There are many different options to use as grafts during ACL reconstruction surgery, These include both allograft and autograft tissue and different options for autografts.
Lenny Macrina and I talk about the latest trends in ACL reconstruction graft options, the pros and cons of each, and how different grafts may impact the rehabilitation in this week's episode of The Sports Physical Therapy Podcast.
Full show notes: https://mikereinold.com/acl-graft-options-with-lenny-macrina/
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Save $200 Off Our Online Knee Course
Learn how to evaluate and treat the knee with my online knee course with Lenny Macrina. Click here to learn more and save $200 off the course this week only.
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Want to learn more? Check out my blog, podcasts, and online courses
Follow me: Instagram | Twitter | Facebook | Youtube
There are many different options to use as grafts during ACL reconstruction surgery, These include both allograft and autograft tissue and different options for autografts.
Lenny Macrina and I talk about the latest trends in ACL reconstruction graft options, the pros and cons of each, and how different grafts may impact the rehabilitation in this week's episode of The Sports Physical Therapy Podcast.
Full show notes: https://mikereinold.com/acl-graft-options-with-lenny-macrina/
_____
Save $200 Off Our Online Knee Course
Learn how to evaluate and treat the knee with my online knee course with Lenny Macrina. Click here to learn more and save $200 off the course this week only.
_____
Want to learn more? Check out my blog, podcasts, and online courses
Follow me: Instagram | Twitter | Facebook | Youtube
On this episode of the sports physical therapy podcast. I am joined by my good friend and partner in crime at Lenny Macrina. Lenny and I are co-founders of champion P team performance up in Boston, and I'm sure he doesn't need a bigger introduction. We all know and love Lenny. In this podcast, we're going to talk about ACL graft options, the pros and cons of each, and how we should approach the different options as rehabilitation specialist as always some great rants from Lenny. I think you're going to really enjoy this episode.
Mike Reinold:Hey man. Welcome to the podcast today. Great. So it's so formal and so great to officially have you on this podcast. In addition to obviously the podcast we've been doing for five years now or whatever it's been, but, um, you know, good to have you as a guest, because I think, you know your performance on our other podcast. I mean, you need your own, you need your own episode, right? This is a full, full Leonie episode we have here, right?
Lenny Macrina:This is good. This is going to be good. I'll uh, I'll probably go on a rant at some point. And, um, probably we'll talk about golf at some point, and then it'll circle back around at physical therapy at some point. So yeah, it'll be, it'll be fun.
Mike Reinold:That's it, that sounds like a brief snapshot of your Twitter account, right?
Lenny Macrina:It sounds like my Twitter sounds like my day. It sounds like every day at work, So
Mike Reinold:we. you know, we, we were talking about that. I posted on Twitter a little bit ago about, you know, like, like the, the reason why you may be on Twitter and this was from a conversation from you and I, and, uh, it was funny. Uh, Shelby asked me she put a good comment in there. Um, um, and just ask like, you know, how do I prefer to learn? And it was funny. It was like, you know, I love to learn on social media, but I learned about golf and smoking a brisket and, and you know, those sorts of things. That's how I liked to learn on social media. But, you know, It's funny. I think a lot of people were saying that
Lenny Macrina:Yeah, no, I definitely agree. And I, what I get out of it is, you know, the, the discussions, you know, with certain people, um, and, but then also somebody would throw a random paper out them like, oh, I missed that one. And then I'll go in this rabbit hole of oh, okay. Good. Is that, is that, you know, leads me into this world of thinking. So it's a, it's valuable to me, but yeah, on Instagram, just like at a golf swings and what rod Mansky smoked for a brisket that week in some way that.
Mike Reinold:He does smoke some good to me. I, you know, I've got a lot of good people that I follow that, that have great stuff, but, um, awesome. So, I mean, I think that's a good lead in, right. So you recently had, um, what I would say is a fairly large Twitter discussion, right? I mean, you know, th that. That was a pretty good response, right? Because you know, you got a lot of opinions, like doctors, physical therapists and stuff was great, but yet you had a big discussion about graft choices following an ACL reconstruction. And I thought it was super interesting to read all the responses like, and it was good to hear different. Stuff like that. And I thought that would be a good, uh, topic for today's podcast, because I think it's, it's a really big, important, uh, thing to discuss, like, you know, PTs, especially younger professionals. They need to know, you know, what's out there and they need to know the options and stuff like that. So, um, why don't we start with that and why don't we kind of go over there? So ACL reconstruction is one surgery, right. But for some reason, you know, the type of graph. There are a ton of options. Why don't you start with that? And kind of just, you know, you know, get everybody up to date. What are the current options for ACL reconstruction for a graph?
Lenny Macrina:Yeah, that tweet was spawned ironically, um, by a blog post that I wrote for you, um, a few years ago that I am still editing. Uh, you mentioned the edited and
Mike Reinold:right. Making a new one.
