Multiligament Knee Injuries with Jill Monson - Episode 43

Multiligament knee injuries are complex injuries that must be addressed with a comprehensive diagnostic workup, surgical procedure, and postoperative treatment plan.

In this episode, I talk with Jill Monson about her experience with this complex cases.

Full show notes: https://mikereinold.com/multiligament-knee-injuries-with-jill-monson

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Transcript

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On this episode of the sports physical therapy podcast. I am joined by Jill Munson. Jill's the lead physical therapist for the complex knee injury clinic and the practice of Dr. Robert At twin cities, orthopedics in Minnesota, she's done a bunch of great research, but also shares her knowledge on these complicated cases all the time at national meetings and publications. In this episode we're going to dive deep into some of the thoughts she has behind these multi-ligament as knee injuries This was a really great episode and almost like a masterclass from Jill herself. You're going to really enjoy it. Welcome to the Sports Physical Therapy Podcast. I'm your host, Mike Reinald from Mike Reinald. com. Hey, Jill, how's it going? Welcome to the podcast today. It's going great. Thanks so much for having me, Mike. Yeah, I've been excited about this for a little bit. Um, obviously, you're somebody that I've looked up to in this field, uh, for physical therapy just in general, but obviously for the topic today, it's something that you've published a lot on. It's something that I've heard you speak about, um, and it's a really exciting topic for me because unless you see a lot of people a specific injury. It's, you know, it's, it's usually a daunting thing when you, when you get a new case on your schedule that may be complex. So, um, I'm really, really excited to, uh, to talk to you about this stuff today. Well, and right back at you, because I remember early in my practice when I would get Tricky things, or I had a cartilage case and nobody had great information on cartilage. I remember something that you and Kevin Wilk wrote on following cartilage transplantation procedures. And that was, you know, essentially my manuscript, my Bible for how I was going to go about it because there wasn't content available that was clinically practical. It may have been really, um, scientific, but as a clinician, you need examples of what to do. So thank you because your type of work that you did in your career was kind of foundational for the type of work that we strive to do with our group. Yeah. And you're, and you're doing it right. Like, so you're, for example, like your multi ligament is knee injury paper. I mean, that is, that's the same style paper that we always write about the things that we're, you know, that we see a lot. So, um, yeah, you guys, you guys are kicking some butt with that, but, um. I want to start with this, right? I mean, you have this, uh, I don't know if unique's quite the word, but it's a very strict niche, uh, of expertise around these complex injuries, right? Multiligamentous, things like capsular meniscal involvement, I think that's a little bit more common, but we're talking about the multiligaments, the nerve involvements. These are some of the most. daunting things that nobody really wants to see on their schedule. Unfortunately, um, why don't we start with this? How do you get so much experience in this area? Because, uh, you know, to me, that's the tricky part, right? Somebody might see a complex knee injury once every, you know, 234 years, right? So how do you get so much experience here? That's, that's very true. It's a scary population and it's scary for the patient mostly. Um, but the clinician should be adequately scared as well. And, um, you know, my practice early on, I was fortunate to be partnered up, um, with some very good nationally and internationally acclaimed orthopedic surgeons at the University of Minnesota, where I was part of Fairview, and they were with U of M. And I was with Elizabeth Arndt, Dr. Elizabeth Arndt, and Dr. Rob Leprad. And Dr. Arndt did a lot of complex patellofemoral procedures, and then, you know, my, my relationship developed with Dr. Leprad during my time at the university as well, when he was first doing his research on posterior lateral corner. And so everybody did sports. Everybody did ACL was patella femoral was dr. Aren't niche. And, you know, people were dabbling with meniscus when they weren't just taking it out. Right. And so dr. LePrade was a big fan of understand the native anatomy where, where do things. Sit in the joint normally, what do they normally do? Because what he would end up seeing was failures of ACLs that had this profound rotational instability. And he started to do his research on posterior lateral corner. And of course I was two years, three years out of PT school. And I'm like, the who? Like, what are we talking about here? I didn't, I didn't learn this structure. Nevermind three or more structures combined. And so I felt very naive. And exposed like I don't even know what language you're speaking right now. And so I really just bothered him and lurked around his region of clinic because I was curious about this. And when, when a surgeon or a clinician gets known as seeing the. Other everybody sends the other to that person because they don't have to do with it. And so he started to be this lightning rod for the other. And he was meticulous enough in his study of the joints and his awareness of the anatomy and developing surgical techniques that were His language is anatomical reconstruction. So the goal is to reconstruct things as close to back to their native state as possible, but defend your technical choices with a significant body of biomechanical literature. And so he was doing that. I was slinking around in the background, very curious about this and asking a lot of annoying questions. And, and as a result, he started to say, well, she's obviously curious and started to send me these complex cases. And I would shadow in the OR and he, his answer to my questions in the OR was usually we'll read these three papers I wrote. And I'm like, so I would go back and I would Google words. I didn't know. And I would read papers that, that were written and I would try to dig up whatever I could, but there really wasn't much. So you ended up kind of going to the, um, kind of bench work, like the biomechanical literature to start to just understand, well, what does this ligament even do? And then, like, Kevin Willick and Ralph Escamilla's work on here's what happens when we squat and when we do certain exercises, and you just try to piece it together, but I think the important thing is the exposure over and over again, and, and having a sufficient level of fear early on. And then as reps come along, then you start to learn where you can let go a little bit. Do you regret this? We have a lot of fun just treating isolated ACLs in our clinic. I mean, do you, do you regret showing this much, uh, excitement over these complex cases? Because like you said, now I'm sure your caseload is jam packed with complicated people, right? Yeah, it's, it's a mix, but you know, I love them. They're, they're, I like to make people feel safe and normal because what you don't want to be is the one person that everybody in clinic comes over to see, like, Oh, you got to check this out. Oh, I've never seen anything this bad, like, kind of, but, but also like, is that the response you want as the patient to be like, okay, so