Part 2 interviews Søren T. Skou is a Professor of Exercise and Human Health at University of Southern Denmark and Næstved, Slagelse, Ringsted Hospital. We continue the discussion on meniscus injuries for runners and focus our attention on the chronic population, especially with the correlation early onset osteoarthritis. Søren talks about why there is such a high correlation between knee damage and arthritis and ways we can delay or prevent this early onset. We also delve into treatment & management principles upon returning from a meniscus injury including strength tips, running tips and general loading principles. Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
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today's episode, part two of Meniscal Injuries with Professor Sorin Skool. Welcome to the Run Smarter podcast, the podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle. And once you are injured, you're looking for answers. and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default, become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence, and start spreading the right information back into your running community. So let's begin today's lesson. Welcome to part two of this two-parter where we're delving into all things, meniscal injuries, management, treatment, prevention. And this episode is exactly, it promises to deliver just that. Um, Professor Sorin is, um, colleagues with Jonas, who we spoke about in part one. And we spoke to in part one. And yeah, we dive straight into the connection between meniscal injuries and osteoarthritis and. the careful relationship between the two. We delve into prevention. We delve into running. We delve into the likelihood of it developing into OA and yeah, very engaging, um, some very interesting topics here. So look forward to bring you that. But before we do, um, a bit of an update, uh, as you know, if you've listened to the previous episodes, I'm in the process of moving house and up to this new big business adventure, I guess, with converting part of that house into a physio clinic. So I'll still be primarily, especially with COVID and lockdown restrictions these days, doing most of my online physio like I have been in the past, but will slowly be converting the house, part of the house anyway, into a clinic and starting to see people in person when we're allowed to. I've got a massive Rumpus room there that I'm going to convert into a gym. And so very exciting on, uh, coming from my end and I'll keep you guys up to date on how that's progressing and maybe on social media, we'll let you know when. You know, the gym gets converted or when I get new, um, equipment coming in, those sort of things, because I am very excited and I need to tell some people. So the podcast audience, you'll have to listen. And also before we get started with the interview, I've had some, um, I guess mixed reviews when it comes to Amy Novotny, some people really loved it. Uh, when we're talking about breathing pain levels, um, the relationship between the nervous system, breathing pain performance, um, was very, very interesting, some of the claims I guess she made would be something that I wouldn't recommend, um, I think some of the, she's very used to using language like bone on bone and pinching, um, pinching bones and that kind of. Derogatory terms that like I said, I wouldn't use but I think we cleared things up really nicely and the overall message the overall Takeaways were just really profound and I thought I need to Something that I hadn't really explored much something I've been very curious about and it was happy with the final product and I thought I'd share a comment coming from one of our new patrons Terry and he left a comment on the podcast Facebook page or the podcast Facebook group and asked if I could share it out. And he was more than happy for me to read it out. So this is just his experience after listening to the podcast with Amy. So he writes, I was pleased to hear Amy state that nasal breathing is more efficient than solely breathing through the mouth. As I've read this in a number of publications, I was on a 60 minute treadmill run when listening to the podcast. I was hearing a go, mainly letting my tummy and ribcage drop to relax and focusing on breathing through the nose and the mouth. Having dropped my belly, the first thing I noticed was that my feet seemed to disappear from view a lot sooner as I moved over to the leading foot courtesy of my spare tyre. Despite this, I have to say, after a few minutes, felt more relaxed in the movement and comfortable running this way. The nasal breathing was a little bit more of a challenge, but strangely seemed to come up with a workable pattern of four lots of nasal and mouth breaths, followed by one deep nasal breath in, and then out through the mouth and just going through repeating that cycle. An unusual approach, I know, but it seems to tick all the boxes in being comfortable while allowing to maintain a steady breathing rate, which I think is a pretty sensible decision. Terry goes on to say that after a few minutes of practice, I was then able to increase my pace to 13 Ks per hour following this process and finished the session feeling relaxed with no stress in the body at all and completely in control of my breathing. This compares to my runs over the past couple of months where anything above the speed of 11.5 Ks over an extended period of time would have me panting at the end. So pretty good, pretty good finding. Perhaps this is just one of those good runs that happened from time to time. No doubt the efforts that I've been putting in with strength training have contributed to the improvements too. Well done, Terry claps from this end of the microphone. Well done. And he goes on, it has certainly sparked my interest through to the extent where I'm going to work on this process for the next few