Lenny Macrina:I am. And I'm still actually working on it. And it's interesting. Cause I wanted to dive back in and just see, Hey, has anything changed? Um, you'd be surprised. The more things change, the more they stay the same. Right. I think that's an old term from somewhere. And, um, so I wanted to just dive in and see. So I just want to throw that out there because I love interacting with surgeons because I want to hear what they have to say. Cause they're doing it every day and were relying on their knowledge of the research and just their information when they make a decision. So we have a piece in that puzzle. We have a say in that decision, Oftentimes, especially at our practice where we have direct access, where we can see people right after an injury. So I want them to just see what was going on out there. And it just led to this huge discussion. So for me, I think the big four, right. Are going to be patella, tendon, quad, tendon, hamstring, tendon, and cadaver graft. Right? So you have the big four and then it's just a matter of fitting, potentially the right graft for the person and the surgeon. Now some would say, and I tend to agree. Is that the big three are going to be your patella Hampton. In your quad attendant autograph. So it's using your own tissue. The big three are probably going to be, do they make a difference? I say yes. Some saying no. Um, you know, it depends on the person depends on the situation. Depends on the rehab. And that's the problem with a lot of the studies is we try to control for the graph choice and we say, all right, they have a 1.8 times increased risk of a retailer. If they use a hamstring over patella 10 or whatever, the research is probably not even that high. But they never control for the rehab. And that's such a huge component of getting somebody back. And so the big three, I think, are all good options. It's just, what's the best option for the person sitting in front of me going to the surgeon who does specific. On a day-to-day basis. You want to, you ask a surgeon to do a quad tendon graft. He or she may not be able to be, not be used to doing that graph, but you you're trying to get them to do it. And it's just not their comfort zone. And so the big three come to mind, and then I make a decision based off of the person sitting in front of me, who the surgeon is. So that's a long-winded answer, but, and then after that, now it's just coming up with risk reward. Like, what do we got a 16 year old female who's loose jointed and is a cheerleader or, um, you know, it was playing soccer or something like that. Or is it a 25 year old male? Who's going back to, uh, you know, flag football with his buddies and wants to go skiing or are they just kind of relatively sedentary? And it was a freak accident and they're 35 years old. But you just need maybe a hamstring graft or even a cadaver graft. Believe it or not. You know, there are options out there. I'm not against any of them just picking the Right. one for that person.
Mike Reinold:Right. And that's probably, that's probably going to be a general consensus that we probably get from an episode like this is that there is no. Answer potentially, but you know, that doesn't mean there isn't a, a bigger, a better, so, so, you know, to break it down a little bit again, like, I think you started top level was, uh, you know, an autograft or an allograft, right? An autograph being your tissue and an allograph being a cadaver tissue. Right. Um, maybe, maybe like that to me is, is like a good first place to start.
Lenny Macrina:Yeah.
Mike Reinold:W w w what is it about the allographs that you don't like his allographs off the table? Is there a certain subset that maybe should get an allograph, you know, a cadaver tissue, or is that pretty much something that you don't recommend for anybody?
Lenny Macrina:Yeah, no, I mean, if they're older, if they just need a stable knee and they want to play some like doubles tennis or something like that, I'm not against. I had a lady a couple of years ago, got one with one of the surgeons that we use all the time and I should probably do fine. The risk is I've seen it enough. And I don't know what the literature says, obviously, honestly, because I, I don't know if it's truly studied, but I, I worry about that allograft being absorbed or basically. By your body. Um, your body recognizes it as a foreign substance, a foreign something different in your body. It's not your own seller makeup. It's on your own tissue. And literally your immune system will just chew away at it where you'll have, I've heard numerous, numerous people say that they had an episode where there was almost nothing. It was like they just misstepped in their knee, completely gave out. And so they did an MRI and there was no graph there You bought the body had completely. And so I can't that, those enough that it just, it makes me worry about an allograph. And again, I don't know what the percentage is. Is it 5% is 2% is a 10%. I don't know, but I just know, it's enough that I I'm always here. To recommend it. and if I'm going to recommend it, it's going to be somebody who's older, not doing as much activity, not going, not doing like high level skiing or even any skiing and somebody who just wants a stable knee. And then if it's not that, and then I automatically go back to autograft and then I started figuring out I do kind of almost an algorithmic thinking in my head of what's going to be the best for them.
Mike Reinold:You know, and that's a good, that's a good way of thinking of it too. So I like how, that's almost like a first step maybe to use the cadaver tissue or the allograft tissue, but I bet you there's actually, even times where, you know, like for example, an older individual that doesn't need a lot of, uh, you know, maybe sport activities with their lower body, uh, still though, like maybe you go hamstring graft or something. Right. I mean, there's, there's
Lenny Macrina:absolutely. Yeah,
Mike Reinold:there's others out there for sure. So.
Lenny Macrina:absolutely. The hamstring graft, the, you know, the 30 plus 30 to 45, something like that. I would probably recommend hamstring because when you start getting into the 50, 55, 60 year old, who wants a stable knee, it has some issues with functional stuff. Their knee is given away. They want to go skiing still. They're active. Um, you know, I'm getting close to that. When I do a cadaver, probably wouldn't, I'd probably. I'd probably go some kind of autograph just because I know of what could go wrong. And again, it's a risk reward thing for me. And. The, the, the old deal adage of you go cadaver. It's a faster rehab. Um, it's less pain. Um, it's just, it's just not true because it's not your own tissue. It takes longer for it to incorporate than an autograph And then your own tissue. And so you worry about, are there early and early retear or doing something dumb or the whole immune response to it where you, you get some, uh, eaten away in the graph. So it's little things like that. That just stick in my head. And I just, I just can't, I can't handle that.
Mike Reinold:And w what are the like, so just so we understand, so for an allograph, what do you, what are the most common types of allograft tissue? What are they using for.
Lenny Macrina:Patella tendon Achilles. Um, you know, those are going to be your, your two and from what I've seen, um, I don't doubt that they're using any hamstring or anything like that. I've seen probably patella, tendon and Achilles, or maybe Tim to be Alice. Um, I don't see a lot in my practice, I guess, because I'm seeing the 15 to 30 year old ACL. And every once in a while, every maybe few years, I'll see somebody who had a cadaver graft and, you know, it's, you rehab them and you tell them to go slowly. And, and we did with this person who I just saw recently a couple of years ago and so far so good. You know, she's playing tennis and playing a little recreational golf and, you know, she works out at a facility still. So it's, it's fun to get out from her.
Mike Reinold:That's great. Yeah, that's great. All right. So, so allograft tissue, probably our least favorite. Right. You know, I
Lenny Macrina:I would say so.
Mike Reinold:safe. That's safe to say. I mean, you always want to use your own tissue as best as possible. So now that we've maybe identified that, so autograft is our preferred one. Why don't you go through, you know, the big three that you mentioned, so patellar, tendon, quad, tendon, and hamstring graft, you know, w what, what are the differences between them and what are the pros and cons of.