I'm your end of one. No, I don't regret it because to me, it's, um, it's like the island of misfit toys where, you know, people don't understand them and you created really powerful connections with patients when you say things to them that demonstrate that you understand, like, I get tears a lot in, in our practice because people are like, Oh my gosh, you're the first person who you know, we had that a lot with patellar instability patients, but with these multi legs, you get a, an 18 year old coming in with their nerve out. And three ligaments out and everybody around them has been like, Oh my gosh. Oh my gosh. Oh my gosh. And, and we just sit down and we say, it's going to be okay. Here's what we're going to do. But I need you to understand, like, things are going to be different. This is not cute. This is not a cute ACL, like what your friend had. And it's not just a sports injury, like it's a medically traumatic situation and, and it allows you to create connections. You know, I just had a patient of ours send us a video of her squatting the bar in, in the weight room with all of her softball teammates around her, like screaming at the top of their lungs. Like she was maxing out with like three 45s on, but she had the bar and it was just like. I was like, like weeping openly on zoom with her because it was such a moment because her nerve is still out and she's she had three ligaments out and like that does not make me regret it for a minute. In fact, it's like my calling to be on this little special island with these people. I love that. And that's, that's what makes you special about that too. But that it definitely feels good to help these people because they are complicated and they know it's complicated, right? They, they know that. So, you know, it's, you know, we, we always joke and say that we deal with blisters and crack fingernails and baseball and, and that's why we didn't get into the NFL. But, um, you know, I, I, I can see that, right? Like we've, we, we've had a lot of these complex patients just over my career. And they're so challenging to get over both physically and mentally. So I can see where that emotional reward comes in. That's, that's pretty special. Uh, athletes, it's everyday people who really just want to be able to go back to work and take their kids to the park. And, you know, so it does ground you. Because, I mean, don't get me wrong. We see plenty of ACLs and Lord knows, we've not figured that out. Right. But, you know, the expectations and the demands in terms of, um, what are people getting, what are they getting back to how soon it's kind of refreshing to have a degree of appreciation for just the simple things when you're working with someone who's, you know, truly complex because they don't take the little things as for granted. Well said. I love that. Let's dig in a little bit here. These, again, complex cases, often multiple structures. Why don't we start talking about that a little bit? Um, obviously, there's some trauma involved, oftentimes. Maybe some high velocity, those types of things. But let's talk about the mechanism and some of the anatomical considerations for these types of injuries. Because, like you said, as an early career professional, at one point in your career, you didn't... You know, respect this probably as much as, as we, we probably need to. So I'd love to hear your thoughts on how these injuries happen and anatomically what happens like during these complicated cases. Yeah, fantastic. So as you'd alluded to, you know, there's these different velocities of injury and you know, you can have a high, a lot of times it's a high velocity trauma sort of thing where patients, you know, what patient of ours was bouldering and fell from a height. There's a good example, or you're in a car accident or, or some type of an ATV. You know, we get people who ATV through the woods up here in Minnesota, and, you know, that can result in a high velocity trauma. And there's also low velocity. And actually in this world, sport is considered low velocity by comparison. So a sporting injury, or you can have instances of someone with a high BMI that will do something benign in daily life and their knee will dislocate underneath them. We don't see that as often, but it. Over the last five to 10 years, though, you're definitely seeing more of a sporting injury presentation. You know, you think about the freakish progression of football athlete in terms of the speed that they get up to on the field and the type of collision that they have with other players. And you can certainly have, um, multiple structures involved. I just saw a guy fall into a flex knee last night and I thought, oh, there's a PCL. Um, but sporting injury is representing more and more and younger patients, you know, this is, there's an inverse relationship between age and the likelihood of a knee dislocation because young, brave men in particular, um, will sometimes find themselves doing silly things. you said BMI and I thought that was an interesting take here because I've actually seen, um, just for the listeners here, I've actually seen, uh, very large, but super athletic people have multiligaments that ligament is like complex knee injuries with some things that you and I may consider. You know, a benign event, right? Just a typical thing that you wouldn't expect that had that big of a, an injury, tibial plant, toe fracture, stuff like that. Like just from having a six foot four, 254, you know, pound athlete. Um, so, you know, it's, you know, the velocity spectrum's there, but I think like you said, it's, it comes down to our athletes getting bigger, faster, stronger. right? Are they putting themselves in more disadvantageous positions? Um, you know, it, it, it makes sense. Um, so it's very scary what people have to get back to, especially, you know, at, at the level of professional sport. Yeah. All right. So tell us about the anatomical considerations here with this, because again, I think an area that's probably not like physical therapy, one on one that you learn in PT school, necessarily like the complexity of the posterior lateral corner, stuff like that. Talk to us a little bit about what you typically see in these complicated cases. Yes, there's going to be a variety of things. I mean, there's different grading scales for multi ligament knee injuries, and I think it's important that we can distinguish between a knee dislocation versus multiple ligaments because a knee dislocation where the entire joint completely disarticulates. is different. It's more traumatic. You can have an ACL MCL and that can be considered a multi ligament injury, but it may not have actually been the result of a true knee dislocation. Certainly there'll be subluxation involved. You have to have a degree of subluxation in order to have the ligaments rupture, but a true dislocation like those pictures you see where the femur is over here and the tibia is over there. That's. That's uglier. That has that has more challenges. I would say those patients struggle more postoperatively. And so when you're following something like a shank classification, you go from having a cruciate plus a collateral to then I believe it's it's both cruciates out plus one collateral, both cruciates plus both collaterals, all of them plus a fracture. And so you see this progressive and progressive involvement of more structures. Um, it's important to, to recognize like for our colleagues that do on the field coverage, when you see that gross deformity of the limb, or when you do see what's Suspected as a