Understanding Synovial Cysts in Knee Replacement Surgery

In this conversation, Beau Beard discusses various aspects of healthcare, focusing on patient assessment, treatment strategies, and the complexities of conditions like Lyme disease and knee injuries. He shares insights from case studies, emphasizing the importance of confidence in treatment and the need for a functional approach in physical therapy. The dialogue also touches on the challenges faced by patients post-surgery and the role of functional medicine in managing chronic conditions.

Full Transcript

Beau Beard (00:00.014)

Get that as the intro. Good thing this camera's on my left. That's not just his creepy Catch Predator voice. That's damaged vocal cords right there. yeah. Can I make this full screen? No, whatever. Yeah, updates. Anything new? Last podcast. Mr. Trent. Yeah, we got his farewell dinner tonight. Last meal before death row. So what'd you pick?

Death Row meal. are you going with? Bittness. Just a bunch of ice cream. Yeah. Pancakes. I don't think we're going to the right place. Yeah. So Trent's last show. guess he'll be last dates tomorrow. Today's a Thursday when we're recording this. So we're going to head to dinner tonight. So we'll miss you. Well, let's put you on the spot here instead of doing it on Instagram. Oh man. No, we'll post it from here. Wow.

So what's one of your biggest takeaways from?

from being here at the farm besides learning the idiosyncrasies of Mr. Alex Coleman. I think just like being more confident in my assessment and treatment all the way around. learning how to look at function and treat function, I guess. Not just like worry about pain. Which I know everybody talks about it, but until you actually see somebody do it every day, day in day out.

It's kind of hard to figure out exactly what they mean unless we just say hey go shockwave them Yeah, I mean I appreciate that because hopefully that's what we're doing and As one of my mentors says Brett Winchester get kicked in the teeth long enough eventually just say I'm treating function Then he kind of don't care as much even though he still are But you're just like this what I'm doing and it makes your life a lot easier But it's like like you said, it's a lot of lip service sometimes. Yeah, that's what I'm doing and you get caught like I get caught sometimes like

Beau Beard (02:00.334)

I'm just trying to make them feel better. And sometimes you got to do that. So if we're talking about knee cases, the one we weren't going to talk about today was somebody that I think needs somebody to talk to about their knee case, somebody to rub their boo boo a little bit based on what they think's going on with the boo boo. And then, yeah, I think that's a big part of it. And we started on this whole functional route and it came around a weird turn to a little bit of a breakdown visit with some crying and yeah.

And then I was like, okay, I'm handle this a little bit different. So knee case that I don't think we were gonna talk about it. And I was like, I don't really think my knee has a big problem anymore. And you can call that chronic pain, but I don't even know if that's a good categorization for that patient. think it's just that they needed, had a bad college training room scenario going and had been treated by multiple people. I just think stuff got messy. yeah, to kick that off, let's actually start, if you don't mind, with.

your case. He's over here texting people about golf and now he's got a new driver. Find a mentor 2027. But Seth's got a good case because it's an abnormal case. Yeah, and I don't even really know what you're doing with it treatment wise at this point. So I'm interested. Yeah. So that's the other fun thing is I haven't really gotten to treat it, which we'll kind get to that as well. But

Junior in high school, I think she's 16 or 17 year old female. We got a text from our coach one weekend saying that her knee was swollen. Her left knee was swollen on the outside. Had no trauma done to it. She just was, I mean, like the normal diving that you do in volleyball. Woke up the next morning and noticed that her knee was just swollen. It was pretty...

She said it was also kind of red. And they also mentioned that there was like a rash around it. I didn't get the rash whenever it came into me. Okay, so that's kind of what I was like the forefront of what all I was told. So she shows up and there's like a little nodule underneath her like left kneecap. It's a lateral aspect of it. And it's pretty tender to touch. But...

Beau Beard (04:25.118)

In my assessment originally, had only found that like Thesales, right? So like bent knee twisting on it was the only thing that reproduced inner pain. She could kneel on it. She could jump up and down. I mean, she could do anything and everything. She's also super flexible. I she passes like pretty much all of SFMA and any of my like movement assessments, like with flying colors. So then it's kind of like, okay, well, why did this thing pop up?

She had at one point talked about that she had like dislocated her knee before, the Nutella had actually like gone out one time. She like extended her knee, right? Popped it back in place. But that was like a year or two ago. But she has noticed that as the more she plays, she has started having more and more like lateral knee pain. Just she doesn't notice it during the games. It's only when she gets done with the games. So,

I originally went after some knee extensions because that's the only thing that really was limited was extension of her knee. Nothing with low back. mean, couldn't reproduce anything with her low back. She's again, like she's super flexible. I mean, she's, crushes everything. She has some trigger points around the quad, but none of them reproduce the same pain that she was feeling. And also we can go super local and there's like a mass there and you push on it. It's kind of like,

It's tough not to be like, I got to chase function. It's like, well, that's the thing that's in front of you that's causing it. so I, I think I taped it that day and then also sent her home with knee extensions because she still had to play another game because there was a, it was a two day tournament on our Saturday. She still played on Sunday. So my goal was just to kind of make sure she could try and get through it before we went too heavy on like needling or anything like that. Came in two days later. It was a little bit larger.

and also said that walking around now is a little painful, but was not painful to jump, play volleyball or anything like that. So I sent her out for an MRI just to rule out anything that's there. Cause when you start seeing something that's kind of like red, a little warm, right? You start kind of thinking like infection is like one thing that I need to make sure she doesn't have. And also she wears like knee pads. So making sure like landing on things she's not having some type of, know, MRSA or something like that that's going on inside the knee that you just,

Beau Beard (06:52.96)

Not catching because you can't see maybe where the portal of entry was at. So that's kind of what I sent her home with, but she didn't have any nausea, have any vomiting, no fever, nothing like that. So it was kind of low, but also just to make sure I checked it off. Got the report back and she had a synovial cyst that popped up on the outside of the knee. That's kind of what you could see underneath the kneecap. And I want to say it was like a two and a half or three centimeter cyst. I mean, it's pretty large, big guy.

