What ACL Surgeons Won’t Tell You (But You NEED to Hear)

Podcast Intro and Guest Background 0:00

This is Dr. Jiu Jitsu, your go-to podcast for combat sports, military performance, injury prevention, and treatment. Now here's your badass host, Dr Megan Jimenez. Bow to your sensei. Hey guys, I'm Dr, Megan Menez, an orthopedic surgeon specializing in sports surgery and Jujitsu brown belt. I am here with my mentor and good friend Dr X who is originally from California and completed his medical school and training in Atlanta. was in Pittsburgh and at Vale for some of his training to be a sports surgeon.

He is very well versed in ACLs and that is his main focus. So I'm really excited to have him here today. Thanks for coming on. Anytime, thanks for having me. Yeah, it's awesome to you here and be in your awesome house. And I want to talk to about how you got into orthopedics. What brought you to this route? You know, it's kind of interesting. When I was probably in eighth grade and I had Osgood Slaughter, which is when you grow too fast and you have pain on the front of your knee and they wanted to bring us to the pediatrician, I wouldn't go because the guy a year before me that had it, the guys said, oh, you can't play sports for a And so I just didn't complain and didn t go.

It hurt, but I didn' want someone to tell me that. And then in high school, I was frustrated because every time you got hurt they send you to pediatrician. I mean, if you get lucky, you don't even know what orthopedist was, they sent you the orthopaedist. When I broke my thumb and then I had a guy who actually kind of understood sports a little more, that was really helpful for me because he you know, understood that I wanted to get back to play and then just say, well, let's just keep you out for three months.

And that kind of led me all through, played football in college and our team orthopedist, you was helpful, but again, not a guy who ever played the game.

Why Sports Doctors Need Athletic Experience 1:51

I said, I want to do that, But I wanna come at it from a different perspective because I've been there. and I think that is what made it my lifelong goal. Yeah, I think that's super important. Doctors participating in the sports that we're treating athletes in because, for example, with jujitsu with fight sports, have a whole different understanding of how athletes are hurting themselves. And, you know, when they get back to sport, hey, can I do this move? Can I? Do that move. So if you don't know you might just say you're out for three months.

Don't do anything. Absolutely. And I think when taking care of athletes, if you've played a sport and you train, especially something like football, there's contact, head injuries, it's violent. You train very similarly now to the way most other athletes are training. It's a lot of weightlifting, its explosive movements, you do endurance work, very different than being a cross-country runner. But I still think you have to learn about these sports. I didn't know much about Brazilian Jiu Jitsu but my roommate in college is a guy named Tim Lasek and Tim was a defensive tackle and a heavyweight wrestler and he was actually fought in I think UFC 29 or 30. One of those two.

And I learned a lot about because he started boxing then he start getting his other stuff and I didn't know what the hell it was but I just started watching him and Ken Shamrock and these other guys fighting in the UFC and you started to get some understanding on what's going on. Then you kind of become interested and, you know, spend a little time talking to people like you or Chris Hirazi or other, I've taken care of a bunch of MMA guys at this point. A lot of them, especially Brazilians, are all Jiu-Jitsu based.

So, you learn a lot about their sport and I think that's important with any sport you take care. Yeah. So with Jiu-Jitsu in particular, injury patterns, what's the worst you've ever seen? Or fight sports in general? You know, in fight sport, it's funny. You see the broken hands, you see a lot of dislocated shoulders. you don't see as much knee stuff. If you have a lower extremity injury, much like a baseball player, You're going to lose your power and your velocity. So like when we have baseball players who hurt their ACL, you know, we got to be very careful when you return them.

They're not going to return and throw really well within that first year. they're Not strong enough. You know they can throw again, but if you let them return to the mound too early, they are going hurt the shoulder and change their mechanics. So similarly with boxers or any strikers, You're going not to have the striking power if your lower extremities aren't strong. Yeah, it all comes from the base. Right. And then if you get into the wrestlers, you've got to be very careful what type of ACL you do on them.

They spend a lot of time on their knees, they need hyperflexion.

Common Fight-Sport Injuries and Knee Basics 4:38

Often times when we fix knees we'll say these people look fine and a football player could lose the ability to bend their knee. No one's going to take a footbal player and put their heel to their butt. Okay? Unless it's by accident. But you can do it in your sports. Yeah. When I was returning to sport after my ACL, I remember particularly being at one of the MRAPT facilities and they were like, oh, your range of motion is zero to 140 degrees. And I like that's not good. They were, like. That's excellent.