Lenny Macrina:Yeah. Uh, for me, if I have a younger athlete, I automatically in my head start off patella tendon graft. That is the gold standard, so to speak. And that was my tweet, you know, recently not to date the episode. Um, but that was my, that was my that's the gold standard in, in Dr. Duke duke is sent a Birmingham friend and colleague who. He completely agreed and said, it's the gold standard, because that's what we put in high level athletes. And nothing has really changed with that. Nobody's been able to prove it otherwise. And that's why we still consider it the gold standard. Patella tendon graft you, when you dissect out the middle, third of the patella tendon, the patella tendon is roughly 30 millimeters wide or three centimeters wide. They take out the middle 10 millimeters onto a one centimeter, but when they take up the middle third, they take out a piece of bone from the patella and they take a piece of bone from the tibia. And so that bone patella tendon bone gets inserted into the joint as your. And you could bone from the two ends hailing into bone from the femur and the tibia. So you have good bony healing. And we think, you know, bone heals in about six to eight weeks. So you have good graft fixation. You're not going to get graft elongation most likely. And you have the blood coming from the bone. That's growing into the femur and the tibia that can infiltrate the graft and give you that ligament ligaments, ligaments process, easier to say, um, probably a little more readily and it probably matures a little faster, we think, than a hamstring or even a quad tendon who doesn't have that bone boney bone interface. So that's why I tell it, but I like to tell the tender. It's a nice, strong graft. Um, it's been tried and tested. It's survived that years of testing. Um, and then you have the hamstring and quantity graphs that are just soft tissue grafts. So they have to be sewn into basically the femur and the tibia, and then you wait for that fixation to hopefully heal. Um, and it will, it does heal. Um, and then the ligament ligamentization process takes longer. The healing, the maturity takes longer than a patella tendon graft, and that's always my skepticism. That could be a reason why they stretch out a little bit more. Um, and hamstring graft, quad tendons are more of. a robust graph, a bigger graph. Um, and so you have a positive and negative VH1 is just, what's the best for your athletes sitting in front of you. And again, I stopped patella tendon and I tried to figure out why not patella time to, you know,
Mike Reinold:As, as a good approach. And, uh, for the quad tendon does one side have a bony piece.
Lenny Macrina:Uh, sometimes I think they've gotten away from that because you can't take it from the patella. Um, and one side would be from the patella. The other side obviously would attach to like starting going into muscle. Um, and so they take, I don't think the surgeons are doing, um, one one-sided, you know, bony fixation. I just think it's a soft tissue graft at this point. It's a big old graph. Massive wad of tissue that they're putting in the knee. So it's got it's strong. Um, it does. Well, it seems like it used to be done years ago. This was probably when I was a new PT and it didn't do well. And so we got away from quad tendon, but, um, they've gotten better, I guess, better fixation techniques and better ways to manipulate the tissue, to get it, to withstand the forces that are needed. And there's very little, very little. It's a tiny incision. You can kneel on the knee versus patella tendon. A lot of people. That's the number one thing with the patella tendon graft is kneeling on the knees. Somebody has to work on their knees. Uh, somebody who's in that position a lot, um, you know, carpentry, plumber, or evenly like a catcher or some, I don't even know, maybe, maybe a patella tendon, maybe. I don't know. Maybe it's not for them, but, um, that's the number one issue is the anterior pain that the kneeling pain, but otherwise. The telling quads seem to be, you know, in hamstring, uh, going to be your big three. I tend again, patella and quad in my kind of one and two right. now in hamstring is we'll probably talk a little bit more about hamstring button. I don't know, hamster hamstring. I'm still, um, I'm still with our younger athletes. I still can't get over the humps a bit, despite my many discussions with, Lynn's not a Mackler who I love when from Delaware, we talk about it all the time And, there is a benefit of each and there's a risk of each. It's just a matter of weighing.
Mike Reinold:right. And, and what, what the hamstring graft, you said like the quad tendons robots, the hamstring graph is actually pretty thick, right? They take a really big piece of the Hampton.
Lenny Macrina:Yeah. I mean, they take your, oftentimes your semi T semitendinosus and your Chrysalis, and they can make a four strand grabbed out of it. Sometimes they're not sufficient enough and they have to use a cadaver to make a hybrid graph. And so when you start having to mess with stuff like that, we don't know that. And that's another negative of using the hamstrings is you don't know until you get into the surgery, that the hamstring is not robust enough. And so now they have to think about analogous. Combined with the hamstring graft or they have to punt and use something else and you have to, you know, we have to verify all this private surgery that we may have to make a change in surgery and drop. Um, and so I'm just not prepared for. And so I just, plus if they take your semi T Andrew those are two very prominent dynamic stabilizes of the knee. Some people will say that the tendon does grow back. So if you take the tendons out of those muscles, that red muscle is now just floating in the back of your knee without an attachment to them. For maybe a year or two. I think Lynn Snyder has talked about one of her previous researchers. Um, did some studies on this and show, it has shown that the tendon will grow back and they think it'll grow back similar to what it was prior to the surgery. But at a year or two, it's still not the same, which means you're not getting hamstring. Activation the same. And we know the hamstrings are a huge dynamic stabilizer, anterior tibial translation, which is a huge thing we're trying to prevent after an ACL. You know? So again, you're, you're, you're trying to piece stuff together where the patella tendon, you don't have to deal with that stuff. The big thing is the anterior knee pain. If you rehab it correctly, you don't have to necessarily deal with any of the other secondary stuff that goes along with it. And that's why I tend to go fidelity autograph.
Mike Reinold:well, Uh, but, you know, I think it's a good point, right? Because we have a problem with quadriceps strength after ACL reconstruction. That's, well-documented a big issue that we have when you take the hamstrings. Now you potentially have a problem with, with the quadriceps and the hamstrings with, with, with getting their strength back over time. So I can see that being an interesting, you know, negative. I often wonder too sometimes if sometimes is a bigger, is a bigger graft, a good thing or a bad thing. Is there a such thing as being too thick of a graft where it consumes too much space, maybe restricts a joint, has that been discussed?