So yeah, we kind of just talk to the mom about what all we need to do with that. Which on the MRI, which I know we had talked about at one point, some of the reasons that you create a synovial cyst is obviously to be a protective barrier, just like any other tissue. So with the laxity that she has in her tissues, she's probably having some recurrent, small, needless locations that she doesn't realize, which they typically go laterally.

So she's probably just bombarding those tissues over and over and over again. And her tissues are like, hey, we got to do something about like maybe one, stabilizing this knee caps, we're going to put a little bolster up and two, protecting things on the outside. So that's kind of why that snow veal cyst forms. So we looked at the MRI as well. You can see that on her femur, it's pretty shallow. I mean, it's pretty flat across there. So...

There's not really a pocket that the patella really sits in, that little trochlear groove. There's not really anything there. And also the kneecap itself is a little less triangular in shape, it's a little bit flatter, which we kind of talked about lends itself to, she's probably gonna potentially have those continue because just structurally it sets her up for it. So then you get down to it, okay, well, what are you gonna do for the rest of the season?

Right? Do you pull her and it's like, needs to, for sure, need to go have a consult with an ortho. Or number two, are you like, hey, how bad does it hurt? It doesn't hurt her during her games. It doesn't really hurt her any other time except when she gets down playing. Doesn't feel it at rest, doesn't feel it any other time. So it's kind of like, do I pull her when she doesn't have any pain while she's playing? So then you go, okay, well, we could maybe get a brace that has some type of like patellar

Beau Beard (09:16.834)

stabilization piece on there, right? How effective is it? I have no idea, but at least it's something that is extra and that can maybe help to get her through the season. And so I explained all that to her mom and her mom's obviously like wanting to avoid surgery as much as possible, but also talking to her about like, I get that we want to avoid surgery, but at the same time, just looking for like long-term health, I don't want that to continue being an issue. And so...

I sent her home with...

trying to think. I haven't seen her in a few weeks because her mom was just like, she chose that she just wants to get through the season. They bought the brace and then she's actually coming back in today to get seen now. So I'm trying to think. I can't remember what all I did that I sent her home with. But I think it was like some single leg differentiation just to work on like foot, hip, just stabilization as much as we could. And then I think I also worked on some like, I think I sent her home with some Pogo's as well.

Just to kind of work on some stiffening of some tissues as well around her knee and ankle. But that was pretty much it. Just trying to keep it pretty basic as well. Because since her mom was like, we'll just do the brace for right now and then we'll consider other things down the road. What are your guys thoughts on, like you said, like a cyst is kind of tissue that's being bombarded or, know, in this case we could literally say maybe for one of the rare cases that there is like patellar tracking issues just because of like how the knees form, like this plastic change.

What do we think about like, that's basically a callus, right? You're just running into, you know, what are fibrocartilage or, know, some other tissue that kind of acts like an internal brace almost at this point, right? Like the kneecaps running into that big cyst. then I think it's kind of an interesting conundrum of like, if you just, cause I think that's pretty minor surgery. mean, you're moving a cyst. That should be like minor incision. They drain it. So like you're cutting it out through probably a tiny, you know, half inch hole, if not a quarter inch.

Beau Beard (11:17.134)

but I wonder if you would see a dislocation or something. See, I was just curious. I wonder how much that would affect that, I don't know. Did you guys or had you thought about or discussed with parents or would you like any, because I assume she was kind of hypermobile, which you're have more likelihood of collagen disorder, cystic formation, but other autoimmune things, knowing that that was also red and hot. Because yeah, you can have obviously a true...

I guess if it's a cyst, guess that's different than, you know, some sort of itis. But if it's red warm and maybe she had a rash, so skin thing, like maybe she's having an autoimmune issue and like that might be a bigger part of the, like why it hurts, why it flares up or gets bigger sometimes. Were there any other like health issues like known like that were discussed? Like sometimes you don't get, especially a teenage girl GI distress, stuff like that, which yeah. So we also talked about that one.

The mom says that she has Lyme disease because she got it chronically because she has Lyme disease. boy. So, try it. If that mom is listening and just listen to me say, boy, here's my take on that. There is an overabundance of diagnosis in the functional medicine world, in particular, Lyme disease, chronic or current Lyme disease where we test for antibodies.