I said, no, i need like 160. Right. My knee to be sitting on my heels. So it's very different. It was one of my old football players who played for the Cowboys and he's coaching at Texas right now. He's a running back coach. And I did a simple operation on his knee. No big complex thing. But he played again two weeks later. It's in the playoffs. They interviewed him and said, how was your knee? He said fine, no problem. I talked to him. Tashard, how was your knee? It didn't hurt you? He goes, hell yeah, it hurt.

I said, well, you didn' t say that. He said they didn t ask me that, what they asked me was, How did I do? My knee did fine. If someone tackled me and pushed the heel to my butt, I would have passed out. And it teaches you a lot because we'll go in on these wrestlers and we' ll do a little simple little meniscal surgery. We're just trimming something up. But they're back training on the mat within a week. But if someone is riding them or someone in Jiu-Jitsu submits them, they are going to tap out.

I mean it's horrible and it takes time to get that flexion back. So those are the little things I think it is helpful to understand the sport when you're working with athletes. Yeah, and something you brought up there, a meniscus like trimming, right? That meniskus, they've heard the word, but they don't know what it is. And then when you talk about a trimming versus fixing it, you said he went back in a week. But if you're doing different surgeries on the menuscus, it's very important. When people are talking to people like us, my language is kind of one of a miscreant rather than someone who's trying to be smart, but you have to make sure you understand everything we're saying.

And if you don't, I try to like look at it and make it as simple as possible because the person needs to understand what's going on with their knee. Very similar to me, you coming in as a jujitsu person and telling me well I did this, got him in a kimura, did that and I'm going to go, okay I think I know what you mean but you better just kind of go over that slowly so I really understand you know, what your transition from move one to two is so i understand that. You have to be the same way and ask me those questions like that so I can explain it to you.

Like a meniscus is a piece of gristle that looks like a c-shape and it's a pad inside your knee like, a brake pad. If you tear it, part of it has blood supply. We can sew it together. That's called a repair. And when you sew together, that takes time to heal. But if it tears where there's no blood, then we just trim it That means I trim the meniscus but people get say oh my menuscus was repaired and use that to mean both things and it doesn't. But there's totally then I say hey you can get back as soon as you.

Can but realistically it's about six weeks for most athletes to get. Back working after a minute you, can do it sooner but you're gonna have pain. Yeah. All right. So there was a recent paper out in 2021 talking about most common jiu-jitsu injuries. I thought it was super interesting. Most people they talked to were competitors, so probably getting after it at a higher level. And what they showed was that the most commonly injury was the knee, to your point, the common ones being meniscus, ACL and MCL.

We kind of touched on meniskus a little bit. Can you talk a bit about ACL, MCl, surgery versus no surgery? Sure. You know, it's interesting, as I see more and more injuries, I'm starting to see guys 40 to 60 starting get involved in Jiu Jitsu who've never done wrestling or anything ever. And they're having a blast doing it. But you're seeing, so in that age group, we've seen a lot of groin injuries. Okay, and we're seeing a lot of, you know, because guys don't stretch, they lose pliability. And so, we've seen a lots of groins.

We're seen lot muscular tendinous injuries that aren't necessarily surgical. They're just irritating. In some cases, it could be debilitating. When you look at a knee, you got to think of your knee as just two bricks on top of each other and they're held together by four rubber bands. You got a rubber band on each side that prevents your brick from going this way and two rubberbands in the middle that control this and also rotation. the two most common injury to those rubber bands or the rubber band on the outside on that inside part of your knee that goes on you know right underneath

Meniscus Repair vs Trimming 9:26

your skin and that's called the MCL. Now the mcl is what some injury the Mcl happens when you get hit from the side. So think about it you. Know if someone strikes you, know kicks you a Muay Thai guy hitting you on outside of the knee. That's going to be an MCl injury. Okay, so that the first thing to go just like if you're a football player someone rolls into you When these offensive linemen, you'll see them in knee braces. That's usually not because of ACLs, although they think it helps their ACL.

It helps an MCL injury because if they get hit on the side, it actually stops their leg from bowing in. Now, those injuries are interesting because when I was in Pittsburgh, they would make the young guys see all these five foot tall, 350 pound women who slip on ice. Okay, very common injury up there the first time it snows. Trampolines, too. Yep, and they have MCL injuries. And why did they make us see them? Because they all heal. 90% of them, you very rarely have to operate on them. But they hurt for six to eight months.