weeks and see what happens. Congratulations on the terrific podcast. Apart from being really interesting. I've learned loads about how so many aspects of running that previously had not paid much attention to. And I'm convinced that it's made me a smarter, more successful runner. Thanks for sharing that, Terry. Thanks for sharing your experience. And I encourage any other runner, um, whether you've implemented something, whether it's worked, hasn't worked, please share your experiences. Cause I'll be more than happy to share it on the podcast. And yeah, I think it's a really good idea. So thanks for that. Um, let's dive into our interview with Sauron. I think there was. Well, during the interview, there was some slight lag issues from my end, because as we're moving house, we've just yesterday disconnected the NBN and so just relying on local wifi. And so there was a bit of performance issues, a bit of lag, but with the editing on board, I've managed to splice it all together. That's really nice and seamless. So hopefully enjoy. Soren, welcome to the podcast. Thanks for joining me today. How about we dive in with just talking about you as a, like what your background is like, and what sort of studies you've been in, how you got involved around this particular interest. Yeah, sure. So I've been a researcher for more than 10 years now. And at the beginning, I focused on knee osteoarthritis, both because of my background as a physiotherapist. working with exercise as treatment, but also due to the fact that I was very interested in questioning or at least evaluating some of the more established treatments that were out there for osteoarthritis. That's why I started off with a very challenging trial, I would say, a trial of knee replacement surgery as compared to non-surgical treatments or in addition to non-surgical treatments. At the same time or... After that my interest grew in directions related to knee osteotritis, which is also meniscal tears and degenerative meniscal tears, which will be part of our focus today. I guess in the last 10 years my interest has also changed a bit, so it's not only in knees, it's also hips. It's also related to people with other chronic conditions like diabetes, cardiovascular disease. C O P D and even people with more than one chronic condition, which is really a problem today in the community. A lot of people is actually affected by more than one condition. Yeah, and I think this is going to segue really well into what we had with our conversation with Jonas and talking around meniscal injuries. He sort of highlighted the link when it comes to meniscal injuries and the development. of osteoarthritis and so I think the conversation will flow really nicely into this episode. So I might as well just start off by asking why is there such a link? I don't think we delved into this too much with Jonas but we recognise that there was a link between meniscal injuries and the development of osteoarthritis but why is there a link there? What's actually occurring? Yeah, it's really interesting. I think it's important to think of the knee, the healthy knee. We have the menisci in the joint which are both shock absorbers and distribute the load when we are walking and running and so on. And if they are injured, then part of this shock or part of this load will be distributed over the cartilage. And the cartilage is a crucial part of osteotritis, even though osteotritis is considered a condition affecting the whole joint. it is associated with cartilage degeneration. So you can imagine that if you injure your menisci, then the load will be higher on the cartilage, which would then lead to or can lead to osteotritis over time. In fact, and this is something I think is really important to highlight, that you can have osteotritis quite early. As we know that around 50% of people who have a severe knee injury that could be a meniscal injury, but it could also be an ACL injury, would actually have osteoarthritis 10 to 15 years later, which means that if you had the injury at 15 or 20, you would actually have the risk of having osteoarthritis before 40. So it's not only a condition affecting people that are middle-aged or older. Wow. the I guess the incidence is quite severe, like you say 50% in 50% of cases in 10 to 15 years. And it follows on with Paul asked a really nice question after he listened to the episode with Jonas and he asks, like after a partial menisectomy, does the amount of meniscal removal or the amount of damage that's done, does that correlate to an increased likelihood? Arthur is going to pull some surgery to help repair the meniscal injury. If it's quite a severe meniscal injury, does that increase the likelihood of osteoarthritis and vice versa? Yeah, definitely. The size of the injury, the meniscal tear is somewhat associated with the risk of having osteoarthritis later. Also because as I said before, it's a condition. osteotritis that is driven among others by mechanical factors. So an increased load on a greater part of the knee cartilage would increase the risk of having osteotritis. And I think another point in that direction that is important to mention is that the severity of the injury. For example if you have both a meniscal injury and an the risk of having osteoarthritis also seemed to increase as compared to only having the ACL tear or only having the meniscal tear. I suppose that would make sense if you're based on your explanation. If there's a severe meniscal damage, it just means that the distribution of load is more severely concentrated onto, I guess, healthier cartilage or remaining cartilage and therefore there's that increased likelihood of that severity just because of the load placement and load distribution, you could say. And so is there anything a runner could do if they wanted to try and decrease their risk of developing osteoarthritis or if they