264 ‒ Hip, knee, ankle, and foot: common injuries, prevention, and treatment options

1. 0:00 – 0:30

   Intro

   1. ACAdam Cohen0:00

      There's no way that that's not helpful for all of lower extremity injuries, is to be able to know where you are in space, and to have good training in those dynamic situations, because that's when people are injured. Nobody wanted to trip on the sidewalk, but what happens when you trip? Are you able to recover quickly, or do you end up with an injury?

   2. PAPeter Attia0:21

      [upbeat music] Hey, everyone, welcome to the Drive Podcast. I'm your host, Peter Attia.

2. 0:30 – 9:52

   Anatomy of the hip, hip dysplasia in infants, and the development of arthritis

   1. PAPeter Attia0:31

      Hey, Adam, thank you so much for coming, uh, from New York to Austin. [lip smack] I'm very excited to do this, and of course, this needs to be done in person. Um, we're gonna do today what I did with your colleague, Dr. Baron, a little while ago, on the upper extremity, which is everything you need to know about the lower extremity and its orthopedic injuries. So, um, for each of the major issues, the hip, the knee, the foot, we're gonna talk about the anatomy, talk about what goes wrong. We'll talk about the surgical and non-surgical management for those things. Um, so thanks very much for joining.

   2. ACAdam Cohen1:04

      Sure. Great. Thanks for having me. Appreciate it. L- ladies-

   3. PAPeter Attia1:07

      Wanna start with the hip?

   4. ACAdam Cohen1:08

      Yeah, let's jump right in. Um, so let's talk about the anatomy of the hip. Uh, the hip joint is a ball and socket joint. Um, have a model here. The... Unlike the shoulder, it's, it's a very contained, concentric joint, and, and much more stable under normal circumstances than the shoulder. It's a, it's a deep socket. The socket is called the acetabulum. This is the femoral head, and the femoral head is covered with cartilage. Let me place this down for a moment. If we just focus on the proximal femur, we have the head, as I mentioned, the neck, and this is the subtrochanteric region, and this is the trochanteric region. Um, the acetabulum is formed in utero. It starts about fourth, fourth week in utero, and then by the, uh, 30th week, it starts to develop. Um, and I think that's a good starting spot because a lot of the problems that we see, or a number of the problems we see in the hip really start that early. There's a condition called, uh, developmental dysplasia of the hip. Used to be referred to as congenital dysplasia of the hip, but we felt that, uh, it's, it's, there, there are more factors involved than, than any congenital ones in particular. Basically, what happens is, if the, if the hip is not concentrically reduced, um, as e- either late in stages of pregnancy or in early childhood, the first several months of life, in fact, um, the acetabulum will not form properly. So for example, if the ball is shifted out of the socket, let's say due to positioning in utero, where it's not completely, uh, in, the acetabulum will not form correctly. What that means is, is that after birth, if the, if it's sitting outward, this deep socket will not form, and it'll be quite shallow. That has major implications later in life because if it's not deep in the socket, it's sitting on the edge of the socket, which means there's greater pressure here, and that pressure can lead to mechanical overload and arthritis. So even, um, conditions that have much, happen much later in life, uh, can start quite early.

   5. PAPeter Attia3:36

      So a child that's breached, for example-

   6. ACAdam Cohen3:38

      Yes

   7. PAPeter Attia3:38

      ... during pregnancy, which our, one of our kids was breached, um, as soon as he was born, they immediately said he has hip dysplasia. He was in a brace for nine months.

   8. ACAdam Cohen3:50

      Right.

   9. PAPeter Attia3:50

      He was in a splayed-open brace for nine months, and I remember sort of freaking out, thinking, "Oh my God, he's never gonna be able to do anything." And they're like, "No, he'll be fine, like, as long as-

   10. ACAdam Cohen3:59

       Right

   11. PAPeter Attia4:00

       ... you keep him in this brace."

   12. ACAdam Cohen4:01

       Right.

   13. PAPeter Attia4:01

       And he was in that brace 23 hours and 45 minutes a day.

   14. ACAdam Cohen4:05

       Right.

   15. PAPeter Attia4:05

       He basically only came out of it for a bath. I m- it was actually hell on my wife, but nine months later, his hips were fine.

