Tips From Author of The Knee Book: A Guide to the Aging Knee (Part 1/2)

Luna was honored to recently sit down with Dr. Adam Rosen, who talked through some of the points discussed in his book on how to best take care of injured or aging knees.

Here are Dr. Rosen's answers to frequently asked questions by patients with knee injuries:

What are risk factors for arthritis?

Dr. Rosen: “Unfortunately, everybody’s at risk of developing knee arthritis, so there are some people that - even if they do everything right - are still going to get arthritis. One of the most common reasons that we know that people will develop arthritis, though, is obesity. So if the rate of arthritis is around 16% for most Americans, and if they’re obese, that risk is more than double. So, when I’m talking to patients who have severe bone on bone arthritis, we’re talking about weight loss to lower the risks that may occur at the time of surgery, and their pain’s probably not going to go away because they’re already bone on bone. But if someone has very mild arthritis on X-ray, and more advanced symptoms, sometimes weight loss alone can decrease that pain.

The other big thing is prior injury, so if somebody had a meniscus tear - whether or not they had surgery for it, or they had a fracture involved within the joint - those traumatic injuries, whether or not they were [ages] 15 or 30, as they age, that would lead to arthritis down the road. And then, if they have arthritis, weight loss does become a huge important part, because depending on where you read, the weight on the joint for every pound is about 3-5 pounds of pressure. So for someone losing 5 pounds, that can take 25 pounds of pressure off that arthritic knee - so it’s like taking a backpack off their back, every single day, every step. The other thing is modifications and activity - we do have some people that, as they age and develop arthritis, have to realize that you may not be able to run or participate in high-impact sports because that excess load is going to cause more pain.

I think the biggest key factor, though, is strengthening, which is a Catch 22 for a lot of patients. The patients that I see with the worst arthritis on X-ray, with the least symptoms, have the greatest muscle strength. You ask them to straighten their leg and it’s like a tree trunk; these are usually people that are still hiking and skiing and doing other outdoor activities where they maintain the strength. So their symptoms are minimal, but as someone gets fearful of doing exercise - or a little exercise hurts and they stop exercising and get weaker - that lack of strength in the muscle (i.e., the quad) just leads to a lot more pain in those people.”

What are you or a primary care doctor looking for if you/they order an MRI?

Dr. Rosen: “The MRI, in our world (i.e., orthopedic surgeons that specialize in patients with arthritis), we’re talking about patients typically over the age of 50. Orthopedic surgeons hate or cringe [at] the idea of the MRI, and I always kind of joke that I think most people, if you ask them about the human body, they know we have 3 things: ‘I have a brain, I have a heart, and I have a meniscus.’ And it’s like the most common thing, and the mind is a really impressive thing because if you have a test that shows an abnormality, your mind right away goes ‘Yeah, that abnormality is causing my pain.’ And a lot of patients forget that a meniscus tear is a normal process of aging.

The other big issue just becomes cost and delivery of care. We always talk about doing tests [and ask ourselves]: ‘How do they change or alter the management of the patient?’ And if you have a really expensive test like an MRI, and that test doesn’t change the treatment management, well, it’s not a useful test, [whereas] in our country, the cost of healthcare is just skyrocketing. There are studies that have shown the number of MRIs that are unnecessary is astronomical. And it’s a weird Catch 22 - patients believe that MRIs are better. They’re better than X-rays if you’re looking for soft tissue injuries or looking at the spine. But they’re not better at looking at arthritis.

So, not all tears are surgical and an orthopedic surgeon can say that, but the radiologist doesn't always put that in the report (e.g., ‘This is torn and needs surgery’, vs. ‘This is torn and a normal process of aging’) That’s where we, I think, on the backend, do a lot more of re-education and calming down the situation that arose from the MRI. So MRI should be used with caution and [for] specific indications, but definitely not the first choice or the go-to choice for the arthritic knee.”

How do you, as a surgeon, determine if surgery will help? What's the decision-making process?