wanted to delay that onset? Like you said, there's around about a 10 to 15 year development for this osteoarthritis to start having an effect for most people. Is there something they can do to be like proactive to delay that onset or to reduce the risk of that onset? Well, first of all, we know from evidence that there are no difference in whether we start with surgical treatment or non-surgical treatment for these severe knee injuries in degenerative knee meniscal tears or in ACL tears. So we cannot say that we should suggest the patient to start with surgery or even start with non-surgical treatment. With that said, we know that one of the risk factors for having osteotritis is muscle strength or low muscle strength, reduced muscle strength. So one way to try to avoid or to at least prevent to some stage the osteotritis to develop is to increase muscle strength. It has primarily been focused on the quadriceps, but overall, low limb exercise is important, as well as core treatment or core exercises, of course. So that is at least one place where it would be important for a person who has sustained a meniscal tear to start working. Initially, of course, after at least if it's the trauma, it would require the typical... approach with resting and gradually increasing the activity. But over time, a good way to try to avoid the osteotritis would be to initiate exercises and also avoid being overweight or obese, which is another factor that is a risk factor for having osteotritis later on. Okay. And I guess when you're talking about that, it kind of sounds counterintuitive to what a lot of people might, or the path or experience that a lot of people might have, because if they have a meniscal injury and they say their knee flares up, if they overdo things, they're more likely to avoid things like strength work or avoid things like cardio to help with their weight management. And therefore you might see as the years go on, the actual knee and the whole like kinetic chain, the lower leg get weaker and weaker, which could actually be quite detrimental. But what you're saying is in a way to be proactive is actually to maintain strength and maintain a healthy weight, stay as active as possible. So is there a safe way to do that? Like are we basing on symptoms? Are we basing it on like a particular type of exercise that we talk about non-weight bearing exercises, are there any guidelines around that strength training? I guess, first of all, it's important to recognise that we're talking about the phase, not the initial phase after a trauma, but the later phase when kind of the initial trauma has been overcome through reducing the load and so on. But if we're talking about that phase, we know that Any type of exercise is good for people with degenerative meniscal terror and osteotritis. We know that focusing specifically on strengthening exercise could potentially reduce the risk of osteotritis. But other types of exercise like neuromuscular exercise, which is somewhat a combination of different types of exercise, but it has a more functional approach. It could be going up and down. of a step bench, it could be rising and sitting on a chair and then of course adding weight if that is necessary, but focusing on the actual movement, the alignment of the foot, knee and hip on a straight line instead of focusing on putting more and more weight on, it's the actual alignment that is important for that type of exercise. And that is weight bearing. And the same goes with the the strengthening exercise, we cannot say that it shouldn't be weight bearing. Of course, if it increases your knee pain, you should consult a physio and have adapted exercises, not just keep on going. But we cannot recommend one type of exercise over the other or say that we shouldn't go for weight bearing. It's really, really individual what is necessary. And then the cardio component of course is important also for a runner. And that's where you could start off by doing it on a bike. For example, if you're unable to run and then gradually increase your, your run and your distance and so on. I guess that's a really nice way of transitioning into running and running advice because, um, I think weight management and just, uh, running itself would have a really nice effect on. strength, strength of the knee, strength of the hips, strength of the ankle, and potentially helping with the, that, like I say, that neuromuscular control that you were talking about. So if someone is following, to say surgery after having a meniscal injury, and they're well into like the kind of end stage, they've done all their rehab, built up strength and remained or gained a lot of function. Is running still okay for this type of population if we know that there's such a high risk of developing this osteoarthritis because of that low distribution and loading of the joints might lead to an increased risk of developing OA? So is it advised that people run and what are the guidelines around that? Yeah, this is really a question that I got a lot when I were a clinician, not 10 years ago but... several years ago and a question that a lot of clinicians actually ask me now and patients for that matter. And you know, I've consulted my good colleague and friend Christian Barton, who is also an expert within this area to try to get an input on his both clinical but also research-wise perspective on it. And if we're talking about people who already have osteoarthritis or degenerative meniscal tear, who have had a meniscal tear... they should not be afraid of running. It is safe to continue to run and running does not seem to accelerate the progression of the osteoarthritis in middle-aged and older runners. So I guess the overall point to take home from that is that you shouldn't cease running just because you have a degenerative meniscus there. Of course you should try to adapt to any pain that you