   16. ACAdam Cohen4:13

       Fine.

   17. PAPeter Attia4:13

       That's kind of remarkable.

   18. ACAdam Cohen4:15

       Right. So it's called a Pavlik harness, and, um, you know, there's... It, it actually is quite comfortable for the child. There's, they don't... You can put it on and take it off without much of a fuss, uh, or no more fuss than normally. Um, but we know that if the ball is not sitting in there, in that socket, um, it will not form properly. So the, the harness keeps, keeps that positioning until the acetab- acetabulum forms properly. The, you know, the exams that pediatricians do, we always check the hip, and we wanna make sure that it's, it's in its, in the socket. Um, I, I think going forward, a lot of, lot more physicians and orthopedic pediatric specialists are using ultrasound to better quantify that the hip is in the socket, because we really don't wanna miss any dysplastic hips. If you have a dysplastic hip, um, you are going to get arthritis. Now, it doesn't mean it's going to be symptomatic necessarily. It doesn't mean you're gonna need a hip replacement, but people who have dysplastic hips, that is an acetabulum that did not form properly, are going to get arthritis. It's a mechanical problem where the forces are unevenly distributed across that ball, and there's edge loading, and that will break down over time, no matter what you do.

   19. PAPeter Attia5:38

       What... Do we have a sense of what the, uh, incidence is of, uh, congenital dysplasia, or whatever the new name is?

   20. ACAdam Cohen5:45

       Yeah, developmental dysplasia of the hip. Um, I don't, I, as far as-

   21. PAPeter Attia5:51

       How many children born, or for every-

   22. ACAdam Cohen5:53

       Oh, right

   23. PAPeter Attia5:53

       ... you know, thousand kids that are born.

   24. ACAdam Cohen5:54

       I think, I think it's about one in 1,000, I think. I might be wrong. I, I would need to check on those numbers. Um, but the important part is, is that we shouldn't miss any, and if we're basing it solely on an exam, um, I think we're going to miss more than if we base it on ultrasound. And the ultrasound is really not that hard to do, and certainly teachable. Um, but that confirms that the ball is in the socket, and the socket is healing properly. Um, i- it's, you know, there was a study once done many, many years ago where it was an animal study, and they put a cube-shaped object in the acetabulum, and the acetabulum formed in the shape of a cube.

   25. PAPeter Attia6:36

       Wow.

   26. ACAdam Cohen6:36

       It is going to develop based on what is sitting in that area. And if you wait too long, what happens is the soft tissue deep in the socket will become hypertrophied, and it's harder to get in. So I have patients that I've seen who, they come in to see me 'cause their hip hurts. They're 28, 29 years old, never had a problem before, did not suspect anything wrong, and we have, get an X-ray of the hip, and they have arthritis. And it's quite a shocking development because you don't know. You don't necessarily know.

   27. PAPeter Attia7:13

       And for folks just listening-

   28. ACAdam Cohen7:15

       Mm-hmm

   29. PAPeter Attia7:15

       ... the plain X-ray is a good enough tool for that diagnosis because you'll see the absence or thinning of cartilage where you should see it, as in that diagram there.

   30. ACAdam Cohen7:26

       Correct. So for, yes, for arthritis that becomes symptomatic, we can usually see that. Uh, there obviously is a spectrum where the process starts to happen before it's e- we're even clinically aware of it, and, you know, I think that's, that's the future, that's the trick, is to find out before someone has clinical arthritis, do we know about it, and what can we do to avoid it? And I also think it's important to really discuss what arthritis is, because I know just from my own patients, um, I say, "You have arthritis," and there's a lot of conversation of what actually, what actually does that mean? Um, the surfaces, the ends of all long bones have cartilage at the end. It's, it's a layer. It's a very smooth layer, and the only reason joints move pain-free without friction is because of that cartilage. The coefficient of friction of cartilage is so smooth, it's smoother than ice on ice. There's no man-made substance. I mean, it's smoother than Teflon.
3. 9:52 – 18:49

   Diagnosing hip pain in people under 50, stress fractures in the femoral neck, and more

   1. PAPeter Attia9:52

      So when a person comes to your office and they're complaining of hip pain, what is, you know, the most, I don't know, call it the three most likely sources of that pain? And obviously we'll, we'll go through some of the examinations so people can sort of see how-

   2. ACAdam Cohen10:09

      Sure

   3. PAPeter Attia10:09

      ... you will go about gathering that information.