Lenny Macrina:Yeah, that was discussed? during that Twitter stolen. Um, and we talked about that a little because the quad tendon is so robust that if the surgeon doesn't account for that tissue, um, and most surgeons are good. Like I give them credit. They, they are on their stuff, but some I've seen. With, if they don't do a notch plasty or create space for that graph to then to get pinching of the graph within the intercostal or not. So you have your two con dials in between. There's a space where the VCL attaches. If they don't account for that robust tendon or robust ligament, that's going to be living in there. Um, then it's gonna be. On the, on the, on the non, the notch and you can lose motion. So I've, I've seen it up here where the person is just can't get extension. Their knee keeps, um, getting stuck at zero or other, uh, are, um, uh, you know, lacking extension range of motion. And it turns out that the graft was impinging on the knots because it was a notch plasty done where they actually shaved down bone to create extra space in the joint. So that's something you need to consider as well. Is, do they have enough? If they had a quad tendon, if they didn't, that could be explaining why you're struggling with your range of motion.
Mike Reinold:And that that's definitely a preconceived notion that I have that one of the potential issues with a quad tendon is, uh, sometimes some limitations in restoring your knee extension. So, um, is that, is that real? Is that a, is that false? Is that a false, a false preconception on my part? Or is that.
Lenny Macrina:No I've seen it. I've seen a recently, I've had a kid where I had inherited kind of inherited his case and struggling to get as much. And back I'm like, this is weird. And you start thinking as a Cyclops lesion, if you're not familiar, the Cyclops lesion, it's just a lot of scarring in the front of the knee, um, from the remnants of the old ACL and it turned out there wasn't an arthroplasty done and they had to go back in and create a. have shaved down bone, his knee, and that completely freed up his joint. We were able to, now we were dealing with months and months of not getting the knee extended, but once we did the notch class, it gave us the ability to actually get the need to be able to straighten out. And his motion came back. His function came back and it was smooth sailing after that he was back to playing lacrosse. So yeah, I've seen it even recently. So it does still happen. And you have to, as a PT or an athletic trainer, you need to be aware of that. And maybe get the op note and see if it was done. And That's when you stopped communicating, you want a question? The surgeon would just say, I'm still struggling. You know, it's a good quad tendon graphic seen these before, you know, what do we think? Do we think that the graph is impinged? Remember the graph is going to expand to, we can get some gorgeous blood as it's becoming a ligament. And so it, the whatever was in there for a diameter is now probably a little bit wider, taking a more space, the joint, um, as it's maturing. So you got to account for that too. And then it kind of goes back down to normal.
Mike Reinold:I always assume that just maybe it was a little easier to scar from the incision in, in determine the graph site, just anteriorly, maybe somehow that gets stuck. But, but, you know, uh, you know, considering it's, it's probably that plus some of the notch plot plasty or, or even just the size that that is an interesting thing or at least something, if you do have a quad tenant in front of you, that you should keep an eye out for, uh,
Lenny Macrina:think it's definitely always in my head when I'm, when I always get an op report, you try to get an op report with your athletes. And so you fully understand what went on the surgeon cause you'd be surprised like, oh, they had, he had a grade three or grade four cartilage issue or big old bone bruise on the lateral tibial plateau and lateral conduct. Well, that changed my rehab. I don't want somebody to be going maybe as fast and creating a new wonder why their swelling persists three, four months out of surgery. They probably had a bone bruise and you're trying to have them jog past that. So getting a little piece of information from an opera, it's gonna be huge. So, and again, you'll find out if they did an arthroplasty, uh,
Mike Reinold:Yeah, I like that. So,
Lenny Macrina:Now I know in Birmingham, I, in Birmingham, they all did not posses all of them. And So, I put that question out in social media and it would seem like surgeons aren't big into that anymore. Um, but it seems like some are still doing a bunch of them and some are completely not unless needed. So again, I know we're talking about a lot, but not the class is a new word for a lot of people. So look it up and try to figure out, you know, how it applies to your practice and the people that you're seeing from your surgeons.
Mike Reinold:Yeah, that makes sense. That's a good tip. And um, one thing we, we kind of, uh, we glanced over quickly here, but I wanted to talk about a little bit more. Here is a lot of people. If you say. Um, you know, what's the difference in strength between these three different graph types? A lot of people are going to come and hit you with the concept. Well, a hamstring graft is stronger, you know, probably cause it's thicker. Right. And it's just, you know, physics from that's when we've been a lot to say it's stronger, but you know, Uh, every time somebody says that I always go back and think, well, it's not just the strength of the graph. It's also the fixation strength of the graft within the bony tunnels. Right? So, so you glance on that a little bit, which I thought was neat. The patellar tendon has bony plugs on both ends that get to sit within the, the, the tunnels and actually heal bone to bone and allow some vascularity to come from that bone growth. I think that's something. People shouldn't underestimate. Right. You know, compared to a soft tissue, just, just kinda digging in there. So, um, and so what's the difference between graph strength and fixation strength? Do we know any of the science behind that?
Lenny Macrina:Yeah, I would say from a PT standpoint, um, it's, to me, it seems like bony hailing, um, allows me to do things a little faster. When you know, the bone is healed. That's six to eight weeks ago, your bone healing and bone, you get vascular vascularization happening. I think that that's a positive thing for the graph. And so, Uh, with the hamstring again, then might be a slight change in the amount of laxity, or maybe even a pivot shift long-term in some of the literature. Um, and is that something that is caused by the graphics? I don't know if we've studied that. If we know that a hundred percent, I know that's a big difference in the two now to go back to your point about graft, uh, strengths, they're all stronger than our native ACL, right? If you look at, if you look at the they're all, so no matter what our ETL pull us Terri amount of force needed to tear it up, tell it in the hamstring. If you at the amount of strength or force, it needs to tear them or all exceeds what our native ACL is. So whatever you're putting in is better, right. Then, um, our ECL at time, zero, and then they slowly become ligament and gets closer to what our native ACL is, but they all stronger hamstring. It is stronger. It's a stronger tissue type of tear type, but the retail rate, ironically, Is higher statistically in numerous studies, um, with, uh, hamstrings than a patella tendon. And so why, what, what, what are we missing? Is it that we're taking the dynamic stabilizer? Oh, is it that, um, the fixate. Is the point of weakness, um, with the hamstring again, I don't know if we can, if that's studyable, um, there's so many variables that go with that. Again, the rehab is so critical to these people, but I know it seems like a significant difference in the patella tenant has been, has been tested and tested and it's still used on our high-level athletes. And it seems, that's why I always go back to it for my, again, teenage mature teenager with a growth plates are closed 16. 20 to 25 years old. So yeah, fixation, uh, in retail rates, it's just, I can't get through that. I can't get past that with my athletes.