experience while running. It is advisable to add exercises to your day-to-day or weekly training program to stabilize and strengthen your joints. But it's not that we should avoid running. The same goes of course to try to prevent running or prevent osteoarthritis. We see kind of a U-shaped pattern when it comes to running or to activity in general. It's not good to be sedentary for development of knee and hip osteoarthritis. And on the other hand we see that people at elite level training for years and years who might even have had knee injuries are at a greater risk of developing osteoarthritis. All of us who are in between being sedentary and elite level athletes for many, many years, activity is good and running is good and it won't cause more osteoarthritis. Very encouraging to know for a lot of the running listeners that are, that are out there. And I think that, um, highlights a big misconception that a lot of people might have and a lot of people might be told because I can just see a lot of, um, non-runners. looking at someone who's had a meniscal tear, had operations and then has returned back to running, they'd be like, what the hell are you doing? Like, that's just, it sounds so counterintuitive, but it's good that the research might show that or experts might show that I am exactly the same way I follow the guidance of Christian Barton. He is, he's one of the, the heavyweights, the big like world-class heavyweights when it comes to the, this sort of advice. And I guess when it comes to running, I know it's not. specifically your field, but do you have any guidelines around like what surfaces we should be running on, like what shoes we should be wearing, like our technique, the terrain that we run on, do any of those principles apply? Well, there might be some benefit of modifying gait, but really we don't know. So I would be careful on trying to recommend some type or... certain type of exercises or approaches to running over others and the same goes for other things that we could adapt. That doesn't mean that it cannot work for the individual. It just means that the evidence around in this area isn't perfectly clear yet. So of course there are some, it could be clinical recommendations out there, but based on the evidence we cannot perfectly, we certainly say that we should run on. on specific shoes or cadence or whatever. It would be the individual who should evaluate whether they feel that the surface they run on makes their pain a bit worse, then they could of course go to a more soft running surface. On the other hand, some people with osteotritis feel that running on surface that is a bit more soft makes their... leg or knees a bit more unstable, which could also cause pain. So, so overall, you could say that I have no firm recommendations in the defeat this field, but that you should as an individual see what. You know, kind of evaluate or monitor how pain develops running in, on different surfaces and, and find what fits you. Yeah. I think that's very safe advice. And I agree. I'm glad that you point that out because in some runners, it's shown that If they're on softer surfaces like grass, they decrease their, their leg stiffness. And so if they're on concrete or on like a really firm surface, some runners just like that responsiveness from the ground. They respond really well to it and actually increase their leg stiffness, which is good, which increases their kind of their, uh, elastic recoil, their energy kind of efficiency. And so I guess the safe thing to do is to, like you say, try things out and as an individual see what's working for you and what isn't working for you. And I think particularly if you have had a meniscal injury or if you're following post surgery and you're into fully functioning, I think activity modification is something that people need to learn because training errors amongst runners is very prevalent. Like we're usually not as sensible as we should be. So like a a spike in mileage or a spike in say terrain. I think people who are, this type of population need to be very careful about how they manage their loads. And if they do have a sudden increase in mileage or speed or some abrupt shift that the knee might start to react. And it's not necessarily the knee getting worse. I don't think we should interpret it as the knee getting worse, but it just might get a bit stiff and sore. And so, Knowing that and moving forward, I think people, runners in general, should just be very careful about how they manage their loads, both inside their running weekly mileage and also outside their running weekly mileage with their exercises and say like doing stairs or just their general day-to-day activities. And like I say, we want to be as strong as we can, we want to be as active as we can, but any spikes in load might... produce these undesirable outcomes. So being very careful around that. Would you agree with that? Yeah, definitely. And just perhaps moving back to what we discussed before, the issue around whether or not to run and what clinicians recommend patients, kind of an anecdote from the study I mentioned to begin with, where we randomize people to knee replacement or no knee replacement. So that's end stage knee osteotritis in older people. We actually saw a group of the patients who were randomized to non-surgical treatment who started running after participating in the non-surgical treatment program. And to me that just clearly describes the potential. We can actually increase the function and the strength and the capacity, even all the people who are at the end stage of the knee osteoarthritis, so they can start running afterwards. Not that this is something everyone should do. But it just gives me an indication of how far we can go in some individuals. Yeah. And Rory has a question, which would be a nice flow into the conversation. He asks, what are the best