My big question on that one, if you just look at the data of the diagnosis of people, A, it's supposed to be more Northeastern driven, right, based on the tick population. But if you looked at the people who spend the most time outdoors versus people who don't, and then the diagnosis skew, it's people that don't spend much time outdoors, which makes no sense to me. So we're either not very good at understanding what the test is testing for, or my take on this is we're diagnosing stuff.

it's wrong diagnosis 90 % of the time. So like I think of Steven or Nella, if you guys know who he is, meat eater, like he talks about like, legit got Lyme disease. Like he was going, he thought he had mercury poisoning from eating too much fish because his hands and arms or legs and feet were going numb or legs and hands, whatever. Going numb and he's like, yeah, I was having like visual disturbances and like headaches and stuff. And he goes, I don't know what's going on. He go, I thought I had like Giardia or something. Cause he's always back into camping. And then he went, he's like, Oh, I test possible Lyme. How did you like,

Beau Beard (13:40.462)

I'm gonna say six months antibiotics or something. He's like, yeah, I don't want to wait. It's like, that's Lyme disease. So this like low level, and again, I'm going on a tangent before reason, brain fog, I'm having like joint pain. mean, I'm just being honest. I know this is a 14 year old girl. It sounds like you didn't get Lyme disease to create hypermobility and all these things. You are more likely to have autoimmune issues if you're in that kind of phenotype. And I think that's.

good understand. And then the second thing would be there's no genetic pass on ability outside of genes that would create bigger inflammatory responses, different immune reactions to something once we had it. But that would also mean that she had to be exposed to Lyme disease from a vector. So that's my tangent on when we say these things, we got to make sure, could it be true? Because again, I don't know if that's.

I don't know if you know the parents diagnosis of the kid or if the kids even seen somebody because in my opinion like that's damaging to the kid and I don't agree with that. So I'm not a fan of that. Yeah. And I'm not trying to beat up the mom and I have no clue what the mom's scenario is. But to say if you ever had a tick bite with, you know, bullseye rash with immediate symptoms afterwards, it'd be really hard for me to just say, those antibodies test positive because I don't think we're good. Yeah. I go down a big rabbit hole. Anyways. Yeah.

I did not address it. I felt like unless it was hung everything on that, they're like, this is part of that. I'd like, and it is something that I probably am going to have to talk about maybe today or at some point, because a lot of things I, I still treat the mom and mom was a patient for mom. No, the daughter was a patient. got the mom after I treated the daughter and then I got this, another daughter of hers and I'm supposed to be seeing one of her sons as well. So it's.

It's a tricky one because like I've gotten a lot of referrals from treating the family, also like not just like bashing the entire family line of like, maybe we all don't have Lyme disease. Right. but I think again, you have an ethical, moral responsibilities of physicians. if somebody's being told something that's not true and you think it is kind of like in a way, why am I blanking on if you,

Beau Beard (16:05.198)

Pretend you're kid sick, munch housing. It's like a little munch housing type deal. think that's like damaging at some point. You're like, hey, they have Lyme disease. Like, what are you telling a kid that for the, hey, maybe there's never been tested or doesn't have it. Cause that's not different than telling a kid they have, I don't know, ADHD and they never really been tested. You're like, oh, there's hypers. Like, cause that's a, that's a very different thing.

You're like, well, how do you test for it? Yeah, it's a questionnaire. But then you're like, OK, there is a very big difference from somebody who literally can't operate in a normal day-to-day job, school, versus somebody who taps their leg like that all the time and snaps and sings. There's anxiety. There's ADA. You know what I mean? It's damaging. give a label. It's no different than what we talk about of, have Achilles tendonitis. It's like, do you?

Let's be sure before we tell you that because then you're going to go Google that and treat that or is it like your low back or firm pain in your Achilles or it's not tendonitis. Just like it hurts a little bit from sugar point. I don't know. I think it's no different than that. Which again, I think that's something I'm going to have to address at some point because it's also one of the reasons that the younger daughter that I also treat, she got pulled from public schools to be homeschooled because she needed the extra rest because you're more chronically tired when you have

Lyme disease. So wait, this is a different daughter? Mm hmm. my God. I treat I treat three of the family members right now. So again, if they're listening, I'm not beating you up here because I would put this disclaimer out because maybe somebody listens that they're like, that's my case. We're not beating you up, but like there is no way that is no way it is genetically passed. You may be able to pass antibodies, which would actually improve your response. I mean, that's epigenetics of like viral loads and

bacterial infections, there's no way. Like I said, you'd have genetic variants that make your reaction different to diseases, but the disease itself is not a genetically-like testin disease. And that's, yeah. And the way that I went around some of those topics was I discussed, because she's also pretty pale, right? So I just asked one, was like, how well are we sleeping? I just hit some of the very basics of.

Beau Beard (18:21.154)

high school females, I was like, how well are we sleeping? How well are we eating? That we feel like we're always chronically tired. Cause I know you have a lot of games and stuff like that for volleyball. I have a lot of practice. I get that. How well are we doing those other two things? obviously the, eating is not the greatest. She's like, she sleeps really well. She's like, she can sleep 10 to 12 hours a night, you know, no, no issues. we call week for Alex. He'd love that in a week actually. the,

The other one was, since she was pale, also asked, was like, how much are we actually getting outside? Because I do know that another thing, especially for my females is like low vitamin, or low vitamin D can also be a big contributor to some of some like low energy levels as well. So was like, how well are we doing some of those things? And the mom was like, well, she's going to have low vitamin D because it's chronically known that you're going to have low vitamin D with, with Lyme. And I was like, well, that if I told her, I was like, if we're going to go off of that, then we should be doing something about that.

at least looking in that realm. I mean, did you ask like, have they tested any of the girls? I had did not go on that. Because what that test Western block? Yeah. Yeah. So yeah. yeah, I don't know. Yeah, like me at my stage in my career, if somebody somebody's told me that I'm addressing right there, because I'm just like, you're in charge of your kid, you brought them to me for their health, you're telling them something that if I can determine it's absolutely not true, that's absolutely not true.