dislocation. That's not just an orthopedic athletic training moment. That's a medical emergency because the vessels and the nerves can be involved. And when the vessel is involved in particular, it's life threatening. And so having your medical team aware of that, that you're doing a proper on field workup to, to rule in or rule out concern for it, but most of the time, they're going to advocate for advanced imaging with these patients to look at the vascular system and to make sure that there's not some sort of popliteal artery injury. And, you know, that, that, that can be a concern at the time of surgery as well, but certainly acutely when these injuries happen, you have to treat them with more of a, of a trauma medical emergency eye than just a, okay, let's see, come over here. Let me see what ligaments are hurt and get you back on the field. Um, so that's an important distinguishment, but certainly the cruciates are going to play a role. And then you have, you know, simply your collaterals, your medial or lateral collateral, but then we have this kind of emerging concept in the last. 10 years or so of the posterior lateral corner. Well, certainly posterior but posterior medial corner where you're talking about MCL, but also you go deeper, you've got superficial and deep MCL, but then you have the posterior oblique ligament, which is essentially a capsular expansion and thickening. That's a little more posterior at the lateral side of the knee. The posterior lateral corner is three structures together can be more. But it's the FCL or the LCL. It's the popliteus tendon, and then it's the popliteal fibular ligament that comes off of the tendon of the popliteus and goes over to the fibula. And those three structures partner to, to control against varus and recurvatum the tibia and the femur. And so when you get these combined injuries, oftentimes there's like, hyperextension plus verus, or I'm going into velgus and my tibia is being rotated underneath me because my foot was planted. So when you see guys go down with their foot planted and you see their foot rotating, probably ACL, probably MCL, and if it rotates far enough, you know, they might bring on that lateral side as well. And then if they have force coming down through their tibia as they land, well, goodbye to the PCL too. So you, you can kind of appreciate this progressive disruption depending on the. The angle, the angular movement of the injury and then the rotational movement of the injury. And, you know, I think the, the take home with that for me is it's, it's short sighted to think the knee flexes and extends and, you know, sometimes you can have a medial lateral torque. It's a three dimensional joint. Right. And sometimes young clinicians don't, don't comprehend that as well, or maybe they're just oversimplifying in their mind. But this is a, a 3d type injury that is going to involve a lot of different structures. And that's going to really not only add to the complexity of it, but something that we have to appreciate during the rehab process. Right? Absolutely. And that's The type of foundational thinking that you want to have. I will tell you, having tried to go into a DPT program and give a lecture after I just came back from talking to a group of PTs who are in practice, smoke like starts to come out of their ears when you start to talk about all these structures. And we, so you kind of, you have to start with that, that single plane, like, what does AP, and then what does Veris Velgus. And now let's start to talk about what controls the rotational elements of the knee because you're exactly right. And that's what you think about when you start to tackle your post op rehab is like what happens natively, which structure is primarily and which structure is secondarily responsible for stabilizing this movement at the knee. And those are the things that we might want to show some caution for early on in our rehab. I love it. That makes sense. So big, big injury, obviously we're going to have a big surgery. Right? This is, these aren't non operative cases, right? So, big surgery, I'm sure there's going to be a bunch of factors that lead to better or maybe less optimistic, we'll say, we won't say pessimistic, we'll say less optimistic outcomes perhaps. But tell us a little bit about some of these surgical factors. Like what, what is it in your experience that you've seen lead to better or worse outcomes? Just so people are aware as you know, anything that you've, you've seen in your practice, is there anything you've, you've picked up on? Yeah, I, you know, I've been very fortunate in my practice because I happen to be by the forces of the universe aligned with someone who's the world expert in this domain of surgery. So I'm very fortunate and that makes my job so much easier because The surgical job is being done so precisely. Um, so I would say first, uh, someone who's technically expert. This is not a a dabbling area of expertise. So if you don't know who the go to is in your region, you know, it's as simple as asking a question of a few providers to say, hey, Who is the person that handles the most complex? And so getting patients into the hands of somebody who is technically expert is really critical here because graft placement, graft fixation, even the, the order in which the grafts are fixed, the angle at which the grafts are fixed is, is going to influence this because it's not just, Oh, my ACL was tensioned a little bit off, or we got a little too forward on the tibia. Well, Now three other graphs are going to be impacted by the placement of that other graph and certainly that's not what we're doing. But as we can appreciate you get a misplaced ACL graph and now we're banging away trying to get extension thinking what am I doing wrong. Well, sorry, you're not the one who did something wrong here. And so I, so technically expert is important because that just makes it so much easier for things to, to be logical with, with our observations. Most operatively someone who's capable of doing the surgery efficiently is helpful because the less time the patient's on the table, the less blood loss, the less infection exposure, the, just the morbidity of the surgery is down. If they're not full open on the table for three hours. You know, if they're there for an hour and 15 minutes, fantastic. You know, Dr. LePron's incredibly efficient because he's very organized, surprisingly, in his approach. And so they have everything ready to go and they complete these surgeries very quickly. But I hate using the word quick because that seems medically irresponsible, but it's efficient. And, you know, timing of surgery, I know that that is, that's an area where you say, okay, is it's hotly debated in the surgical literature, you'll see some big review papers say earlier surgery does better. You'll see some big review papers say, you know, later surgery does better, you know, there's, there's a greater risk of stiffness or, you know, they'll have all of their outcomes that they're comparing and you'll see. Two papers within two years of each other, even sometimes in the same journal come to a different conclusion on that. And so with our patients, what we like to do is, well, first of all, if they have like a tendon rupture, if the biceps femoris is off or, you know, the gastroc, the lateral gastroc can even be off sometimes, or there's like a fracture or some sort of impaction fracture, you might bring that patient to surgery sooner. If there are certain things that are just going to retract and become problematic with a delay. But