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Prof. Jonas Thorlund is Head of the Research Unit for Musculoskeletal Function and Physiotherapy at the University of Southern Denmark. His research interests are around knee meniscus injuries and developments in knee arthritis. Brodie chats to Jonas about the anatomy and physiology around acute and chronic meniscal injuries. They talk about common symptoms, tests to diagnose and potential pitfalls when relying too much on scans. Lastly, Jonas shares the research finding around surgery vs non-surgery for young and older populations and educates us on the evidence-based rehabilitation prinicples. 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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On today's episode, treatment and management of meniscal injuries with Professor Jonas Thorland. 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 back. I know this topic has been a long time coming. Uh, I know a lot of people have been reaching out and saying, where's a episode that I can find on meniscal injuries. And yeah, I was reluctant to start with because it wasn't much of a running related injury, but a lot of runners have faced it, whether they've been having meniscal injuries in the past, playing team sports or whether it's like a slow degenerative type of injury. And so, yeah, I thought I would try and find the best person for meniscal injuries. And so I reached out to JF Esquilier on Twitter. Um, he's a long time guest of the show and asked who he would recommend. And he recommended, um, first of all, he recommended, um, Sorin, who I've been in contact with, he's going to jump on the next episode, uh, contacted him. And he said, look, if we're talking about chronic meniscus and osteoarthritis, then it's right up my alley. But if you want to talk more about the acute side of injuries and what the research shows around the surgery for acute injuries, this is your man. And this was, um, Professor Jonas Thorland, who we're talking about today. He is a professor of musculoskeletal health at the University of Southern Denmark. He is the head of research unit of musculoskeletal function and physiotherapy. And he is just. Um, very well known amongst this particular topic, very heavily researched, done tons of papers on this particular injury. And so we delve into the science. Um, he does say in the interview, but he's not a practicing clinician. So he doesn't see people with these conditions and treats them per se, person to person, he is more on the research side of things, so finding publications, producing his own publications. coming up with systematic reviews around this injury. And so what we talk about today, along with all the patron questions, there was a ton that came in for this particular topic. But first of all, like the type of injuries that can happen, the type of severities that can happen around meniscal injuries, what are the signs symptoms, what are some treatments? We talk about surgery versus non-surgery, what are the risks of going into surgery or the risks of not having surgery. And a couple of differences between the acute setting and the chronic type of setting. I was going to initially set this up to have the more of the chronic side of things for next episode when we talk to Sorin, but it seems like you've got best of both worlds with this particular interview, and then we'll take a different shift talking to Sorin next episode more about more on the chronic side of things, but also the arthritis side of things as well. Okay. So without further ado, let's jump right into the interview. Professor Jonas Thorland, welcome to the podcast. Thank you very much. I think we might just dive in with people like learning more about you. So if you don't mind talking a little bit about where you're from, um, your career and background, how you got involved into this particular interest around, around these. Yeah, sure. So, um, I have a background in, uh, in sports science. Um, and after completing my degree in 2007, I, uh, took on a PhD about neuromuscular function in patients with meniscal tears. So that's how my interest about these patients with meniscal tears came about. And then during my PhD I spent time both at Rush University Medical Center in Chicago with Professor Joel Glock and I also visited Melbourne for a longer period of time where I was at Melbourne University with Professor Kim Ben-El's group. I consider myself as a clinical researcher. That's what I've developed into the past 10, 15 years. I'm not a clinician, so I don't have a clinical background, but a clinical researcher. Well, and you know, a lot of people know that I'm fairly big into the research side of things. I do like delving into the research. So speaking to a researcher who hasn't had a lot of clinical experience or seeing many people in the clinician setting is Very intriguing for me. I'm excited to dive into the topic today, but it seems like you've travelled all around the world for all just developing the skills that you have. I guess that's one of the perks of being a researcher that you see a lot of the world, which is something that we've missed out a lot on the last couple of years during the COVID pandemic. And we really look forward to being able to travel again. And as I've kind of prepped you beforehand, knowing that a lot of the people who listen to this podcast are mainly just recreational runners who don't have much of a science or research background for doing so much extensive work around the knees and around the meniscus. Do you have a best way of describing where the meniscus is, what the role is around it and like what purpose does it serve? Sure, I'll try my best. So Basically we have two menisci in each knee. One is located on the medial side which is you can explain that as the inside of the knee and the other one is located on the lateral side. There are basically two pieces of cartilage that are placed between the lower leg also known as the tibia