I there's not an opportunity for it. If there's an opportunity, have to kind of be like, okay, like I might still bring it up with a caveat, but with that I'd be like, that's just not how it is. And if they decide not to come back, be like, that's my job at this point is not to keep them here necessarily. would be like, what you're telling your kids is not true. And like now you're saying that is part of what we're treating. Like, the, you know, this low energy and stuff. It's like, yeah, like most kids nowadays suck at the basics.

eating, sleeping, oh, you sleep enough. Okay. Your diet sucks. You don't get outside. It would take vitamin D. That still doesn't change that you're not outside. Like, yeah, I don't know. That's a tough one. Um, yeah. Cause then we even go down the pathway of how old is a girl with the knee issue 16 or 17. So talk about low vitamin D and how it's going to like play around with their hormones and things like that at this age and how then that can contribute to cystic formation, um, even more or worse or change it.

Beau Beard (20:43.382)

those kind of things do matter. then if we like said, everything's led by this like, you know, thought pattern around Lyme that gets tough. Yeah. That's why I brought it to the table. Yeah, it's fun. Cause it's a... I'd like to know people, if you're listening, like how would you handle it? A, if somebody's got different thoughts, like, and I'm, I'm not saying I know everything by Lyme disease by a long shot, but I was told that I have low level, you know,

when we test this stuff. So as my wife with a functional medicine doctor, I've known tons of people that have, I've known people that actually have Lyme disease personally, and people like we were talking that are celebrities. Yeah, think it is kind of like, fibromyalgia is maybe a little bit different now, but it's like that. You're like, oh, you have all these symptoms, we know that you can have these symptoms with this thing, people will show up with antibodies to this thing, and I think that's, people are like, well, how do you have antibodies if you don't have it? How do people have, you know,

Epstein-Barr virus, know, antibodies that have seemingly never had mono or something like that. And then that's what they test for later in life for autoimmune things. It's like, I was never diagnosed with it. Like, oh, you probably had it. You just didn't get diagnosed. Is that, that's what we're just going to go off of? Like, I don't know. And then we treat that thing. That's where I have a big problem. If you're just like, oh, that's kind of weird that you have that. And then you don't address it. be like, okay, cool. That's a good thing to know maybe. Yeah. I just know that based on the guy that you talked about, like.

how much healthier he's gotten after the antibiotic stuff. And also our buddy Steven, that was at Logan, he also legitimately got Lyme disease as well. got bit by a tick, because he's just a guy who goes camping. Had a tick bite him, got the red bull's-eye rash. It's like napalm with antibiotics. Yeah, he had like three to six months or so where he was like heavy antibiotics, and now he's like the guy who's eating raw meat. And you're like, that shouldn't be a thing. I look at him, and I hear that guy, and then I look at

the family I treat and there's just a, there's a large difference. And again, we always say most likely the least likely thing is that you're the Lyme disease is the main factor of a low energy thing. And I'm, I'm game to be wrong, but like you would have to prove that to me unequivocally with like testing and like, how'd you get a, Oh, I dealt with an initial thing. Why aren't we treating it then if we know what the treatment is, that's the whole thing. So when we look at this again, functionally, we can do a quick segue into functional medicine.

Beau Beard (23:06.858)

What's the most common treatments for this like chronic recurrent Lyme disease stuff? It all, everybody hinges on what? Phase two detoxification. You need to clear those pathways because it's basically bombarded your body. That's why you're lethargic and that's like, why that doesn't make me okay. So we know how to treat it. And I know they're saying, it's in your body and you're just kind of having a memory. Like you're having an immune reaction, right?

Don't get it. That makes sense. At to me. I don't know. Same thing with EBV. Like I just think in this functional mass world, it's kind of like if we had to create a parallel to our world in musculoskeletal realm, it's like, it's kind of like, people are going to beat me up. It's like polykinesiology. Just making shit up. It's not that your muscle test wasn't weak. So that's true. It's not that you don't have the antibodies to EBV or Lyme. The correlation of this muscle test, you know, it's what I do treatment wise.

And then that true test, right? The test being what I do for treatment. think that's where the false is. You're creating a very loose, if no correlation than acting on it. I have a problem with that. That's just me. Bring it, attack me. Apply kinesiologist fans. If you got chronic Lyme disease and you're like, that's me. I mean, I'm thinking of arm pole massage therapist. And she got knocked out like quit because of like chronic Lyme. But she also stated that she had like had an acute episode and then had this massive flare up years later.

I won't deny that because you literally can say like, dude, I like, had, was six months antibiotics and it was terrible. Like that was one where I was like, and later she was like, I was really stressed out. I think it just flared up. I could buy that. Like I can't buy a kid that's never had it. know the mom is on a lot of different supplements and I do know that she's also been on antibiotics for two plus years. For what? For the lime.

Who's doing that? Apparently her, is it her rheumatologist maybe? Or whoever is treating that?