we usually like to get our patients into some rehab ahead of time, get the knee quieted down a little bit. They'll have a lot of knee swelling and also a lot of limb swelling and bruising. And so we want to resolve some of that. And then we also want to get the quad woken up a little bit so that it can find itself at all post surgically and start to get range of motion coming on. But also critically, it gives us an opportunity to sit down with the patient and their family and talk about what happened and give them that, that permission that. Hey, this is a little bigger. This is a little bigger deal, and it's pretty traumatic. And, you know, we even talk about, you know, bring in mental health. If you're somebody who has struggled previously with mental health, this is going to be an exacerbation, certainly. Um, if you're, if you've never had a mental health issue, but now all of a sudden you're in the middle of a traumatic medical situation, it can be, and not everybody is like that. I mean, some of our cases are truly athletes who have, ligaments out, the nerve is fine, it's ACL plus territory, but you get those bigger injuries where you get two or three ligaments and the nerve is out and that's, that's got a different feel to it. So it gives us that opportunity to sit down with the patient and kind of process the situation and lay out a roadmap for what they can expect in the recovery period. And do you, do you have like certain criteria that you want them to fulfill prior to going into surgery? Do you ever have to get into surgery just because it's taking too long, but there are certain like KPIs that you want to achieve before you actually proceed to the, to the operating table? Yeah. You know, ideally we want to see that they're getting a strong volitional quad contraction. Um, you know, if the nerve is out, it's, it's going to be out and typically there'll be some type of a neural lysis done at the time of surgery to free up any scar around it and hopefully relieve it a little bit, but we'd like to see that the patient can get a strong volitional quad contraction. Full extension is nice. Um, sometimes these have. full extension plus a whole lot of recurvatum if the PCL and posterolateral corner is out. So we're not going to be hanging into hyperextension with those. But you know, getting flexion, if we can get up to 90 or beyond, that's great. If ideally, if we can get closer to 120 and beyond, that's even better. Um, you know, a lot of times the effusion is limiting the motion, but what limits the motion a lot is fear. These patients are really, really, really gross and weird just happened at their leg and now they feel terrible and so educating them, putting them in positions where they feel supported and confident to move and then giving them permission on how to move in a way that's safe because oftentimes they will move in a very simple way and their knee will sublux, they can visually and physically feel their knee sublux and so understandably they're not super excited about moving it. And so just showing a good feeling, like here, we're going to place this on the grounds that your foot's on the floor to mitigate the weight of your tibia, I gotta say, I've done a lot of podcast episodes. There, there hasn't been an episode where I've made that like. Remus kind of face more often than, than, than we've done so far in this episode. So kudos to you for that. You've, uh, my stomach, my stomach's upset already, but I can, I can only imagine, but yeah, you know, you kind of started talking about this a little bit, but like there, there's a lot that goes into these, right? So. As a therapist, we have to reconcile all these different structures. They all have unique considerations, right? They're, they all have their own, own things that we should work on, things that we should, we should avoid, right? Like you just brought up a really good example of ACL and PCL. But, you know, we, we want to get full knee extension back, but you're right. Is that stressful for, for PCL and posterior lateral corner? So, you know, how do you, how do these surgical factors, how do all these things involve? Go into your decision making for how you progress somebody like, how do you put all of that together and make sure that people are going as, as fast, but more importantly, as safe as possible through the process. Yeah, absolutely. And we, you know, we get patients who come in from all over the country and all over the world for surgery with Dr. LaPrade and the scariest thing is sending them home. And, but also I want to respect that my peers and colleagues throughout the country are They're skilled, they're smart people. It's just that lack of exposure. And so I always send my email home with our patients and say, send an email to your patient, to your therapist with me cc'd on it. Because I want them to be able to type in JI and Outlook and I pop up. And then we can easily talk about, like once people get it. It makes sense. And let me do the brain work for you because I tell you what, even like when I was first learning these things and going through periods of relearning like smoke would come out of my ears. And I want to shortcut that process for my colleagues who don't see a lot of it because if we have a 15 minute phone call on my commute home, you'll be like. Oh, okay. That makes sense. So structurally, you know, again, you're thinking about natively, what happens, you know, we all think about the PCL is the dashboard injury, that 90 degrees of flexion. And the PCL is, is a monster, you know, it's, it's Newton's load to failure is significantly higher than the other structures in the knee. And so when the PCL has been reconstructed, you really want to make sure that the, the graft integrity is sound and that we're not. Doing things that create a lot of elongation stress, um, at the PCL when it's first healing, because I'll tell patients that the PCL is kind of like that center beam for the knee. And if the PCL is healed in the right length and the knee is in the right alignment, the right neutral alignment when it heals, all the other structures around it are going to be functioning at their ideal length as well. Whereas if the PCL Doesn't, and the tibia has sagged back. Not only is the p c L in a non-ideal length, but so are the other structures inside of the knee and, and your articular cartilage loading pathways have been changed as well. So now you're stressing a different part of the tibial femoral compartment. You're slinging the patella back against the trochlea with a little more tension, and that's where you'll see these long-term changes in articular cartilage. Where in PCLs that are. that are um, continuously lax. And so the PCL, yes, you think about flexion, but hyperextension is important, is another important structure, function that the PCL helps to manage. Same thing with the posterolateral corner, it helps to block recurve bottoms. So we're careful, but we're not so careful that we create a flexion. a flexion contracture at the knee. And so it's about giving people a little clearer guidelines of we don't want to hyperextend initially, but we do want to get to zero. So please make sure that your calf and the popliteal space are able to touch the table, but I don't want you. Hanging your heel on a coffee table with your knee hanging down freely and, you know, rotationally thinking and, you know, various and vulgar stress. Okay, we can start to work on hip strengthening, but I'm not going to put you in sideline. If you had a posterior lateral corner or an FCL