So people keep coming back, it hurts, so you have explain to them and when orthopedists, we all hate when we can't fix something and it's going to heal over time because it doesn't make the patient happy. Okay, if we can't fix it and we know it's going to heal then we do a myriad of other things to try to get them to be happier with their situation. So MCLs heal and it is because it has a big thick wide ligament that is stuck between two planes. It's like a peanut butter and jelly sandwich. If you tear the jelly inside the bread but the Bread is still intact and the peanut butter is intact, it holds it there.

It just kind of all slushes together again and heals. The ACL is different. the ACL's like a rope and PCL are ropes on the inside of your knee which attach the bricks together. Now they're little ropes and if they pull apart and break they retract like rubber bands and then since they never go back together they don't heal. And then that's the problem because those injuries are usually getting hit from the side and rotating. If you watch football, it's almost always non-contact. They jump and they land on the knee.

You'll see it in the UFC. When guys, they'll go, you'll kick a guy and grab his leg and hold one of them. and then he jumps around, kind of that leg that's on the ground. He's being twisted, he lands. You'll see it with, again, if you get hit inside of the knee, oftentimes you'll tear the MCL, and if it's a big enough blow, you can tear that ACL on top of it. So you do both those things. And it is hard, that is a near impossible injury to compete with if your an MMA guy or a boxer. Now interestingly, there's been plenty of really good Jiu Jitsu guys who are ACL deficient.

because they're not spending much time on their legs. Most of the time, especially in Brazilian Jiu-Jitsu, they do their best work on the ground and you don't need an ACL for that.

ACL and MCL Injuries in Jiu-Jitsu 12:28

You need a ACL planning and pivoting and some people can get away without it. Yeah. And so we talked about planting and pivoting the main way, like football, soccer, anybody in those kinds of change direction type sports on their feet. In jujitsu though, it's often a contact type injury and it can happen a lot of ways. The legs locked up or how my way was a heel hook. Heel hook is one of the top three submissions for creating an issue in the knee. Yeah, your injury because you see it. In fact, I'm going to show your injuries.

I have to give a talk in Pittsburgh at the end of the year on ACL injuries and the other one that's on the internet. And I just saw it the day and this guy was doing like a, you know, the sit-up machines, but he planted his feet and he's leaning back with a weight and it goes back and you'll see both pop. So you're looking at these things. You realize that it's a rope. So if you put tension on it and keep going, it's going to break. Just like if your arm barring someone, you could break their arm.

It's no different with an ACL. And that's what you see in jujitsu. Like your injury, I knew it was coming. You could see it. Then you kind of rolled in and I'm like, and pop. Yep. So with ju jitsu as well, This is an opinion. I think a lot of people walk around with partial tears, maybe not full like mine, because that rotation happens kind of more slowly and you can spin. You can do things to kind relieve the tension and it's not totally too late where the whole knee explodes. And I know one of the best Brazilian Jiu Jitsu guys of all time.

who was a soccer player until he was about 12, because at 12 or 13, he had a knee injury. He didn't know what was going on. And then he has another injury and he said, you know, I can't play soccer too well. I'll get him in jujitsu. And he came to me with a complaint of the doctor because he had ACL injuries and two meniscal tears. They said they want to reconstruct them and it's a long recovery. And then when I have to start talking to him and looking at him, I realized that his ACLs have been out for 15 years.

From soccer or from Jiu-Jitsu? From Soccer. So we went in and just took care of his meniscus and on both sides and he did great. He did. I mean he finished out his career and you know he's coaching and doing other stuff now. Never had him fixed because he doesn't do anything that requires them and his style of fighting he didn't need his ACLs. So there are some people that we can say do not need the surgery and jujitsu I think may be one that you weigh the risks and benefits like I did and talk to people you trust.

So I mean I have wonderful colleagues and wonderful people in my network. How do you tell people to go find a doctor they can trust? Well, let me get back to that one point first. Hockey players, they don't need an ACL to play hockey, most of them. They used to not get their ACLs fixed 25 years ago. Why do they get them fixed, especially now? Because probably around in the mid-90s, when the penguins started getting big, hockey players. They were all little guys, the Wayne Gretzky type. Then you started getting the Samuelsons and Mario Lemieux.