   4. ACAdam Cohen10:11

      Sure.

   5. PAPeter Attia10:11

      But what would be the top three most common diagnoses you'll encounter for-

   6. ACAdam Cohen10:15

      Right

   7. PAPeter Attia10:15

      ... a person with hip pain? And let's maybe bracket this by saying a person under 50.

   8. ACAdam Cohen10:19

      Okay. Sure. Um, so, you know, someone comes in with hip pain. R- right away, I'm sort of thinking about the different layers of the hip. So in my mind, I'm thinking, "Is this, is this a bone problem? Is it a bone cartilage problem? Is it a, uh, connective tissue problem, that is, a ligament problem? Is it something, is the capsule too loose?" 'Cause the, the ball, it, it's held in the socket by a capsular layer. Um, or, "Is it a, is it a muscle and tendon problem?" So we sort of, we, from deep to superficial, we have bone, cartilage, and then we have connective tissue, ligaments, capsule, and then we have muscle, tendon. And then we also have to recognize that sometimes hip pain is referred pain. That is, it could be coming from your back. So we're thinking about those separate layers, and then we're also thinking about location. So someone who has pain in the front of the knee, fr- sorry, the front of the hip is, is different than someone side of the hip, back of the hip. So we need to tease all those factors out. Um, so someone under the age of 50, you not, would not necessarily be thinking about arthritis, but it obviously is always on, on your mind. Um, and it, finding out a clue to what the diagnosis often depends on when it hurts, where it hurts, and what their activity is. So for example, um- You know, I think about patients, they come and they say, you know, we have the endurance athlete, we have the power athlete, we have, um, the-

   9. PAPeter Attia11:50

      The non-athlete presumably. Yeah

   10. ACAdam Cohen11:51

       ... the non-athlete, the, the individual who is a flexible gymnast, ballet dancers. They sort of have different patterns of hip problems. Um, if we start with the endurance athlete, let's start there. Endurance, endurance athletes is we start deep down in the joint. The first thing we have to rule out is that this is not a stress fracture. Stress fractures can happen in a lot of different areas in the lower extremity, and we separate them out is to high-risk stress fractures and low-risk stress fractures.

   11. PAPeter Attia12:24

       Risk of bad consequence if not treated?

   12. ACAdam Cohen12:27

       Correct. So if someone, if someone comes in and they have a marathon coming up, and they say, "My hip hurts," we have to make sure that this is not a stress fracture. Femoral neck stress fractures-

   13. PAPeter Attia12:41

       So just differentiate a stress fracture from a fracture

   14. ACAdam Cohen12:45

       Sure. So a stress fracture is something that occurs slowly. So a stress fracture, at baseline, potentially normal bone with a substantial load to that bone that is in excess of what the normal healing capacity is of that bone. That is, bone constantly remodels. Every time we put stress on it, the microarchitecture is changing. There's small, tiny microfractures that occur from normal weight bearing. The body is very capable of adjusting to that load and making new bone. When you start exercising or working out or running, the bone will get stronger based on the stresses that that bone sees. So for runners, for example, um, if you are training properly, there's no reason to expect that that bone can- can't adjust to the increased load that it's seeing. But oftentimes, due to over-training, where you're not giving that bone enough of a chance-

   15. PAPeter Attia13:44

       Mm

   16. ACAdam Cohen13:44

       ... to heal, you develop these tiny little microfractures that aren't given enough time to then heal, and then it gets compounded when you go run the next day, and the next day, and you're increasing not only the number of times that you run, but you're increasing the distance and the speed all at the same time. You get groin pain, 'cause that's where, that's where stress fractures of the femoral neck hurt. Right away, we know n- we need to rule it out. And they tend to occur in the femoral neck, and we have two locations. Either this is called the compression side, and this is called the tension side of the neck. And tension-sided fractures, where you get a little crack in the bone here, are much more severe than compression side. But the bottom line is that we need to know that this exists.