reconstruction, because I don't want various stress through this knee. When the graft is just trying to get its bearings and heal sometimes into a bony tunnel, sometimes with a suture fixation, right? And so, you know, we have a lot of bony tunnels in our world, but different surgeons around the country will have different fixation techniques. And so you need to be aware of that. So you're, you're thinking about the native function of the, of the ligament itself when times are good. Um, what happens when the knee is moving through range of motion, what happens when the quadriceps and hamstrings are pulling to create that range of motion. And then finally, what happens when we get up on our sticks and we start walking and doing squats, what are the normal sliding and gliding forces at the knee, and which structures usually control that because you don't want to You don't want to all of a sudden vault the knee into a position where it's trying to control a lot. You want to, you want to drop, drop, drop a little bit of that medicine of load onto those ligaments gradually over time. And let's back out. And then remember, what about a meniscus repair? Because it's not that often that we have three ligaments go and the meniscus is sitting in there smiling at us. You know, you usually have some type of meniscal involvement, which is going to bring on a different You know, it's not necessarily going to intensify the precautions because you might already have a lot of precautions on, but it'll make the joint a little angrier. It'll make the joint stay swollen a little bit longer and, and then you have a nerve out, you know, so you just kind of layer it on and you take it one at a time and you think about which of these precautions kind of fit with each other. Some of them kind of go together. So now my precautions aren't anymore because the same precaution is going to cover both structures. And again, that's, that's where I think you said it very well, there are professions, a bunch of smart individuals around this country. Um, it's about putting together all these little pieces of the puzzle and then just knowing which factors, uh, way more than other factors. And what you just said about the PCL and, and that being kind of like the starting point there, I thought that was amazing. That was a great, uh, pearl for everybody. So, um. But people are going to want to know specifics. I know that because, you know, we're, that's, that's us, right? In the, in the PT world, we want to know specifics. So let's, let's take some of the big chunk, uh, topics that we, uh, tend to talk about PT and, uh, kind of hit your thought process for each one, but let's start with weight bearing, you know, when you're going through your range or, um, your rehab process, like how do you determine when does somebody, when does somebody safe to progress their weight bearing? How, how cautious are you with that after surgery? Yeah, that's a very good question. And that is something that we are currently investigating. Um, because I pride myself on kind of being a squeaky wheel. And if something doesn't make sense to me and there's not great literature to say yes or no definitively, I will continuously ask why and why and why. And, um, you know, an ACL can be weight bearing as tolerated after surgery, which ligament manages the tibia most with gait. It's the ACL, you know, it's the anterior translation, you're in that shallow angle of knee flexion. You've got tibial slope working, you know, to bias toward the ACL and that's the one we let weight bear. But we don't want to make sense. Right. Um, now, now with that said, um, certainly when you're talking multi leg, um, you with, with that traumatic subluxation, you're going to have bone bruising, you're going to have meniscal pathology. So, so a lot of our patients are non weight bearing and for multiple reasons, but we're currently investigating different weight bearing statuses. So we're looking at non weight bearing versus. partial weight bearing with all of our ligamentous structures. Now, before, right when Dr. LaPrade was transitioning back to Minnesota from Vail, he had just wrapped up a trial looking at an ACL, FCL, pardon me, ACL, FCL and FCL by itself, looking at non weight bearing versus partial weight bearing. And looking at stress radiographs where you stress the knee into varus and you look for a difference in side to side gapping of the lateral compartment. And they determined that outcomes were very good. It was safe. We weren't seeing graft elongation at the FCL in patients who were allowed to be partial weight bearing. So then you push pause there and you back up and you say, well, wait a minute, besides the ACL. Which other structure should be the loaded, loaded most with gait? There's a varus moment through the knee. There's an adduction moment through the knee at mid stance with gait. So the, likely the second most problematic structure for gait should be the FCL. And our, his research on that showed that partial weight bearing after an FCL. Was not problematic in terms of graft elongation and patients had very comparable outcomes. In fact, better in terms of pain and swelling and, and some of their patient reported outcomes early on. Um, so when he came home with that, I was like, well, looky, looky, what about these? Yeah, exactly. Certainly, you know, the MCL, unless someone's limb is in a malalignment position, the MCL should not be stressed significant with significantly with straightforward gait. PCL is is big and important, um, but the weight bearing portion of gait theoretically shouldn't stress it too much. Now there's some literature and it's all very experimental design looking at PCL stresses with gait and squatting and things like that, and and the outcomes are a little bit mixed, but for the most part it When in these computational models, it appears that the load is significantly below load to failure for PCL, but the thing you do have to keep in mind when you're talking about GATE is when you let somebody walk, what else do they start doing? They start to pivot, they start to go up and down the stairs, they get up and down from the chair, and so that there is A space for being cautious with weight bearing because weight bearing to us means forward ambulation. Weight bearing to our patients means a whole variety of other things. And when you have this big of a surgery, is six weeks really that big of a deal to hold your horses for the long term outcome? Right, right. And let the knees settle down a little bit and you know, probably get your quad back as long as you're doing the right rehab and you're not, you know, falling behind. But yeah, I, I, I see it. I mean, you convinced me to be honest with you. I had everybody weight bearing immediately after our, after the beginning of your conversation there. But yeah, but you're right. Sometimes, sometimes we settle down, but, um, how about range of motion? Are you similar with range of motion? I mean, how do you progress this without getting tight? Because I think that's, that's. The biggest complication I would assume that most people are afraid of here is that they're going to get a stiff knee and that's going to be a problem down the road. How do you, how do you reconcile that? Yeah. And let me clarify too on weight bearing. So right now we are seeing if ACLs and FCLs and FCLs can tolerate weight bearing is tolerated. And we're looking at our other ligaments that do not have meniscal involvement. We're looking at them with partial weight bearing right now and our preliminary results look