, this athlete versus that, they are all tremendous athletes. So that's the first thing you recognize is just how fast, strong, powerful, gifted, graceful, all of these guys.

And longevity matters. You know, I mean, Ryan Flarety, who's a friend of mine that I do need to get on this podcast at some point. I've talked about him in the past, but, you know, Ryan is really the guru of speed training. He does two things. Basically, trains guys in college who are the top 10 recruits that are going to go to the combine and do really well. And then also, trains guys once through in the NFL.

And he said to me, the focus changes so much after the combine to what you care about. So when you are in college trying to get there, it's all about performance at the combine and performance to get in the league. And that predominantly comes down to speed. And then he said, but once you get in the NFL, once he's working with these guys that get there, it's all about performance at the combine and performance to get in the league. And that predominantly comes down to speed. And then he said, but once you get in the NFL, once he's working with these guys that are there, it's longevity.

It's just don't get injured. And he changes the strategy is completely dedicated towards maintaining how long they can stay healthy. And that's a huge challenge. It is so violent on the sidelines. It's very, very difficult to really get a sense of how violent it is unless you're right next to it, but the hits are Massive. I mean when they talk about it being like a car wreck. It really is like a car wreck

It's an incredibly high-energy Collisions that happen over and over and over again. I mean the closest I've ever sat in in a foul game is probably 20 rows back in the end zone so you're far enough away like it's still great to be able to you know I was watching Barry Sanders play the 49ers. That was like, I was the only time I've ever seen Barry Sanders in person. But yeah, I can't imagine where you're sitting on the sidelines, just even acoustically what that's like.

Yeah, I mean, I remember there was an interception once and the giants that throw in the interception and then Chris Ney, who was an all pro guard and Tom Cofflin's son-in-law, as it turns out, he was married to Cofflin's daughter, comes over and just wrecks this guy. I mean, and it was right in front of me, and he flattened this guy. And this guy got up, but it was the most acoustically impactful if I felt like a sonic boom when this guy popped him, like just really took him out. That's the other thing I think people don't appreciate. I only appreciate this because I've seen them train

how fast those linemen can run. Like you look at those guys and you think, ah, he's 320 pounds, he's got a little bit of a belly, he's probably not that fast. And he's gonna run a 40 in like five seconds flat if not four, nine. Right. And then I couldn't run today

if my life depended on it. So they would do gasters. Kaufflin had them do gasters where they'd go 50 yards across the field, 50 yards back and you'd have to do it in 18 seconds, 16 seconds, depending on your position. So I said, let me give this a try.

And I wasn't as good a shape then as I had been five years earlier. I sort of fallen off the, you know, once the kids came, the wheels kind of came off. But I was trying to do the gasser and the lineman time and it was very challenging. And these guys can motor. They are exceptionally good athletes.

They are big, but they're also graceful and they're strong and they're all that, they're coordinated. You name it. But the freakishness of the athletes is certainly something that sticks out. The stress that these guys are under, I don't think people appreciate it. I mean, people think about professional athletes just sort of coasting.

They're making millions and everything else, but that's not, it's not anywhere near the truth and particularly in football where they really feel and far between guaranteed contracts. So these guys don't see their money unless they stay healthy and play. And there's so few games. I mean, I remember reading an editorial a while ago that talked about imagine we just took hockey basketball and baseball and made it a 16 game season. Like think of what that would do to the intensity of every game. Every play, every game. So that's exactly what it is. It is intense. And if you're in the league and you know that the

you know, you're fighting with everybody on your team for a position You're fighting with everybody in the league for your position. You're fighting with everybody out of league trying to get into the league for a position It's an incredibly stressful environment for a young 20 something year old to be exposed to I mean these guys are under an tremendous amount of stress to just perform, keep their job, not get hurt. And it's an intensely difficult situation. So that's certainly something that stood out. What were the most common injuries? Like I remember reading, and this is almost assuredly

dated and no longer correct, but directionally, I'm sure it's correct, but the median tenure of a player in the NFL was like three to four years. Yeah. We hear about Tom Brady. I mean, it's great to talk. I mean, frankly, most of the players we know about, you know, the great quarterbacks, you know, they've been around for a decade and you sort of take that for granted, but that's not the norm. Not even close. I mean, it is positionally dependent. The running backs have the shortest careers, linebackers have shorter careers, but they really, really, again, because everyone's trying to get in the league. Everyone in the league is competing. And there's a trition. I mean,

these guys leak oil and they leak oil relatively quickly because of the violence of the game. And it was funny. I remember at the combine, the combine, you'd examine the 300 participants who were in the combine. And would you actually examine every one or would the giants say, hey, look, these are the guys who are most interested in go examine them? It wasn't that they would cherry pick the players. They got a grade on everybody. So all the 300 participants, they got a medical grade.

But what would happen is the teams getting groups of four, five and the docs groups of four, five. So the players are going to seven or eight medical exams. They're going the same physical exams seven or eight times. Exactly. And if they had an injury history, obviously, that would be what would be of interest. an array of medical exams. They're going the same physical exams seven or eight times. Exactly. And if they had an injury history, obviously, that would be what would be of interest. The docs would share the information among the teams.

They were, you know, very much working as a group of physicians trying to evaluate the medical care that these players had gotten in the past. But I remember, I mean, all these kids coming through had something and, you know, risk surgeries for scaphoids, stability surgeries for shoulder dislocations, ACLs, meniscus surgery. I mean, it seemed like more often than not, these kids had already had a prior medical history or prior surgical history. And I said to Ronnie Barnes, I said, God, Ronnie, all these guys are somewhat injured and Lincoln oil, yet these are the best guys coming through.

And he said, he said, they're all injured because they're the best guys coming through and they play. And it's made me realize, boy, it's a very tough sport to play at a very high level without exposing yourself to injury and that everybody gets hurt at some point. And it's usually those injuries that slow you down just a little bit, that again is that margin that razor thin margin of being a star in the league and being out of the league. Do you either your boys play football? My youngest does actually.

JJ does. He's playing freshman football. Does it worry you at all? Not just with everything you know, but also with all the same stuff we've since learned. Yeah, sure. It worries me like crazy. And you know, he started playing football as he's probably the only Jewish kid in the history of the world to leverages bar mitzvah into a football spot. But he got to hear that story.

So yeah, he was in seventh grade and he was preparing for his bar mitzvah, and he was hating it. And he basically struck up a deal. It's like, you guys let me play tackle football. You won't hear a word about the bar mitzvah preparation. I'll just, I'm gonna say word. And we took him up on the deal and he

was playing in a weighted football league. So 125 pounds is a max. And they, everyone's acutely aware of of CTE concussions, head injuries, that way the game is coached is changed drastically among the youth level. And then when you watch the games, it, it seems relatively safe. I mean, it's sort of kids bumping hips. It certainly doesn't seem any more violent than the lacrosse and hockey the kids are playing at that age. And we let them play. He then he played again as eighth grade year, because he's a little bigger.

And so again, it was still a size limited league. So he's a little bit more advantaged then. And then sort of reluctantly, he's playing as a freshman and simply because he loves playing the game. And we look at the mentors who are his coaches and we have such admiration for his coaches and we look at his teammates and he gets an awful lot out of it. And I remember hearing Curtis Martin's Hall of Fame acceptance speech. Oh, which I will link to it, but it is beautiful.

It's an awesome speech. So you're better off listening to it. I don't know if you want me to spoil the punchline. Yeah, I mean, go ahead and paraphrase it for the folks who don off listening to it. I don't know if you want me to spoil the punchline. Yeah, I mean go ahead and paraphrase it for the Poes of the folks who don't want to listen. So Curtis Martin talks basically off the cuff about football and his closing line was and he came from very poor disadvantage environment in Pittsburgh and football gave him him in

Avenue and He talks about all the dangers of the game and he's not certain whether or not he let his son play football or not. But he says to himself, if football can do for your kid what it did for me, there's no question that I let you play. I mean, that's fundamentally the punchline that there's a lot of pros and cons. You have to weigh the pros and cons for your own kid and decide whether or not it's worth it. And for us, we felt it was worth it. I shit my pants we felt it was worth it. And I shit my pants nearly every game. I'm always worried about him playing. But then again, I see

the joy he derives from playing it. And it's hard to hold that now. As time goes on and the game gets faster and the kids get bigger and he may decide, this is for me or this is not for me. You know, we'll see how he develops and he's still just a freshman and still an underdeveloped freshman. But it is something we let him do despite then being a pediatrician, me being an orthopedist and both of us being fully aware of the risks of playing because in the end we felt the benefits outweighed the risk. Yeah, I don't know. As far as actually, as I was on the way over here to meet you, I was talking to my brother and my brother's really in a mountain biking and he keeps trying to

get me to do it. And I'm like, yeah, I just don't want to do it. Like, I just, you know, I just, hey, I don't need a new thing to get into. But also it's like, just don't, the risk of injury. Like, I don't, even silly injuries. Like, I don't want to break my wrist or do something like that. But look, he's obsessed with it. And we have a mutual friend who he's much closer to who's a motorcycle racer and used to do a lot of road riding.

And whenever we would be on road rides, this guy was the best descender. Like because he had been racing motorcycles all his life, he could basically rip hell going down a mountain. When all of us would be a little more tentative and on our brakes and stuff. And this guy's name is Jimmy. And now Jimmy's got my brother into something

I didn't even realize was an activity which is downhill mountain biking. So they go to ski slopes in the summer and you ride, you take your mountain bike up the ski slope and you just come down and I'm like, my brother's like, I know what you're gonna say before you say it, so don't say it. I thought it was crazy too,

but it is the frickin' best thing in the world. Not sure it's a rush. And I was like, you couldn't pay me to do that, Paul. What are you thinking? Riding a mountain bike down a ski slope like, I don't know. I think I'm just a pussy. I mean, I think I'm the other day. I took a trip with my buddy Jim Barker from Tell Your Ride to Moab on a mountain bike over the Uncomparker Plateau, but we were such novice rookies. We even like, hey, let's go mountain biking.

Yeah. What do you want to do? Let's go to Colorado and go down some ski slopes and like, hey, let's go mountain biking. Yeah, what do you want to do? Let's go to Colorado and go down some ski slopes and then barrel down on our mountain bikes. That's what we thought we were going to do. Go all we think it'd be fun. It's like outpine sliding on a bike. So let's talk a little bit about some of the nuts and bolts of orthopedic surgery because I can't imagine there's somebody listening to this who hasn't either personally, directly or indirectly been touched by an orthopedic injury. And I don't know the right way to go through it, but why don't we just start with the knee,

since that seems to be a pretty common joint that gets injured. Talk to me about it through the lens of an engineer. What is the knee really good at? What is it bad at if you could be God for a day? What would you change? So, those are good questions. So the knee is incredibly good at bearing weight and supporting your weight.

And it's incredibly stable for what it's being asked to do. But it's an incredibly complex design with more moving parts. Every degree of freedom is in play with rotation, translation. So if I were God for a day, I would make the ligaments, actually, no, I would make the cartilage immortal because the cartilage wearing down in the knee is fundamentally what will slow people down. I see. So you're not going to save the ACL tear, but you're going to save the knee replacements

for arthritis. Correct. And the cartilage is what, when that wears down, that's when people have pain. People can live without an ACL. I've lived without an ACL on my left knee since I was 12 years old. I was able to play sports. Not many not everybody can. So wait, 12 you tore your ACLs and you at the time, you could have had a catavaric replacement. So at 12 years old, at that time, I was casted for... Or Patel or Tenden. It was in the early 80s, so I mean, when I was 12, and so ACL reconstruction was in its nays and sann,

I'm not even sure anything was really being done on any sort of widespread level, and if it was, it was being done through open incisions, and there was a five and one procedure where it sling bits of the IT band around the knee, and certainly not what modern techniques would be of reconstruction. Sometimes repairs were being done at the time

that's failing, basically trying to sew the legum it back together. And so you can live without an ACL and you can live a very productive back to life without one. But you will be prone to instability. And the instability can wear down the knee, the repetitive giving out episodes can start wearing

through the meniscus. And then once the meniscus starts going, the articular hard cartilage starts going. then once the meniscus starts going, the articular hard cartilage starts going. And once the hard cartilage starts going, the knee pain, the knee swelling, the limitations. So let's describe the joint, because now I'm realizing,

it's hard to do this over audio, but you've got this thing called the tibia, and it has a plateau, and that's where the cartilage sits, right? On top of the plateau, yes. And then the other end of the joint is the sort of bottom end or the distal end of the femur. That's kind of roundish.