Dr. Rosen: “Yeah, it’s always the hardest question that patients have. And, you know, I understand what they go through; I always tell them that it’s easier if I meet you in an emergency room because you feel and broke your leg and the bone’s sticking out of your skin. You know, yes, you need surgery, no questions asked, nobody questions that. Or, if someone’s having a heart attack, and the cardiologist says ‘We have to take you to the cath lab and put in a stent.’ There’s no thought process there, you just do it. But when someone has arthritis, and you don’t know what you’re gonna get, and what the recovery’s like, it’s a hard decision. And honestly, I don’t think anybody knows the exact answer, so we try to lead patients down that path.

It’s very important that people try conservative care first, especially if their arthritis is not the worst of the worst. In my world, you get some patients that walk in, they’re so bone on bone, their knee is deformed, they’re already on a cane or walker - I mean, they just had this high pain threshold and just sucked it up, and waited for way too long - that is a meet and greet, and this person needs surgery. That’s the easy answer. You know, the harder answer is when someone’s still fairly active, and they’re doing things, but they have pain. And, are they taking medications, is the medication helping, did they have an injection, did the injection help, and are they happy with the quality of their life? But then, you have to put that into perspective of - what is the realistic expectation? And I always tell people, ‘Surgery’s good, it’s not great, and I can’t make you normal or bionic,’ so you never want to put somebody through a surgery where they’re not as good after surgery as they were before surgery. Even though we think, ‘The X-rays look perfect,’ or you’ll hear, ‘Oh, I gave you a good knee’... But listening to the patient, if they’re not happy, that surgery was not successful.

So, you have to really sit down with patients and say, ‘How is your pain or your symptoms, what limitations are you having,’ and [put] that into context with what the activity level or symptoms or pain of a knee replacement would be just to make sure that that outcome is going to be better than what they have now, so they’re happy with the outcome.”

What's the one exercise you recommend for people with knee pain?

Dr. Rosen: “Over the years, the idea of pre-hab or prehabilitation - it was there, and then it was weird, there was a bunch of studies for a number of years that kind of went away [saying] ‘Oh, it wasn’t necessary,’ and then it kind of came back into focus of ‘Yes, it’s really, really necessary.’ So, the simplest exercise that I teach everybody is that straight leg raise. And, it’s interesting and amazing because there’s a lot of importance in a lot of ways to that one exercise. You know, patients, they want to go to therapy [but] they can’t afford it, or they want to go to the gym, but don’t have access to one, and they don’t have any fancy equipment, so you ask them to straighten and they don’t know what to do. This one’s great because I always tell patients, ‘You don’t need any special equipment, you can lay on the floor.’ Most of our patients are arthritic or older [and will say] ‘I can’t lay on the floor, I have a bad back, I have a bad hip,’ [to which we say] ‘Great! You can do it laying on your bed.’

So it’s laying on your bed, and the straight leg raise is bending the opposite knee to take the pressure off the back (because a lot of patients also have back pain). And then, engaging the knee to do that straight leg raise. You know, engaging the leg by pulling the toes and ankles up to lock the ankle, engage the quad, lock the knee so it’s straight, and then lifting it up and down 10 times (at about 8-12 inches - not very high). And I tell patients they should be able to do 10, Monday Wednesday Friday, and they should be able to do 10 on both legs. And if patients struggle to do 10, I say ‘Hey, this is a perfect reason why your knee hurts. Your leg is weak; let’s start with 5.’ You know, I have the overachievers: ‘Oh I can do 20!’ [to which I say] ‘Okay, let’s start with 20.’ But more often, they go home and do 60, and the next day they wake up and they’re hurting, and now they don’t want to do it again.

So the idea of building up is to create lifelong change, and it’s also important because that’s the first exercise we do after knee replacement surgery, and if they can’t do it now, they’re not gonna be able to do it after surgery. Because what we do to the leg makes the quad workers - studies have shown that the surgery makes them weaker, so I say if you come in weak, it’s gonna be impossible for you to walk and do these exercises. If you can make it stronger before surgery, you have less pain now, and which means your recovery might be a little easier on the backend.”

You offered some thoughts on OTC medications, CBD, and supplements. Can you share those? What about collagen supplements?