Mike Reinold:And I hate to say it too, because this is just an N of one with one clinician being me. But, um, when I'm doing like a lock man, I'm doing, you know, even a pivot, you have down the road and you've kind of, you know, checking on somebody over the course of their ACL reconstruction. I don't want to say it happens a lot, but if I think back into the history of, of people that I felt were lax after an ACL reconstruction, it was almost always a hamstring. And then almost, always even more so an allograft that I felt 6, 7, 8, 9 months down the road, you do a lock and you're like, whoa, that's pretty loose right there.
Lenny Macrina:Yeah.
Mike Reinold:The patellar tendon to me seems to restore the normal kind of translation that we see in a Lockman compared to the others. Is that misinformation I'll be the first to admit. I just, you know, but eh, or, or is that just a small sample size in my hands?
Lenny Macrina:I think it depends on, it depends on the person. It depends on the surgeon. Um, you know, you could do KT testing of these people, which is using, you know, a little bit more objective information to get the amount of translation going on in millimeters. Um, I think statistically it's probably all very close. I think you're going to get a little bit more laxity in, in studies that show in the hamstring graph than a telephony graph. So statistically overall, Yeah, probably in the people that we see, we may be able to feel that I think you can feel that. And I probably had five has definitely felt it too when the hamstrings, um, but they're all solid graphs. They're all solid. Um, you know, fixation relative fixation, and they're all a good just, I just worry again, that the hamstring and the allograft and that they're in the same world. They're just not my top two Right? now, again, going back to consult any question, just because of the retail rates. And I see a lot of female athletes and I just don't want to take out a robust and nice tendon from that, from that person and, and risk and risk for them. So, yeah, I mean, I think they do get a little, a little stretchy, especially cause we've seen a lot of females and females tend to have a little bit more mobility and maybe it plays into what we're feeling with a lot of.
Mike Reinold:That's a good point. That's a good point too, with w between the gender. So, um, I, I, I think, I think I have a good understanding of the cons of the soft tissue grafts, the allografts that, that we've kind of talked about. Um, I don't know if we hit this enough, but what are the cons and why aren't we just doing patellar, tendon, grass, bone, bone, patellar, tendon, bone graphs, with, with autographs, with everybody. What are the cons.
Lenny Macrina:Yeah. I mean, it's a big surgery, so it's, it's dissecting the tissue whenever you get bone involved, that's painful. Um, and so, you know, and then you have this part on the front of your knee. So kneeling pain is your number one issue. You've got some loss of sensation, um, along the knee as well. And when they take out the tendon just by cutting through the skin. So people sometimes can't handle that. Um, it's, you know, you got. Bone pain. You have 10 and coming out of the anterior knee pain swelling, the quads tend to struggle to come back. Cause you have a muscular inhibition from pain and swelling. So it's tough to get quads back in. They, they took out the middle, third of your patella tendon. And so I can see in the older athlete, um, Maybe going a hamstring. But again, I I've seen enough in my practice that hamstring for me, maybe it's me. Maybe, maybe it's the way I treat them. They struggle sometimes to get their motion back and like they're fluxing and they got posterior knee pain from where they take the. Um, and they, uh, they struggled sometimes and in my hands with extension and I am a stickler to try to get an extension back for some reason, that's because they take the hamstring I'll posteriorly. They don't want to get their knee into full extension because of, because of where they took the graft, I think. And so I struggled with that. So, Patella tendon again, is it's going to be more than anterior knee pain and quad caught inhibition. But for an athlete I'll, I'll, I'll get them through that. I'll talk him through it and I'll walk them through it. And, you know, we can ice and use tens. And there was a nice, uh, sports section, uh, SIG, uh, I think it was a strength conditioning SIG that talked about, um, You know, a muscular inhibition, uh, after an ACL. And he ironically talked about using tens using ice and get this ready? Sorry. Social media, world pulse
Mike Reinold:What that is, that is, that is such as a damaging to the profession
Lenny Macrina:So, so if we use those three prior to doing our strength training, so meaning early stem, early BFR, right. Leg raises all that early stuff. If you do that stuff and try to get some of the swelling out, then that muscular inhibition that is, that goes along with the ACL is decreased in your ability to get. Enhances. So I thought it was very interesting and he kind of glanced over and I kind of pointed it out and during the talk during the zoom meeting, but I thought it was interesting that there are, there is a study it's positive, but we don't want to talk about positive ultrasound studies, intense that shows that you can get the quadric. So it's something that maybe that's a checkbox for a potential tenant is not as bad or, or quad 10 is not as bad because you have some tools to use to get that quality.
Mike Reinold:Uh, my impression of a patellar tendon rehab, I feel like we, and you kind of said it, well, you call yourself a stickler. Actually, you called yourself a stick law just with w w with the Boston accent, a stick law, but. That is a stickler to get his knee extension back. If I had to like defined patellar tendon rehab in my mind, eh, we have to be much more on top of the person. Initially, maybe the first two to four weeks. There's a little bit more of, you know, effort and attention to making sure that they're clicking in the steps versus a let's just wait and let the knees settle down for a little bit. There's a little bit more attention. But again, achievable, right? That we can get older. Some of those cons if we're paying attention to it and you, and you know it, and, and, and that might even be one of the most important aspects of what we get out of this podcast episode, as an example, is just to understand that there's going to be some differences between our approaches based on the different grass, right.
