Knee Pain: The Real Reason You’re Still Hurting ( How to Avoid a Replacement) with Dr. Aneesh Garg

Transcript

Speaker labels are inferred from the caption export’s turn markers (a short question is Nicole, the practice manager; the rest is Dr. Garg).

Hook: You’ve been told it’s arthritis, it’s your age, come back in three months 0:04

Dr. Garg: Welcome to the Regen Doc podcast powered by DynamicAthlete.com. I’m your host Dr. Aneesh Garg. I’m Yale trained, Andrews trained, and a two sport US national team doctor here to help you make sense of regenerative medicine. Knee pain, the real reason you’re still hurting. You’ve been told it’s arthritis. You’ve been told it’s your age. You’ve been handed a corticosteroid injection and told to come back in three months, but nobody has actually explained why your knee still hurts. And nobody’s told you there’s a whole category of treatments still sitting there between that corticosteroid shot, that cortisone shot, and a knee replacement. Let’s get into it.

The treatment gap nobody owns: pain, imaging, steroid shot, wait, replacement 0:52

Nicole: I’ve had knee pain for two years. My doctor says it’s arthritis and I should wait until I’m old enough for a replacement. Is that really all I can do?

Dr. Garg: The gap here is the standard pathway is pain, imaging, steroid injection, wait till you’re older, replacement. Nobody owns this middle space between that injection. Actually, I’ll even say between pain and replacement. If you’re going to the steroid injection first again, right, we’re trying to mask symptoms here. So, if you haven’t heard me on other podcasts where we talk about this, please don’t get a steroid injection for your knee arthritis. Unless you want to fast-track a knee replacement and get surgery quicker, then I would tell you that that’s your route. I think this is the challenge that people don’t know. what do I do between pain and getting a knee replacement or between pain and getting a steroid shot even? And so that’s where that’s where we talk about regenerative medicine and what the options are. So

What fills the gap: EMTT, focused shockwave, PRP, stem cells, hyaluronic acid 2:05

things like EMTT uh which is extra corprial magneto transduction therapy things like focused shockwave and again remember there’s there’s different ones out there and and we have a separate podcast for shockwave specifically and then also remember radial pressure waves. If somebody tells you radial shockwave that’s not true shock waves. So just be careful on that. And then plus on top of that that’ll hurt when when you’re trying to do that on bone. But that’s really the big thing here is people don’t know what to do between their pain and surgery. And so and I think that’s the biggest thing that that we’re trying to educate on. Arthritis also isn’t like a light switch where you just turn on and off. There’s a huge spectrum between mild and bone on bone. So imagine, you know, as people are are noticing that they’re starting to pay attention to their body a little bit more, and so you’re picking up on the early arthritis a little bit quicker, which is uh which is great because the earlier you can do something about it, the the better chance you have of slowing down, stopping, or even in some cases reversing that arthritis train. And I think that’s really the big thing that if you know your options early and have access to some of these things, I think it’s it’s a tremendous differencemaker in that arthritic knee space. So patients sit in this gap for years and don’t know what to do because that old paradigm still continues to to hold true where it’s that pain PT steroid injection surgery and and now you know when part of the reason why we started the podcast is so people can know what else is out there. I didn’t even talk about PRP or stem cells or hyaluronic acid, right? And and so in our clinic, if you look at hyaluronic acid, which is the gel injection that people that people get, if you do that by itself, there’s been studies to show that it’s less than 50% that it actually is beneficial by itself. Is it better than nothing? Yeah, absolutely. It’s better than nothing. So for the insurance companies that are arguing that it shouldn’t be covered by insurance in this respect, I disagree with them in that space, but we actually combine PRP with the hyaluronic acid. And there’s been numerous studies to show that that actually works better. So if you’re in the position where you can get PRP with your hyaluronic acid, do that 100 out of 100 times.

Your MRI is a picture, not a verdict: meniscus tears and arthritis 4:56

Nicole: So my MRI says I have a meniscus tear and arthritis. Does that mean I need surgery?

Dr. Garg: Yeah. What people get wrong here is that your MRI is a picture, not a verdict. So half of the people over 40 have some level of a meniscus tear but no pain. So now are we just treating the image or are we treating the person in front of us? And I think that’s really the the challenge, right? And so are we just doing a surgery just to do surgery because we saw it on an MRI. Hope these guys cut this out. Right. So all right. Um so I think that’s the challenge here is are we treating the image versus the person in front of us? And I think that’s really the the big component here. So part of the advantage that I think we have in the office is we have the patient right in front of us. So not only do we get to not only do we review the images, right, where where I’m looking at a certain thing and I have the patient in front of me and I say, “Okay, well here’s what I see on the MRI and here’s where you’re hurting or here’s what I see. does this correlate with where you’re hurting or so that gives me a huge advantage to be able to look at the MRI in a in a more detailed way. So I think that’s the challenge when you’re looking at a radiologist report and they’re doing the best they can in terms of trying to to find the pathology without very much history without very without being able to see the patient without be able to get an idea of where they hurt. So, they do a phenomenal job reading these images. I think that’s where it gives me a really big advantage to be able to look at the images, understand what I’m looking at, and then being able to explain it to our patient and to be able to have the patient in front of us. If you are ordering images and not looking at them yourself or have a really good understanding of it, I would tell you probably don’t order the image.