Beau Beard (25:19.438)

Again, maybe I poorly understand it but I don't know. I don't know. That makes sense. Like there's just, she listed out so many different things to me. I mean, I just had to have like the recording going because like I didn't, there's no way for me to be able to, she didn't have enough room in our intake box to write all of it down. And also explain how much of each one she was taking. I think my approach maybe if you're like, yeah, this is gonna be like, you're gonna burn a bridge.

you really lean on the fundamentals and like that's what you dog them on. So instead of dog in the disease state, right? Like, hey, what's your diet like? And then like really try to pin them down. Like they're like, oh, it's six out 10. is it six out of 10? And if like, oh, I sleep, it's like, oh, you might be in bed that long. Like are you actually sleeping? Like have ever tracked it? Like nail down hydration, sleep, diet, and be like, I want you to go all in on those and then prove them right or wrong. And again, I know that's hard because like you don't know if they're really doing it. They're just telling you, but then say like, how have you felt?

Be like, in the face of everything else he told me, that's what I'd still go with. Now, if you feel good enough that you feel like you don't have to take antibiotics, then at least you've shown them a change that's not correlated to what they're bringing to you. No different than if somebody comes in, they were told they got, I don't know, an atlas subluxation, like Trent was telling my patient yesterday. We're joking. And do I address that, or do I just say, well, hey, I...

we're gonna treat this. And then if you get changed, then you say, hey, we treated this, we had change. I'm not saying that's right or wrong. Just we're going this route and like, do feel better and dysfunctional changing? Yeah, cool. That's what we're going. Maybe you never address it. Maybe you get to know them well enough. You're like, well, that's kind of who we, in my opinion. Yeah, interesting case. Mine's a little different than that. I hope so. But still kind of a little confusion from the patient side. So.

I had a patient come in a little over a month ago now, super nice lady in her 60s. It had a partial knee replacement, which in her case is basically just a fake patella, right? With some supposed realignment stuff, which I'll talk about all that here in a second. Back in February of this year, or January, and then she did post-op PT for I think just six weeks is what she said. I didn't have to look at the note. Six, eight weeks. For the month after that initial post-op PT, she's like, I felt really good. But she never left PT.

Beau Beard (27:45.55)

doing any like weights or loading. was just kind of general range motion, some stabilization stuff, but literally no, she never did a lunge, never did split squat, never did a squat. So then she goes, then after that, I tried to get back into working out and it's kind of been a roller coaster. get kind of better, but not gone. And then worse. And now it's slowly just progressed to worse. And I was like, what's worse? just kind of aches and hurts all the time. It hurts going up and downstairs, especially going downstairs. So when we hear that kind of thing, my first thing is not injury, especially in her scenario. It's like, oh, you probably just not very good at going up and downstairs.

it's, what do we say, weakness or how you're doing it. So we started talking to her. She's a pretty healthy person. Like she's super active. She's able to play tennis or pickleball and golf and all this stuff. Wants to be as active as she can. Like she's motivated, wants to do everything. Big scar, obviously down the middle of her knee. So the first thing after we're talking and she moves awesome. Like she didn't have a whole lot of things where I'm like, this is like standout. Numb over scar. Like, okay, we can change that.

So why would we want to change that? If we can improve feedback over that scar, you're going to improve feedback to your, know, a spinal cord, then your, you know, sensory motor cortex. But then same thing with her. I was working on it and then she was kind of little, the person that's a little grossed out to touch her scar, right? With a lot of our knee patients. And I was like, you're going to do it with, she didn't, some people are like, oh no, she didn't have a problem with it. I was like, I'm going have you do it. So you're making a physical connection of like you do it. Cause she's like, well, can I use a tool? go, no, just use your hand. Right.

She did that, I would say as I saw her two or three days ago, she's like, it's probably 90 % back. Like it still doesn't feel perfect. And then from like skin movement, like over her patella or tendon, it was just like stuck. And now that moves awesome. So that's like, that was my biggest thing with her. was like, I think we need to improve feedback to decrease pain because no positive orthopedic test, knee range motion is absolutely perfect. Her patella glides and moves all around. The real reason she came into me besides the pain was she had went back to her surgeon and they wanted to do a revision surgery.

not a full knee replacement, a revision to work on her patellar tracking because her patellar tracking was off.

Beau Beard (29:51.89)

It wasn't like the lady can squat and lunge and like we worked on the nuance of it, but like Yeah, with no pain I'm flexing. She's pretty flexible full flexion. No pain full extension. No pain Nothing creates pain in her knee except when she's going up and down like in the office. We couldn't create pain We did lunges and stuff. She goes and I could kind of it's tight but no pain and then the longer she's on it So going downstairs at the end of the day, right all these things

So I was like, and I told her that confidently. was like, dude, you, A, I don't know if you needed the surgery to begin with. I don't know. And then I told her the story of my stepmom, that they wanted her to have the same surgery that they, that she did, a partial knee replacement with some sort of realignment. And I basically just told my stepmom, like, that's a kind of archaic surgery because partial knee replacements don't have a great success outcome rate, which here we have my grandma. Here's this patient, like, you know, all these people personally, plus the statistics. My stepmom,

Like that surgeon wanted her to get a knee replacement. She didn't want one. He goes, well, here's the second option. So it wasn't the best option. This lady, I don't think she needed this surgeon in the first place because her knee moves like a peach. Now, sup, patella? I mean, tell me you got crap at us in your knee and you know, a bunch of like, I bet she had a little degenerative change about her a little bit. And I'm just being honest. I don't think the surgery, don't know. I have no clue. didn't see her. So I can't say that. But based on what I see now, I can't imagine that was the case. So basically.