Yes. And it actually kind of looks more like a knuckle, right? Like it's sort of, yeah. And there are two condos, two knuckles to it. Yeah. Yes. So you've talked about the cartilage, but then where does the ACL, MCL, and Meniskay fit into that

for the person listening to this? So again, like you said, it's hard to describe. And we'll put cool pictures up so people can kind of look and see this. So the MCL is on the inside zone of the knee. And it's actually a ligament that's, we consider extraarticular. It's outside the joint capsule.

And the MCL is a very stout ligament that controls the knee from swaying side to side. So if you can imagine your TBS swaying out towards your hip or back towards your other foot, the MCL controls that. The LCL, which is the lateral collateral ligament on the other side of the knee and the outside zone of the knee, has the same function, but just in the opposite direction. And then the cruciate ligaments are crossing ligaments that are directly in the center of the knee. And the anterior cruciate ligament is crucial for rotational control of the knee.

And when people tear their ACL, it's usually a rotational injury that does it. And it's almost a near dislocation of the knee that occurs. And so usually the outer part of the femur will rotate backwards and even come all the way off the tibia and then rotate back. And as it comes off and comes back, that's where the tearing of the ACL occurs. Why did people tear the ACL more than the PCL? PCL usually gets torn from a direct blow injury from falling onto the knee,

but falling specifically on the tibial tubercle. And it's not easy to do that. I mean, most of the time you're falling more in your patella. But if you fall directly in your tibial tubercle, you will drive the tibia backwards posteriorly. And that's what puts the PCL on stretch and it gives out. But people do very well with a full PCL tear as long as they don't have any other ligament injury

in the knee and plenty of the professional athletes, including a few on the giant's had to complete PCL tears, who were functioning at that high athletic level. So it doesn't have the same rotational implications when patients tear their PCL. They typically, if they're having complication from a PCL tear, it's from the increased contact pressures that happen in the patella because it's tibias now sitting back and it's pulling

the patella into the femur as it sits back. And that pressure between the patella and the femur is what gives people disability from a PCL tear. And then, so where do the meniscus sit? The meniscus sit on top of the plateau. They're rounded. And they basically contour the flatish plateau into a more rounded femur.

So it allows for the contact pressures within the need to be distributed evenly, more evenly. And their critical tissue structures, as it turns out, it wasn't long ago that we were removing menis guy without really any thought consequence. There was no foreseen consequence of taking were removing meniscus without really any thought consequence. There was no foreseen consequence of taking out the meniscus or even parts of it. And it's become very clear that losing the meniscus

is sort of the beginning of the end for most people's needs once they start having meniscus tears. It's far more likely that at a younger age, their cartilage is gonna wear down their hard cartilage. And so when a person gets a knee replacement, the tibial plateau has that built-in little curvature up at the edges to mimic what the meniscus would be doing sitting on the actual tibial cartridge. Is that necessary?

With a replacement. So the meniscus is also stabilizing structure within the knee. And again, it takes the flat tibia and makes it more rounded so that the femur fits in it. And that gives some natural anterior and posterior resistance to translation. And losing that meniscus puts the articular cartilage under a lot more pressure and it tends to wear down more quickly. Now, there are several other factors besides the status of the meniscus that leads to loss of that articular cartilage, that hard cartilage that coats the end of the bones. But when people end up losing that coating of hard cartilage on the end of the bones in the joint,

that's the cartilage that we really care about because losing that will lead to swelling and pain and difficulty walking and feelings of instability and all the things that slow people down as they're trying to live a long life. And that's where their health span and their life span starts separating. As you, you know, you've taught me this whole concept about life span and health span, but that's where it starts separating when that particular cartilage starts wearing down.

Now, I tell all my patients, everyone's going to lose their hard cartilage. That's, that's not an if, it's a matter of when. And we all want to lose ours one more 150 years old. And the things that influence that are genetics, exposure to injury, trauma, but also things that are modifiable, you're weight, you're exercise, things that really tend to help. And so when people have knee replacement, the plastic that's put in between is really again for stability and to distribute some force

and to hold the knee in place. And there are different designs with... Is it still alter a homologated or a polyethylene? It is polyethylene that's used. In hips, there's more cross-linked polyethylene to resist where the knee replacements tend to fail because of loosening of the prosthetic from the bone. And one of the things that can lead to loosening is particulate wear, causing inflammation,

leading to a cascade that eventually results in failure of the knee. And unlike changing the tires on your car, when you have a new knee, it's not the same as the old set. It's not as durable, it's typically not as satisfying, it's not as flexible. And so people don't have the same sort of euphoric outcome with their second knee replacement, for instance, than they do with their first. What's the typical

expected or median expected utility out of any replacement? Again, it defends heavily. I'm sure on the age of the patient and activity level, but as a general rule, do you? We don't necessarily give a number because it does depend on the activity. The younger patient is the more active they'll be and the more likely they will loosen at an earlier age. And so for the people who need the knee replacements, the longest people in their 40s and 50s will have the shortest life. 40 to 50 year old, you'll tell them just to set expectations. You're probably going to need two of these in your lifetime. It's going to need a revision at some point in the lifetime.

But it's a significant difference in longevity for the 50 year old getting a knee replacement than the 65 year old. And so we try and kick the can down as far as we can down the road so that if patients end up needing knee replacement, that it's going to be their knee replacement will out less them and that they'll only have one operation on their knee. So it's not not unlike the way you think about a heart valve. It's the same age and we use tissue versus mechanical different situation. Let's the same. It's the same age and we use tissue versus mechanical, different situation. Let's go back to some of the modifiable factors you talked about.

So, wait, how clear, I mean, it's intuitively obvious, how clear is the relationship? Is it linear? Is it nonlinear between? It may be geometric. I mean, because every pound of weight loss up top is four pounds of weight loss through the knee which is walking.

And it becomes amplified. Wait, why is that? That's just mechanics of the knee. Again, the mechanics of the knee. So your center of gravity and how that applies torque into the knee is part of the reason why that body weight is amplified. So it's not just pound for pound. So when patients gain a pound, they're putting four more pounds of pressure through the knee, which is walking six pounds more with going up and down stairs, eight pounds more with

running. So it's a significant multiplier. And there's similar multipliers with a hip and in the back. And so we, it's so interestingly bring this up. We've been trying to help patients with these modifiable factors for their knee and particularly their weight.

And we started a program in our practice called the OrthoHealth, which is based off a lot of the work you do. I don't know if you've ever seen the webinar I give, but you're sort of an all-star in the webinar. And so as Lynn, but we're trying to help patients sleep better, trying to help them manage their stress better, trying to help them eat better, and try to help them exercise more efficiently. I think people exercise way too much, trying to get it all in, burn all, they have a concept of burning all the calories, as opposed to sort of activating their metabolism.

And so we're trying with these group of patients who are typically overweight, BMI over 30, 35, 40, they're pretty ill patients. They're not just their knee that's bothering them and trying to get them that turn their lives around a little bit. So from an activity standpoint, is all things equal running harder on the knee than any other activity a patient does? It is harder and what's more strain on it. But the body reacts to this. I think it's called wolf's law, where the body reacts to stress. So the more stress that's put on it, the more bone that's laid down for instance, that's why we emphasize weight bearing exercise for

patients in their 30s in particular before they start losing bone so that they can build up their bone density. And so the body reacts. When do you lose the ability to increase bone density through that activity? It's usually around 30 and women have an accelerated bone loss in menopause. So the bone building is occurring through the first couple of decades of life and then on it's down. But there's a big, big decrease during menopause in bone density for women. And that's where it's all the homo therapy and all the exercise basically isn't to bring you back to where you were when you were 30. It's to slow it down.

Slow it down. Because it's an inevitable decline. What is driving that? Is it osteoclastic? Is it? Well, it has to be, to some degree, because the osteoclaster, what are the, they're the cells that resort bone. But how well understood is the why? Like what's the evolutionary reason that we would, we're not sure of any of the minerals that are in bone.

We could certainly get them exogenously. Why in the world would we just decide to enter a catabolic state at the age of 30? I don't have a clue. And I don't know whether for women it's childbearing and building the skeleton of the fetus. Certainly there's a transient osteopenia of pregnancy that occurs. But I don't have the phanus clue. And those are that's a fantastic question that people are trying to answer. And you know, pharmacologically we try and slow down the osteoclastic function. We try and slow we try and slow down the osteoclastic function. We try and slow down the speed at which the osteoclastic function.

And I use that term technically, I should have defined it. So osteoclastic is breaking down of bone. Osteoblastic is the building up of bone. And they're the cells that do that. And so the osteoclastic get inhibited by some of the pharmacotherapies, the Phosamax, Boniva's, the B phosphonates, that slow down and quote unquote, bill bone density.

But it's not necessarily building great bone. And so it's building denser bone, but there's concerns that there may be fault lines in the bone that it may not necessarily be more torsionally resistant. It's not more tension resistant. So you see tension side of failure of bone with prolonged use of phosphonates. Those are some of the typical femur fractures that you see people get foot fractures with this. It's not going to be the answer just inhibiting osteoclasts to build healthier bone,

or to slow down the process of bone resorption. Is there anything that's in the pipeline pharmacologically with respect to activating osteoblasts? Great question. Most of it is focused on osteoclastic inhibition. And there are thoughts about bumping up osteoblastic production with magnetic fields. And that's what's the technology behind bone stimulators for when patients have hard to heal fractures.

You can use a bone stimulator, which is an electromagnetic field that seems to be stimulating to the osteoblasts. But there's always concern that when you stimulate the osteoblasts that you may be provoking a cancer type of situation. Right, because you don't necessarily wear it nowhere, you're directing them. Right. And so we don't use these bone stimulators in patients with cancer. We purposely avoid that to avoid stimulating out of control growth.

So if you're listening to this and you're not an athlete, so many, you're like most of us, you're just, your sport is life at this point. You exercise mainly to help you perform through life better as opposed to playing the NFL. It's relatively easy to avoid the twisting injuries, but it's these repetitive strain injuries, you know, the person who's riding the bike that doesn't have their pedals and their cleats fully attuned correctly or they're running, but they're doing it so inefficiently or got I see people that ride, you know, spend hours on ellipticals and their hips are jacked because they're just in a lousy position. Is that the case or is that just my bias that I see towards it? I mean, are you still seeing people are age that show up? Like is it just as common to see the guy who's playing pick basketball and still tears as ACL through a torsional injury? No, I share your bias.

I do think people exercise incorrectly, and I think part of it is because there seems to be such an emphasis on volume of exercise. And the volume of exercise and intensity, or not intensity, but getting in your volume of exercise within an hour because of your sedentary lifestyle for the other 23. I think that is what leads people to injury. They do too much repetition with poor form like you're saying, exposing themselves to injury. So there's no question that repetitive bad form will lead to injury. And especially under load.

Correct. And then if you have a torsional, if you just happen to be playing hoops and you happen to put your foot down on a wet piece of turf or on someone's ankle and your knee twist, I mean, those are sort of freak accidents that can occur at any point. And if you want to keep it as safe as possible and as helpful as possible, then you should walk. I mean, walking will give you the cardiovascular benefits that most exercises, most any other exercise will. I think the Harvard School of Public Health

has done an awful lot of work at looking at walking and cardiovascular risk and near, you know, 30 to 40% risk reduction with walking. Yeah, I mean, you won't find many people that are more critical of the Harvard School of Public Health is the fact that it's associated with a little school back case. Yeah, it's the, I don't know the answer.