ways to heal the meniscus tissue and whether you want to interpret that away that you say my best fit, but can we heal the meniscus, the meniscus itself? And if we can, or if we can't, what are some ways that, um, that are best managed? Yeah. So in general the healing potential of the menisci after an injury is not that good, actually quite poor compared to other tissue in the body where you also sustain injuries like in the muscles. And it's also influenced by the size and location of the tear and the age and activity level or other related injuries we talked about before. You can divide the menisci into different portions or areas of where they are located. What you could call the outer portion, which some call the red zone, has a good blood supply and can therefore, or is therefore more likely to be able to heal if the tear is small. In contrast, the inner two thirds of the menisci, which some call the white zone, does not have good supply and tears in this region are typically not as good as healing as the outer part. So in theory you could say that to help the menisci to heal in young adults the type of surgery called repair has been tried out but actually we do not know whether that type of surgery is better or not. in individuals who have a meniscal tear. Obviously it sounds good from a biomechanical perspective, but we also know that some of the people who actually have this repair later on actually end up undergoing surgery again. So that's up for the future to discover whether repair can help in this population of young adults with an acute meniscal tear. But generally I could say that the focus So people of 40 years or older and people with osteoarthritis shouldn't be on healing the meniscus. It should be on increasing function and decreasing pain. And that can be accomplished through exercise and education to help self-manage your conditions. So I would actually recommend that unless you are a young individual with an acute tear, to try to increase strength and function and not focus too much on the menisci. Of course, if you have an acute locking of your knee, that's different, but if you have clicking and popping, you shouldn't be that afraid of running and moving with it. I heard, I think it was J.F. Esculier who talked about this, who connected us with this interview. He mentioned when it comes to cartilage around the... particularly around the knee and the hip, that ground reaction force actually the act of running the act of jumping and landing might stimulate cartilage growth and might actually that the actual shock absorption itself might actually stimulate the cartilage to trigger it into some sort of stimulus to into some sort of growth and adaption. Is that what you see in your research when it comes to the acts such as running, jumping, landing and So my research is not that focused on the more mechanical aspects or the measurable aspects, but I have read a lot of the great work that J.F. Schoolyer and his colleagues have done. And I think what is important to say that in the healthy joint, the changes to the cartilage following running are transitioned. And there are of course some changes, but over time the cartilage will recover well from both single running bouts but also repeated exposures. This is of course different in clinical populations where you already have osteoarthritis or at least the developing osteoarthritis. We see that the quality of the cartilage in people who have had a meniscal tear can improve, but that's not the same as the size or the volume of the cartilage increases. And again, I think it's... important for us to focus not on things we see on the imaging but actually how people feel and their function and quality of life and there we see that these types of exercise and activity actually improve over time. If this is your favourite podcast and you want to have inner circle access and a VIP podcast experience then join our podcast Patreon Tribe. Mingle with like minded listeners. who love the podcast so much that they are happy to contribute $5 Aussie dollars per month to receive exclusive benefits and play a key role in the future direction of this podcast. So the first step is to click on the Patreon link in the show notes. Step 2 is to follow the instructions to subscribe and instructions on how to join the private Facebook group. You can cancel at any time. Step 3, log back into your Run Smarter app. and all the Patreon episodes will be unlocked for you to binge on. Step 4 is to keep active in the private Facebook group that's designed only for our patrons by voting on future podcast topics, submitting questions to future guests, interacting in our Facebook Live episodes, and helping me out with your feedback whenever I need your assistance for future podcast steps. So sign up and say hi to your new Patreon family and we'll see you there. the question written down here around, like misconceptions that you might hear around menisci and osteoarthritis and Jonas talked about a good misconception, which if someone comes in with a sore knee, they get scanned straight away and it reveals that there might there's a bit of a meniscus damage. It might be an incidental finding, but they automatically diagnose someone as having a sore meniscus and that might not actually correlate that is highly like relying on the scans and the scan findings. So that's one misconception that we might have. There's a few that you've also talked about here, which is actually to stay active, stay strong, and actually the sedentary population manages injury a lot worse because they are, I guess, not managing their weight as well. They're quite weak around that structure, around the whole lower leg. So... I can see a very common experience with meniscal injuries and osteoarthritis of a population that overdo things, their knee gets sore and they say, well, I've got meniscus injuries and like