Who reads your MRI matters: get a sports medicine physician’s eyes on it 7:12

I know. I know. Which is fascinating and some of my colleagues may get upset here about this and I and it isn’t about the ordering component. It’s more about what’s afterward. So I can’t tell you how many times that I’ve had a discussion with my radiologist colleagues and said, “Hey, here’s what I see on the MRI. Here’s the history. Here’s who I have in front of me. Here’s where they hurt. Are you sure about this cut on the MRI or on this slice?” and they and we talk about it and they put an addendum in after speaking to me. The the flip side of that is imagine if you’re getting an MRI and somebody’s just reading the report to you and they say, “Oh, it’s normal.” Or you have this and then you’re like, “Well, how do you know?” Or like, you know, like, “Tell me what your thoughts are.” And they say, “Well, I just read the report.” I think if whoever is getting your MRI is just reading the report, I would this isn’t a walk out moment, but this is just saying, “Hey, I think we need somebody else’s help on this, right?” And I think that would be a a really good spot to have a regenerative medicine, a sports medicine physician on board to be able to interpret the MRI because, you know, my PT colleagues, they don’t have any training on this. I think, you know, when we had a practice in Chicago and Nashville, physical therapists could not order imaging. Here in Colorado, it’s different, totally fine. But I think that’s the I think that’s where the hang-up is a little bit where uh they tend to rely more just on the radiology reports and and in fairness to them, they just don’t have training in it. And so I think that’s where I think that’s where it can make a big difference. So that’s that’s really the the big thing that I look at that people get wrong here is that they just look at the image alone and then make a determined solely on that. There’s a whole bigger piece to the puzzle here. You know, that’s one thing in terms of making a really comprehensive diagnosis. So I think the it isn’t really a question of what the MRI shows. It’s actually what’s going on, what’s generating your pain. So I think that’s what people need to look at. And so if any of this is hitting home, this is what I would tell you. Go and look at DynamicAthlete.com. I think this is going to give you a lot of information in terms of what could be causing your pain and take a look around and see if it feels right for you. But dynamic.com has got a wealth of resources for you to be able to be more informed.

Are you a candidate? No 100% guarantees, and why PRP dosing matters 9:49

Dr. Garg: So what should I actually be asking my doctor before I agree to anything? I think what matters here is are you a candidate? Is the cartilage damaged? Is the tissue environment failing to support what I’m trying to do? I think for us, we always look at is this person going to succeed with what we’re trying to do like reasonably. You know, there’s no 100% guaranteed anything. I I would tell you the same thing that if somebody’s guaranteeing you 100% outcome, be very suspicious. Be very cautious because nothing is 100%. You could be perfect in every technical component. You could be a great candidate and sometimes it just doesn’t work. Like even in our office, like when we’re when our success rate is over 90%, right? And I even tell patients, I go, “Somebody’s got to be in the 10%.” and and it might be you but you know even even our success rates probably even higher than the 90 but I think just having that understanding that we’re doing the best we can and how do you mitigate and how do you lessen the chances of somebody being in a 10% are they a good candidate for what you’re doing do you have a good reason for why you’re doing um I and you look at even a steroid injection so I’ve been very clear on my disdain my absolute disdain for steroid injections because all they do is mask symptoms and not help. And then you start to see how PRP outperforms steroid injections headtohead. I mean, it’s pretty it’s pretty evident. Now, the caveat here is people will pull up studies and say, “Well, PRP doesn’t work against steroid injections or this and that.” It’s the type of PRP in that study that is substandard that people are quoting. And I go back to the same thing. It’s like if you’re supposed to take two scoops of protein powder and you take half a scoop and then you declare to the world, you go up on a mountain, you say, “Protein powder doesn’t work. I’m not getting stronger. It doesn’t help me or whatever.” It’s because the dosing is not right. Right? You don’t take the pediatric the kids version of a medicine for an adult and then say the medicine doesn’t work. Why are you doing this? Why are you allowing this from a PRP standpoint or biologic standpoint or even shockwave? I’ll tell you there’s people that come in and and like, well, here’s what I did. And I look at them, I go, what what are we doing here? Right? When they come in for training at the American Shockwave Training Institute when we when we teach them, uh, and this is sort of why even in Boulder and when we talk about shockwave, even for arthritis, people will come into the clinic and say, “I’ve had shockwave before. or it doesn’t work for me, right? And then I ask them what it is and they’ll say, “I’ve had this and and it’s a broad unfocused device or I’ve had the radial pressure waves, which again, right, it’s these are not hitting what they’re supposed to be hitting.” So, um, you you start to