kind of reorganizing feedback through scar work. The bottom of kind of like the bottom quarter of both her quads are just stiff as bricks. It's like you can tell she hasn't gotten a deep knee flexion loaded for a long time, right? It's just stiff, full range of motion though. So you're like, okay, that's just kind of how she's operating. So I'm doing some soft tissue work in there, which she's like, that feels really good, even though it hurts. Immediately have her start doing like body weight, like front foot elevated split squats, just like, hey, load knee flexion, you know, get it moving.

and like no pain and she'd come back, she goes, it's a little bit better, it's a little bit better. And then literally I think I saw her three, maybe four times. I think it was three. I was like, you need to just go next door to our gym and start working out. Like you need to start loading this thing. And I go, I think that's, and she agreed with me. I go, I just don't think you did enough in PT, right? You just didn't kind of go hard enough in the paint. She wanted to do that. We kind of had some logistic stuff where she's going to be out of town and didn't get in the gym. So I saw her again one more time and she's like, how do think I'm doing? I was like, how do you think you're doing?

Beau Beard (32:14.392)

doesn't hurt going up and down stairs. She goes maybe a little bit again towards the end of the day, but she goes, I can do it and I don't think about it. That was our big functional check for her. She was saying the numbness tingling or whatever around her scars better. And then she just wanted a game plan while she's going to her daughter for the birth or second grandkid to just like do a circuit, like get stronger. And I was like, cool. So the reason I want to bring this one up is, being, as you started with like treating function, her function was really good.

Besides like, I talked to Tim Brown yesterday and he kind of has, I was like, do you have a hierarchy of just general things? He goes, this is the way I go. goes posture, which I know he gets like, I know a bunch of people laugh at that. He goes, I've been in practice for 40 years. He goes, can't tell me you can sit around like this and then perform at your optimum. If you don't think about that throughout the day, cause then you think about it in golf posture. Like everything else is posture driven. We're like, I can get away with this and do whatever. And like, which I get what he's saying. And you know, I can, I can play on both sides of that. The next one would be breathing.

The third one was mobility, which kind of plays into the FMS. Next one is stability. And he told a really interesting story, which I won't tell here about Mick fanning a pro surfer and kind of giving somebody more ability that entered in a big injury. Cause he didn't have enough time to work with them, but stability and then strength. This lady just never did the strength component. Not saying she breathes perfect or has great perfect posture, but she's really good, right? Top tier SMA, awesome. Balance was a little bit off. Can do a full deep squat. Okay. I mean,

some of the rarities that we don't see. So great function. So my no different than, you know, somebody comes in and like, Oh, I have Lyme disease. Like, do you or don't you? My first responsibility is, well, do I just use all my tools? Cause that's what you expect. No. Yeah. I do some tool work and I'm like, you're going to do that. Um, I do some stack on your quad. You're going to start from one your quad, right? Like quick as I can, like hand it off. So it's not me, it's her. And they'll be like, yeah, you're doing awesome. Like get out of my office. Like three visits, like bad business move, good business move, longterm.

And then being like unequivocal with your assessment because she was looking down the barrel of another surgery that was recommended. And I was like, I mean, you better be confident if you're like, no, that's a bad move. Cause I mean, then they go back to the surgeon, let's say she gets her, she's going to put down her stairs and knee pops and then she's back in surgery. Like, Dr. Tom, I didn't need it. Like, well, based on all this information. And on as another side note case, I talked about last time with softball pitcher, low back pain.

Beau Beard (34:40.494)

I pulled an extra on her two visits in because her mom was, I think we talked about this, she was complaining about pain with everything. Well, she ended up going on an ortho between last podcast and this one. Ortho did an MRI, showed a deem around the facet. So they shut her down. It's no different than what I thought it was. I just didn't think I needed to go far enough with the MRI because she seemed like she was doing okay. So obviously there's something changed since I saw her or it was just a low enough level bother that they went to an ortho. And now I kind of look like I have a little bit of egg on my face because of like.

thought you said nothing's going on. like, yeah, the x-ray showed nothing. If it's not bad enough for the x-ray and based on her pain level, I would keep going, which is exactly what I told him, saying that I was treating exactly what that MRI found, right? That the possibility of like a Pard's injury, stress reaction, spondylolysis, whatever. So that being said, same thing with her. You run the risk of being like, yeah, something could happen, right? You could fall on your knee. Because her biggest thing that she still doesn't want to do is put pressure on that knee, right? It's fake patella. I was like, that's where we gotta go just from a tolerance standpoint.

to start loading that. So yeah, she's just kind of an interesting one. She had nothing wrong with her knee besides numbness and like, yeah, stiffness in her quad, I guess. So going back to my step mom for a second, had a full knee replacement. One of her biggest complaints wasn't her knee, it was actually her low back. So she is six weeks out now and has been walking on a walker and that's protective so you don't fall and blow out your knee and stuff. And then going to PT and we just talked to her

a couple of ago and like her biggest thing was like, I don't feel my back at all. So that's why we also try to make these decisions. have a guy that's doing, or he did a console yesterday, which we talked about on here, of a hip replacement for low back pain. I'm curious to see what they said, I can imagine. But again, he called back in about his back and he's like, I really need to do something about this. you can, but you need to work on your hip or have somebody fix your hip or change it. So yeah, same thing here. Just like,

being confident based on your assessment, not just kind of drawing straws, which again, I can't, I would say I'm at a 70 % confidence interval with the whole Lyme disease conversation. Not super high, but it's above 50 for sure. So it's enough for me to talk about it be like, hey, I think we need to address this. Or you bring me all the information or I'd love to talk to your rheumatologist so I can learn more. Like maybe I don't know. Or maybe you talk to a rheumatologist and you're like, oh, think what you're telling me is kind of hooey. And then you're like,