   17. PAPeter Attia14:33

       And the, the patient will feel groin pain, which is otherwise difficult for them to differentiate. I mean, they're not gonna come in and say, "My femoral neck hurts."

   18. ACAdam Cohen14:43

       Correct.

   19. PAPeter Attia14:44

       It's... What, what is the actual feeling? Does it feel akin to what you would feel if you pulled a muscle in your groin?

   20. ACAdam Cohen14:50

       It does, except it's very weight-bearing dependent.

   21. PAPeter Attia14:53

       Mm.

   22. ACAdam Cohen14:54

       So, um, most people come and say, "I, I think I tore a muscle. I think I have a muscle strain." I, I don't see a lot of muscle strains in runners without an injury, right? You run, you're training, you're not necessarily gonna get a, a, a s- an acute injury like that. So sort of the presentation's slightly different. Um, but it hurts in the groin, and right away, you don't let them run until you find out if it's, if it's a stress fracture, and here's why.

   23. PAPeter Attia15:25

       And, sorry, the MRI is the gold standard?

   24. ACAdam Cohen15:27

       It is. So x-rays, we always need to get x-rays to make sure you're making sure that the joint looks healthy. There are other conditions that can cause groin pain. Uh, but it's usually negative. It's usually hard to detect a stress fracture right when the pain starts. The MRI is the gold standard to see that. It used to be bone scan, but that is impractical. Um, and an MRI really is excellent at looking, 'cause you can see the architecture of the bone, and you can see, um, basically what we call edema in the bone, or a bone marrow lesion, and sometimes a crack in the bone. And it's graded. There's stress reactions, and then there's stress fracture. A stress reaction is like a pre-stress fracture. And the reason why it's a high-risk s- stress fracture as opposed to a low-risk is if it becomes a complete fracture, which was the other part of your question, what's a complete fracture, it's where this completely separates from the ball. Um, and that's very important in this area, because the blood supply to the head comes from this direction. So all of the nutrients that the ball sees comes from this direction. If this breaks, and the blood supply is disrupted, and that's not corrected quickly, then the bone in that area no longer has n- blood supply. It will die, and can't support the cartilage anymore. The cartilage-

   25. PAPeter Attia16:57

       Avascular necrosis

   26. ACAdam Cohen16:57

       ... will collapse, and you get AV- AVN of the head, and that is a hip replacement, which is obviously difficult for anybody, but for someone who's in their 20s, 30s, 40s, it's-

   27. PAPeter Attia17:09

       So the treatment for this when you make the diagnosis is rest.

   28. ACAdam Cohen17:13

       Is rest, typically. So if it's on the compression side, this is the compression side, you can go on cru- on crutches, uh, until you start to have no pain with weight bearing. Once you have no pain with weight bearing, you can continue along that path. Takes six to eight weeks to heal, and then you can slowly start up your exercises to regain some of your endurance, physical therapy, et cetera. And oftentimes, I'll get a follow-up MRI to make sure, um, that it's, that it is healing and not increasing. If the stress fracture is on the tension side, the other, 'cause you can imagine, if it starts to crack on this side, and, and the whole weight of your body is coming down this way, it can more likely-

   29. PAPeter Attia17:57

       Mm-hmm

   30. ACAdam Cohen17:57

       ... displace mechanically. Um, that often will need to get surgery, which is to put pins in And we, we will often just put three pins from here to here into the femoral head, and it will heal, and they heal quickly. And oftentimes you can let that individual bear weight sooner.
4. 18:49 – 25:26

   Common hip injuries, gender differences, and problems that occur when the hip isn’t formed normally

   1. ACAdam Cohen18:49

      that.

   2. PAPeter Attia18:49

      Are there any differences in hip injuries between men and women? I mean, one thing that stands out to me, just having taken care of a number of patients, is I always, I, for, again, in the, at least in the under-50 population, it seems that more, far more female patients of mine have had hip issues than male patients. Um, I've had a, a number of females who have had hip resurfacing, labral repairs.

   3. ACAdam Cohen19:15

      Mm-hmm.

   4. PAPeter Attia19:16

      Again, these are all young women, so they're typically-

   5. ACAdam Cohen19:17

      Right

   6. PAPeter Attia19:17

      ... in their 40s. Is there, is that just a l- small number issue, and th- th- that's actually not a disproportionate, uh, finding? Or do women, based on the anatomy of their pelvis, are they more susceptible to labral tears or other types of injuries in the hip?