Buying back time: the math on 15 months of function 13:00

look at this and and dosing matters kind of in this regard. So, and the other thing too to look at here is that if surgery is in your future, so be it, right? That that ends up happening. And so, the goal is to buy back some time. And that’s a big thing that we always say in the office. We’re buying back time. We get the ability to buy back time. Your greatest resource, your most valuable resource, your time, we get to buy back. What do I mean by that? Imagine you’re having two years of pain, but instead of going the route that you went, which is the PT steroid route, you went and you said, “Okay, I’m going to get shockwave and PRP and hyaluronic acid or stem cells or whatever.” And now after 6 to 12 weeks, you’re 95 to 100% better. And now you’ve bought back essentially 15 months. If we go three months that you are that you are, you know, in getting treatment and I’m just saying that’s a year and a half, right? Take the average. So 18 months. So you subtract the three you’re 15 months. So we’ve bought back 15 months of significantly less pain. So that’s what I mean by buying back years of function. So that’s what we’re trying to do is we’re not trying to eliminate surgery. Although there’s a lot of cases where you can and negate the need for surgery, but even in those instances where surgery’s coming, we can hold that off. And I think that’s really important. We’re just going to cut here for a second. Let me flip Make sure we’re good there. All right, let’s do it.

The trail runner told he needed a replacement, and the three takeaways 15:03

Nicole: What does the patient experience look like for someone who came to you with bad knee pain?

Dr. Garg: Yeah. So, we’ll give you like the patient side of this and we’ll use an example like we had a 50-year-old trail runner told he had a knee replacement in his future. Um, came in frustrated, defeated. PRPL PL um shockwave PRP in a targeted rehab protocol. He’s back on the trail running in 12 weeks. Still two years later, he’s doing this. So, we talk about buying back time, right? The EMTT actually. So, what we did was EMTT, focused shockwave, and PRP with hyaluronic acid. And this is actually targeting the tissue. So if you look at the arthritic bone, what we’re targeting is that subcondrial bone, which is fancy way of saying bone underneath, right? Sub underneath, condr bone. And we’re targeting that with the EMTT and shockwave. So now we’re creating a better environment. And then you start to use the the healing and transformative effects of the PRP combining it with the hyaluronic acid. This gives you a significantly better environment for your knee pain to slow down or even in some cases if we’re using stem cells like the atapost or bone marrow. Is this something that we can make a big difference? And now you have this patient coming in who’s frustrated, told he has a knee that he needs a knee replacement, defeated, and now he’s back on the trail doing the things that he loves to do. And I think what changed here? So somebody looked at the something meaning we we we looked at this where we look at this as not just the image on an MRI or a CT scan. We’re looking at the person in totality and figuring out what do we need to get them ready back or what do we need to get them ready for and back to what they’re doing. And so that’s been the biggest difference I think when people come and are not resigned to the fact that oh I need surgery here. What do I need to do? We go from there.

Nicole: If I came to you tomorrow with knee pain, what would you do that’s different from what I’ve already tried?

Dr. Garg: Yeah. I mean I think the things that we do differently is that I want to know what you are trying to get back to. Right. We talked about in another episode where our first procedure a woman wanting to get back to gardening. That’s important to her. So it’s that’s important to me then and then that’s what we’re trying to do. So if I don’t know your goal, I can’t build a plan around what your dream outcome is and what you’re trying to get back to. So I think that’s really the big thing. The other thing too is understanding that it’s not just about the image. And we’ve it’s been a steady theme throughout this podcast in terms of just you’re evaluating the tissue quality and you are actually looking at a combination of things. What’s your function? What’s your range of motion? What’s your strength component? What does it look like on the imaging? What does it look like and feel like pre and post EMTT and shockwave? These give us a lot of things and a lot of information. So I think that’s where where the big thing. So the question really isn’t um in terms of regenerative medicine replacing the need for surgery in all cases. It is about negating the need for a lot of the cases and then certainly pushing back the need for those surgeries and buying back time in that regard. So I feel like there’s a huge component that regenerative medicine has the ability to buy back time and and that’s that’s the the beautiful part about this. So I think the the biggest thing that you can take away from this is that there is a multitude of components and options that you can do before having pain, just dealing with it and then going to go get surgery. And I think that’s the once you start asking those questions and starting to educate yourself and becoming more informed, I think you’re there’s a huge avenue for you to buy back time in that space. So the big thing the big three things I would tell people, right? So your MRI is information. It’s not it’s not a verdict or sentence one way or the other. Um a torn meniscus on imaging doesn’t mean surgery is your only path. we EMTT, shockwave, PRP, stem cells. There’s a lot of things that can be done in that regard. There is a secondly, there’s a massive treatment gap between your pain, getting an injection, and surgery, the the knee replacement that most people don’t know about. So, educate yourself, find out what those options are, like we talked about on on the show here. And then the right question really isn’t how bad is my knee. I think if you ask what do I do if I want to get back to this activity and what’s the smartest pathway to get there and what are my options? So if you’re asking those those then I think you’re you’re looking at the right things and you should be able to get a much deeper sense of what your options are when you ask that type of question. So, if any of this resonates with you, DynamicAthlete.com is a great resource to find out more information and really learn about the options that you can that you can have. But that’s what I would tell you to do. And hopefully this has been something where you can extract and take away and really be able to ask some of these questions and start to learn about what your options are between pain and surgery. So, we’ll see you next time.