Lenny Macrina:Yeah, definitely. And I think you can really make or break a rehab process those first two to four weeks. That's why I think it's so critical. You got to get buy in the patient has to be comfortable with you and your knowledge and how you're communicating it to them. And they need to see the fruits of their labor. They're in pain. They're hurting at home. So you give them stuff to do. Um, and they start to see that their knee is calming down. The swelling is going away. They're not as much pain. They're Okay. with getting the knee straight or even a little hyperextension. And they are like, wow, this is, this is actually working their Fluxions coming back. I got a kid right now, hockey player from Middlebury college. He, you know, I'm going to see him in a little while after I, stopped recording this podcast. And I'm hoping. Doing well over the weekend cause he was cruising and you know, he's got a CPM at home, which I know is controversial, but I think that's helped him a ton with pain. He doesn't have to use narcotics as much anymore, if any. Um, and his motions coming back really easily, including his extension is feeling good about it. His swelling is going down his swatches coming. He's not scarring in and getting, getting frustrated and getting him getting anxious about his knee. And I think this whole process is a little easier the first two to four weeks because we're building a positive environment for him. You know, to prosper and get his knee to feel good and get him feeling good about the rehab process. It's huge. Absolutely huge.
Mike Reinold:I, I think those are all important concepts that, you know, to keep in mind. I think that's important. So, um, one thing we haven't talked about yet kind of curious about this. W w what about contralateral graphs? Right. So we've just assumed we were talking ipsilateral meaning you're taking the graph out of the same knee. What if you, you tear your ACL on the right and you want to take a contralateral graph from the other side to help with that knee. What w w why do people do that? What are some of the pros and con.
Lenny Macrina:Yeah, no, I think it's a great option in Dr. Shelbourne down in Indianapolis has been doing it for years. And I interacted with his therapist online on social media, and I think they got a good thing going on down there. And you know, for me, you know, if somebody tears their ACL and they had a patella tendon, Uh, initially I wouldn't be against recommended recommending a contralateral patella tendon graft prior to some of the other graft options. I think it's still, um, it's, it's not a bad rehab. Believe it or not. When you, when you tear the receipt, when you have to take the graft from the other side, that area heals pretty quickly. They do really well. Really. You'd be surprised you think, oh, you get to rehab two knees now, and it's a pain for them and a person's hurting. It's not that bad. Um, And they do really, they do really well. Um, and again, so if you're interested in some of that stuff, Dr. Shelbourne, uh, down in Indianapolis is kind of the guy for that. And so I would probably, I would throw that option out there for the person as a let's do a Cabos. Talk about a contralateral before we talk about a hamstring. I don't know if the one who use a quad tended to have to take a patella tendon, but if they want to use a hamstring tendon fury, Maybe we start talking about a contract, a patella tendon first, if they're young athletic and trying to get back to us, particularly a particular sport or something like that, you know?
Mike Reinold:Our contract law graphs, just for revisions or somebody doing that as the primary
Lenny Macrina:No they're doing it as a primary surgery. And so I don't, I don't know if I've seen it up here. Um, very much probably if a Shelbourne fellow ended up in Boston, we'd probably see it from. But, um, I think he's kind of the man doing That And so is his, we'll say disciples. Okay. So to speak, um, is, um, how they're bringing it to their practice. But I would, I would definitely consider that an option for a revision, maybe even for a primary, but again, I don't think I've surgeon was doing so I've just go patella tendon on the ipsilateral side or on the same side. I also want to talk about the BIA procedure to them. Just not to, as if we're talking about other graph choices, it's not really a graph it's using, um, stem cells implanted into the. ACL your native ECL and that's used as well. So that's another option as well. That's being done. The research is being done here at children's hospital in Boston. So I think that's another kind of out of the box thinking that's an entre for people it's still being researched and it's, um, I don't think it's FDA approved yet. I don't think, um, but it seems promising Martha Murray is doing research out of children's hospital. Um, we've had one person go rehab that I've seen and she's doing well. Um, again, it's still experimental. So, um, Waiting to see how that does, but it's interesting concept to be able to basically. I have the two ends of the ACL, basically fused back together via stem cell, a bridge, so to speak they're enhanced. Um, um, for our rehab about Baron has reconstruction, um, putting stem cells within the two ends of the ACL graft, and then it will basically fuse back together and grow. So it's an interesting concept to not have to take a graft out as well. But again,
Mike Reinold:That would be
Lenny Macrina:wait on that
Mike Reinold:I mean,
Lenny Macrina:crazy, right.
Mike Reinold:Yeah. I mean, and, and I mean, the benefits of that are enormous, right? Like, cause most of what we talked about with these pros and cons are from the graft, right. It's not, you know, it's it's so, you know, I mean, if you can make some advancements in that field, I think that's, that's enormous. Uh, w w what are the current indications for the bear procedure right now?
Lenny Macrina:I think it has to be that it's mid substance tear. Um, and so they be, they need to be able to basically get the two ends and basically get them to go back together. Um, and so I think that's the big thing. Um, but I, I think it seems very promising. Um, again, I don't see a lot of them, even though the surgeon's like five minutes from us, I don't know where they're rehabbing and they haven't stumbled into our facility unless they have a protocol that they have to stay in children's. But I doubt that. Um, and so I would love if more came to us, if Martha wants to reach out and we could work with her somehow, but Dr. Marie, um, that would be great to be able to, you know, interact with them and, and, and, and kind of dive into that data. I think also another doc, uh, down in, uh, HSS. He's doing ACL repairs. So again, a lot of people misuse the term repair, and they're talking about reconstruction, he's actually doing, um, repairs of, of the, of a proximal tearing. And so, um, if you, if you look at some of his research, some doctors will say he's crazy. Um, but I have seen one, I haven't seen equals one and he is doing really good work and it's their quads come back real easy. It's Dr. De de Felice, um, down in HSS. And so there is some research on that. Showing, if you have a proximal tear of the graft or of your primary, your native ACL, he can go in and basically sew it back down to the femur. And the corporate section comes back, the quads come back and it's an amazing rehab process that I've seen again, any equals one for me, but he's a big proponent of it. And it seems promising as well, but has to be a very specific tiering of the, of the, of your native ACL, kind of like the BIA procedure.