   7. ACAdam Cohen19:33

      There are different patterns. There are certain, there are certain conditions, uh, of, of ligamentous laxity that are more prevalent in women. Uh, developmental dysplasia is more prominen- more, more prevalent in women, and so sometimes that sometimes is the inciting issue. Uh, there are other types of hip problems that are more prevalent in men. Um, there's one, there's a condition that we often have to treat that has implications to a lot of the structures around the hip. It's called femoral acetabular impingement. Um, the femoral acetabular impingement is, w- we think, at least the, the prevailing theory is-- Let me tell you what it is first. Basically, on, on the neck, right around here, it's actually sort of in the front, a bump develops. So if I, if I look at the model, f- a model here of the, uh, femoral neck, and there's sort of one here, and this is typically the location of it. And I'll just color it. You get a prominent bump of bone. So this area, it's called a, a cam lesion, and what happens is it changes the shape of the, at the head and neck junction, so it's not really spherical. It's sort of this oblong shape so that when it goes into the acetabulum, it can pinch on the acetabular rim. And on the acetabular rim is not only the cartilage, but the labrum. Let me show a picture. So if we open up the hip, and we look inside, again, here's the cartilage, this blue hue, and this lining is called the labrum. So if the ball is no longer spherical, but oblong, it will, the cam lesion will pinch on the, on the labrum, and the labrum will tear and will injure the cartilage that is connected to that area. So how does this happen? It, we think it happens because the growth plate, which closes in males late teens, slightly earlier in females, because of repetitive stress from certain sporting activities, hockey, football, basketball, if there's impingement because of those high-stress sports, that growth plate will have a delayed closure, and it, it will close later, and a new, new bone will form in that area.

   8. PAPeter Attia22:21

      Mm.

   9. ACAdam Cohen22:22

      And that's important because one of the risks of, of FAI that continues is you can get arthritis. Because if the cartilage is being injured, then the, um, then the increase of the risk of needing a procedure later in life. So that's, so it's more common, that's more common in men, FAI. It's certainly prevalent in women, too, not as. Uh, sometimes it's different sports, but I think it's because the growth plate closes a little earlier in women, that it may not be as much of an issue. It also may be the type of sport. The power-type sport, where there's a lot of ground reaction force when you land, tends to make this situation worse.

   10. PAPeter Attia23:06

       Now, in the shoulder, the labrum creates, effectively, the socket. So if you have a person who's never had a subluxation of their shoulder, um, you know, that, that labrum is creating kind of a, a vacuum around the glenoid, uh, head. This seems to be a much more stable ball and socket than the shoulder. What is the role of the labrum in stabilizing that joint? I can understand how asymmetries can cause arthritis-

   11. ACAdam Cohen23:37

       Mm-hmm

   12. PAPeter Attia23:37

       ... but just in terms of pure stability-

   13. ACAdam Cohen23:39

       Right

   14. PAPeter Attia23:40

       ... um, you don't really hear about dislocations of the hip very often. Obviously, the most famous example I can think of is Bo Jackson-

   15. ACAdam Cohen23:47

       Right

   16. PAPeter Attia23:47

       ... um, which maybe we can talk about that case a bit. But, um, what is it that the labrum is doing from a stability standpoint, or is it simply just providing a clean and neutral articulating surface for the cartilage?

   17. ACAdam Cohen24:01

       It, it, it also helps to create a seal around the ball, so it is a s- sort of a suction effect, too. And it's very similar to the shoulder. We have dynamic stabilizers in the hip. Um, it becomes more of a ... concern when the hip isn't formed normally.

   18. PAPeter Attia24:18

       Mm-hmm, because then that acetabulum becomes flatter, which actually mimics the shoulder a little bit in terms of-

   19. ACAdam Cohen24:24

       Correct

   20. PAPeter Attia24:24

       ... lack of stability.

   21. ACAdam Cohen24:25

       Correct. And some of those patients who have instability of the hip because maybe they have some dysplasia, so the ball never really is in the hip, they have greater motion.

   22. PAPeter Attia24:36

       Yeah.