early onset osteoarthritis, so that's probably why it's sore. And they just back off for years, not really engaging the knee too much. And then as soon as they go for a walk for too long, it flares up again. And that's confirmation that in their mind, it's confirmation that exercise increases pain and decreases function and that's sort of the narrative they go along with as their pathology progresses because they're not being very proactive in those early days with maintaining their strength. So I guess that's another very common misconception. Is there any others that spring to your mind that we haven't discussed already? Yeah, I think in relation to what you said already, being sedentary is obvious not good. We know from evidence that just being somewhat active in your younger years or middle age, it would actually reduce the likelihood of you having lower limb symptoms later on. But another typical example is what we could call a weekend warrior, that is a person who go out in the weekend and do something, high load, high impact sport, and then they have pain in the knee for a week, and then they repeat that pattern over and over again. And that's the... That's just not a good approach for knee symptoms. And that's where the exercises for your joint comes in, and perhaps reducing the high impact, high load activities, if not for good, at least for a while, until you build up strength and your muscular capacity to participate in that type of activity. Another very important thing to highlight, which I know a lot. people are mentioning or patients are mentioning is that they think that exercise harms their knee and that pain during exercise is not good. That is something that we have been brought up with for years and years. I understand why this misconception is something that a lot of people think is true. But actually we know that exercising while or having pain while exercising is not necessarily bad. We typically use a 0 to 10 scale, so 0 is no pain and 10 is worst pain imaginable. We say to the patient, as long as your pain on this scale is not worse 24 hours after your activity or your exercise, then you have done no harm to your joint. As long as you feel that the pain is acceptable, on this 0 to 10 scale that could be up to 4 or 5, then it's not harmful for your joint. Sometimes it would require you to consult a physiotherapist or someone with similar skills in order to be sure that the activity you do is not harmful, but it's at least a couple of rule of thumbs that you could use in your life being physically active with adegentotrimoniscal tear or osteoarthritis. highlight that because I had that written down for my next question around the best management guidelines. And I think what we've already repeated was, you know, just make sure we're maintaining an active lifestyle, maintaining a lot of strength, maintaining a lot of cardio responses. And so my question was going to be around pain. And I think the listeners will be reassured to know that these are the same pain principles that I have for a lot of running related injuries, we want to make sure that Like we're not aiming, the aim shouldn't be for pain free exercise, especially if you've been managing an injury for quite a long time, you should actually find acceptable levels of pain, low levels of pain, but acceptable and having those kind of three snapshots that I always talk about the pain during the exercise, the pain following the exercise. So later on that day and then pain 24 hours later or the next day and making sure within those snapshots that there's no flare up, no like spike in symptoms and things to stay at a very acceptable level of pain or like you say, return to kind of baseline symptoms. So it'd be reassuring to know that these are principles that follow on into this particular population as well. Are there any other best management guidelines that we haven't really addressed yet? Or do you think we've covered all of them? I think we've been around a lot of the good management principles, I think. perhaps not relevant for a runner who is active and probably it's quite difficult to stay less active for a runner, but at least for their family members or friends. I think something that I've spent a lot of time trying to reiterate and say out loud for some years now is that although we have these guidelines for physical activity, which is 150 minutes of moderate to vigorous physical activity weekly. less can also do it. We know that less physical activity can actually prevent or reduce the symptoms you have from your joint. And we actually also know that more is better than nothing. So if you usually move 10 minutes per week, 20 minutes is better. And if you usually move 20, then 30 is better and so on. And I think this is a really important message to let everyone know because... Some might think, well, I don't meet the guidelines, so I can't get any benefit out from being just less physically active. But we know the health benefits is actually also true if you do less, and then you could gradually increase and try to reach the level that is recommended over time. In addition to that, I'd say that if you have pain, another important aspect in addition to... to maintaining a healthy weight and exercise is the self-management. And we have spoken a bit about it already, but something you could consider if you have pain is to try to find ways to reduce the load you have in your daily life. One good example is if you're molding your lawn and it takes one hour, then instead of trying to do the full one hour, you could divide it into smaller pieces like 20, which I think would actually help also decrease the pain you feel in your joints. So try to look at your day-to-day activities and see which activities are actually causing the pain. And can I reduce them or do anything to reduce the pain that I feel after participating in these