These are big guys. 6'5", 240. And now they're training like football players, so they need to run, cut, clean, jerk. You need an ACL for all those activities. So you may not need it for the certain moves you're doing on the mat, but to train to be good at that and to cross train like all we all do now, you need a ACL. And I think the wrestling component of Jiu Jitsu, there are some... Especially if you're more of a Judo guy, then you need an ACL. You can't be a judo person without an ACL. So if you were to have somebody that said, look, I don't want my ACL touched, would they say, what could happen down the line?

Like, are there any repercussions to not doing it? Absolutely. The same guy that I told you about that did fine, lost both of his meniscus because he had an unstable knee and his Meniscius was doing more than many people's doing at tears. So when you have undiagnosed meniscal tears in young kid, all of them, if they do that and when they're under 14, every one of will have irreparable meniscule tear by the time they are 20. Okay. And that's what leads to arthritis and leads the problems with the knee.

So it's not as easy as, oh, I don't want to get it fixed. I'm going to go play. You know, you never hear during football, tore an ACL and we're going fix it at the end of the year. you hear tore the ACL. We're gonna get fixed, he's out for the years. In almost every sport, You hear that. Okay, so the sports involves running, jumping, cutting. It's to protect the knees and allow the athlete a longer lifespan. Yeah. Awesome. So talking about ACL surgeries, you indicate somebody for an ACL. What kind of talk do you have with athletes about what you're going to do?

So I think the important thing is if someone says, hey, do have an ACL tear, You've got to sit down and say, and have someone look at your knee and see how unstable you are, meaning how much they can move your need, And then talk to you about your goals are and what your training is like and how you feel. It's super important not to rush into surgery. ACL is not urgent surgery. The most important thing is when you have this injury, you're going to swell, You're gonna get stiff, is to get right back in the gym, get on a bike right away, work on getting your full motion out, getting it straight, bending it, Getting back to full lifting.

It's aggressive prehab. And as soon as you tear an ACL, the neurologic connection between your brain and your quad muscle gets disrupted because there's a nerve in the ACL that goes back to the spinal cord. And it's amazing because as long as do it, you're going to start losing size and strength. If people get put in a neomobilizer or it takes three weeks to get in to see a doctor, they're way behind the eight ball.

When ACL Surgery Is Needed 18:38

That's how we get them a lot because they went to the ER and they're in an e-mobilizer. Exactly. And it's the work of the devil. I hate it. So I have a website that as soon as someone says, hey, I got a knee injury, just send it to them. Because you're not going to hurt yourself by going on a stationary bike. If you get that thing working immediately and start getting your motion back and get your quad working, you are going do better sooner because an ACL is not a six-month thing. It takes nine months to get all your strength back, for the ligament itself to be strong enough to sustain a blow, and for you to start training aggressively again.

Then there's a difference between training and competing too. So, NBA basketball guys are some of the best athletes in the world. And you go and take care of these guys and they're back doing everything at nine months, okay? And by 12 months they say, I'm ready to go. Well, if you're one or two guard, you are not going to be ready for the NBA at that time. It's going take between 12 and 18 months to really play well. Most people are on the latter end of that. You know, I just had a guy that I fixed.

He's awesome. And he didn't mind me telling the story. But he came back, did well, but went from the NBA into the G League. and he was MVP of the g league the same year after he had his ACL done. That is unbelievable. Now, what people don't talk about is how great an athlete it takes to be in the nba. These guys are phenomenal athletes and the better athlete you are the, better you're going to do but even with those guys it takes time and I think the discussion I have with people right when they come in is number one get all your you know the prehab part and then number two the length of time it, takes and number three the re-injury rate.

Because I think you've got to drive that home, especially when younger athletes. It's not zero. Between 14 and 22 years old, elite athletes have a 10% chance of re-injuring their ACL, 15% of tearing their other one. That is a big number. With a patellar tendon or quad tendon ACL the best surgeon doing it and we have that data. That's not little, that's one in 10. You'd say, hey, I'll bet any day and 90% I'm going to go to Vegas and take that bet. Yeah, it's great unless you're in that 10%. Okay, because you are not just betting 100 bucks, you've been betting your life savings on this.

So I think that then I go in and talk to them about the actual surgery. That is the last thing I talk them apart because they have to understand what they are getting into, what do they need, and what can and can't do and they're looking at. Yeah, I think that the biggest thing that I have also implemented since my injury, because a lot has changed about how I approach ACLs since mine. I almost learned more than residency when I just going through mine, was when called you after I tore mine and I was so sad, like I'm out, this sucks, and you said, get on the bike right now.