and the upper leg known as the femur and the menisci have different functions. They are joint stability of the joint. But I think the most important things about the meniscus is their role in shock absorption and especially load distribution, which is probably also why damaged meniscus are very, it's a very bad thing in terms of, in terms of later development of osteoarthritis. Hmm. And so we're looking at something that's quite smooth and it just is positioned within the need to provide. Like you say that lubrication and kind of deepen the joint to provide a little bit of stability here and there. And so if it does get injured, um, what's happening exactly to, to the tissues itself, is it like a strain or is it like a tear? So I, I guess it could be both, but I guess the, the thing that you most typically see in the knee when you have damaged the meniscus is a tear to the meniscus and these tests, they come in different sizes of course and shapes and can also be located in different parts of the meniscus. Some of the most common types of tears, especially if it's a traumatic tear, that would be what you would call a longitudinal tear. So it's a tear that goes through the meniscus kind of in going through the entire meniscus along the meniscus and that can then extend into something that's typically known as a bucket handle tear. There are also other types of tears. You can have a horizontal tear, which can then involve into a flap tear, which is part of the meniscus kind of flapping inside the joint. Another common tear is a radial tear, which is more like a kind of like a cut from the middle of the meniscus in. And that can kind of also, when that becomes larger, it's also known as a parrot beak tear because it kind of resembles that. Right. And so if someone were to What would the mechanism need to be or like a common mechanism for a tear to kind of be created within this meniscus, keeping in mind that like a lot of runners assume or think that if they do have a meniscal tear that it's due to running. But to my best understanding, it's not necessarily a very common mechanism that would produce the tear. It's more like a sports environment. The typically kind of explained mechanism of a meniscal tear, that's kind of like it happens during a twisting of the knee. But there are some studies that looked at the meniscal tears in general and actually it's only about one third of meniscal tears that actually occur during sport. Then there's about one third that occurs during activities of daily living and that could both be like a major traumas like in an accident or something but a lot of them also happens like when you are squatting or bending in your knees and sometimes it's mostly explained that people have this sensation of something happening actually when they are rising up from a kneeling or squatting position and then actually at least one third of the tears they don't really have any clear history so they just gradually symptoms gradually occur over time. So I think it's very hard to give a very specific and general mechanism of the tear. And I would also say that it probably depends a lot on how the general environment in the knee joint is. You can either, in my opinion, you can either have a tear to a healthy meniscus or you could have a tear to an already degenerated meniscus. And clearly... probably not as much trauma is needed for a tear in an already degenerated meniscus as compared to a tear in a healthy meniscus. Okay. And would you maybe suspect that the degenerative meniscus is more found in the older population or someone who's quite deconditioned? Well, I think in general, in general, we... The thing is that there is really no, it's very hard to distinguish it and there's no clear cut between a traumatic and degenerative tear. There's this kind of gray zone where it can be very hard to determine if it's one or the other. But generally, I would say that if you look at a population that's aged 40 and older, you would probably have the vast majority of tears being of degenerative origin. And if you have a population that's below 40, you would probably have a population where the majority of tests would be of more traumatic origin. But again, traumatic tests may also occur in older people who have healthy meniscus. And again, degenerative tests could also happen in younger people that for some reason have a deconditioned or degenerative meniscus already because of perhaps prior trauma already. Yeah. So we're not. categorizing a certain age group or a certain activity level to one specific cause or one specific reason. I think it's taken me a while. We're at like 160 podcast episodes for me to discuss Meniscus because I thought that it's not much to do with the recreational runner. It's not a running related injury per se, but I have had a lot of people on Facebook or people on social media reach out to me saying, do you have an episode on knee Meniscus because they've either... had a history playing sports in the past, like that involved like some sort of cutting change in direction, they've damaged their meniscus or in the gym, they've damaged their meniscus but they love running and they want to resume running or continue participating in running. And so if there is a, I guess if there's a more likely a traumatic knee twisting, knees really sore afterwards, it most likely... Assume that you'd get scans or something, but if there's this third that you described that come on kind of asymptomatically, it was just a very gradual buildup where the meniscus do start to become a little bit more sore or worn out or injured. What would be some clear signs and symptoms for someone to suspect meniscus over another say common knee pathology? So typically the diagnosis would be. of a meniscal tear would be a combination of the history of the patient, what actually happened or did something really happen as you said, it could also be gradual onset. If you go see a doctor or an official who try to investigate your