activities? I think, um, back when I was working in clinics, Gardening would be the number one activity that people would participate in that I would just, for some reason, I just hate it because gardening was one of those activities, which there's awkward movements involved. There's bending, there's kneeling, there's twisting and kind of awkward movements that people aren't used to, but they would have a 15 minute gardening session to say, I just need to get rid of these weeds. It'd be 15 minutes. And then all of a sudden they're out there for two or three hours. And then they really, really saw the next day. So I'm glad that you kind of advise around that, those pacing strategies and making sure that people are aware of those sort of activities. Um, and I guess that goes on into general load management as well. Um, being doing things more frequently and more spread out throughout the week, rather than these big loads. Like you said, as an example for those weekend warriors who just are loading. Um, quite substantially on weekends, they're having a big spike, but they're not really doing much during the week because their knee is sore. You're more often, well, you're more, you'll fare a bit better if you spread those loads gradually more throughout the week. One of the questions I do have though, if someone is managing a chronic meniscal injury and they're managing fine with their running, they're maintaining quite high mileage and they've been fine. But then all of a sudden, they might have done something a bit too much and their knee is quite sore like they've had a flare up. What would be the best management principles for the next couple of days if they are quite stiff and quite sore? So first of all I think it's important to recognize that flare ups during activity is quite frequent. It's something that a lot of people with degenerative meniscal tear or osteoarthritis would experience. What we see is that when you participate in a supervised group-based exercise program, gradually these pain flare-ups would decrease over time. So I would say that at least if you haven't started the strengthening or neuromuscular exercise program yet, it would be a good chance for you to start with the program because over time you would then increase or decrease the risk of having these flare-ups. Other than that, the typical approach to handling injuries like the rest, the eyes and so on would be something that could be relevant to consider with the flare-up. And then gradually increase the activity, the running activity that you had before instead of just jumping right back into the activity or the frequency and intensity that you had before you had the flare-up. First of all, don't consider it as something that is necessarily something that is very harmful to your knee, but something that is normal and part of the process of having adjuvant or meniscal tear or osteoarthritis. I think laying down the expectations of the management is really important. Like you said, a flare-up is nothing that should be fearful or it's nothing that... should spark anxiety around people. It should just be just a normal part of expectations and their management moving forward. So I'm glad that you sort of address that. As we finish up, I think we've answered everything that I've got written down here. Are there any principles or any tips or anything around the meniscus and osteoarthritis that or maybe final takeaways that we haven't yet talked about? Or do you think we've covered everything? I think one thing that we haven't covered because that wasn't part of the program today is the importance and relevance of actually focusing on exercise prior to your injury. If we look to high impact sports like handball or football or soccer, whatever you would call it, we can actually see that a neuromuscular exercise program as part of your routine prior specific sport that you participate in can prevent the injury rate by around 50% in these high impact sports. Of course it's not the same for knee or for running because running is different from playing high impact sports. But I think there are some very interesting and relevant home messages from that. That is that trying to prevent the injury is really important and we know from running that it's... This is challenging and it is not that we have firm solid evidence that the same goes for running, but I think it's something that is relevant to focus on, to also build the strength prior to or to avoid, try to avoid an injury. It's always good to take that preventative approach and it's good to know the importance of that preventative approach as well. So a really nice message to finish up on. And like I said, I wanted to do an episode around meniscal injuries. And so I reached out to J for school year and I said, who's your, who should I reach out to? Who's your pick? And he's gone straight away like contact Soren. And I'm so glad that you agreed to come on to share this wisdom. I think. being a part of clinics and a part of all the research that you're a part of, just a world-class, really wealth of knowledge on this topic. So I'm really happy and very grateful that you've come on to share the knowledge. So thanks for coming on and sharing. Yeah, and thanks for inviting me. I think this is a really important aspect and I really want to congratulate you on bringing this up because it is really, really important. And that concludes another Run Smarter lesson. I hope you walk away from this episode feeling empowered and proud to be a Run Smarter scholar. Because when I think of runners like you who are listening, I think of runners who recognize the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated, active role in their rehab, who are looking for evidence-based long-term solutions. not accept problematic quick fixes. And last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your Run Smarter path.