Beau Beard (37:05.934)

I've talked to orthopedic surgeons, have told me stuff, and I'm like, I don't agree with that at all. some of it has been a good interaction where I told him that, and other ones, I'm thinking of one of our oldest patients, tennis player, it's not a photographer, you guys know who I'm talking about. His surgeon, you know, we disagreed on, because he wanted to do a surgery on his other hip. And was like, prophylactically, was like, what are you talking about? No, like, and great conversation, right? But I was unequivocal and like, no, I don't agree with that, and told him why, and he's like, okay, cool.

versus like, no, this is, I'm the surgeon, I'm right. It's like, if you get people that are willing to play, like, and I'll give a shout out and maybe we'll get them on the podcast, Dr. Matt Davis, him and I have been working on more cases together just as of late too. And like, it's good to have dialogue where I send somebody for, I know what's going on or he needs to manage, or I just sent somebody to like, hey, I'm not quite sure what's going on. He came back with something, I'm gonna be honest. I'm like, I don't know if that's it. We're getting further testing. We'll kind of find out maybe based on the test.

But it's not bad to disagree, but if you get working with somebody, whether that's you as a patient working with a physician, or a physician a physician, whether it's more argumentative rather than conversational, I that's a problem. To a certain extent, mean, if you feel like somebody is doing something wrong, obviously, how you handle that's up to you. Any questions on our OG lady that needs to go do some split squats with some weights? Speaking of like, replacements just in general, not necessarily her, people that have...

full or partial knee replacements, not wanting to put that knee on the ground. What are you doing for that? Like how am getting there? Yeah, cause they're just like, it just hurts so bad to put that on the ground. And I'm like, okay. think the two things, she can't have any of that sensitivity around there and that's going to drive it nuts. mean, well, that's true nervy stuff or just like how you process it. I think one of the biggest things is, which I'm trying to think who said like,

like a lunge hold where your knee's floating off the ground is like one of the best isometric loads for like your quad tendon and then like the top side, like, or sorry, front leg quad tendon, backside, like hip extender flexors, right? And just like hold that and you're gonna get a lot of bang for your buck. I think you could do that. And I bet you start to basically sensitize that, cause a lot of people have pain. Like she had some discomfort with that as the back leg in a split squat. Nothing in the front, we could load her knees over toes style, whatever you're call it. And like, she puts the back leg, she's like,

Beau Beard (39:25.71)

And that's probably how they're loading stuff or half forever. And I'd like, Hey, that's where we're going to sensitize. Um, and then I'd have her not like kneel and like a lunge and have her start sitting back on her heels. So we're still in full knee flexion to hang onto that. And then there's a little less just like compression on your kneecap. Cause you're like whole shins loaded and then work her back on the quadruped or whatever we're to do there. Cause I told her I'm going to do that like last time when who was in there with me and she's like, I said, well, how is it getting down on your knees? She goes, Oh, I still want to do that.

I go, okay, we're gonna do that when you come in. That's the biggest thing is I like every patient I have that has a knee replacement, they're like, my surgeon told me do not put any weight on this knee. Like don't kneel on it. The reason they say that is like, and I don't disagree with this, like an easy, not an easy way, a way to dislocate a knee that has dysplastic change or a shallow groove in the trochlea or whatever is to basically be on it in the pivot. I mean, which should make sense. I mean, that's how we relocate it.

push it in. So that's what they're saying is we wouldn't want somebody to like be on and then reach for something you literally like push it over the trochlea. I don't disagree with that. That's so different than what do they tell people with hip replacements? Don't cross your leg. I get the abduction. They think that you're going to have this like anterior inferior dislocation of your hip. Yeah, you're a hundred percent like, yeah. Or if do a very aggressive fey bear on somebody, I mean, okay, but I think of one of our

good friends and a patient that had a hip replacement years ago and then just had another one on the other hip. He was a professional ice skater forever and doesn't like that position. He's like, oh, I do this all the time. It's not that I just don't do it. goes, it just feels weird. And I, maybe that's what he was told. Um, but he's doing all sorts of crazy stuff. That's putting him in positions that are that. And then we think, oh, I can't do this, which is silly. He'll be out there cutting down trees and he's probably got one leg up on a log and he's been over and it's a big loaded.

abduction, flexion, then maybe, I'm not saying him, gets coached like, when I'm hanging around, I just can't cross my leg. And you're like, that's a silly thing. You might not have been doing that right after this. Or they're not doing yoga poses like Lotus or frog sits. You're like, yeah, we're just not going to push you there. But to say you're never going to do it, then you create another problem because you just expect to never grab something. Yeah. Or have to do it a different way for the rest of

Beau Beard (41:52.812)

And that's why I tell all my patients that go into a replacement surgery to make sure they know what the expected range of motion norm is after certain, not really the same. So again, based on how your knee is before you get a knee replacement, how deep your hip has to have, like all these things matter because some people will have full abduction, some wouldn't. And then to think like, I'm gonna push them there. You don't know the shape of their hip, which way their pelvis is rotated, like, you know, from a true torsion standpoint.