Mike Reinold:That's super interesting. I liked that and I liked it. I like these new approaches that we're seeing, uh, is anybody trying, you know, the trend that we're seeing, like in the ankle, the elbow is doing a repair with an internal brace. Is that something that's being, uh, you know, kind of, kind of thought about anywhere is actually using like an augmented, uh, you know, you know, biological tissue tech to kind of mesh it almost and, and repair it with some, uh, some extra strength to it. Is that a thing that's happened?
Lenny Macrina:Yeah, that's what he's doing. So he, he reinforces that repair. So again, truly a repair. Um, and he'll put the internal brace in there. Yeah. They are doing really well. Surprisingly, I've talked to him, we had a, uh, uh, a phone call on the drive home from work one night, and he's very passionate about it. He's presenting data on it and he's published papers on it. And it's something that I keep in mind, uh, believe it or not. And I can talk offline when we get off the podcast. One of our friends, you and I has had this procedure done down in Birmingham with Dr. Dugas. And so I'm curious how he's doing, but, um,
Mike Reinold:I think we can get the real scoop. I like what you're saying.
Lenny Macrina:yeah, exactly. But no, it's an interesting proposal and it's interesting concept again, we're using internal brief for everything, Right. Ankles for elbow, Tommy Johns, And, he's using it for ACL's and it seems like so far. Um, it's for the appropriate person, it's an option.
Mike Reinold:And, you know, the ones we're seeing at the elbow, the ain't got, I mean, they're doing great. So, you know, w w we don't necessarily, you know, have haven't had anything crazy. So, so it's funny, maybe in the future, I don't know how many years or 35 8. I don't know how many years it is. I wonder if this conversation is even completely moot because we've moved on to things we're talking about stem cells, we're talking about internal bracing of repairs. I mean, you know, the future is really interesting that we can kind of keep our eye on for these ACL graft options. So,
Lenny Macrina:I hope So, although we've been, how long has an ECL, Dr. Clancy was doing them in the seventies, right? No Clancy friend of us. um, and so we're what, 50 years later, which is scary that that's even talked about. And we're still talking about patella, tendons and hamstrings and all that. So as much as I know, the future is going to be exciting, we still tend to hold onto what's tried and true. Right.
Mike Reinold:Yeah, for sure. All right. I'm going to, I'm going to put you on the spot. So you're, you know, you're, I don't, I don't want to call you elderly. And so when, when do you go from, from, uh, midlife to late life? Are you late life yet? When do you
Lenny Macrina:I think I'm, I mean, I'm gonna probably Ford I'll be 48. So if I'm mid 96 years old, I don't know about that.
Mike Reinold:Um, I love it. So, all right, so you, you learn, you tear your ACL tomorrow. What are you going to
Lenny Macrina:Yeah. Um,
Mike Reinold:on the
Lenny Macrina:Tim ACL. I know. I probably, um, I would probably consider either, um, I probably go either a hamstring or quad. Just to experience it, um, because I still want to be I, I have to, I have to weigh the risks and rewards for me. I don't do skiing, so I'm not a big cutting kind of athlete. So I'm not doing, um, soccer. I'm not doing volleyball, I'm not doing basketball. I basically golf or mess around at work. So can I get away with the hamstring? Maybe I'm 48 and I just wanna get back to walking and. That's kinda my, my thing. Um, and you know, maybe some lightweight training, I've been doing 16 kilogram goblet squats for five years now. Um, and so I don't need to be doing, you know, CrossFit type stuff or anything like that. So, um, I don't know. I would consider hamstring or quad tendon as something viable for, for me, definitely. Um, it's all attended. I probably reserve it for younger Lenny.
Mike Reinold:I, I feel like I was the same thing I remember. I remember at 10 years ago, if you asked me this question, I would say, oh, definitely patellar tendon. And I definitely feel like as I'm, as I'm getting older, I definitely start to, you know, think, you know, maybe I should go hamstring that type of thing. So, um, all right. What about your daughter? Your daughter's in high school. She's a competitive dancer, right? Yeah. She chose resale. What do you recommend her do?
Lenny Macrina:Um, I would probably get if she's good mature growth plates, she's 16 years old. I'd go Patel. I would recommend a Patel attendant. I wouldn't do a hamstring tendon on her. I just, I just couldn't do it. I can't recommend it by patient. I can't recommend it for family members. I just, I want those dynamic stabilizes. I want the strong fixation. I want the research backed patella tendon compared to a hamstring. Again. Hamstring is an awesome option. It's a great. But for a female, um, who is potentially, you know, getting back to a cutting sport, knowing the risks and rewards and tighten the ability of the hamstrings to regenerate. Yeah, probably they do. Yes, they do. But is it a strong, I just, I want that strong patella, tendon graft, fixation, and, and, and, and trust the rehab. I would, I don't know if I would rehab her, but, um, somebody would, and I would have to trust that rehab, you know,
Mike Reinold:Well, you know, I always go back to, I remember doing this, this is a little bit ago, but, um, you know, I helped rehab Dr. Andrews, his daughter after she tore her ACL. Right. So, you know, you have, you have Dr. Andrews in Alabama, you know, one of the, you know, most, most well-known, you know, and she did a patellar tendon graft. Right. So, you know, for me, again, like that means a lot to me that Dr. Andrews would do that on his own daughter. Right. Pretty daunting, right. To do surgery on your own daughter, but, uh, you know, pretty, pretty interesting, so, awesome. All right. Great stuff. Lynn, I think we learned a ton about ACL grass. Uh, let's get to the high five. This is where we learned a little bit more about you, right? Five quick questions, five quick answers to learn about the deeper inner working of Lenny's brain. You ready? All right. Question number one. What do you, what are you currently doing and what are you reading? What are you working on for your own development? Your own con ed.