And I said I am already there. So my right leg was bigger than my left leg going into surgery, my injured leg. Because I went to the gym every day. How long did you take before injury and surgery? A month, four weeks, but I was every day. On it immediately. Every day I'm in PT already doing proprioception, so single leg balancing stuff, strengthening my glutes, doing pistol squats. I would do everything. Leg pressing like a maniac. And I just wanted to be as strong as I could because that surgery is a second injury.

Yeah, absolutely. Then you're back to square one. So you don't want to back negative. Yeah, which you will be many people and they all want to rush into surgery. I'm like, no, just give it a little time. Yep. All right. And so the next thing you talked, you said quad versus BTB when you were mentioning the rates of injury. So let's talk about that. When you're looking at ACOs, You can fix them in two big groups, either using dead people tissue or using your own. There's dead people tissue is not a good option if you're under 30. If you are over 30, it can be a better option.

The older you get, the better and better. What are the downsides? The upside of it is it hurts a lot less. It's a faster surgery and the initial recovery is faster. With the dead, with the cadaver. You're getting dead tissue, so a dead guy you're borrowing his tissue. You don't borrow his ACL, you borrow the tendon from the front of his ankle usually is what we use. Keep it, don t give it back. Yeah, we keep it. We take it but when we used that it never totally becomes your tissue Some people, their body attacks it a little bit.

Other people they don't incorporate it. I mean, it doesn't heal in as well. And some people heal it in really well, but it's unpredictable. So the re-injury rate is higher. It kind of levels off at about 35. 35 and over, we tend to do a lot of cadaver grafts. Thirty-five and younger, We tend do do your own tissue. What's the oldest person that you've done their own tissues for? probably 54, and that's because they wanted it. Which leads us to the second big group is borrowing from yourself. So if you're going to, on a younger or higher level athlete, we're gonna take their own tissue and you can either take a little piece of their quad tendon from above the knee.

Some of their kneecap, bone, tendon, and bone from the front are some of the hamstring tendon. Now, the problem with the Hamstring Tendon is the failure rate is higher. And if you're a judo guy and you do a ham string on someone, they'll hate you because you can't heel hook.

ACL Graft Choices and Surgeon Preference 24:10

You're going to lose strength beyond 90 degrees of flexion. So, when you start pulling here, you are going lose some strength. I don't use that graft at all anymore. Patella tendons are good. It's a great graft. We've been using a long time. When you kneel on it, the chances of getting frontal knee pain are higher. So you spend a lot of time on your knees. That's the problem. Quad tendon doesn't have that issue and outcomes are almost exactly the same as patellar tendon. But the collateral damage is a aot less.

so that's kind of my go-to graft but there's you know outcomes wise there is really no difference between taking a quad and patellar tendon. Yeah, and I agree with you. I mean, I learned quad from you when I got to Atlanta because we were doing mostly the BTB, the patella tendon in training. When I see wrestlers or any type of jujitsu, anybody that's going to be on their knees when they're competing, do push them towards quad. But if any of my other athletes, usually give them the option between the two.

And I say, exactly, we're not doing hamstring because of the higher failure rates and then allograft is, or the cadavers out of question when there are young athletes. Right and I think the important thing is people get really caught up in the type of grafts and i think there's some bad like you have a 20 year old you don't want to do a cadaver or that's a bad choice the dead person graft but in that 20-year-old if your doctor says listen I do patella tendon I don' t do quads you want do with what he's comfortable doing or find another if you really want the quad you wanna find someone who's done them okay and so when you're picking a doctor if people are too dogmatic If they say, this is the best graft, you know, I'm not sure that's a true statement.

You could say this, is best graphed in my hands. That's, a good statement if they, say look I do you, know I, do all of them I say. Look you can you. Can choose this. This is what I would recommend your mentor when we start in about 2000. When did you train? What year? when I was a Dr. Mitava. Yeah. That was 2019 to 20. Okay. So he was getting into, at the time Matt's patellar tendon guy, Jim Bradley, Walt Lowe, other NFL guys were all patella tendon. And I have this stat in 2013, I think my 14, my first quad tendon went to the NFL and they downgraded them or say, well, we're going to, when you sit there and you look, they were going downgrade them.