Dr. Rosen: “I’m very open-minded with that a lot…because if you look at a lot of drugs, you know, a lot of drugs weren’t just designed in a lab. A lot of drugs were plants or things that we find in nature that were then modified by pharmaceutical companies. And a lot of patients have desires to use homeopathic medicine or naturopathic medicine or other supplements. I think they’re great… but again, supplements, they should never take the place of modern day healthcare. Just like for cancer - if someone has cancer, you might need surgery, chemo, radiation; it doesn’t mean forgo that and try some herbal remedy to cure your cancer. But, if that as an adjunct will help the symptoms, I think it’s important. So, you know, weight loss strengthening is all important and things like anti-inflammatories have been shown to be helpful. Taking them may help, but there’s not the clear science. And it’s hard, because as a doctor, when we say ‘There’s not scientific evidence,’ nowadays patients will say, ‘Well, I saw [it] on the internet.’ And there’s a scientific method, so if someone does a study with 20 patients, that’s not statistically significant, but if they have a power analysis or hundreds of thousands of patients with a placebo or who are blinded, and there’s a true answer, that’s the statistical study that we’re looking for to put our name and our license behind to say ‘Ah, this will work.’

Now, CBD is a separate topic, and I’m really interested in CBD because for years I had patients that came and asked about CBD, and I think I probably gave a lot of the same answers that many doctors give: ‘Well, it might not, we’re not sure…’ We were probably a lot more cautious before 2018, because the pharm bill came out in 2018 which made it legal to grow hemp for medicinal purposes. The other hard part though, which I told patients, is that if I tell you to buy, say, Ibuprofen, whether or not you buy Advil, Motrin, or generic Ibuprofen at Bond’s or Costco or on Amazon, I pretty much know what you’re getting, and the safety of those pills. If you get CBD from your neighbor, from your kids, from Walmart, from Amazon, from the dispensary, who knows what’s in it? And that was always the fear - there’s data that shows that it may help on lots of different receptors, but the safety and purity…that’s the hard thing for us to understand.

So I think studies in the near future may be really helpful for knee replacement patients, but it’s gonna be interesting to see with some of these new products and well-designed studies how much it helps patients with CBD. Because 1 in 5 patients are using CBD already, and so many of them are afraid to bring it up. So I’ve really made a habit to ask people if they’re using it, and you see a sigh of relief in a lot of people, like ‘Oh, yes, I was using it but I didn’t want to tell you.’ And some patients are against it, which is fine, great, you know, don’t use it, you don’t have to. But it’s an adjunct that I think may make a big difference in the near future.”

How do you spot a good PT vs. a not so great one?

Dr. Rosen: “So many years ago… I tried - and I think, like many surgeons, we’re really algorithmic in how we think - I tried keeping track of therapists, therapy centers, zip codes… What I found was, it was pretty much impossible (at least for the human mind) to figure out a good vs. a bad therapist on a general sense, because I would have a patient that would tell me, ‘Oh, I love this therapist, they were so aggressive, they pushed me really hard,’ and they had a great outcome. And then the next patient, I say ‘Oh, in your area, there’s this great therapist,’ and they go to them, and come back and tell me, ‘I hated the therapist! He/she was so aggressive, they pushed me so hard, I had all this pain.’

So, I think a good therapist looks at every patient, and it’s kind of the way that I describe therapists to patients, [where] most of the patients, if you give them exercises, can do them, like ‘Here, if you follow the instructions, this is what you do.’ And that’s not the goal of the therapist, it is to help them, but if we start everybody at the same spot, in a week or 2, you may be doing great with extension. But you may be struggling with flection. So a good therapist recognizes that, and then says, ‘OK, we’re going to spend 60-70% of your time on flection. Because you’ve already mastered the extension, so we’re going to modify your program for you.’ And they’re also gonna notice, ‘Oh, you’re struggling with walking or getting off the walker or the cane - it’s because you’re weak. You have an extensor lag - OK, we’re gonna work on quad strengthening. Or, you have an extensor lag because you had quad inhibition.’ So those are the greatest ones where they’re really dedicating the therapy and making it directive to each individual patient based on their deficiencies. And I think it’s hard for a therapist, because, like us, the therapists work with the patients more intimately right after surgery… so me and the therapists, we’re gonna hurt you, and we’re not not understanding your pain.

We understand that you’re in pain, but all of us understand that if we put you through some pain or discomfort, it is to make you better. And if we don’t push you because you hurt and we back off because you’re uncomfortable, you’re gonna have a bad outcome for the rest of your life. So we’d rather push you, even if it causes some pain for 6 or 8 or 10 weeks, as opposed to not pushing you, and having you in pain for the rest of your life. So, there’s a lot of empathy that comes with that. [Overall], I think a good therapist listens and modifies, but still pushes patients to get that good outcome.”