very favorable. And so I think the next leg of our research will be taking that cohort from partial weight bearing to weight bearing is tolerated. But again, we don't have good literature that specifically follows an outcome that looks at joint laxity to tell us that yes, it's safe or no, it's not. We don't have that in the non A. C. L. World. So, you know, flipping to range of motion, we start range of motion day one post up 0 to 90 with everybody. Um, the Exception would be, you know, if somebody had a huge patellar tendon reconstruction, in addition to this other work, we might gate them to 45 degrees the first couple of weeks. Um, but typically our ligamentous procedures and even our meniscal repairs are 0 to 90 day one. Now, there's different things. And so, you know, Dr. LaPrade published a cohort of 194, 197 ish single stage multi legs. Um, in 2019 AJSM and those patients, the protocol they followed was they were non weight bearing at that time, but they were range of motion day one, zero to 90 and the graphs do not stretch out. Now that's his graphs with his surgical techniques. And that's a physical therapy team that sees these patients often. So, you know, it's not necessarily generalizable across all surgeons and all therapy centers, but we follow. A structure specific and surgery specific framework for how we approach range of motion and the things that are important to keep in mind is again, what movement stress the structure natively. And so we want to be conscientious of that who normally blocks hyper extension, what structure comes into tension and length as we go deeper into flexion, you will, but you also want to think how was the ligament fixed in the joint. Was it a bone plug was it soft tissue fixation was it suturing, where was it fixed you know was it in the big beefy tibia or were they fixed into the fibular head where it's a little. Smaller zone of bone. And then you also wanna think about where was the graft taken from? Was the graft an allograft or was it an autographt? And if it was an autographt, where did it come from? Because that's going to be an additional source of trauma for the patient, especially hamstrings. Um, you know, additional soft tissue trauma is not unusual in this patient group. So the biceps femorals being off is not unusual. And so in that situation, we might start passively for the first couple of weeks and then then kind of trickle into active assisted and then trickle into active, we, we trickle a lot where we are. Um, the precautions we might send out to a center outside of ourselves might be a little more restrictive because sometimes how people have people ranging the knee. requires a lot of hamstring pulling. We have our patients seated, their foot's on the floor, they use a strap underneath their thigh to kind of lift the thigh up, and their foot comes sliding back with no effort at all. Now, PCLs are going to be prone for the first couple of weeks after surgery, because if you've ever seen a PCL that's out, What does it look like? It like droops back and looks weird and you're like, why does it look like a ski jump? Because just the weight of the tibia, the fibula sag back when the PCL is out. So the PCL injury makes gravity and the weight of the tibia Stress that. And we don't want to have that elongation during those early healing phases just because it's such a big, beefy ligament. And so we really want to make sure that it's healing in the ideal length. So we put them prone, as much as it's a pain in the butt, we put them prone because then gravity's not sagging their tibia back. Because if I'm in long sitting, or even sitting with my foot out in front of me from 0 to 60 degrees, Gravity is going to catch the tibia and sag it back. And if I'm doing that four times a day for my therapy exercises, that's going to be problematic. So we flip on their belly, they have a partner help them with range of motion, so they're doing it passively. Because the other thing that we know is if we're pulling hard with the hamstring, because my knee is stiff, so I have to pull hard, or 40 degrees of knee flexion, creates posterior shear. Might not be a lot, but if we're doing it 30 reps, four times a day, every single day for four weeks, that might not be great. So in the first two weeks, the patients are prone doing partner assisted passive motion. And then after that, we have them continue with passive motion, but they can go into a seated position with their PCL brace on, or they can have a therapist providing just a little bit of a manual anterior drawer support at the tibia. Might that be overkill? Perhaps I don't know. But what I do know is that our outcomes in terms of posterior um, tibial stress x rays, PCL stress x rays look better than most people around the country and internationally. And the reason people wouldn't reconstruct PCLs historically is because they stretched out. And they say, well, why bother? They're just going to stretch out. We can demonstrate that ours don't stretch out. And so then the question is, would, what, why not? Is it the masterful surgical technique of Dr. Leprade or is it the fact that we're passive or is it the PCL brace they wear? Or is it that they're non weight bearing? We don't know. So my job is to kind of slowly pull down some precautions that might be heavy and see, make sure that we can preserve our really good outcomes so that we kind of get to that place where we're not creating more morbidity. By being so restrictive post operatively, you know, think about their bone density. ACLs have bone density loss and their weight bearing is tolerated. So I'm horrified is what, what these non weight bearing folks look like. So with our PCLs, we're also protecting against hyperextension. That would be the same with a posterior lateral corner. You know, your FCLs and MCLs, you're being thoughtful about varus and velgus stress positions. Um, you know, if the posterior capsule is involved like the posterior oblique ligament or the posterior lateral corner, you're going to be cautious with hyperextension just like you would with a PCL. And so like when I first started doing this at TCO, I built a little table that just had each structure. And the things so that everybody's heads didn't explode, including my own. So you can kind of go through this little checklist of understanding, what does the structure do? And as a result, what are we careful with? And we might be too careful, right? Um, but if somebody has had their semi tendinosis harvested and they've had a posterolateral coronary reconstruction, do you want them pulling, pulling, pulling with their hamstring? Probably not the most comfortable thing. And if they're not comfortable, they're not going to be successful in recovering the range of motion. That's that that's amazing. So how do you progress strengthening exercises now on top of all this right because the blend from you know Active range of motion to now actually adding some load to it. How do you progress through that? Yeah, absolutely. So it's kind of taking those concepts because again, range of motion, you could say, well, the literature looking at sheer had a load of, you know, 10 pounds at the distal tibia when they were doing that. And so that's what we think about when we go into our strengthening and you want to come back to like these larger tissue based concepts, mechanical load. Once we get into that remodeling phase, you know, so early on, we have this big bomb of an inflammatory phase. And then we go into this proliferation phase. That's very delicate. And, and you're creating