knee with this, if they suspect a meniscal tear, they will likely do a number of different clinical tests on your knee. They will probably test your range of motion of the knee. They will... most likely palpate your joint line for tenderness both along the lateral joint line, so the outside of the knee and also the medial side, the inside of the knee. They will probably also try and provoke your knee by twisting or compressing it in different types of positions and also while a diagnosis that's made up on a combination of things and the clinical experience of the clinician. And then sometimes you would do an MRI to try and confirm it. But one thing that is common with all these clinical tests and the symptoms that they actually provoke or make is that they are not very specific to a meniscal tear. So it's actually likely that you could have symptoms from other structures within the knee joint or for other reasons than a meniscal tear. So they are actually quite uncertain. And generally that's also why the diagnosis is typically made based on kind of like the overall clinical picture of what you find from the tests and the history that the patient tell the clinician. Hmm. It reminds me of doing tests around the shoulder back when I was working in clinics where you have to try and, or the, the patient itself would want a diagnosis of the shoulder injury. And there's like a whole barrage of tests that you can do for the shoulder. But a lot of them don't really, um, if it's positive or if it's painful to say, yes, you have this diagnosis, it's, it's very inaccurate. But if you start to do a multitude of tests and it starts to fit a pattern based on like combining a whole bunch of other tests, you can start to kind of have a little bit more of a picture and it can start being a little bit more accurate. And so what you're saying is with the combination of the history, asking questions about the symptoms and the onset of symptoms and then combining that with a few of these physio tests, you can sort of start to draw a conclusion or the likelihood of it potentially being a meniscal injury. Yeah, exactly. And then sometimes you have an MRI. that might confirm it's that you have a meniscal tear, but again, that's not necessarily a guarantee that your symptoms actually stem from the meniscal tear. And that's one of the tricky parts of, of this type of injury, especially among the older patients. And so if someone said they had pain doing deep squats or kneeling or doing stairs like the actual patient experience, we can't really draw any conclusions and say if you're experiencing this, the likelihood of it's more likely to be a meniscal tear. We can't really say anything like that. So I would probably say that if you have young patients that if you have a very clear memory of what happened and then you have tests that confirm a meniscal tear. And then you perhaps have an MRI that actually shows the tear. I would probably say that it's more likely that it's due to the meniscal tear. Whereas if you are an older patient who have other types of need in degeneration in your joint, it might as well be because you have osteoarthritis or starting osteoarthritis, it might be because of cyanobitis inside the knee or other. Other reasons that you cannot really see actually. I think clinically, what I've seen is someone who has knee pain, they can't really describe the location, it feels a little bit deep and they have a presenting symptom of like the stiffness. There's like stiffness within the joints, like moving, especially if there's a bit of a flare up, especially in mornings, like it actually just feels quite stiff. And if there's something like an ITB or something like a patellofemoral pain, it's It doesn't really present with stiffness. That's more pain rather than the stiffness. Um, have you found that to be a kind of common symptom when it comes to these like articular sort of pathologies? Well, uh, stiffness is, uh, one of the very common symptoms with it, with knee osteoarthritis, that's actually one of the hallmarks of osteoarthritis. And that is also one of the clinical criteria. If you, if you, uh, make a clinical diagnosis of osteoarthritis, then stiffness and especially morning stiffness would be one of the things that you would be asking the patient. And that's one of the indications that it could be osteoarthritis. We also see that stiffness is common in patients with meniscal tears, also in younger patients, but not to the extent as it is seen in middle-aged and older patients. And how about like swelling if someone's visibly seeing their knee, it's like a bit bigger as well as stiffness, but it's just a bit hot and a bit swollen. Would that maybe start to suspect something? Thanks. I'm not sure that would be very specific to a meniscal tear. It could be, but swelling is something that you see with many, many forms of injuries and pain in the knee joint and also in other joints for that matter. That could be a sign of inflammation or something more acute going on that you triggered for some reason, I would say. We've done a study actually where we looked at We asked about 650 patients with meniscal tests what their most common symptoms were. And what we found was that some of the most common symptoms was that they had some sort of feeling of the knee grinding or some sort of clicking sound. They also had knee pain in general, but also specifically on twisting the knee, on bending the knee fully and also something that very commonly came up with pain when going up and down stairs. So twisting the knee while, um, weight bearing. So while you're standing, um, so this was, this was self-reported. So it was not during a clinical test per se, but it was asked the patient, do you have a knee pain while twisting or pivoting your knee? Yeah. So maybe changing direction while walking, like examples like that. Exactly. Yeah. Oh, it could also be during sports, of course, depending on how you perceive the question when you