My intuition is that those studies are so biased by the people who have the luxury of being able to walk. Like, in other words, there's, there may be too many healthy, healthy user biases within those studies. I think, unfortunately, to get, to do long-term clinical trials with randomization here is going to pose a huge problem. It's not going to happen. So, we are stuck with, I think, some combination of short term clinical studies that can show

us measurable changes in short terms, coupled with, I think, trying to do better epidemiology, which is, you know, that's sort of like saying, trying to make toilet water taste a little bit better. But, yeah, I think I struggle with this. I mean, yeah, my view is, and again, it's so unlike me to say this because it's so sort of hand-wavy bullshitty, but I really do think that there is the less time you are sitting around the better. And I think in part, it's not just the benefits you get from walking around. It's the damage that's done by shortening the hamstrings, by tightening the so-ass and the hip flexors. Like, that stuff starts to translate into these other things that set you up

for orthopedic failure when you actually are doing your one hour of activity or whatever it is. Very well put. So when you have, again, a primarily sedentary life, but you're trying to make up for that with one hour of exercise or two hours of exercise, I think that's the setup that leads people to injury. Yet, people have jobs and families to provide for, and they are sitting around.

So then how can you get a moving more consistently through the day? I do think that that sort of consistent movement is what leads to better orthopedic musculoskeletal health. And it's not necessarily having to do an hour exercise a day. I think it's more generalized movement for the majority of hours of the day. So I couldn't agree with you more. And I don't want to get into a thing with you of all people about any sort of epidemiologic study, but I don't see a lot of patients coming to me who've injured themselves walking. And I do see, oh, yeah, no, that I totally agree with. I think my

question is, I guess I'm not at a point yet where I know enough, even though this is a very high priority for me to understand this, can walking be sufficient from a cardiovascular standpoint? In other words, if you told somebody, all you gotta do is lift weights and walk, but you can skip any of the high intensity training. You can skip doing your tabatas and med ball slams

or, you know, palatine stuff, like, there's like a type of exercise that's still in the middle of those. I'm still trying to, I think I'm to grips with what the relative physiologic benefits are. Because I, the way I think about exercise and like all things, there's a vent diagram, but there are certain exercises that we are doing where the emphasis is on the exoskeleton. So maintaining muscle mass, maintaining functional movement, maintaining bone density, and doing so free of pain. And then there are some aspects of exercise as you alluded to,

where really what we're doing is talking about physiologic benefits. We're talking about what it's doing to the microvascular, what it's potentially doing to the mitochondria, what it's doing with other hormones, for example, BDNF and the role that that plays in the brain. I mean, that I think you can make a pretty compelling case that there is no intervention that has shown a larger impact in mitigating cognitive decline than exercise. Yes. And all avenues seem to flow through BDNF and increase microvascular composure. So those are kind of like what I put in this sort of reduced exercise to reduce the risk

of disease versus exercise to increase health span. And then of course, the sweet spot is when they overlap. But then the question is where do they not? This is actually probably the thing I think about the most in my free time. Is that a particular question? Yeah, so I try and ask the octogenarians that I see in my practice who look like they're in pretty good health, who get around pretty well. And you know, what's the secret?

I ask as many of the older people as I can, what's the secret? How'd you do it? I can totally see's the secret, how'd you do it? I can totally see you doing this. I can't see you. And commonly, they're not saying, some people say, I've been working out every single day of my life. Some people say, I make all my meals.

Some people say, I just go for a walk. And there's probably such a, everybody probably has their fingerprint or their metabolic footprint that for some people walking is sufficient for some people with high intensity intervals, that would be sufficient to. Yeah, probably a function of what's their sleep like, what's their nutrition like. And so it becomes such a, you know, huge variable equation that you're trying to solve that I'm not sure it's ever going to be solved.

I hope it can be. But I do give the advice to patients because I see a lot of injuries from people trying to overdo it. That, I mean, it really is important to start in increments when you're just starting. It's very difficult to go from zero to 60 without exposing yourself to injury unless you are 20 years old. Yeah, and that's an important point. I want to come back to the joint stuff, but my patients, they're pretty tired of hearing me say this, but I always say sort of rule number one of exercises. You can't get injured. Because if you get injured, then you know, you're defeating the whole of the steps backwards. I don't want to put you on the spot because this is a question that I should have asked you earlier to let you think about it,

but top five exercise, bad moves that end up coming into your clinic for adults. Let's take that. Let's not talk about the high school and college kids who are doing crazy sports. So probably the most common thing I see is knee pain and knee swelling from excessive squats and lunges. And I understand the core benefits and the quad benefits of doing squats and lunges. But like I said, it puts a lot of strain on the knee. And some knees just aren't ready to absorb that strain or don't have enough cartilage to absorb that strain or most commonly don't have enough muscle to absorb that strain. And so they come in with an overloaded joint that's swollen, injured, and that particular

cartilage has been put under too much pressure and it might be failing. And do you get the sense that they're too anterior when they do these things, especially on the lunges? I mean, the technique for a lunge is actually so counterintuitive, because really a lunge, the front knee should be under no load. The front leg should be all glute-based loading. And my guess is, if you don't know that and you don't have a trainer who can put you in the correct position, you end up being too far forward. You're going to load that knee. Is that what you think is happening? Without a doubt. And they come in with an overloaded knee,

anterior knee pain from not using their glutes from overly relying on their quadriceps. And I mean, look, most of the trainers in our area are kids who like lift weights and they have their clients. And so I mean, it's really important like you're alluding to to have a trainer who knows what they're doing because it makes all the difference in the world.

But I see a lot of patients for having trouble with their knees from repetitive squats and lunges that are again probably done with poor form, which is what we were talking about earlier about repetitive injuries being a result of poor form. And then I see patients with shoulder injuries using weights and again being in significantly disadvantaged positions. And you know, when you're using weights, you're trying to, the ultimate weight training would

be to activate the muscle without loading the joint. And you can do that. You can activate the muscle and not load the joint when you use very light weights, but enough weight that the muscle gets challenged, just even the most minor degree. Because once it's challenged, you can then overflex that muscle. You can voluntarily flex the muscle beyond. So you need just enough weight to initiate the muscle activation and contraction.

And that's usually not very much at all. And then the joints not being loaded, the muscles being activated, and you're getting a much safer workout. Do most shoulder injuries occur from loading the shoulder above the plane of the neck? In other words, an overhead type resistance? I think so. I mean, I can't say for certain. I'm not sure anyone can, but it seems that most people when they come in, the shoulder pain will have commented that the biggest problem has been that they're having trouble with overhead.

They were doing an overhead press. And it's usually a press over a pole. It seems like the bench pressing, the military pressing, the inclines are causing a little bit more trouble than, for instance, the pole downs and the bench rows. So I think the, again, the joint load is much higher when you're doing a press compared to a pole. So when patients are recovering from shoulder injuries or they have sustained in shoulder injury, my sort of generic advice, sort of take home advice is, you know, try and emphasize

more of the poles and the presses as you're recovering. So what are the most common injuries you're seeing for elbows, wrists, hips, ankles, that kind of stuff? So elbows and wrists are typically tendonopathies, again, tendon overload, tendon and flammatory injuries. And I'm not sure whether they happen because of inflammatory changes or just biologic and age-related changes, blood flow-related changes. So around the elbow and the 40s and 50s, I see, you know, endless. It seems like epiconolitis, which is tendonitis around the forearm muscles that flexure wrists and straighten your hand or bend your wrist and curl your hand.

And those tendonopathies, whether they current the wrist, the shoulder, the elbow, the knee, the ankle, I'm absolutely certain have the same biologic mechanism. And I do think the blood flow to these tendons as they decline between the fourth and fifth decade of life, they decline between the fourth and fifth decade of life. That loss of blood flow, that loss of reparative mechanism is what leads to this sort of, again, uniform, biologic problem in these very joints. So I don't consider albaud, lateral lepicondylitis or tenacelbogolphyselvol,

that much different from shoulder tenonitis or impingement or that much different from patellite tendonitis or Achilles tendonitis From a biologic standpoint. I'm pretty certain they're exactly the same thing And I think again the common pathway is probably loss of micro vascular to the tendons What about ankles? Well, ankles so ankles again, it's usually the Achilles tendon. That's the key to the foot It's the Achilles tendon that's the key key. To the foot, it's the Achilles tendon that's the key. With the foot, the most common sort of acquired problem is a posterior to be allis tendon deficiency where there's a tenuation and stretch of the posterior to be allis tendon. And that's

the tendon that supports the arch. And over time, that just starts getting stretched out as you can imagine. It's a mechanical issue and unless it can keep itself in prime shape, it's going to stretch out over time just due to the forces that it's under. And when it does, the foot starts changing shape, the foot starts changing how it loads, and pain is the most frequent presenting problem with a poster to be Alice-10 in deficiency. And you can help support that with orthotics. There are some very complex foot reconstructions that can be done to help reconstruct the foot in such a way that the posterior to be allis tendon isn't playing as much of a role. But, you know, those are difficult reconstructions to undergo your non-weight bearing for, you know,

six weeks strictly, and then, you know, gradually weight bearing, you're taking a big chunk out of your life. And you're definitely knocking yourself down to both yourself back up again. And whenever you do that, there's always a risk that you knock yourself down and you don't bounce. That's the problem with a lot of the surgeries that we do is that we do set people back,

and not every single person is gonna bounce back better than what they started, and that's sort of the challenge and the difficulty. And what about the hip? It's a simpler joint in the sense that it's a ball and socket. So it tends to just wear down, not to oversimplify it. Now, there are some muscles around the hip that act like that were much more familiar with because of the accessibility of it

like the rotator cuff. So a lot of the abductor muscles around the hip can act like a rotator cuff does in the shoulder. But because of the again the weight bearing nature of the hip, the congruency of the hip, it tends to just wear down and that lateral cartilage, which is the soft cartilage of the hip, can get frayed, but it's the articular cartilage that really makes a difference. Now, there are some conditions around the hip that we can change the natural history to.

It seems that we can, where we can reshape the hip a bit, so it's not banging into itself as much. That's called femurocetabular impingement. And that seems to be a place where we can be, make a difference in terms of long-term outcomes of those patients by reshaping the hip to some degree. And you know, labral tears, I think the jury's out a bit. It strikes me as one of those things,

it's sort of a little bit like lumbar disc herniation where someone can have hip pain, you do an MRI, they've got a labral tear, you're no further ahead than you were before, you don't know if that's the cause, right? You're exactly right. So you and I can go on an MRI scan and both of our hips are incredibly likely, 90% likely to have labral tearing on MR.

And you put a 20-year-old in there and it's not 90% but it's about 80%. So the odds are... That high. It's very high. So you're gonna see some sort of lab no more at malony on an MRI. And nearly everybody put in.

So then you're basically right where you started from. You don't know much more than what you did. So a lot of people will be given the test of time, they'll be put into physical therapy, they'll see if this remains an issue. And for those people who fall out, then some type of correction can be helpful. But again, our experience with the meniscus

is kind of a good example of that, where having a meniscus injury on MRI is essentially, in a 40 or 50 year where, you know, having a meniscus injury on MRI is essentially, you know, in a 40 or 50-year-old isn't very meaningful. It's much more meaningful that, if you suspect there's a meniscus, that the patient hasn't been able to have sort of righted on their own. They haven't been able to use physical therapy or time to their advantage to get their knee right. And then those people will typically benefit a lot from a procedure.

Let's talk about this in a little bit more detail. So this is still a kind of controversial area, or is the controversy within the, you know, esteemed orthopedic surgery community no longer a controversy, but it's taking a while to trickle down to the rest of us. So no, I mean, it's a funny topic. So Gina Collada wrote that article about how surgeons are addicted to useless surgery. I don't know if you saw this. Oh, I saw it.