Like in the combine. In the Combine. They took them in. When you evaluate everyone before the draft, now Walt Low is 70% quad and Jim Bradley's probably 35 to 40% quads and they don't downgrade them at all anymore. And Matt's, I don' t know what Matt is, he's doing a lot of quods now. So we evolve too. If someone doesn't want to evolve and is stuck in what they do, that's great if you're not doing very many of these. But I think you had to ask someone, and I know it's a valid statement, how many do you do a year?

And is this your primary area of focus? Or are you doing knee replacements or ankle replacements? Are you all over the place? And that allows you to pick someone who does a fair amount of these. The last thing I kind of want to talk to you about was with ACL injuries. So people come into the gym a lot, or they come see me and they say, hey, I had an ACL on this knee. And we just talked about what the importance is of the different types of grafts. You want know what exactly was done. But there's a of other injuries that can happen alongside an ACL.

How does that change things? What should people look out for? what kind questions should they ask their doctor to see if anything else is going on that is important? Right. So, an MC, if it's a significant MCL injury, not something the guy says, oh, on the MRI I saw, but you have a lot of pain on inside of your knee, you got to watch for stiffness. Those people, we got a move. If you're going to have ACL surgery, better get on a bike right away and you've got move I don't use like knee braces, I use them for most injuries, most ACL injuries.

MCL I will use. I want these people putting weight on it pretty quick and I wanna move in quick. Now, if you had damage to the end of the bone, your articular cartilage, and they had to repair that, that's going to slow things down significantly. If you had a meniscal repair, again, it depends on the doctor. Unless it's a huge repair I'm moving you just as fast. But you have to be aware that progression is not to get back to doing sport in the first three months or running in first 3 months, or jumping.

It's It's neuromuscular control, strength, and more strength. You've got to get the strength back. We want you to have neuromorphic control but often therapists are concentrating all that and not worrying about strength you can't do anything without strength So we start the leg extensions, leg curls, legs press, squats, lunges quickly. And it's not an ass to the grass type thing. It's doing squats slowly and where you're comfortable. But the faster we get your core region to your knees firing, the better off you are going to be.

Yeah. And I'm a big fan of BFR. I don't know if you send your athletes, I post a lot about it. It's like blood pressure cuffs on the thighs and it kind of decreases a little bit of the oxygen. So you're working in more of an anaerobic state because as athletes we want to be squatting more, we wanna be breaking our record, doing more. but you can't when you're right out. So, BFR allows you to do more reps and feel that intensity. Yeah, and BFR, especially in the beginning, once you do a straight contraction, then people find it very helpful.

It jumpstarts things. And sometimes, the hardest thing to after an ACL, as we know, is you see these people in their quads asleep. What are we gonna do? We gotta wake it up. Bfr is one of those things that people or athletes like. You don't need a million dollar cuff. You can use a rubber band. You could use your blood pressure cuff. I mean, the thing that costs a couple grand, it's a blood-pressure cuff and the PTs mostly have it. Yeah, I bought a set because I like to go to the gym and sometimes I'll put it on my arms.

And if I don't feel like lifting heavy that day, just get a light set in with a lot of reps. It's rough. You know, my son broke his ankle so he's got to work his calf. So we did BFR and he absolutely after he got rid of that thing is I never want to see that damn thing again. It sucks. I hate that it works. But he said that's good. And I'm not training with nothing ever again, so it's kind of funny.

Associated Injuries, Rehab, and Stiffness 30:40

Yeah, I mean and to your point with the quad being asleep I remember one of my first physical therapy sessions a week out. I couldn't lift my leg straight up and I started crying I was just like I knew this was going to happen right but when it happens you're just in total shock and you know I always call people on Sunday after the week after their surgery I say hey could you do a straight leg lift and then they get all kind of depressed well you 80% of them I can't Lift my Leg up. And I said okay, that's normal.

Can you contract your quad? They said I'm starting to see moving. I said good and you just keep at it and sooner or later they'll get it up. It usually happens within a week to 10 days so we don't get too upset and that's why I love to start walking on it or with crutches just put in weight because it helps that quad wake up Yeah. Another thing, stiffness, that we kind of talked about, just MCL injuries. I remember when I first started and I had a big lineman that had an MCO and called you and said, man, this is a Big Boy.

He's got higher grade MCl. And I was like, what are the biggest things that you look out for? And you said stiffness and not just mcls, even though they are more prone to getting stiff. After ACLs, people get so stiff. And I see, I have a bunch of friends post-op years out that can't sit on their heels. So how do you promote that safely in the beginning? Well, the most important thing we work on in being is extension. That's our being and existence. and I look at it and there's an orthopedic surgeon named Don Shelburne who's in his 70s now but he studied his patients and he's always said if you lose any extension, straightening, you're never going to get your strength back.