asked. Sure. Yeah. I had a few patrons submit some questions to you. And one of them was Grant, which I think we've already passed his question. He said, how is this diagnosed compared to something else, which I think you've done a great job of explaining that. But Tony asks, some people have torn meniscus, but without symptoms. And it's only just revealed. after like when an MRI is done. So he's asking why does this happen and can a meniscus injury happen independently? Or is there some co injuries that go on? Well, I think the most clear answer to that question, why you can have an MNNISCUS tear on MRI without no symptoms is that the meniscus tear may not cause symptoms. It's There are not many nerves in the meniscus actually, and there's only blood supply in the inner one third. So it's not very innovative with nerves and there's not much blood supply. So I think that's one of the reasons that there might not be pain from a meniscus tear. And then some would say, I know other groups of researchers that say, so if you... This is especially if you do MRI scans of middle-aged and older people. There will be many of those who have a meniscal tear but have no symptoms. And they would basically argue, you know, when you get older, your skin also wrinkles. And this is basically what you see to the meniscus as well. This is having small tears to your meniscus fibrillations. That is basically just part of natural aging. And for some, that is what also develops into osteoarthritis. I think it's very important to talk around the subject of like an incidental finding when it comes to things like MRIs. And it's why you highlighted at the very start that we need to kind of match the athletes or the runners past history, their actual symptoms, the tests, and then the scans themselves. And I think a lot of people just cut straight to the scans and heavily rely on what is written on those reports. When in fact, it could just be... this incidental finding where the meniscus might just have all the blame, but might not be actually the cause of your symptoms. It could be something completely different. And so that's why we need to match all these things, particularly if you say like during a degenerative meniscus where these wrinkles might show it and might have like tears, like very small tears might just be totally normal within that population or within that individual and very rarely do people. scan an MRI the other knee that's asymptomatic when they're investigating something because they might just as well find other little tears and things on that side and talking with runners and they send me all their injury and scans and they're worried about certain scans but it doesn't really fit their patterns but they're really fixated on what the written report is. It's very important for people to know that they only just write what they pattern, it's not fitting the runner, all the radiographers job is to do is to look at a scan and just write what they see. Doesn't matter if they report what's going on. And I know in the past I suspected a fractured, a stress fracture in my foot and so I had it MRI'd and they commented on like mild to moderate osteoarthritis of your big toe and like all these other things. I'm like, that's not what I'm coming in for. Why are you writing this down on paper is just that's what they're trained to do. They're designed to write what they see. And so a lot of people can get really confused sometimes when the reports come back and sometimes they can be quite worried or anxious because it might be quite. The language that you use is very detrimental and it's very fearful and anxiety provoking. And so it's important that we do highlight the importance around these incidental findings. Yeah, I agree. I completely agree. And it's not only for the knee joint. This is seen, I guess this is basically for all joints that we investigate that we become more and more knowledgeable about the fact that a lot of things go on inside the knee that doesn't necessarily lead to symptoms. And there's been many studies in different parts of the joints, also the shoulder. And I think actually also the elbow showing that. If you have patients that have symptoms in one joint and then you take a scan of the other joint on the other side, then you more or less find the same actually. Thanks for your question, Tony. Also, second part of Tony's question was around, can a meniscus injury happen like independent, I guess with an acute injury, if there's like trauma, is it common for there just to be an isolated meniscus injury or is there other like ligaments and tendons that are affected? Well, I would say that it's quite common. Obviously, you can have it especially if you have a major trauma Meniscal tears are very commonly combined with an ACL tear anterior cruciate ligament tear it's very common to see meniscal tears in combination with those types of Injuries because they are often very traumatic I'm not sure how common it is with in terms of collateral ligament injuries. We don't see that much. But one thing that is very common in combination with the meniscal tests is different degrees of cartilage damage inside the joint. And I guess that's also especially in those middle aged and older people. That's that's basically part of. part of the degeneration of the joint that you have cartilage damage as well. So basically indications of osteoarthritis rather than perhaps the meniscus being the cause of the symptoms. So cartilage lesions are quite common and also actually if you have patients with traumatic knee injuries where you have a meniscal tear and then you often also see some sort of cartilage damage. treatment, rehab, surgery, that side of things. Paul asks, how important is it to have good rehab for avoiding injury, avoiding surgery, I should say. How important is rehab when it comes to maybe preventing surgery moving forward? And I guess talking about the acute setting, does it depend? I know sometimes when someone will get a scan, it's