I mean, I'm going to reserve my comments. No, no, no, no, no, no, no, that's fine. But she's a little off base on this one in particular. It's not the only thing she's off base on. Right, right, right. So there was a paper that my buddy did. He said, watch you, Rob Brophy. He's a very accomplished researcher and he's great surgeon, great doc.

And they did a study that was published in the New England Journal regarding physical therapy versus surgery for meniscus tears. And the punch line was that there's no difference between physical therapy and surgery. And so Gina Collada interprets that as, hey, it doesn't matter whether you do surgery or therapy. So why are we doing surgery at all? We should just do therapy for everybody.

Well, it turns out in one of the arms of the physical therapy group, there was a crossover to surgery for those patients who weren't getting better, but it was an intention to treat models. So they were still counted. There was still counted. Yep. They were still counted as physical therapy. So the take home message of the study wasn't, hey, it doesn't matter if you do therapy or surgery, it'll end up in the same place. It's more, hey, look, it's reasonable to try. It's reasonable to try both. Just to start with physical therapy and start conservatively, but don't, you know, there

are some subsets of patients that will benefit from crossing over. That's exactly right. That's exactly the message. And that's exactly what I tell my patients. They look, you have a meniscus injury. Odds are, it's probably going to get better with therapy in time. And you should play those odds. If, however, the odds aren't your favor and you start having pain or you continue to have pain, you're not getting any better in a month, it's go up your knee, take care of your meniscus. What unit was that paper? That was pretty recent. 2016. Yeah, okay. We'll make sure we link to that paper because I think it'll be good for people to see it. I get, we can go back and look,

but do you remember off the top of your head or even never mind that? Just clinically, what do you say to patients is how long a period of time do you want to give them on the conservative approach before you cross over? So I usually give about a month or two, but when patients come in a month later saying, yeah, I'm feeling a little better. I'll keep riding it out. You'll keep riding it out. Right. And even though they might be just feeling a little better, there are other people coming

a month later, it feel a lot better. I remember working with John Healey, who's an orthopedic oncologist at Sloan Kettering. And I mean, he's really taken care of some very, very sick patients with osteosarcomas, con just sarcomas, they're younger, they're older than it. And he's an amazing doctor, an amazing surgeon. And he once made a comment about people scoping for dollars. And I hate to think that that happens, but there's no question that it happens. None of us like to think we're the ones doing it, but the fact of the matter is that it has

to happen. There has to be some pressures for people to feel like, you know, the arthroscopy is the right thing to do. Even though the data is pretty clear, that someone walking in your office with a degenerative minuscustare probably shouldn't be scoped as a first line of treatment. And so I don't know what's motivating that person, whether they're past experience of they're getting better, which is again, tainted by the fact that they were probably going to get better whether they did surgery or not.

So then idea of doing useless surgery, the fact is I see where it comes from because we kind of as a group can dig our own hole by making these decisions that are whether consciously or not are being influenced by outside factors. I think this is a really interesting point in medicine. And I struggle with this a lot. When you're not a proceduralist, which I'm not, the stakes are a little bit lower and the opportunities are a bit lower,

but I, I don't know if I've told the story before, but this was a moment when I had a realization. So one of the things that a lot of people in my type of practice do is they also sell drugs, meaning they can get a license to become a pharmacy, basically, and they can sell anything license to become a pharmacy basically, and they can sell anything that's sort of compounded. And it becomes another profit center,

so you can start to sell what it ever it is that you would be prescribing to your patients. So you get to make the money instead of sending them to a pharmacy. And on the surface, that sounds okay. But the problem with that is, and I realized it one day when I was really on the fence about two different therapies for a patient,

and they were different, but one of them is actually quite inexpensive. It's generic, it's basically a free drug. And then the other one is not. Now, I was sitting there really wrestling with which one to put them on because of the age of the patient and a few other factors. It really wasn't a clear cut case of which to do. And I remember thinking, holy shit,

if I were the one selling both of these, do I trust myself enough that subconsciously I wouldn't lean towards the more expensive one because I would make $10 on the nothing burger one and I'd make like $400 on the other one. And I thought to myself, you know, don't be so sure. It's probably a good thing that you don't actually have to make that. You don't have to think about that. Because it's not to say that you're a bad doctor

if you fall prey, I think that's human nature. Or a bad person. Or a bad person. And it's harder for you guys, because you're proceduralist. Yes, you get judged on this. You get judged on by the people who write about medicine, who like to expose the surgeons is doing things that are unnecessary or the $50,000 diabetic foot that was talked about with Obamac.

I mean, this stuff is just so crazy. The fact of the matter is, the highest percentage of doctors are really looking out for the best interest of their patient, but they're human, like you said, and they may be influenced by other factors that have nothing to do with the best interest of their patient. One of the things about orthopedics that I think actually makes it a little easier if I've done in the right setting, and I'm sure this was the case at HSS, is it's so multidisciplinary that you have these physiatrists who aren't getting paid to operate, and yet they're still a part of the team that's sort of saying, yeah, you know, this patient probably does do better with surgery.

Not that this guy. And so I don't know how prevalent that sort of that model is, but I've been lucky every time I've been evaluated for a pretty, what I consider at least significant orthopedic injury. I've had the luxury of not just having to talk to a surgeon, not that I can't talk to a surgeon, but it's nice to be able to balance that with taking one layer of bias away. I think that's a great point. Not easy to find though.

I mean, a lot of people don't even know what to do. No, that's exactly like HSS is one of the places where you get lucky enough that you're going to be able to see a physiatrist. Yeah, or non-operative sports medicine. That's something that's been very prevalent. You know, laboral injuries, you had a laboral injury, correct? I have a right shoulder, laboral tear that, you know, I was weeks away from seeing all check for surgery at HSS.

What's happened with it? So I was getting a massage with my bodywork guy and, you know, this thing had been dragging me down for probably been five years, four years from Oh 9 to about 13. And it was just getting worse and worse. And it got to the point, you know, it started when I was swimming marathons. And so it was any time I swam longer than six hours, the pain became really unbearable to which any person listening to this is like, why are you? What? Who cares? Right? Start swimming less than six hours. Okay. But the point is it very quickly turned into if I swam two hours, it hurt. If it's one hour, it hurt. Actually, swimming just hurts hours. Okay, but the point is it very quickly turned into if I swim two hours it hurt. If it's one hour it hurt. Actually, swimming just hurts constantly.

And you know, you can do 50 push-ups. Nope, you can only do 30 push-ups. No, actually, you can't do one push-up. When it hit that point, so that was four years after the initial injury, I thought, okay, well, I got to go do something about it. So anyway, so you and I spoke and you basically said, look, these are basically your two best guys in the country, right? I forget the... Neil... I'll check and Neil L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. L. Yeah, yeah.

I forgot to mention that all check is also one of those mentors. Yeah, yeah. I mean, a superb guy, great surgeon. Well, that's why ultimately I was going to go to see all check because, and also because I'm in New York, it was just easier to do. So, I'm seeing my guy and he's working on it, and he said, you know, I know you have a labral tear. I mean, I can read the MRI, but he goes,

I don't think that's why you're, I don't think that's why you're in so much pain. I actually think the pain is due to the fact that the labral tell labral tear caused you to move differently. And over the past four years, you have changed the way you use this arm. And now it's actually in your tricep, your deltoid, your sub scapularis and your infraspinatus. And he said, you know, the recovery from the labral terror is going to be brutal.

It's, you're in a sling for six weeks, you're not going to be swimming for nine months. I mean, for you, that's a big compromise. He said, I think in six months with manual therapy and PT, I can get you better. I said, okay, let's give it a try. Within three months, I was at 80% of baseline. And today I would say, it's hard to say I'm 100% because I've also aged. Like, so you're dealing with the declining curve anyway.

But I, there's really nothing I can't do anymore. Like, including like any number of pushups or sort of any activity. I have to be careful with certain things. So one thing I've learned how to do correctly is when I do pull-ups, which I love doing, I never do a full dead hang without a scapular retraction. And so I'm always protecting my shoulder.

I don't do any overhead pressing activities. I do a lot of static overhead stuff. But yeah, I consider that along with the IT band injury I had that basically ended me from riding a bike in medical school and almost ended me from riding a bike a second time. And I was, again, ready to have surgery on my IT band before this same guy was like, actually, it's not really, I mean, yeah, your IT band is jacked, but it's because, you know, the real issue is your glute meat and your TFL aren't firing correctly.

And as a result of that, your vastest lateralis and your quads are moving the IT band in an imbalanced way. And it was the same thing. I mean, I think within two months, I was better. To have someone that skilled with evaluating balance and muscle skeletal balance, they're viewing far between, I mean, I usually don't claim to be one of them.

Yeah, these guys are gods. And I'll tell you just to give you the flip side of that story. Of course, this guy, and now his protege, you know, really work with my patients. And that's, you know, so what I basically do in my practice is try to find the people who are the best and just figure out a way to utilize all of their time, you know, close down the rest of their practice.

They now, so Josh, who now basically only sees my patients, you know, the flip side of that is I've sent patients there where after one appointment they say this guy needs a shoulder replacement. Like clear as day, I could sit here and take a lot of money from this guy for the next six months and do conservative therapy, but it's not gonna work.

And so I've always appreciated people who had the ability for an out, totally unbiased point of view. And that's working against his own best interest. The other thing though that I will say against this, and this is just kind of me on my soapbox about how I get a little pissed when people sort of say, all surgeons are incentivized. You know, it's like, you know, when you're a hammer, everything's a nail.

Great surgeons aren't looking for business, right? Like the great practitioners are so overbooked, they don't have to do that. So, you know, in the case of this guy, his name is Brian. Brian doesn't need any more patience. So it's easy for him when I send him somebody who he thinks needs a shoulder replacement to say, you need a shoulder replacement.

And similarly, like I actually sent a patient up to Stanford recently to get an aortic route replacement and an aortic valve and it was a huge operation. And he was a little reluctant to do the surgery and he said, you know, I'm a little worried because the surgeon says I need this operation. But, you know, he's a surgeon and I said, let me give you a little secret about this surgeon. He's God. He doesn't need you. He has an infinite number of patients who need his help, whether you are or not one of them. So I promise you, this guy's, he doesn't make one more or less a dollar as a result of your

existence. The recommendation to have surgery is because of the physiology of your disease. But that's how I'm sympathetic to this and I think it's, I don't have a good answer to it other than this sort of multidisciplinary approach. I think there's something to be said, when it's available to be able to be evaluated

by more than one individual, but that those individuals are working in your best interest, not their own. And that doesn't grow on trees. Yeah, again, I'd like to think that most people in our profession are genuinely working in the best interest of their patients. And again, I think it's the overwhelming majority

of physicians who do that, at least in my experience here. But there again, like you've also mentioned, there are some unforeseen influences or unrecognized influences that affect all of us because we are human and maybe taint our decisions in a way that may not be fully within the best interest of the patients. So, there are a lot of things in orthopedic surgery now that are quite popular and they've become almost rampant and I don't have enough of a sense of their value.

So for example, like PRP and stem cells, let's talk about PRP for a moment. So maybe just explain for someone who's listening to this who hasn't heard of it, what is it? PRP is a super concentrated portion of your blood. It's a platelet rich plasma. And the procedure itself is quite simple. We basically take a needle, put it in your vein, take some blood out, and then put that tuba blood

into a centrifuge. And the heavy portions of your blood go to the bottom, the lighter portions go up top, the platelet rich plasma is typically in the middle. And you take the platelet rich plasma, and you inject it into a knee, a shoulder, a tendon for healing purposes. And the idea is that the platelets are rich in healing factors

in the VEGF and platelet-derived growth factors so that you can stimulate and accelerate. Vascular entity, growth factors. So another one of these growth factors that would promote growth here. So again, the idea being that you can accelerate healing, you can take the bodies, natural healing responses, and really supercharge them to some degree, or super concentrate them to some degree. So the study is about PRP are somewhat imperfect because there's so many different commercial preparations of PRP and there's sort of general categories.