this framework of structure that your body fills in over time, but it's kind of delicate initially. And that's two weeks, three weeks. And then we start to get into that remodeling and maturation, which goes on and on and on. And we can't forget that during that phase, mechanical load helps. And so we want to use mechanical load. But again, you think about the eyedropper where you want to drop, drop, drop mechanical load delicately more, more, more onto the tissue based on the tissue's reaction to it. And so we start off with weight of the limb, just doing the motion actively. And then we start with a lot of isometrics. Isometrics are great because you put that knee at 60 degrees and you do a quad kick out. They're not going to get. A significant amount of anterior nor posterior shear, you know, don't forget deeper in knee flexion. You can get some posterior shear when you're doing resisted quad work, you know, from say a hundred degrees up towards 60. And then of course, you know, the dreaded 40 to zero debate of, of don't post this anywhere on social media. We'll never, so appreciating that you're going to get anterior and posterior shear with resisted quad. You're going to get posterior shear with resisted hamstring. So resisted hamstring comes on slower for us with patients with structures that are tensioned with posterior shear. So we're going to be particularly slow with our PCLs. We might ease into it a little bit with our FCLs and posterior lateral corners because that posterior shear touches on that a bit. And, and again, if they've had a hamstring autographed, so open chain, we're thinking about what sort of shear is being created. And we start with an ISO at mid range and we work into it. When we start our hamstring ISOs down the road with our PCLs, we started a really shallow angle of knee flexion. So, you know, stand up, put your heel against the wall with your knee bent to about 30 degrees and engage your hamstring there. And then you start to work into some active motion, and then you maybe do some fixed angles, isos at different angles, and then you gradually progress into your resisted arc. You can hit the hamstrings with hip hinging, um, you know, and standing with a little bit of a deadlift movement. Um, so you want to be creative in the different ways that you can hit the structure of interest. You can create a lot of intensity at a fixed angle ISO for the quad in at zero degrees at 60 degrees. You know, we use a Tindex, um, that, and the patients look at an iPad and they can see how hard they're pushing out over at the training house. We've got Kaiser equipment. So patients, you know, can pneumatically adjust it and know how hard they're kicking out. And so you're using those different sources of feedback to modulate intensity while you still have the patient's knee in a position that doesn't put a lot of stress on the ligament. So creatively create muscular intensity without the joint being in a position that creates structural intensity. And, and then over time you open it up and now I'm doing an arc of motion, but I'm doing it with lightweight. And now I start to progress the load and maybe I start to play with tempo. So you're thinking about sheer, you're thinking about, you know, rotational stress as you move into squatting, you know, we move into squatting and you go deeper, deeper, deeper. The hamstrings start to come on the hamstrings, create that nice posterior pole, which is great for an ACL that might not be great for a posterior lateral corner. And so we're going to modify squat depth in the beginning, and then we're going to gradually open that once we get further down the maturation road, kind of four months and later, we feel a little bit better about going deeper and introducing more shear at the joint. So how do you get somebody now to get more to a return to sport type progression and assuming that not all of these people are going to be athletes, they just may have to get back to just general orthopedic, right? But how do you get them back now to, to the advanced stages? You talked about the maturation of, of the surgical procedures. I think that's obviously going to be important, but does this look pretty similar to, to an ACL down the road? It's just further down the road, or is this something where you have some unique pearls that you think are helpful for them? Yeah, I mean, I really think it's once you get out of the first four to six months, it's not as scary, you know, we have this somewhat nebulous timeframe of four months where our heaviest precautions lapse, and that has more to do with like histology. And the healing of the tissue and having some confidence that we've had good bony integration in the graft tunnels, we've had a period of time where where the tissue has been able to kind of go through its ligamentization process, and it's getting a little more mature. It's not fully mature, but it's at a point where we're not worried about something small being problematic. And In some ways, yes, Mike, where you get beyond that, it starts to look and feel like an ACL may where all right now, what are what are our primary goals for returning your high level activity? It's not any different. It's the same goal. So you need those foundational elements. If you don't have great range of motion, don't just leapfrog over that step and try to look cool and sexy by doing other things like training. You're very not sexy for a very long time in this world. And so you just have to stay true to the basics and clean them up. Like I'll tell people the visual of you're walking through a series of rooms with doors in between them and you have to look back at that last room you were in and make sure you didn't leave it a mess. Otherwise you have to go back there, clean up your mess and walk into the next room. And so range of motion has got to be solid because if you're going to sprint, you need your knee to flex. If you're going to be a gymnast, you need your knee to straighten out fully or they hate it. Um, you have to get good foundational strength at all of the muscle groups. And as much as we have cool ways of. Testing athletic performance with different gadgets. Now you can't athletes will be athletes and they will cheat tests. If you just let them move, they'll figure out a way to get it done. And what, how many seconds do you want me to get this done? And cool. I can do it. And my 60 percent LSI to body weight, but I managed to get that done in 3. 