quite severe, say bucket some more inclined to operate straight away. So does it depend on the grade of the tear and what sort of guidelines are we following? So we recently, I had a colleague of mine who I supervised during his PhD and he actually did a study where we tried to see which patients do best and this was all patients in this study had surgery. And we were actually not able to find really anything that could predict if you had a poor or bad outcome. So in terms of what type of tear you have, that doesn't really seem to influence if you have a good or bad outcome, at least after surgery, which was what we investigated in that study. So I'm not sure how important it is that you have a very specific diagnosis on the type of tear that you have. And I guess with most knee injuries, one of the important things in combination with exercise therapy or rehabilitation is activity modification. And I think this is actually perhaps one of the most important things to remember that if you have an injured joint, you should definitely do rehab, but you also need to think that You have a joint that needs some extent of rest and you should be very, very careful on how you progress because I think that one of the most common reasons for knee injuries to keep coming back or keep annoying you as a patient is that you're too eager to get back to your sport. I know that from myself. I'm a very enthusiastic sports person myself. I often take, I've often taken myself when I had an injury in, in starting too soon. Um, it's actually going quite well. And then you think now I'm ready and then you start full on. And I think that's a very common mistake for most, um, both on the elite level, but also, especially among recreational athletes. And I think that's where it can be very, very good to kind of lean on a clinician that can help you in that process. I actually think they play a very big, big role there. And is there a certain presentation where you might lean someone towards conservative management versus surgery and vice versa? So, in terms of a meniscal test, we definitely know that if you are kind of like, if you're representative of this middle-aged and older persons who are more likely to have a degenerative meniscal tear, we would generally not, we would not recommend surgery because it doesn't, there are several studies that have shown really no benefit over placebo for surgery, but also that those who have exercise therapy, they do just as well. And even though that the risk of having complications is actually relatively small with a with a knee arthroscopy. you can be very unlucky and have a very poor outcome and actually infections that in some really, really rare cases lead to patient death. And I would not personally, you know, set myself at that risk if there's really no good evidence that surgery is better than exercise therapy. And there is really not for those who are middle-aged and older. For the younger population, it's somewhat different. We actually really don't know the best treatment. Generally, younger patients with traumatic meniscal tests has mainly been treated with surgery. And we don't know if exercise therapy is actually a good treatment for that population as well. There are two studies at the moment that are coming to an end, two European studies, one from Holland and one study that... that we are conducting comparing either surgery to exercise therapy or different treatment strategies so that one group has exercise therapy with the option of later surgery if it needed and the other group has early surgery that's in the study that we're doing. And we are kind of in the middle of getting the results from those studies. So I can't really tell yet what is the best treatment for those. Okay. So to summarise, if you are the middle aged, older aged population, you're representing this more of a degenerative meniscus, then surgery is most likely not a good option for you. But if you're younger, we're sort of like on the fence, we're not too sure how you'd fare whether you do surgery or just treat it conservatively with the strength training and like you say, those activity modifications. Exactly. Speaking of the, the exercise and the activity modifications, I think it's pretty indicative of like most running related injuries, especially like I've talked about this all the time on the podcast, if you are injured, it's all about finding like a level of fitness or an exercise that your injury and your structure can tolerate. And so maybe, um, say for example, squats might not be good for this particular injury, cause if you do some squats, it irritates the structure and you know, you, if you go on the bike, maybe that range of movement is actually quite good for the knee. So when it comes to the modification side of things, is it just about trying out a few different fitness exercises, a few different movements and seeing how that injury or how the knee would tolerate those exercise levels? So from the evidence from those trials on the middle-aged and older patients that we have, There are actually a few trials and they've used very different exercise therapy regimens and the different studies. Some are relatively low intensity exercise and actually a majority of, and in some of the studies the majority of the exercise was home exercises with elastic bands and things like that. So they've been in that range and then to very... intense heavy resistance training two times a week, almost to failure in some of the studies. When you compare them in the trials, they actually do more or less just as well in compared to surgery. So it's actually a little bit hard to say. We've done a small kind of study where we've tried to look into the quality of the exercise and the different trials and from This is a study that we have ongoing, but from the preliminary results that we have now, it looks like those studies who kind of have an exercise regimen that lives up to the standards of the American College of Sports