There's Lucasite Rich, PRP, so high in white count, white cells, there's Lucasite Poor. Those were deliberate design choices or those are just methodology differences. Yes, yes, design choices. And then again, several different types of preparations for PRP. So you're dealing with a very heterogeneous starting point. And so one PRP injection doesn't isn't the equivalent of another PRP injection. But it's hard to really know whether PRP is making a big difference in tendonopathy is most commonly. It doesn't seem to be regrowing articular cartilage when you inject it into a knee or a shoulder or an ankle or a hip. It may be helping to stimulate tendon injury, but that's a very hard end point to measure because most of the time we're measuring pain and function with that.

And it might be getting better in the tendon because of the injection itself and the VEGF and the plate that the grove factors are doing exactly what you are hoping that they're doing or it might be because there's a placebo factor. It might be because you're resting because it's pretty sore after you get one of these injections. And, you know, again, you don't really know the answer why. But the study, studies seem to demonstrate that PRP has a marginal benefit for tendon opathies. It's not a make or break, which is why not everybody's running to get it, which is why the insurance companies are actively paying for it. And the end point for tendonopathy is pain or function, pain and function. And the placebo is used in these are what?

Sailing or they might be had to have a quarter zone or they might be had to head with if you're doing an intratutical injection with the viscals supplements, the the hyoronic acid injections. And each of these has their own limits, too, by the way. I mean, they're only a efficacy. One of the challenges with this space is it's so nascent. And if I were going to make the case that PRP is better than the studies let on, and I'm not making that case because I actually don't know. But if you believe that PRP is better than the study suggests, you'd probably also believe

that the reason the studies are under finding benefit is that they're underpowered because of the heterogeneity and approach and the inconsistency in patient selection. So I suspect that with all new procedures, you know, if you had a crystal ball and you could look into the future in a decade, you'd say, well, actually, we now know that like a third of the patients we did this on should have never had it. And so now you've reduced your patient population to a more homogeneous. In medicine, it all comes down to the more homogeneous the population you can treat and

the study, the better your outcomes you're going to be. In the end, we're all heterogeneous. The better your outcomes will be, but also the better your science will be. That's my point. The better the science will lead to a better inference about who to do it. But so it always makes me wonder, like we're still in the wild west of a lot of these things.

And I do wonder if, you know, will this stick around long enough to get rigorous enough to actually understand what are the patients that are best suited for this procedure and is there a way to standardize and Optimize really the preparations and the technique and where do you think if one out of 10 is when it's starting and 10 out of 10 is when it's fully Diled where are we probably three out of 10 and we're still I think there's a long way to go on the biologics But I mean they are the most promising

Intuitive avenue to go down. How do you think about it personally when you're treating patients? So patients ask me every day about stem cells and therapy every single day. And I think the issue with stem cells is that we don't know why it works for the people who it does work. But it doesn't seem to be working because it's regrowing their cartilage. So that's the big issue. Now it might be working as an anti-inflammatory, it might be working as a placebo, and it turns out as you're aware

that sort of the bigger the procedure, the better the placebo effect. So the more you're digging, the more you're extracting, you are harnessing a larger placebo effect by the size of the placebo effect. What is the placebo effect with that procedure? Is it viewed as about 15% benefit? Because that's the all-in typical placebo effect. What is the placebo effect with that procedure? Is it viewed as about 15% benefit? Because that's the all-in typical placebo benefit. Yeah, I couldn't give you the number. I actually don't know the number. But I think with

stem cells, there is a lot of promise and I hope it works because I'm going to need it myself. And we'll all need it. But right now, there are people who I think are particularly in the orthopedic form are taking advantage of the fact that we don't have great treatments for arthritis. We don't have any reversal for our arthritis. We have ways of managing arthritis and maybe slowing down the pace of worsening arthritis. But we don't have anything that reverses the course of arthritis that turns your older knee into a younger knee, your older hip into a younger hip. And the stem cells seems to be that sort of molecular fountain of youth that people have

glombed onto. They have this idea that they can regenerate their hip. They can grow their native hip back to what it was when they were 20. And a lot of it, there is promise in this. There's no question that there's promise in it. And the animal studies really demonstrate it. But for instance, there's a local group that's doing stem cell injections here where they take a bone marrow biopsy, a bone marrow asperate from your posterior earlach crest. They take a slurry of fat from your abdomen, they take some pure appear from your arm, they put it together and they inject it.

And they charge five to six thousand dollars per for this procedure, cash. And talk about incentives. I mean, they're highly incentivized to do this and they charge five to $6,000 per for this procedure, cash. And talk about incentives. I mean, they're highly incentivized to do this, and they will have patients come back to them saying, I feel better. But again, there's no rigor. Are they feeling better because of the placebo effect? Are they feeling better because there's an anti-inflammatory

effect, which you can get with cortisol for 25 bucks? Or, you know, what's really the deal? But I don't think it's the cartilage we're growing. And when they do those injections, those preparations, they're putting a couple hundred stem cells in. The studies that showed some benefit in rats and small animals, it's about 10 to 20 million. So we're orders of magnitude.

Yeah, we're orders of magnitude off. And so I, and this is one story I do tell my patients as well. I had a woman who said, I went to a stem cell talk. They offered a free stake dinner. And I listened to the talk and I sat aside to sign up for it and I ended up paying $13,000 for three stem cell injections. For the stake? Right, exactly. Exactly. I'm like, how do you feel? I feel a little better. And she's like, what do you think? And I didn't have the heart to tell her. Like you said, that she paid $13,000 for a stake dinner. 13,000 or 13,000? 13,000 dollars for three stem cell injections. So these price tags that come with it are so exorbitant. And I think there's some exploitation that's going on because

again, we don't have the solutions. And it doesn't take a lot of anecdotes out in the community. I got this. I feel a little bit better. I feel better. I can do things I couldn't do. And that's all great. But we don't know why you can't do better, I feel better, I can do things I could do. That's all great, but we don't know why you can't do the things. Why you now can do the things you could do, is it because the stem cell is doing what is being advertised, growing new cartilage, or is it because of an anti-inflammatory effect or a placebo effect? Are there randomized trials going on, looking at this?

Yeah, and most of the time they show some clinical subjective benefit, but again, not a single radiograph or MRI showing rest reconstituted cartilage. And that's with not just PRP, but stem cells exclusively. Correct. There are RCTs that are ongoing. There are randomized control trials. Now the randomization process might be a little bit. Well, because I mean, this is the exact reason

you actually have to have double blinded. Yes. So you these have to be complicated trials. Yes. You're not doing this in general. And again, there's nothing that's come through that says we should be doing this at this point. I struggle with this.

I get a lot of patients that ask me about this and I've had probably half a dozen patients that have had it done and swear by it. And sort of like you, I have a hard time sort of having a straight conversation with them because deep down I sort of think it's bullshit, frankly. But I, but at the same time, I'd like to think I have the humility to say I have no clue. And my first question is, is it doing harm? And I say that specifically with the IV stem cells. So that's the one that I'm most skeptical.

So question one is, what's the probability of harm? And let's bracket harm as physical harm, financial harm. Like, let's actually break this thing out. And then we talk efficacy. In other words, you want to think about it through the lens that you would think of drug development. Phase one, safety, phase two, efficacy, phase three effectiveness. I don't know. I hope that that level of rigors being applied to this because I do feel really bad. Like, again, I don't know how wealthy your patient was that about the $13,000 stake, but boy, that would break my heart to think

that that was a meaningful chunk of change to her. Yeah. And in her case, she didn't get a big benefit. She felt a little bit better. And she had a problem that pretty clear that it's a surgical issue. It's a surgical issue. So, but she's does my name or surgery. She really wants to try everything prior to surgery.

And so again, the do-know-harm part is, again, I don't discourage when people ask, I just try to steal them towards one of the academic medical centers where they are doing trials. So that, yes, they may get a placebo, yes, they may get the stem cell, but they won't get fleeced, and eventually we'll get an answer whether or not this is effective. You know, when we talk about placebo effects in particularly in orthopedics, there was a recent paper published in the British JBGS, I think it was,

regarding subocromal decompression, which is a very common procedure used for shoulder pain, for shoulder tendonitis and impingement. And for patients who don't have rotator cuff tearing, but have to shoulder dysfunction and pain, traditionally, subocromal decompressions have been a procedure of choice where you shave a little bit of the under surface of the acromion, remove the bursa, and allow for more space for the rotator cuff to move.

And it generally leads to pretty good outcome as a result of the surgery. You seem to be pretty good. Well, I was having dinner with a law professor at University of Chicago, Todd Henderson. And the paper that was done looked at subocromro-dekompression versus sham surgery. And there was no difference between the sham surgery. You can tell people what a sham surgery is. Yeah, you make the incisions, you don't do anything. So, and you blind it to the...

So, it's a single blind. Obviously, the surgeon can't be blinded to a sham surgery. Correct. But all the therapists and the patients, so everyone downstream from the operating room has blinded. And the results were the same between a sham surgery and the decompression, which would speak to, you know, the decompression being worthless,

except that both groups got better. And so when both groups get better, his argument was the only ethical thing you can do as a surgeon is to offer the sham surgery. The problem is if you offer it as a sham, you might lose the benefit. Right, so you can't do that, but then you are doping the patient, taking them to an operating room for what they consider to be a procedure.

That's a procedure when in fact, unless you explain to them that, look, the reason we would explain the equivalence of the sham to the procedure is the post-operative care that you got. It's the PT, it's the, or it's some combination of the rest, the post-operative care. The first rest from the surgery. The first rest and the forced PT because you're going to take PT way more seriously when you're in a sling and you've had surgery. Right. So, I will say that the patient sometimes with menistical injuries say, let's cut out the

middle man. It's probably the rest in the therapy that's helping you so why don't we do that. But you are also withdrawing the placebo effect of the procedure, what seems to be a placebo effect. Now, I do subocromal decompressions, I've done them and I probably will still do them because yet the science, that's a reasonable study

of randomizing patients and finding not much of a difference. And so, and these studies have been done with an ESC is better. And how much better did the patients get? You recall what the absolute improvements were? I don't know the absolute improvements. I don't recall.

Because that's the other thing that kind of has to be weighed into these things. I mean, people who listen to this podcast have heard me sort of rant about the difference between absolute and relative improvements and those things have to be. Well, they're relative improvements by definition when you're doing shoulder surgery. But it is, look, again, I thought that was a very interesting point, the most ethical thing you can do is the sham surgery. Let's talk about what I consider the elephant in the room when it comes

to orthopedic injuries, which is lower back injuries. I, you probably remember what happened to me in my career. I totally remember what happened to you. You had a, you had a caught a quina. Yeah, I mean, I had a free fragment, the alpha-ves one free fragment stuck in the canal. I mean, the whole thing was a disaster. I hate even talking about that. And then you got infected afterwards, too, right? I did have a little infection after.

The bigger issue is that he dropped right on the wrong side. The first procedure he went, he did a left side injury. Or he, yeah, it was the left side injury. He did a right side of the compression and dinged the right side, it was the left side injury that I right-sided the compression and then the right side of nerves. So I came out with a right-sided foot drop, even though I went in with the left-sided injury. I did not know that.

Yeah, yeah. And had a bunch of reduce. So it's something that's near and dear to my heart for personal reasons, because I spent basically a year of my life recovering from the back injury, three months of which I was debilitated, meaning I couldn't move,

my mom had to fly down from Toronto to feed me. I mean, literally I couldn't even make a meal. And my roommate, Matt, was like, he's still a med student, he's not like, you can't sit there and feed me in white my ass. So yeah, I'm still partially traumatized, I think, from that, but also,

I now realize that it was, and I've talked about this in the past, it was the best worst thing that ever happened to me, right? It was the worst thing that ever happened because it's just a year of being hooked on opiates and all this other crap that comes with it. But it's also where you learn how to move again. And in many ways, I think I feel very fortunate now that that happened to me when I was 27, I'm 45 today, I've never really had a back issue ever since.