Lenny Macrina:Uh, my own development and content, I am working on kind of systemizing our return to sport testing. Uh, we just got the bald force plate and force a frame. Uh, so I am really trying to figure out how we can really get a good system going for, um, creating programs for our athletes to be able to return to their sport return to their full participation. So what are we testing at 12, 16, 18 weeks, whatever it is all the way up to nine plus months. And really trying to understand how the floods plates work I've been working with our strength coaches and really trying to come up with a good, system to put in place to be able to test people. So that's kinda, my deep dive has been returned to sport testing with the equipment that we have, because it's all over the place. Right? Hop testing, it's all over the place what's out there. And I'm just trying to out what we can do. That's best for us and best.
Mike Reinold:Yeah. So, you know, sometimes you, you know, you, you see social media clips of like sound bites from like, from, from podcasts. I think, I think that's going to be the soundbite hot Tez, blah, blah, blah.
Lenny Macrina:Yeah,
Mike Reinold:I guess that tells you what Lenny thinks of hop tests. I like that, but, uh, that's awesome. All right, so maybe this is the next question here, but the next question is what's one thing that you've recently changed or evolved your thoughts on.
Lenny Macrina:Uh, everything I do in PTA, I feel like, um, no, I, I think, um, probably blood flow restriction is definitely something that I've used more, um, for lower body stuff. Uh, probably open chain, the extension type stuff used to be a little more conservative. And then kind of diving into the literature and just kind of, you know, just social media chats. He was like, why, why we probably being so restricted with that? The big key is getting the quads back. So I want to do everything I can to get those quads back. So I've gotten from the being conservative with that. And I'm trying to be, I don't want to, if it's not aggressive, I guess it's progressive, but just staying on top of literature and understanding literature a little bit better. So a lot of it focuses on ECL. I treat a lot of STLs and I treat a lot of Tommy. John is my two worlds, so, um, that's kinda my. Got to focus on is the people that I see. So I think it's just being a little bit more in tune with what the research is telling us on. open James stuff.
Mike Reinold:Awesome. What is the number one best piece of advice that you give students and even young professionals, but yeah, I know you work with a lot of people. What's the, what's your number one piece of advice for them?
Lenny Macrina:I say, get your hands dirty. Um, you know, both you and I, we started off in Burmese. And we were treating a ton of people a day and every day. And it's just it's so it's so important to get that. Database of people that you see people that experiences and how they progressed. And so just dive in and hopefully you have some help from somebody. And we did, we had Kevin and on all the other PTs were so gracious to help us. And, um, but it's just getting that mental database with people. Cause you'd be surprised how the bad cases stick in your head. Right? You never remember the good ones. I always remember the bad ones and those, those little tidbits will stay in your head for the future patients that you see. And it's so important to be able to tap into that every once in a while. When you have a funky case, prep presenting in front of you or a new case where you just you're ready for it, because you know, you've been battle-tested right with it. You don't get nervous when you have an ACL with a, I don't know, an ACI or some kind of coddled procedure you're ready. Cause you treat an ACI, you're treating ACL. And so now you can put it together and get that to feel confident, getting that person rehab. So I think it's just seeing as many people as possible and creating and creating a yes relationship. You know, and again, going to meetings and talking to doctors and other PTs, because having that ability to talk to them and maybe bounce ideas off them is critical. And maybe it'll open doors for you as well.
Mike Reinold:Awesome. What's coming up.
Lenny Macrina:pieces,
Mike Reinold:Yeah, that was too, I didn't want to penalize you for that as the high six, you know, we don't have six fingers, but, uh, but, uh, but, uh, what's coming up next for you line.
Lenny Macrina:Next for me. Um, I am, let's see you because of the pandemic and everything. I've kind of taken some time off from traveling and speaking. So I've had a bunch of people reach out to me to try to go. And I think everybody's dying to have an in-person course. So I'm trying to figure out if I want to dive back into that world and update all my talks. Um, that'll probably be happening, uh, you know, this year or 2023. Um, and I'd also love to, for you and I to get an overhead athlete course out. I think that's huge. We have our Nico SRA, the online, uh, Nikos, and I think there's so much information out there on, on baseball players and overhead. That I think sharing our knowledge, I think would be huge for them because I think we're always getting questions from people and we're always seeing some stuff out there that we don't always agree with. And I just think having something that's we've, we've utilized, we do it all the time. Again, I treat ACL's and Tommy John's. I feel like that's my, my two worlds right now. And your connections with your baseball world. I think that would be huge is to, uh, is to get that out to the people as well.
Mike Reinold:Maybe a little sneak peek their land. I love it. So, so how do we learn more about you? Where can we find you online or, you know, website social media, where do we learn more?
Lenny Macrina:I am a always, I'm always hovering around Twitter at Len Mac PT, Eliana KCPT I'm on Instagram, same handle. Um, I have a Facebook page and I also have my website, Lenny dot com and a YouTube channel. So I am everywhere. And always, despite my wife, giving me dirty looks because I'm on my phone. Um, I am always hovering in. I'm always going to have a comment for You
Mike Reinold:You are on Twitter a lot. I liked that. I D I, I definitely I'll go dark on social media and I just, I stay, I look over at you and you're, you're on your phone and I'm like, he's, he's tweeting at somebody. I just, I don't know how you do it, but that's
Lenny Macrina:I think it's a great, it's a great way to communicate. It is a little controversial, but it's fun. It's fun to interact with people and hear all the sides of the story. Keep my mind open. Definitely.
Mike Reinold:I agree. I agree. Well, awesome. Well, thanks so much for taking some time to join us today, to talk about ACL graphs. That was great. Thank you again.
Lenny Macrina:Yeah, thanks. I'll see you at work at sometime.
Mike Reinold:Sounds good.