Medicine's kind of recommendations for an exercise therapy program to have a physiological response, those who kind of live up to those, they seem to work better. So that would be kind of indicate a little bit more intensity, higher frequency and these kind of things. But in terms of specific exercises, which are the best, I don't think we can say that there's any real good evidence to say which is the best exercise for you. So I think it's a matter of trying out and if one exercise is really painful for you, I would recommend that you kind of. slow down on that exercise and perhaps choose another one. And then you can, after a couple of weeks, you can perhaps try again and see if it's better at that time. Hmm. So we're following kind of a very similar rebuilding rehab phase that we would for most injuries. And this being a running podcast, I need to ask, is it okay for, uh, someone who does have a meniscal injury, can they still run on it? Like if it's a, if it's an acute kind of structural issue, um, Is it just a trial and error and see how things go when it comes to running on this particular injury? So I think if you, if you have an acute error or an acute injury, I would never go out running on it straight away. I would definitely, you know, rest it, start some sort of exercise and rehab, and then I would very, very slowly start running again, but having a meniscal test, it's not like you can never start running again. I would not say that. Okay. So you'd follow general, I guess, protocols of going back after an injury, being very careful with the, with the progressing your running, both the length of the, of the running that you would do in your session, but also the intensity of the speed that you run with and then being, I know it sounds really dull, but it's just... It's really a matter of patience if you have an injury. There are simply too many posts competing for your eyeballs and I'd rest a lot easier knowing that runners who want this content are receiving it safely into their inbox. Plus the additional links and resources I include within my emails means you will get the upper hand than reading it on social media. So if this interests you, there'll be a sign up link in the show notes. Yeah, I think it's worth like. I guess summarizing this because if someone has had an acute injury, they've played sport, twisted, had this meniscal injury, very importantly you have time for that injury itself to rest. But when it comes to rehab and returning back to the sport or returning back to running, it's just following the principles of can you jump on the spot? Can you squat? Can you lunge? Can you... hop on one side compared to the other. Can you jog on the spot for a couple of minutes and then just slowly easing into like a walk run program and seeing how things tolerate. So you're doing a little bit and then just slowly adding a little bit more, a little bit more as symptoms allow. Would you agree with that? Are we following those sort of principles? I think that sounds very reasonable. Well I try and advise reason. and just being very sensible on the podcast. I'm glad that comes across. Uh, along like other common rehab practices, like, um, are there, I've got written down here, are there tests that we can do to determine if we're ready for running? But I think I've just talked about that anyway. Is there any other tests that you might want to administer to see if anyone's ready to resume running? I don't think, you know, I'm, I'm as a research, I always think about is, is there any good research evidence to guide us on this? And I, as you know, often, as you said in the beginning, we don't think about a meniscal injury as a typical running injury, though a lot of runners may have meniscal injuries, perhaps from running, but also for other reasons. I don't think that there is any. good research evidence to kind of guide us in terms of tests specifically for resuming running and meniscal injuries. I don't think I, yeah. I think it's just a simple case of like establishing, okay, what loads need to go through the body in order to run or what range of movement, what strength is required for the activity of running, just mimicking those and seeing how you fare. And if you fare okay, it makes clinical justification just to slowly start with small amounts. Rory asks, when it comes to the rehab, should we focus on other surrounding muscles and tendons such as he commented the popliteus muscle, which is at the back of the knee and also the ITB? Is there any principles that we follow regarding all those other muscles? Not specifically in relation to a meniscal tear. Again, what we can say is that the programs that have been looked at and this again, This is for the middle aged and older where there are evidence for the younger population. Under 40 years of age, we don't have any real good evidence about what is a good exercise program for those patients with meniscus test. It's likely going to be similar to those who are middle aged and older, but we don't know yet. And again, in those middle aged and older. patients, it seems like a variety of different exercise regimens work, not anyone that has any specific focus on the public areas on all the ITB band or yeah. Okay. I think I've already answered this one. So Richard asks, what are the pros and cons of surgery versus non surgery? When should one consider surgery? I might just rephrase the question. If someone has tried... Conservative management, they've tried doing their exercise rehab, they've tried very sensible return to sport, but the knee keeps letting them down, like symptoms keep flaring up and if that's a very common experience and they're following all the guidelines possible in that instance, would you maybe suggest they try surgery or would you recommend they just try other means of conservative management? So again, I think it depends on the history and the age of the patient. You know, if you have a young patient with a traumatic tear, that might be a good