Because it hurt for so long, I learned how to redo everything that you wouldn't be able to relearn if you only had two weeks or a month of pain. So for example, I learned how to sneeze while protecting my back. I learned how to brush my teeth while bracing myself over the counter so that I'm not just completely placing a torque on my lower back by bending forward. brush my teeth while bracing myself over the counter so that I'm not just completely placing, you know, a torque on my lower back by bending forward, like little things. I remember a friend of mine was over at my house and I was putting the dishes away and I put a fork in the thing and I did a squat to bend down to put the fork in it.

He's like, dude, what's wrong is you're back hurting? And I was like, no, it's exactly the opposite. My back doesn't hurt because I do this, because I never get caught picking up that piece of paper because so many people, when they throw their back out, quote unquote, throw their back out, it's usually the tiniest insult that does it. It's not always the, while I was doing the 400 pound deadlift,

right? So that said, you can't go far in life without running into a friend, a family member, a patient who's really suffering from lower back pain. And I gotta say, I'm not convinced that surgery is, there are clearly some amazing cases. I've seen some spinal stenosis cases that the moment this patient comes out of surgery, it's like, it's changed their life.

But more often than not, I wanna say, and maybe I'm biased in my sampling, patients probably would get better without doing a lumbar discectomy, for example. But again, that's now me speaking with a bias. I'm curious as to your thoughts on this, even though I know you focus on joints and within the field of orthopedic surgery,

this is sort of like, it's its own subspecialty of spine. But, you know, look, you know more than I do. So that that's you kind of go if you go to an ophthalmology conference Hmm, and you ask how many people do lasec most of the hands go up in the air and then how many would happen on themselves most of the hands go down If you go to an orthopedic conference and ask how many people have done or would or have done spine surgery and we've all done it And we raise our hands how many people would have it on themselves and the hands go all go down surgery and we've all done it and we raise our hands. How many people would have it on themselves and the hands go all go down? Because we see some of the very poor outcomes that can happen with spine surgery and the difficulty that people can have with it. And low back pain is ubiquitous. It's the number one reason people go to the doctor, not the orthopedist, but the doctor.

And I don't realize that. Yeah, so it's the number one reason. And so when people have low back issues, there may be mechanical issues, like you mentioned a slip disk, which the majority will resolve with time. But when patients have neurologic compromise, weakness, there tends to be a greater urgency to do something about it. Especially cervical, right?

Correct. And because it can affect people's balance, people's ability to walk, not just their hands. And I can show you, I will show you my friend Nick Horgend, moved to London, and he was new to the area, new to the healthcare system, and he calls me out of the blue. He's like, hey, they had, and that's what you're going to have. I got a little problem here, and I got this, this disc, and they're telling me not to fly anywhere, not to go anywhere, and have surgery on Monday.

So I asked Nick to send me the worst picture on the MRI that he could see, I got this, this disc and they're telling me not to fly anywhere, not to go anywhere, and have surgery on Monday. So I asked Nick to send me the worst picture on the MRI that he could see, and he sends me the picture. And he has this massive disc herniation with signal within the spinal cord called mylamalacia, which means that he's getting injury to his spinal cord and will lose neurologic function in short order. And I said to Nick, Nick, do not fly like they told you, do not go anywhere. You go into surgery when they tell you to and

sooner the better. And he underwent a successful cervical decompression infusion. And he had a vertebrae to me at the time and a big graft. And those type of spine surgeries are life altering and life saving. And there are other spine surgeries where the problem isn't so dramatic, but the intervention is so dramatic. And you've mentioned this to me before, you've sort of introduced me to the concept of asymmetric risk, where, you know, when people are functioning 70% and you do something as dramatic as a spine operation, you could take someone from 70% to 90%, but you could also take someone from 70% to 20%. You can really drop them out with a spine operation. Because it's your core, it's your axial skeleton, and if things go awry there, they go

awry for your entire body. If I have a shoulder surgery where I'm trying to take someone who's 80% functional and make them as close to 100% as I can, I'm probably not going down to 20%. And so, again, if anything, they'll be a little bit worse or the same, but it's rare for when you're working on the extremities to take someone way, way down like that. Ken, but it's rare. And the spine, it seems to happen more frequently. And again, you're taking people who are reasonably functional, but not happily functional and trying to make them better.

And then the instances where you don't, you can make them all hell of a lot worse. And it's kind of why I think joint replacement is such a successful, subspecialty in orthopedics. You have people who are 20 to 30% functional. They can't walk more than four or five blocks without pain. They pain all day long where they're sitting. None of the anti-inflammatories are working. Their life is completely dominated by their hip or their knee pain. And you do a joint

replacement. And you make them 70% functional. And they're the happiest people you're going to meet because you make it made them from 20% functional to 70% functional and you have an incredibly wide margin to improve them. If you're in sports medicine where people are about 85% functional, I mean you could do everything except swim and do pushups, but you could do everything else in your life without pain. And you're taking someone who's 80 to 85% functional, you're working with a very small margin. And so it's a harder, it's harder to get the satisfaction that you can get. There's just, there's so much more downside than upside.

There's the potential, but again, because with the work that sports medicine surgeons do, you rarely make someone from 80% to 20% yet in the spine because it's the spine, you can take someone from 80% way down. So I think that's, I don't know how to show if that's making sense. I hope that's why. No, it does make sense. What can people do? You know, obviously like, you're my go-to guy for any orthopedic question,

like I'm always calling you, and I'm always sending you MRIs and my patients and stuff like that, and you're always like, okay, what cities is person in? And you're always a phone call away from like the best person in that city, or if they're willing to go see the best person, period.

In that one case, it got really lucky that person had a foot injury, needed an ankle replacement and the best guy in the country happened to be one of your partners. That's really nice. But your connections through HSS has always been great. But the average person listening to this doesn't get the call you up and doesn't get to say, Eric, here's my MRI, tell me what to do. It's hard to ask because if it's anybody that is your friend or family, you're going to be able to do this for them. But if there's someone you can't help, but you want to give them sort of the guiding

principles of how should they be screening orthopedic surgeons? What questions should they be asking before some of the more common procedures? How would you navigate them? Well, I think you alluded to it earlier with your friend who, you know, doesn't need the business or that patient who is having the orotic root replacement. Volume does speak volumes. I mean, when surgeons have high volumes, that's probably a generally a good sign. Now, there are some surgeons who have high volumes because they're scoping for dollars

or other things. But in general, it's a reasonable rule of thumb that they have a good volume. So, let's talk about a couple procedures. If you're getting your knee replaced, how, you know, I, and I, this is how when we were trying to find the best surgeon to do my friends aorta, this was a big question, right? It's like, you don't want someone who's doing one of these a month. So with, with a knee replacement, what do you consider the volume number above what? Boy, I, I would want it to to be 204 a week. Somewhere in that it range. High volume is considered by the way, creating 30 in some of the studies,

which is once every other week. But the high-volume guys are doing several a day. Wow. And so, you're saying, so someone who's doing four of these a week, 200 a year, that's basically that should be all they're doing pretty much, right? They'll be doing that in a hip replacement, you know between four to six hundred surgeries a year that's an incredibly high volume surgeon those are the HSS type numbers. Yeah, you know those are the people who are going to be really at the top of the game again. And that already introduces something interesting. You use head of studies are considering anybody over 30 to be high volume. You've already seen a great heterogeneity now in the studies. Right, because there's a huge spread between 3,400.

Right? So, but I think the volume of cases that are done, obviously just asking around and seeing what other people's outcomes have been have been really helpful. And you want to pick a surgeon who's not going to run from their complications, because we're all going to have complications. And again, human nature does play a role.

And, you know, no search on likes complications. It's, you don't feel good about yourself when your patient has a complication. It's one of the most interesting dynamics between a patient and a physician because the patient feels horrible because there's been a complication. The physician feels horrible

because if they're even remotely honest with themselves, they realize that something, whether it was entirely their fault or some combination of things, something that they did led to this, and yet the natural tendency is to run, not because you want to abandon the patient, but because you can't stand facing the fact that this happened. Well, there's a shame that's involved. I mean, when you have a complication, you definitely feel completely responsible for it. And you know that shit happens, things happen. But you feel responsible, it is your fault.

I mean, you can't get around that. And you sometimes want to cower away from it. And that is your first instinct to some degree to just, you know, bow away from it. But obviously, when you're choosing a surgeon, everyone's had complications. And the surgeon you want to have is someone who steps up when there is a complication.

We've always been taught, keep your patients close and your complications closer. And I try and do that. I mean, I've had patients who've had infections, I've had patients who've had outcomes that weren't expected. And they're the ones that I obviously remember the most. I can't help it.

There's an emotional component to it. But I try and be available in every possible way that I can be both emotionally being able to just call me, text me directly. And I don't like to put barriers between my patients in the beginning, but for anybody who's had a complication, I try to create zero barriers. I try to make it as seamless as possible. So you want to have a surgeon who has a reputation of being someone who will deal with complications. And I don't know how you find that other way. I would say because there's really those are two interesting traits. Right. You're not going to advertise your complications, right?

Yeah. And it's something I think that patients have a hard time asking physicians about. I don't have a hard time. If I'm when I'm talking to the cardiac surgeon who's going to operate on my friend, I didn't have a hard time saying, all right, let's talk about the complications. Like, how many of your patients get AFib after surgery? How many reblead? How many reduce? Boom, boom, boom, boom. What's your 30-day mortality?

But, you know, I came from that world so I can talk in those terms. But for patients, is it okay to just say, hey, what's your infection rate? What's your re-operate? What's boom, boom, boom? I think you absolutely should do that. I mean, and the heart... And the surgeon who can't answer those who doesn't want to, that's probably a harbinger of something worse.

I agree. I think most people with their salt welcome those questions or happy to answer them. A surgeon who welcomes a second opinion, yeah, please, by all means, I think that's someone that, you know, you don't want someone who shies away from having a second opinion, I think that's a red flag for sure. So volume, the humility to answer questions about complications, the willingness to participate and have second opinions.

I mean, those are three pretty good rules of thumb. Yeah, I mean, generally, someone who's embracing those is concerned more about your best interest than anything else is concerned about themselves and is more concerned about your outcome, your best interest. But it, like choosing a surgeon is really difficult. There's no metric. I mean, you can go on to health grades and you'll see some of the people that when we're in the know who we see operate, who have great outcomes, who are gifted surgeons, have terrible health grades.

I feel like health grades should be taken away. I got to be honest with you. I think there is no benefit to that service. And I don't say that disparagingly about health grades because I think they're doing anything wrong. I think it's a beautiful idea. I'm not sure it translates into directing people to the people that they've been patient to the people that they've been patient to. It's a category of people that we don't need to do.

It is a collection, you know, you're just going to, it's a bunch of extreme selection. Yes. Great way of putting it. And it's like, well, my kids are huge fans of South Park and it reminds me of the Alper Special episode, um, but I know. I mean, I'm a real people reviewer. Anyway, but we'll link to that.

I'm sure you should. It's unbelievable. But it's an imperfect, there's no perfect metric for who's the best doctor. There's just like, you know, Tom Brady's drafted in the sixth round of the NFL. And there are a lot of metrics for measuring athletic performance of how these guys are gonna do. And 32 teams made the same mistake six times over

when Tom Brady was drafted, 199. And they have 40 yard times, they have tons of film, they have pretty much every metric you could want and they still don't get it Now let's take that in the medical world where you don't have 40 times You don't have how many times you can bench. You don't have any game film And it's in the best of circumstances. It's incredibly difficult to measure elite performance Or or predict elite performance

And then you throw something in as complex as the medical world, it's even more difficult. So it's very hard for patients to figure out how to select the best surgeon. But then ultimately it comes down to trust. I mean, I think again, there's a big trust element and you have to trust that that person sitting across from you who is proposing to do a procedure that's quite invasive, that you trust

that they have your best interest, that they're gonna do a good job for you, that they're going to be there when you need them. And so there's a lot of intuition that goes into it. I know that you're one of those surgeons who doesn't shy away from the complications. And of course the irony of it is being so good, you have fewer of those complications, but then you're kind of all in when they're there. I'm guessing the toughest complications are the ones where they're occurring in people who have lost a non-trivial amount of function.