You're not going be as good and we look that and so if we're in three months and that person can't get his legs straight compared to the other side, we'll do a quick little three minute surgery to go in and take out scar tissue. Then they can get their legs straight, then they're going to get strong faster. No one wants to do that. And people ignore that, but you ignore in athletes, you're gonna have problems, especially if you know, look, if your, playing in the NFL, You may get away with that but You're not going be as strong as you were before and the average guy won't.

And then the bending usually comes back and while you're going to get as much extension as you are going get by probably three to four months after, it's not going more than that, flexion you going keep doing more and you got to push it. And you don't stop. You got do a child's pose and it is going hurt. Yeah, it's pushing it. Yeah. And I think you gotta, you know, if you're going to take the time to undergo this operation, an operation like an ACL, You got to buy into it because it is not hard.

You know there's an old movie called Brian Song about Brian Piccolo who died of cancer and Gail Sayers has an ACL and part of the movie was him coming back and this is archaic. ACL surgery, you know, in the 60s when they cut your whole knee open, ended your career most of the time. But the work that it takes to get better from that has never gotten easier. I mean I was doing two a day sometimes in PT just to get the swelling down. It's brutal. Especially when you're trying to have a real job and you are on the feet as much as you as an orthopedic surgeon.

I waited about five weeks to operate again but even then I would at the end of the day swollen and just really Cold tub. My ice baths, I know I got you into cold tubs. The icebaths became very important. I couldn't ice bathe for two weeks because I wanted my incisions to heal. So there's videos of my friends like lowering me into the ice path with my leg out so that the incision, because even just on the rest of body, that effect it has for inflammation. How do you like the Ice Bath? I love it. You know, for old guys, okay, so I'm old and I am stiff and you know you get in there and this is not like, you use a lot of things you can do that make you feel good like massage.

It makes you feels good. I don't know if anyone's ever shown a real benefit to it but we all like it and it makes me feel better. This is different because when you go in, there's a chemical reaction And I know it's happening because I get out of that thing, and I don't drink coffee, but it is like I drank shots of coffee without the jitteriness. And it lasts all day at work. It's addicting. So no drop. You don t drop like coffee. No, it s full on addricting. Because I wake up in the morning, t's miserable.

Then I warm up a little bit, do my workout. By the time I'm at the end of my work out, I look forward to just hopping in there. And you know, the first 30 seconds sucks. But then after that, it doesn't matter, you can stay in it forever. And then you get out and then there's that warming up is like energy exploding in your body and it's norepinephrine. Yeah, there is dopamine. Something's coming up. There's a real response happening because your bodies trying to make sure you don't die. So, but that stuff the rest of the day is awesome.

The funny thing is you said that you're... I don't think you are old. You said, oh, I'm old and stiff. So a lot of people think ice creating more stiffness. See, it's funny because we ice people. Ice should stop the enzymatic activity. People say, well, isn't that bad for healing? and you would think that if you ice just your ankle sometimes you feel like you're stiff afterwards but when you do it in your whole body I mean I every day I wake up with low back pain okay and I don't have I'm just arthritis and from squatting and cleaning and all that so I am stiff now if I take to a leave I feel better, right?

But who wants to take a leave every day? I don't and I'll forget. I mean, I guess sometimes you may need it. But when I get in that damn ice bath, if I'm really stiff in the morning before a workout, and then I got out and it's like I've spent 45 minutes warming up. And so that's not in my head. There's something going on there. People say, I don't know if there's data that backs it up.

Recovery Tools, Mindset, and Return to Sport 36:38

It's one of those things like it works for me and it worked for a lot of my... I was just telling you earlier, that I've had a bunch of buddies buy these things. who are my age, I'm 59 as of Saturday. And that's horrible, you kind of think, but when you get in your 50s, it's harder to keep your training doing the same because you got everything against you. Your body's wearing out, hormones are down. It's not the thing. You can't lift as hard because, not because your muscles can take it, because tendons and joints don't take.

So if I try to give up my kids and really lift, After about three weeks, I have tendonitis. So I had to cross train better and do different things. The recovery is so important. And I've done a few interviews with athletes in their 20s, young professional jujitsu athletes, and they all talk about recovery. But then I don't think that should change when you are not in that, even when coming out of that pro sport, if anything, increase that recovery so you can stay doing the things that you enjoy.