option. But if it's for those middle-aged and older patients who have degenerative meniscal tests, I, you know, we don't really have any good evidence that surgery should help. So I know it's a common, you know, it's a common saying that, okay, when the other things have failed, then we should try surgery. But why? try something that we know doesn't really work. Even though that other things have failed, I don't really follow that rationale. So I think if we have young people with traumatic tests, we don't know. And I think surgery has been an option for those patients for a long time. So before we have any good evidence to suggest that other types of treatments would be fine for those, surgery is definitely an option for those patients. For middle-aged and older patients, I don't think we have any good evidence. Unless, you know, you can have, and this is very rare, you have those patients that have a completely locked knee, where there's something stuck inside the knee, you cannot really move it. And this is not just, you know, small symptom of catching and locking, but patients who can really not objectively move their knee. This is basically, I would think this is probably how the procedure was invented in the first place that was to remove that thing that was stuck inside the knee. But this is a very rare type of patient actually seen in the clinic. Yeah. And if I could maybe explain, like sometimes the tear itself can become like a flap. And sometimes that flap can kind of fold onto itself. If I'm maybe just, maybe just using a very drugatory like image, but Um, when that flap does fold on top of itself, the knees got nowhere to move. Like the space, the joint space is now, um, I guess locked by that, that flap. Is that kind of what you're explaining or is, did I use a very poor example there? That could probably be, but you know, most times if, if that happens, then you, perhaps you can just twist your knee a little bit and then that kind of goes into place again, and then that's something that I wouldn't really not consider. as being a completely locked knee. It's, it's, you have those patients who can, for some reason, not straighten their knee or it's, they cannot flex it for some reason it's, it's really stuck. But those are, that's what we call a completely locked knee, but, and, but those patients are very rare. And most of those would probably come into, you know, that's P people who wouldn't be seen in the emergency room or something like that. When you're talking about surgery and it doesn't really matter the type of tear you see that the outcomes are very similar. Uh, are you seeing in, in the research, people that do have surgery for their meniscus, are they likely to achieve like a full rehab? Are they more, are they likely to return to sport or have a good outcome if their managements and their rehab steps are like in place following that surgery? So I think. Well, what we see and what has been seen from the studies is that those who have surgery, they do just as well as those who do exercise therapy basically. And I think one important thing to remember is that if you have a knee injury, it might be a meniscus injury or it might be any other type of knee injury. It's actually more uncommon than common that you will have to live with a knee that's never going to be real healthy again. So I think for most patients we see that they get a lot better over time, but they will never have a healthy knee again. And I think that's one of the things that you kind of have to come to terms with that if you've had a severe knee injury or another type of knee injury, this is something that you will probably have to live with for the rest of your life. And it may affect the level that you're playing at. Or it might be that you can play at the same level, but your knee might be sore afterwards and these kind of things. And then I think it's up to the individual person to kind of determine if it's kind of worth that. And then, of course, if you've had a knee injury, that's very clear data that us and many others have presented that if you've had a knee injury, your risk of osteoarthritis is just so much greater afterwards. And that's again, I think that. that comes down to the fact that it's, it's for most patients, they don't get the feeling of having a healthy knee again. Can you maybe, um, perhaps go into detail with that? Because when you say a knee injury, and if you have had a knee injury in the past increases the likelihood of arthritis in the future, is that excluding say like a patella femoral pain or ITB? Because I know knee injuries. are very prevalent amongst runners. And some of them might think that an ITB syndrome or patellofemoral pain or some sort of tendinopathy around the outside of the knee might fall within that same category. Um, can you maybe explain to, is that the, still the case for predicting osteoarthritis or arthritis in the future? I'm not entirely sure about those things that you, that that's a little bit, I would say, you know, if It definitely goes with these kind of injuries where you have kind of something going on inside the knee joint. So if there's cartilage damage, meniscus damage, if you have an anterior cruciate ligament injury where you often have a lot of other types of damage inside the knee. For those types of knee injuries, that definitely counts in what we call meta-analysis, systematic reviews and meta-analysis, where we kind of, you know, sum the entire evidence. knee injuries in general, and that would also encompass the things that you say they increase the risk of osteoarthritis, but it's mostly things like meniscal tears and ACL. That's kind of the big players in those types of studies where that's come across. But I would also think that other types of knee injuries would likely increase the risk, but I'm not sure to what extent. Okay. And when you're talking about say after surgery or after just a meniscal injury in general, that this might be something that they