5 seconds because I'm an athlete. So you have to demonstrate the foundation of strength at the large muscle groups. They have to have good foundational movements. You know, we run through, um, kind of your standard, what do we have in the literature to guide us? We have our performance testing that's specific to ACL, but it's not specific so much to ACL, it's specific to getting back to being athletic. And yeah, it just insert the most popular surgery. And so ACL gets the association with testing, but what does somebody need to be athletic? That's what we want to test. And that's what our training should be addressing. And, you know, we're fortunate at our center that we have a biomechanics lab and a great sports biomechanism, uh, biomechanics team of scientists that run it. And so we're able to look at kinetics and kinematics so you can kind of pull the curtain back and see what their strategies are, because when you're looking at it clinically of them squatting, okay, you're doing your one legged squatting. We put you on the Y balance test and we have a side to side comparison. We compare that to your limb length. But what's the strategy? Like how did they manage to get down there? What happens when they have to move faster? What's the strategy that they employ there? So the progression is very similar, but what you're going to find is that each phase takes a little longer because their joint is generally more irritable. It's going to take you longer to get full range of motion than with an ACL. It's going to take you longer to get the quad up and running because they might be more sore at their knee. And so you have to modulate the training a little bit and your hamstrings are going to be delayed. You can't have a hamstring precaution for four months and then at six months have full hamstring strength. I don't care who you are. Right? Exactly. That's what I'm like, really, really? And so, but all of those same parameters for, I want you to achieve X, Y, and Z before I let you run. Are going to be in place, but they're probably not going to meet those goals until, you know, seven months instead of maybe five or four. I don't know how much faster people's ACLs get better than ours, but I've, I call BS on some numbers that I see sometimes. You've seen so much. I'm sure, you know, but, uh, Jill. OMG, that was a master class on multiligamentous knee injuries right there in what, 45 minutes or so. Um, that was a very, very impressive episode that is going to be very, very helpful for so many people. So, uh, thank you for taking time out to do that. Um, I'm going to put a link to, um, at least one of Jill's papers on this topic so you guys Can kind of dig in a little bit deeper and have a reference to go back to as well. So check that out in the show notes. And then Jill, before we let you go, we're going to do high five, uh, five quick questions, five quick answers to learn a little bit more about you, um, and what your brain does, which I think we're, we already get a good sense of from this, uh, amazing episode, but, uh, first question is what are you currently working on for your own content or your own professional development? Yeah, you know, that tends to follow what I've managed to get myself signed up for in terms of presentation lectures. And so it's nice, though, because I'm not I wish I were, but I'm not the type of person who can just dial it in and. Like represent something I presented three years ago and call it good. So I tend to do, my husband wishes I was that person. I always do somewhat of a refreshed and up to date lit review on whatever it is that I'm, that I've been asked to give a talk on. And the reason I commit to doing that is because every time I do that, I end up changing something in my practice because I'm like, Oh, dang, I didn't think about that. Or that's great. Yeah, I mean it's just because we can get lazy and just do what we do and then defend what we do and then there I am like 70 like and then you'll do this and so like I want to evolve. So, you know, we've, I look I've been talking about return to loading after meniscus injury so I dug into that, and you know, a little bit on knee stiffness and the relationship with quad insufficiency and. And there's just some cool stuff in that. And so I kind of immersed myself and, and always have one or two things I changed in my practice because of it. That's awesome, which leads us into the next question. Then what's one thing that you've recently changed your mind about? Yeah, I mean, I don't know about changing my mind. Um, maybe kind of coming back to it a little bit. Um, Lane Bailey did a really good job of, of speaking at our OSET meeting about, um, EMG In addition to thinking about NMES for quad, like the value of EMG, I was kind of an EMG purist early in my career. And then I got on the NMES train. And I like the concepts of what EMG can do. And I think it has a space and value. And, you know, focal cooling is not something I did a whole lot of. You know, we always had everybody ice after their treatment and we do a lot of conversation about inhibition of the quad after surgery and we do a lot of strategies to overcome but I've started, you know, just getting my little baggie ice and sticking it on the knee and while my patient's working on extension and then we go into quad work once they've been 15 or 20 minutes. Brought that on and that kind of relates to that deep dive. And then, you know, another thing is just holistically our center has a lot of, um, kind of multidisciplinary resources. And so I talked to my patients just a lot about recovery and nutrition and sleep and wellness. And those are things that I try to weave into our practice more. So those are things that I may be doing differently now than what I did, you know, five, 10 years earlier. That's great. I love it. Uh, what's your favorite piece of advice that you love to give your students? I challenge them to understand the why behind things. Don't just nod your head and say yes. Um, don't memorize protocols. Figure out why is that precaution on the protocol. And if it's on there with no good reason, or it's maybe because you don't understand the reason, and you need to ask why. So, ask why. Because if you understand the why that opens you up to be creative and think about problems in a new way and maybe be the one who kind of creates a new and different strategy that no one else thought of before because you're not limiting yourself to just following orders. Awesome. That's a great one. Uh, what's coming up next for you, Jill? I got a couple of things. I'm apparently I'm a mentor with ASBT's virtual teammates. That's coming up here in November. Um, so loading in cyberspace between various rooms, I think, our team is presenting at CSM. We've got an educational session. We're on the, we're the, we're the grand finale, baby. We're on Saturday, the last session talking about the collateral ligaments and rehab after collateral ligament reconstruction. And we're also going to be presenting, um, In the research platforms for our preliminary data related to PCL and we've got a couple, you know, projects, research projects in the hopper that are kind of nearing completion, specific to meniscus. And, um, again, weight bearing with our ligament reconstructions. Awesome. Sweet. So where can people find out more about you? Is there anything that, you know, are you prolific on Twitter or Instagram or anything like that? Where, where do you, where can people learn more about some of you and your work? I'm prolifically boring and non confrontational on social media, I'm sorry, I'm not, I'm very confrontational in real life, I just, I just want to be, like if I want to be able to reach out and grab you if I'm going to be confrontational, um, so, I'll have to remember that next time I see you at a meeting, by the way. So if you see me with Mike and I've got him in my hands, so Twitter, Instagram, LinkedIn, I'm on all of those platforms and I can give you my, My little handles for those. And then, you know, my TCO, um, Jill Munson. If you type in Jill Munson TCO and it's Munson with an O, not a U. Um, my, my page within the TCO page has, I've got some little educational resources for patients and just my bio and some of the, some of the literature that I've been a part of. So that's probably as good a resource as any, nothing more attractive and appealing than that. That's fantastic. I'll put links to all that, including Jill's socials in the show notes, so you guys can check her out. But Jill, again, sincerely, that was a masterclass. Thank you so much for such an amazing episode. Thanks for nerding out with me on Complex Knee. I love it.