And then we're the, you know, maybe the dummy that are like, this side's perfect. That was a nonoperable. We get over here and there a year out and we're like, oh, they have 45 degrees. And you're like, we can do some stuff for that. And you're like budding right up against the joint surface, right? Which you should be able to feel from palpation. So yeah, it's just, again, it goes back to assessment. Like what's the norm, but some of that you got to rely on from the surgeon because you're literally the prosthesis itself is determining that for sure. Yeah. Uh, any other questions or ideas, thoughts? guess I just think it's important to know, um,

especially for the young people out there. like, so like after the surgery, you know, people go to PT, but just to ask like, what did you do in PT? Because I think we've seen a lot of people lately where they're just not loaded enough, especially for like their daily living. And that's truly what they need is just to be pushed farther. So not saying that PT did a bad job. Maybe they just ran out of visits, the scheduling conflicts, but they just needed more.

for being a active individual. Yeah, I'd say the most common thing I hear, I'm sure you guys hear it too, is we ran out of visits, so this is what they left me with. And then they hand them a big sheet of exercise, which they don't do. The other question I ask is, what was your return to play criteria, like return to life stuff? Most people, none, which is wild because if there's one profession that's supposed to hinge on that, because they're literally following the white paper of like, this is how you treat Achilles tendonopathy or post ACL, it's like, you should be able to do XYZ, and you just see a lot of people like, they don't ever get that.

You know, so if I had like my patient, elderly patient, physically active, you know they're gonna go back to it. Like I told her like why, I just can't imagine that somebody's gonna put somebody on like, you know, a bike and make them ride for 20 minutes, do general range motion stuff, very low level exercises like body weight. And then they never do like a wing gate test. Literally stepping up and down to see like how's your aerobic capacity match your ability to move around your knee. Which now is her problem, was her problem going up and down stairs.

Beau Beard (44:18.978)

I mean, it's just ridiculous. Like, can you do it? What was your rating? Which we have all that, you standardized and then like, you have pain? Like just that simple thing would like give us a good thing. I was like, Hey, can you keep walking? Right. And then can you do some step ups? That might be better than just whatever they sent it home with or nothing. So, which is still low level, but it's better than nothing. And it's based on something. It's not just the protocol. is why we also talk about a ton in here is like,

Yeah, after surgery, I want you going to PT so they can do some of the not fun stuff. But after like four weeks or so, hop back in here and let's just see and almost have a conversation of like, what are you doing? How are you doing them? Make sure you just have a check-in and be like, they're doing great. They can continue with whatever they're doing. Or like we've mentioned before, they...

need to tweak one exercise, one little thing, because maybe the PT is just like super full, they're super busy, may not be able to put eye eye contact on what they're doing. You switch one little technique and then like, continue doing that exercise just with this cue. And then they're like, that's where they could like start getting a lot better very quickly. What I'm paying with broad strokes, and I say this, but like post-op PT or outpatient PT for the most part to me is quantitative. Like we're trying to be more qualitative. Like we're trying to say like,

Yeah, it's great to split squats. You could also do a split squat and start driving your knee nuts. But some people are like, no, it's, know, form is not that important. Just like, no, come on. Yeah, I don't agree with that at all. So we're the qualitative, especially in that like four to six week. We're saying that in general, right? Big, big difference based on what's going on. But to see like, hey, you're doing this. And it's like, God, you're, you're not loading your foot. Like you're just leaning on the outside of your foot when you do whatever. Right? Like, we're like, that's not awesome. Right? It's going to show up later with something. We'd assume.

But I think people would disagree with us, but I'm just, you know, I'll stand on that soap box. But the further you go through PT, the more qualitative it should become because you're able to do more. Right. So it's not just range motions quantitative, right? your ability to whatever we're going off, like a side backs or quad sets, that's pretty quantitative still. Cause it's a certain amount of like sets and reps and weight that they're trying to get them to before they're like, now it's big movements. Now how do you do a lunge? Right. Or how you stand on one leg or whatever it is. yeah, I don't disagree with that at all.

Beau Beard (46:33.39)

That's what I'd like to see more of. it's not saying, and again, broad strokes, not saying that some PTs aren't doing that, especially maybe even in the outpatient setting. But if you have six people that you run around running through protocols, moving from like handergs to the table and doing some soft tissue, and then you have a PTA doing it, I'm not blaming you, but like, it's going to be harder in a fast food style to have quality versus like a one-on-one. I mean, that's no different than a higher-end restaurant. That's why it's different. So that's my take.

Anything else? Knees, knees, knees. All right. How many more do we got? This is 49. We got like six more episodes we can review in this season. that take us to the end of the year? that where we're trying to go? It goes through January a little bit because I had 10 of each. But we got some cool guests coming up. So like I said, I already did the Tim Brown podcast. We got Clay Gosparovitch, good friend of mine. DC coming out. On the dock, we got Courtney Conley. We got...

Dr. Clayton Skaggs, we got hopefully Dr. Matt Davis, orthopedic surgeon here locally, and then I'm gonna finish it up with like a wrap up show at the end of the season. yeah, lots of stuff coming. I think we're gonna talk about it quite a bit today. I wanted to talk about functional medicine cases, not where it's a whole functional medicine case, musculoskeletal where functional medicine became the bigger part of it. So I think that's what next show will be, but we'll see. See you guys next time.