When it's all said and done, meaning, it's one thing, if God forbid, you have an infection, and that means there's an extra two weeks for you need any antibiotic, and you have to be an impatient, and there's a bunch of inconvenience. But in the long run, it's gonna be the way it was before or better.

But have you had those complications where either through the complication or just the bad luck of the disease? They're worse than when they started. Yeah. And they can't do something that they could once do before. Yes. And it's very difficult.

And it kind of leads into something that I wanted to speak with you about and the idea of coping and From a surgeon's standpoint when you have people have complications You still have the next person who needs a similar procedure and you have to be able to cope with the fact that you had a complication and one patient and move on to the next and do the best you can for them because you feel it's the right thing and that's not easy to do at all for a patient who has a complication that has left them with the deficit, coping becomes

a big part of it. Our role as physicians is to help patients adapt and cope with their new reality. And helping patients focus on what they're able to do as opposed to what they're unable to do is a big part of helping them cope. And if you can change the mindset, hey, from, I know Larkin can do this because of the complication, I know Larkin can do that because of the complication too.

I'm still capable of doing this, I wanna do this. Can I do this more of a, again, focus on what you're capable of doing as opposed to incapable? Then I think you can help patients adapt to a new reality that, again, there's a better acceptance and a better way of coping. And it's not just complications. It's sometimes even without a complication, you know, the person has an injury. Yeah, the natural history of the disease is...

Yeah, and the natural history can be just on a downslope and, and again, trying to help patients cope with that limitation. And again, I think it's so critical to help people focus on what they're capable of doing as opposed to incapable of what they still have ahead of them as opposed to what they've lost from behind. And again, it's very difficult. I mean, I've been in that situation when you've been laid up and think about all the things you're unable to do. And now what you were able to recapture, but some people don't recapture, but still have to look forward to what they can do. And I kind of was exposed to this coping idea through the care of a family member who has a form of cancer that requires ongoing treatment. And this family member through this illness, I was exposed to a physician at Dana Farber, one of the leading cancer centers who's a breast oncologist, Eric Weiner.

And Dr. Weiner was the recipient of a Lifetime Achievement Award in breast cancer treatment. And he gave a lecture, it's the Maguire Memorial Lecture in San Antonio in 2016, I believe, 2016, December of 2016. And he talks about this state of breast cancer and research and developments and reasons for hope and reasons for optimism. But he also, for the last 15 minutes, he tells a very personal story about his own interactions

with medicine and what he feels his primary role is as a physician. And fundamentally, he believes it's our role to help patients cope whether it's with an illness whether it's with an injury whether it's with a psychological it's about coping and helping patients manage and helping them continue to live their lives so that they focus on what they're capable of doing. Again, he delivers it such a powerfully and I don't want to spoil it. I really want people to listen to this. I think everybody who wants to be a physician or is a physician should listen to it.

I think anybody who's receiving medical care has an ongoing issue, should listen to this. It's an incredibly inspiring message that he gives. And again, his own personal example is, it's just, it's tremendous. And his message is spot on. And so I see many patients who are in knee purgatory, I call it, who aren't ready for joint replacement, who don't have a bad enough, aren't at that 20 to 30% point of dysfunction that they would benefit from, knee replacement.

If they're sort of 60% functional and you get a knee replacement, they're 70% functional. They're not typically happy with that because I have to go through hell to get it. So in that Neepurritory, 60% to 70% functional, where we don't have a lot of options, it really is the emphasis on treatment and management is on coping. Let's take an example of that. So, the athlete who's in Neepurritory probably can't run anymore? Yeah, well, the athlete usually isn't in knee purgatory. It's usually someone my age or above is in knee purgatory

with a degenerative condition. Yeah, sorry. I'm so used to calling patients athletes because I try to get this idea of like everyone's an athlete. Like you're an athlete when you're 90, you're an athlete for a life, but yeah, I see your point. Okay, so this person could be a 45 year old

who's been athletic and all of a sudden now she just can't run anymore. Like she, you know, she used to be able to run marathons and now the 5K trot with her daughter at school is unbearable. Right. And then we don't have a lot of treatment options for that person surgically. And there are 45 years old. So you want to get them to 55 or 65 as we talked about earlier. Or if you, you know, I want to get them to 100. No, but yeah, no, no, I'm saying you want to get them to there to do the joint

replace. But the long, long view, you want to get them to a hundred and still moan the lawn. Right. So coping is somewhat of managing the expectations of what you will be capable of doing, but also not setting limits, allowing patients to try the running and allow sort of the joint or their problem to limit them as opposed to you imposing any artificial limits on them. So I draw a graph where I talk about thresholds and above this threshold, if you're developing pain or swelling and below this threshold, you're not. You want to be up against that threshold with your activity level as much as you can be.

And you can modulate your threshold. You can strengthen your, like. You can lose weight. Even the person who weighs 100 pounds who loses five pounds is gonna benefit from weight loss if they have a painful or extremity joint. Well, it's interesting. I'm glad you bring that up because I was gonna ask you about that

and we got off and I forgot about it. So even me, I'm not overweight, but if I lost 10 pounds, presumably, it's gonna be a little easier for me. Yeah, things will feel better and I feel the same thing. I know when my knee, I almost know my weight by the pain of my knee. I can gauge it that precisely because I know what weight I feel good and don't have pain

in what way I don't. But there's typically a threshold. It's kind of a binary issue. And so again, I try and get people to do what they can and then let them know that they can modulate that threshold through effort. I mean, really through strengthening, through weight management, and through education. And the more you learn about your condition, your illness, your injury, the better you'll be able to cope with it, period.

And what are some of those things that you will recommend to those person? So, you know, that 45-year-old mother who's a star athlete, great runner, you know, probably played tennis in college, whatever. Do you say, if they keep hitting that threshold so often, do you just say, look, I want you to try swimming or biking? Of course, yeah. Yeah. And again, if people are focusing on what they can do versus what they can't do. So if she's focused on what, okay, I can swim and I can bike as opposed to, I can't run anymore. That mindset makes a huge difference in managing that and coping with that. So helping to cultivate that mindset is a big role of what we do in terms of again, helping

patients cope. It's not a biologic, it's not an injection, it's not a cure, it's not a Jetsons approach to good health of being able to take this pill on your okay or take this injection in your okay. And we're not pursuing the molecular fountain of youth through this approach. But in the other hand, you can help people still live better and move better if you can focus on what you're capable of doing as opposed to what you're lost. Yeah and this could be especially valuable if by switching to a different track you can slow the decline. You know, one of

the fears that I have in that type of a patient is they stop running because it just becomes simply too difficult, but they don't replace it with something else. And all of a sudden, they have a really precipitous decline in their physical quality of life. Now look, for a 45-year-old to get sedentary, doesn't mean that much. But by the time they're 65, the difference between them having pivoted to a new sport or having done nothing becomes enormous, especially for that woman because in five years she's going to go through menopause and she's going to have another accelerator thrown onto it. And you know, these are the things that really, this is the problem that keeps me up

at night. You know, I was leaving my building the other day, this is in New York, and I came out and I saw a guy who, you know, I recognized, because he's in the building, and he was in one of those sort of motorized scooters. And I was just coming back from the gym, and I was sort of running up the stairs, because I live on the, you know, whatever fourth floor.

And there's a part of me that kind of felt guilty. I was like, God, I can't believe like, there's ever a day me that kind of felt guilty. I was like, God, I can't believe like there's ever a day that I bitch about anything. When I just ran past a dude in his motorized scooter and ran up the stairs and I thought, you know, he didn't look that old. He's probably 75, truthfully, you know, maybe 80,

but look, in today's world, you know, that's just not that old. And yet he, you know, he has to get a door man to hold the door open. He can't go through the revolving door, not going through a revolving door matters. But the point is, I thought, boy, once you get to that point, what would you give to go back in time if somebody says, look, man, go back to when you're 45 and do these seven things different?

You'll be on a different trajectory there. And I wonder how much of it is this adaptability that you talk about, which is, hey, you can't run. Great. You're going to learn how to ride a bike. Can't do that. That's fine. You're going to learn to do X, Y, or Z. Or even again, changing the technique. Oh, you run. Right. Right. And so whether it's barefoot running or getting an analysis of some sort, getting lighter on your feed, taking shorter strides. I mean, whatever it is that you can do 20 pounds. Right. And so aging is such a big part of what we treat in orthopedics. And we do a tremendous

job with traumatic injuries. And the traumatic injuries that don't involve the joints, again, we do a terrific job with those. We can re-align the bone, we can get the bone to heal, we can get people's function restored. The injuries that involve the joints specifically into the intraarticular portion of the knee or the hip, the ankle, or any of the joints, and we have a much harder time. Those are the injuries that linger for a lifetime. A long bone fracture in the middle of femur, you'll pretty much recover from or in the middle of your tibial, you'll pretty much recover from and not have much of a deficit

if any. But the moment you have an intraticular injury to the joint, it puts you on a different trajectory. And how to sort of manage that trajectory and keep it as close to what it would have been had you not been injured is obviously one of the goals and difficult to do. But then also when that trajectory prevents people from doing what they want to do, having them focus on what they're still capable of doing, I think we'll help them cope. Because if they keep thinking about the trajectory, they were on. And compare that to the trajectory that they were on to the trajectory that they are currently

on, that can be a tremendous source of frustration. And so in the end, if they can just focus where they are and realize what they're capable of doing, I think that's a big part of just preserving health. And that fall must be, you know, bringing it back full circle to the guys in the NFL that you worked with. That's gotta be one of the greatest deltas between the former

track of performance and the current track when these guys retire. Well, you see all those horrible videos of like Earl Campbell and these tremendous athletes who are aging so prematurely and so difficulty and they really have no quality of life. But you ask them if they do it all over again again the majority of them will say yes. Yeah, it's so funny. I was actually just thinking about that today on a totally different tangent, but I was in my hotel and there was an silent auction going on and it was a picture of Muhammad Ali with the Beatles and you know, I'm a big boxing fan. I remember I was up so I thought my lobby I'm shaving and so I wanted to look good for you. You do? I thank you.

And I remember thinking to myself, God, you know, from about 1960 to 1980, Muhammad Ali had about the most recognizable face on earth. You could argue that no athlete existed on a larger stage than Muhammad Ali in those two decades. And yet, he, many ways, he died very prematurely. I mean, he died a few years ago, but given how magnificent his star was, all that he could have continued to have done, his quality of life really began to decline precipitously in the mid-80s. And I remember thinking

to myself, like, so he was at his best from age 18 to 38. If someone waved a magic wand and said to me, you could have that life from age 18 to 38, but then it's gonna be a pretty quick decline, would you take it? I guess for me the answer is no, but I realize that having never been there, I don't know what that high would actually be like, but I think I'm just such a conservative person

who's mostly optimizing on the back end of life, perhaps that's wrong, but it gave me a great sense of sadness to think about what would it have felt like to have been Muhammad Ali when you were 60 and to realize that you were once the most gifted physical specimen that ever walked the face of the earth and now you couldn't tie your shoes. And similarly, as you said, you look at these guys who, you know, are in their mid fifties, who were an enormous part of our lives growing up, watching football and now, even ignoring the CTE issue,

which is its own separate tragedy, but just the orthopedic injury, that I don't think gets enough attention. I mean, I think CTE is very important. I'm so, I mean, nothing makes me happier than to see the attention that is getting. But we don't see a lot of these guys whose brains are intact, but whose bodies are destroyed. Yeah.