The one thing that I'll tell as you get older is you never can take off unless you're injured. Because when you take time off, sometimes it takes forever to get back. So the guys, if you continue what you are doing, and you've got to cross-train so you don't have these other issues, overuse issues. But the older you, are if they shut you down for two or three weeks, You know, my dad is 97. My dad worked out, he still works out. He walks, He swims, and during COVID, they shut down the pools. Now, you know he was in California when things were locked down.

They shut his gym down and they Shut his pools down, And that was brutal. I mean, They're worried about him getting COVID. And I'm worried, but he's worried About himself. It took a year, I don't know if he ever got back to the same level, But now that he is swimming every day, Yeah, just a month probably, deconditioned them. Oh, yeah. And it was actually more, it's like a six months period. It was brutal there. But if you do that in your 40s or 50s, I know you get busy, but figure out the time.

That's why I do everything early in the morning. No one's doing anything at five o'clock in morning except me. I get it all done, and I go to work. Then when I come home, all hell's broken loose and you can do anything. Yeah, it's super important, keeping up with it. And even in young people, doctors says, hey, look, you're out for X amount of months. Some of my athletes, they're like, okay, well, I'm done. I am not going to do anything. Just going sit on my couch, play video games. That is the worst thing that you can do.

It's a great thing because I always look at people and say, these high school kids, so you blew out your knee. Well, you know what? That sucks. There's nothing good about that. But you got to turn the negative into a positive. And the people that have embraced the training, the weightlifting, I have people come back bigger, stronger, faster, because they've never trained like that before. Especially female soccer players who all they do is play soccer all year round. They finally took a break from soccer and trained, and those girls come back as beasts.

They're strong and they feel different. And they'll tell you, man, that was the one positive after going through this is, yeah, I took time off from playing, but I am a stronger, faster athlete now that I've trained appropriately. Yeah. And we didn't really talk about the mindset part of it. I'm hoping to have a sports psychologist on too, because that's so, I thought that was bigger than the actual injury itself physically. Like my mind played so many games. Two days later, I'm with my like crutches and everything doing one-legged push-ups, doing pull- ups, like getting my upper body and on the track.

Right. And that helped my mind too. Because the PTSD from any of these injuries is real. If you've ever been injured, and it's not like I popped a hamstring, but if you ever had a trauma, got knocked out, if do get injured you're going to have to get through that PTSD part of things. It's real NACLs. It's so real because even when I started getting back to training, people were very nervous to get after my leg. And I was very. I would give up positions because I. Nope, you could have it if my knee was compromised at all.

But then after about a month or so, I actually need people to kind of people I trust to go after that leg and just put me in a little bit of a precarious situation, not where we can get injured, but where I have to defend it intelligently, where keep putting myself into it. Because the first time somebody put me in the position where I got injured, I was sweating. I stared at them and they freaked out and I said, it's okay, we're going to be good. That's why PPT is the 1st hit. You got to get drilled and then you say you know you're back.

It's a question people ask, how do you you ready to go back? We could test your strength, your biomechanics, everything. We have all these myriad of tests to do and we do a lot of it, But really, it comes down to two questions I ask them. Number one, if your good leg is 100%, what's your other leg? And if you say like, 95%, that's check one. You're ready. The second thing is there a little voice on your shoulder that says, you know, like little devil and angel thing. If you're worried in the back of your mind, that, hey, I mean, you're not ready yet, You got to progress more and get reps and Get used to it.

And that's called the fear index, we actually measure that. That's super important. You want both those things we have 95% I'm not worried, then you are ready to go. Yeah, awesome. Well, thanks so much. Is there anything else you wanted to add? No, that's good. It was fun talking to you. Yeah. Thanks. Where can people find you if they want to come see you? In Atlanta? I'm the only Dr. X in Atlanta. Happy to talk to anyone about their injuries, but I know a lot of people, if you need a recommendation or anything, I probably know people probably everywhere you guys live.

How do you say your last name? Zuroians. And it's spelled a little different. It's X-E-R-O-G- E-A-N-S. So everyone looked at that and says it is X. Yep. And if you type in Dr. X, that's pretty easy to find. I think it comes up. Or Emory X and I'm probably the only one. Yeah. Cool. All right. Well, thanks so much again. Appreciate it. An ironic media production. Visit us at I-r-o-n-i-c-k, media.com.