have to live with moving forward. It reminds me of very similar expectations that I have for people who have really chronic tendon issues, like if they have a chronic tendinopathy, Achilles has been causing them irritation for several years. I find that it's... It's important for them to realize expectation wise that they can still return to full function. They can return to pain-free activities. They can return to everything they want to do if their rehab is, I guess, set, set in a way to set them up for success. But if so happens, you do the wrong thing. If there's a little twist here and there, if there's a certain overload or an under recovery somewhere, if you've done something you probably shouldn't have, that's probably that tendon itself is probably going to spark itself up again. It's just something that's always going to pop up. I know in my case, like I've had plantar fasciitis a few times, I've had proximal hamstring tendinopathy on and off for the last maybe five plus years. And I know if I ever deviate from a set structure, if I do something too much, or if I sit too long, or if I spend too long standing still, like those injuries are still going to pop up here and there. I overcome them very quickly and I can still operate and perform at quite a high level once. because I still remain quite strong. So my level of function is quite high and my pain levels are pain free most of the time, but every now and then they're just going to resurface and sort of create havoc for a little bit. Is that a very similar experience for someone with meniscal injuries moving forward if they do the right things? Yeah. I would consider, you know, I'm Now you tell me about your personal experience. I have a very sore knee and I'm quite certain that if I went to have an MRI scan of my right knee, I would most likely have either osteoarthritis and perhaps also a meniscal tear. And I have exactly the same. If I have a period of time where I just overdo it a little bit because I become too enthusiastic. then it kind of flares up. Then I know I need to be a little bit more careful for a week or two. And then I'll be back to being able to play that at a certain level. So I think again, it comes to those activity modifications where you only basically, you can only ask yourself and your own body. But and then again, if you've had an injury that kind of limit when it starts hurting or having pain, it's probably changed. from when you had a completely healthy knee or shoulder or whatever where you have your injury. I like asking my guests if there's any misconceptions or any mistakes that you often see. And as you're not a clinician and seeing a lot of people with meniscal injuries, you're probably not seeing a lot of mistakes that people are making. But when it comes to misconceptions around this particular injury, Apart from what we've already discussed, is there anything else worth mentioning when it comes to misconceptions that you might hear? So I think one of the most common misconceptions that we see would be the concept about the symptomatic meniscus tear. And this very commonly comes about as we've discussed before, if you have an MRI of your knee joint and then you see the meniscus tear, you have symptoms and then suddenly... that tears becomes a symptomatic meniscus tear. And that is in many cases not necessarily true. It might be a lot of other things going on inside the knee that causes those symptoms. And again, if you took an MRI of the opposite knee, you could perhaps see the same. So I think that's one of the most common misconceptions that when you do the imaging, suddenly... that meniscus tear that you see becomes a symptomatic meniscus tear. And then it suddenly becomes an argument for intervention and most often surgery. Talking to a lot of runners, they're very quick to get scans. They're very quick to rely on getting scans. And some of them even bypass a health professional and go straight to their doctor. The doctor says, let's get scans. Then they have a look at the scan results. And so it's very important that when you're talking about these sort of experiences, you need to really match the past experience, what the trauma was like surrounding the injury, what the onset was like, do a few tests, see what that's like, and then you can piece the scan as just a piece of the puzzle, not the final result. And all those pieces need to fit in order for you to suspect, okay, let's treat it like a meniscus. I think that's, again, a very common... experience for someone just to get a scan and be like, Oh, didn't know I had a meniscal tear or meniscal damage. How do we proceed moving forward? And that can get really puzzling, very, very confusing very quickly. And so I'm glad that you, um, glad that you highlighted that. And as we wrap up any other final takeaways or any other final things that you may not have discussed. No, I think we've been covering most of the things actually. Yeah. Well, I think we've covered plenty, uh, especially when it comes to runners and rehab, um, So I want to thank you for coming on. I want to thank you for sharing. I know your colleagues coming on next to talk a bit more about meniscal injuries as well, and a bit more about arthritis within the knee. So I think it will be a good one, two combo to really cover all about the knee and all about the meniscus and the degenerative joint. And yeah, I'm really looking forward to that one as well. And so as we wrap up, thank you very much for sharing your wisdom. You're obviously. very knowledgeable in this topic. You've obviously had a vast extensive research on this topic and you speak like a true researcher of not adding in your own opinions and just following what the research shows and what the publications have shown amongst your work. And yeah, it's world-class. So thanks for coming on and sharing. Thank you for having me. 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 and will 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.