You wrote that motion, endurance, and strength are the keys to knee health. Post recovery, talk about your expectations for rehab. What does recovering look like, when done right?

Dr. Rosen: “So nowadays, compared to years ago… I mean, it used to be 5-7 days in the hospital, lay in bed for a day or 2 with full catheters, and patients just had a lot of pain, and the outcomes were not that good. So nowadays, aggressive physical therapy [has] changed so much. I remember when I started asking therapy to do therapy day of surgery here at our hospital, and people thought I was crazy. And we now know that that makes a big difference - getting patients up quickly decreases pain, decreases stiffness, decreases the risk of scar tissue forming. And when we look at the sequence, though, the biggest and most important first thing to do is the range of motion. Because if patients get range of motion, they tend to have less chance of scar tissue developing. They also tend to get more mobilization of the soft tissue over the scar, they have less pain, they improve their gate cycle, pain goes down. And what I’ve also seen is when patients get better range of motion, the other big side effect we see with this surgery is difficulty sleeping. I find that as the motion improves, patients’ sleep improves also, so the motion is key.

The second thing we tend to work on is the strengthening because, especially guys, they’re all focused on weight and pounds and leg lifts, but I always tell them, ‘If you focus on strengthening in the beginning, and you put that ahead of range of motion, you may be really strong, but now in 6 or 12 weeks if you try to get motion, it’s too late because the bleeding in the knee (that blood, which sort of coagulates and forms like pudding, and then solidifies into a leather rope), we can’t get that out.

So now the knee won’t bend or straighten well… [therefore], motion first, strength second, and then endurance is last because endurance is something that can come with time. And even if you lack endurance, it may take a year or 2 to get that back, but you don’t want to try walking really far to build up in endurance, to come home in pain and swelling, which now inhibits your ability to get range of motion, because that final outcome at the end of the day is not gonna be as good as it could have been if you focused on the motion first. So always motion first.”

Why do you refer to Luna? Why is Luna a good option for those recovering from a total knee replacement?

Dr. Rosen: “Using Luna, I think there’s 2 sides that I find helpful…one from the surgeons’ side, and one from the patients’ side. I think for any surgeons that are curious, there’s a lot of paperwork that’s involved in this day in age, and I think healthcare is so beyond the IT world from everywhere else, there’s still faxes and so much paperwork and signing for home health and things like that… and it’s just cords and cords of pieces of paper with lots of useless information. So, from the perspective of my work side of things with Luna - it’s great that it’s all digital, I get the templates [with] easy to see progress of how my patients are doing with their HOOS and KOOS scores, and how many visits they have remaining.

And as far as signing off on those patients, it makes it really easy to quickly see, click, and go. It’s a very efficient model of doing the documentation necessary, but [also] giving me a useful template and dashboard so I can watch and follow the patients’ progress. The vast majority of patients that we would see would come in and say, ‘They didn’t do much, they checked my blood pressure, they had me walk around my room.’ The thing that I’ve seen with Luna, which helps me a lot with the patients and I think it helps the patients the most: patients are getting that aggressive physical therapy from Day 1. So, they are even coming in on the day of surgery, and they’ll say, ‘Yeah, Luna already contacted me, and I already know what day and time they’re showing up.’ And that used to be a huge issue with scheduling. But also, the patients are coming in and just telling me the Luna therapists they worked with were great, they were aggressive, they had them motivated, they were progressive in their exercises as they were able to, they were walking far… and I’m seeing it [after] one month when patients come into follow up, they are leaps and bounds ahead of the ballgame from where they were before.

It was 2 weeks of at-home, and 4-8 weeks of outpatient; I’m seeing many patients do 4 weeks of Luna, because they’re getting the aggressive home physical therapy model from Day 1, and they’re done [with] therapy in 4 weeks. So it’s shortening their recovery, and I’ve heard nothing but good responses. Being able to have a therapist come to their home has been instrumental in getting them the care they need.”

If you're interested in purchasing Dr. Rosen's book on the aging knee, you can order it through this link.