And look, I'd never had a brother that's star like that, but I played sports and had a great time doing it, but I'm carrying around the injuries now that I sustain then that aren't going to go away and affect the my quality of life and what I'm capable of doing. But I can't dwell on what I wish I could be doing at age 50, I have to really focus on what I'm capable of doing now and maximizing it. And in essence, not giving a shit what gave up. And I have to say, even for the sort of small time,

good times that I had with athletics and where it's left me now, I still wanna trade it. And this is like the small time stuff because it led me to a group of friends and a long list of memories that I wouldn't really trade for anything. So I guess I would still make that deal. If I could take back that one cut that Torre May,

say, I'll, if I can take that one jump that Torre May, wrote it or not. I mean, sure I would do it. But if I had to give up everything else, so I wasn't exposed to that risk to you know, jump that tore my rotator cuff. I mean, sure, I would do it. But if I had to give up everything else, so I wasn't exposed to that risk to do it, I don't think I'd do it. That makes sense. And so it's a great question that you ask.

I mean, I always admire the way you ask questions. You ask the best questions. I remember one time you asked, I wonder what the first human being thought when they ate an avocado. Ha! Ha! When I don't even remember asking that. What was the context?

Were we eating avocados? No, you and Lynn were talking about health, and I think Lynn was talking about some of the community health projects that she's doing. And you said, yeah, you know, I often think about what the first human must have thought when he ate an avocado. Yeah, come on. Come on, come on, come on, come on. Fuck, thanks to these questions, but these are great questions. And my crew of fuck thinks of these questions,

but these are great questions. And I actually just said this to my kids. I was like, hey, the people really make the world different. Aren't the people with all the answers or the people with the questions. So think about some things that, you know, how can I change this? Why does it work this way?

If you're asking the right questions, you'll be making a difference. It's not necessarily that you have to have the right answers. He will always ask them. The great question. Speaking of questions, I'll wrap this up because I'm really excited that tonight is my first yum kippur break fast. I've only had a handful of these too, by the way. When you told me that I had the opportunity to join you for that tonight, I stopped eating a day and a half ago in anticipation of this. So normally, I would easily go 18, 24 hours without eating, but this time I'm going 36 hours

because I just can't wait. Do I get to wear a yamaka, by the way, or is that not cool? I like to. This is a non-yamaka yamka poor. It's a pretty low key. It's my in-laws who are terrific. It's one of their very close friends, or Lynn and I have become friends with. And she's been hosting it for the last, I think,

eight, nine years that we've been here. But they know I'm coming. They do know you're coming with a great idea. I did send an email saying, I know this is not my place to invite a buddy, but can I invite a buddy? And she's like, of course, she's, she's great. You'll enjoy it. And I'm going to enjoy it. This is the first time I've actually fasted for young Kapoor. And I haven't eaten since, you know, six o'clock last night, which is a new for me. Fantastic. Isn't it amazing? It works.

Yeah, it does. I feel pretty good. Evolution at its finest. Last thing before we go, you alluded to it earlier and it's, I can't believe we haven't given more lip service to it during this discussion, but you introduced me to probably one of the three most important sort of parlor tricks of my life, which are the doctor bucks. So how did you and by the way, just for the listener and we're going to link to it, of course, it's Dr. Buck B. UK K. In medical school, you were walking around with the buck original.

I became pretty obsessed, but the time I was in residency, I had at least five. I had the buck original, I had the cow catchers, I had the speed teeth. I still remember all of these things. And so I only, I think I had the narlies, but my own, our undersecretary defense was the one who introduced me to the buck teeth. And I wish I could say, come over there, but own was the one who introduced me to it.

And remember, you had to bite into the styrofoam cup. Oh my God, a photocopy it, send it to him, and then you get your pair of bucks. And back then, they were 40 bucks. I don't know what they cost today, but at that time, for me to go as well. And as massive chunk of things. It was huge, chunk of things.

When I was dropping, because I'd be buying multiple copies of these, like I wanted at least two of each of them, because I wanted to keep them everywhere. And I don't know if you know this story, but when I got to residency, this is kind of a ridiculous story. It makes me sound like a more of an idiot than I am.

I would wear the bucks everywhere. And I had convinced the entire pediatric tower at Hopkins, which is called CMC, that there were two Dr. Ritias. There was meat like the one with the good teeth. Along the bat, and we were twins. And when we were kids, our parents wanted us to get braces, but Peter, me, I did, and my brother, I forget what his name was, you know, Patrick.

He didn't. We're identical twins, we're the same in every way, we're both now doctors at Hopkins, but when you page Dr. Ritia, you gotta be careful because you don't know which one's coming. It could be the good teeth or the bad teeth one. And I was so egregious in my desire to do social experiments with these things

that like the day I got to Hopkins, when we were doing orientation and filling out our forms, I found the dental clinic and I went in with my teeth and I said, hey, I just, hi, my name's Peter Tia. I'm the new dental fellow. Did you guys get my records? And you cannot believe the discomfort in that room. Because they're so real, right? Like they're so like if you're listening to this and you are even half curious what we're talking to, site unseen, just go buy a bunch of bucks.

And I don't think you could be more amused for 40 bucks. Now, so you remember Ellen from medical school? Yeah, yeah. So she had a faux pop party. You might have been there. I don't know if I can remember. I might have been I might have been too inebriated. Yeah. So I had I had the bucks in my pocket. And I show up at her faux pop party. And she's there with me. Ellen were in their kitchen. I take the milk out of the refrigerator and start drinking from it. Put the milk back, I lift up my leg, I let one rip.

And Ellen goes, it's a fashion faux-paw party. I'm like, oh. So anyway, I had my bucks in later on and I was talking to somebody and I, you know, when you flash the smile, you have to keep and I you know when you when you flash the smile you have to keep your lips purse but once you flash the smile look on people's faces is priceless and you taught me the look yeah you just it's it's the this sort of shy koi yeah and then you flash those teeth and oh my god oh and taught me the look I have to say he's sort of the buck master

and then when I would take a bite out of something like a piece of the ham. I purposely have, oh God. And you know, oh, you okay, oh, I'm okay. And so Lynn was at the party and she goes, oh, Christ, she goes, she goes, I over her, someone say, yeah, yeah, I saw him and he seemed okay, but then he smiled. Oh, that's not the worst of it. He's at the dental school. So I would, I got at the point where I would wear these, there was probably a three year period

where I wasn't not wearing them. I couldn't go more than 12 hours without putting them on. And it drove everybody in my life nuts. Yeah. Because the very first time I met my wife's father and grandmother and brother and sister was at like Easter, you know, one year, right? Or whatever, like after we'd been dating for six months or something like that. And as we're driving over there, she's begging me. She says, please Peter, I know you want to put the teeth in, but just don't. And I was like, look, chill, you gotta let me be me.

You gotta let me be me? I gotta put the teeth in. And she's just, she's like fine. I'm not even gonna, I'm not even gonna acknowledge it. So we get there, put the teeth in, and her dad is a really shy, he can't make eye contact with me, like he gets one glimpse of this, and he is in pure discomfort mode.

He's just, oh, you know, like not looking me in the eye and trying to talk to me and it's super awkward. So we're sitting down to dinner, there's still in. And it's artichoke is the appetizing. And her grandmother's legendary Italian grandmother makes these amazing artichokes. And she's unfazed by my buffoonery. She just, it hasn't registered that it is that unusual.

And so she picks up a big leaf of the artichoke and she goes, look Peter, this is how you do it. And she angsts it out with her teeth. And I'm like, oh, I got it. Okay, let me do that. And her dad at this point is under, like he's beside himself and discomfort. How did Joe contain it?

How did she not like spill the beans? Well, this probably been dating six months. She had seen every minute of it every day. Okay. Like she just, this was like, it was more just annoyance with this. And then her brother figures it out and he can't take it. So he gets up and walks away and he's laughing.

And then finally, like I come, I just, she says, look, she pulls me aside and she goes, you're not leaving here without coming clean. So you can do it on your own terms, but you're coming clean before we leave. So I do. And her grandmother says, what everybody has said when I come clean,

which is, yeah, we couldn't understand how your parents had the money to help you go to college and loss or whatever medical school, but you never got braces. Oh, okay, it makes more sense now. Right. You remember Carlos?

Carveiro. Oh, yeah. I put the box in when he was my chief resident at UCSF, we were rounding in the ICU. And I was presenting a patient and he was in town a couple of like two years ago when he was telling the story and goes, dude, I was looking at you with those fucking teeth. And I'm trying to remember what you're saying about this patient, but I'm just focused on your fucking teeth.

I'm like, what's wrong with this guy? Anyway. I used to be a spare man. They are an incredible, incredible device. Yeah, yeah. And so I remember when I was interviewing for residency because that's at the time that most I'd ever flown in my life because you were doing a round trip every weekend, basically. And I, it wasn't purely randomized, but I would just decide on one leg of the trip

with the teeth, one leg of the trip without the teeth. And I wanted to know how I was treated differently, and I got to tell you, I was treated differently. When I walk around without the teeth, the flight attendant was nice to me, and she wanted to talk to me and blah, blah, blah, blah, blah. When I had the teeth in, nobody, everyone was so uncomfortable around me.

And I felt like a second-class citizen. That's really, well, again, you ask all the good questions. What's life like with the teeth? What's the thing with that? No. We should do a second podcast just on the teeth. Yeah, we should do it a video podcast. Yeah, for sure.

I also, I would get to the point where I liked the way I talked with the teeth, because you get a different talk. You sort of have a funnier way of talking, which I love. Yeah, your asses are a little bit more prolonged. Yeah. I work around it. Yeah, yeah. And it got to the point where in residency, I would wear them during surgery under my mask, even though nobody could see it just because I liked the way I talked with the teeth in. That's a little fucked up, but I love it. I never wore it.

The best part of this story is at my engagement dinner, which you were at, weren't you? The night before the wedding, I mean, you didn't get there in time. I don't think I was actually. Or not an engagement. What's the night before the rehearsal dinner? The rehearsal dinner, yeah.

The rehearsal dinner, the best part of it is, total surprise to me, Joel shows up with a set of teeth. Of her own. Yeah. And you know which one she went with? No, which were the funniest thing. Snaggle tooth. She went with you to man.

All one word. You know, but you demand that. That's good. That's great for her. Man. Eric, thank you so much for setting us at three hours on a Wednesday afternoon or whatever it is here to talk about this stuff. I know that, you know, for many people listening, we probably didn't even scratch the surface of some of the really

deep questions, but I also think that we gave people probably a really good overview of this, this profession of yours, which is in many ways probably one of the few professions that deals disproportionately with health span versus lifespan. So much of medicine is really geared towards how do you extend life, but orthopedics is one of these professions that certainly disproportionately thinks about how do you maintain that quality of life. And I wish everybody could be lucky and have to have an orthopedic surgeon like you.

My hope is that, unfortunately, that while that's not likely or real, you've given people some metrics by which they can at least evaluate feed their own doctor. No, hey Peter, thank you. I love talking to you any time. I first time I've talked to you with for their own doctor. No, Hey Peter, thank you. I love talking to you anytime. First time I've talked to you with headphones and a microphone, but you know, we're very lucky

to be able to do what we do. We have a medical degree. We have a means of helping people. And we see a window into people's lives. It's a very privileged view. And you know, you take that responsibility incredibly seriously. I like to think I do as well. and I admire all the work that you do.

You do incredible work for so many people and many of the principles that you have advocated over the years, we've adopted in our practice to try and help people. And so your legacy and your tree spreads far and wide and helping lots and lots of people. So again, I have an incredible amount of gratitude to you personally for how you've influenced my practice and my ability to help patients, again, cope with their conditions and their injuries and live their life to the fullest. So it's a great opportunity, a great privilege, and it's always great seeing you at any time, but thank you for allowing me to share my perspective on my profession.

Well, thank you, Eric, and that feeling is mutual. My appreciation for you is as deep as yours is for me. Thank you. You can find all of this information and more at peteratiamd.com forward slash podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog and the Nerd Safari at peteratiamd.com. What's a Nerd Safari you ask? Just click on the link at the top of the site to learn more. Maybe the simplest thing to do is to sign up

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