   23. ACAdam Cohen24:36

       I mean, ballet dancers would be a perfect example of that.

   24. PAPeter Attia24:38

       But it comes at the cost of less stability.

   25. ACAdam Cohen24:40

       That's right. And some of those individuals actually have a hypertrophic labrum. It actually gets bigger because it's being asked-

   26. PAPeter Attia24:47

       To do more compensating

   27. ACAdam Cohen24:48

       ... to do more.

   28. PAPeter Attia24:48

       Yeah.

   29. ACAdam Cohen24:48

       There's also, I mean, you can see in the picture here, there's a ligamentum teres. I don't know if you remember that from medical school.

   30. PAPeter Attia24:54

       Only slightly.
5. 25:26 – 28:04

   Advancements in hip replacement surgery

   1. PAPeter Attia25:26

      Is this, um, a good diagram to show how you do a total hip replacement or a hip resurfacing, or explain what some of those procedures look like?

   2. ACAdam Cohen25:35

      Sure. Um, so in a hip replacement, basically you remo- you're taking off the neck. You're cutting this off. You're inserting a metal stem down the shaft of the, of the proximal femur. And then in this area, you're putting a metal cup in that, in that region. And then the cup, there's different ways to do this, but the, the metal cup then has a plastic liner on the inside.

   3. PAPeter Attia25:58

      And is that still made out of ultrahigh molecular weight polyethylene?

   4. ACAdam Cohen26:03

      Yes. Yes.

   5. PAPeter Attia26:05

      That's amazing. That's what they were doing 25 years ago. Um, why has that operation become so tolerable compared to the version of that operation I saw in medical school? Uh, today it's an outpatient surgery.

   6. ACAdam Cohen26:23

      Right.

   7. PAPeter Attia26:23

      The people go home. They seem to recover so well. People used to be debilitated by that operation 30 years ago.

   8. ACAdam Cohen26:30

      Right. So a, a lot of the approaches are, are different now, and h- honestly, in every aspect of the surgery, technology has helped us. So back when I was training as a resident, almost all of the hip replacements were done through a posterior approach, an approach through the back muscles.

   9. PAPeter Attia26:49

      So which muscles were actually getting cut?

   10. ACAdam Cohen26:51

       So the gluteus muscles.

   11. PAPeter Attia26:52

       Which are huge.

   12. ACAdam Cohen26:53

       Right. And now you go anteriorly. Now, I don't perform, it's not one of the surgeries that I perform, hip replacements, but it's much easier to spare the muscle and the ligaments when you do an anterior approach, that is, an approach from the front. Um, it's also-

   13. PAPeter Attia27:07

       So you're saying less of the morbidity is due to less muscular damage on the approach?

   14. ACAdam Cohen27:16

       It i- it is.

   15. PAPeter Attia27:16

       Yeah.

   16. ACAdam Cohen27:17

       It is, and, and also just the way we medically manage patients around the surgery. There's, we give medicine to decrease blood loss, and, and so the whole process is, has become, uh, much more efficient and, uh, safer, to be honest.

   17. PAPeter Attia27:33

       And a resurfacing leaves the femoral head intact and only addresses the acetabulum?

   18. ACAdam Cohen27:40

       No.

   19. PAPeter Attia27:41

       It's the opposite.

   20. ACAdam Cohen27:42

       Yes.

   21. PAPeter Attia27:42

       Okay.

   22. ACAdam Cohen27:42

       Yes. Uh, the, uh, and I don't do this, so I can't really, I don't, I'm not gonna speak to the, the different intricacies of that. Um, but it's, there are, there are ways to preserve the amount of bone that you're taking if the per- individual i- is young. I think that's done less now, actually, lately, of late.

   23. PAPeter Attia28:03

       So

6. 28:04 – 31:20

   Common hip problems in people over age 60

   1. PAPeter Attia28:04

      we talked a little bit about what are kind of the problems that people will show up with when they're young. When people are seeing an orthopedic surgeon north of 60, 65, I'm guessing it's arthritis and fracture that would be the dominant-

   2. ACAdam Cohen28:20

      Right

   3. PAPeter Attia28:20

      ... uh, injuries. Is, is there anything else that's showing up as, as significant?

   4. ACAdam Cohen28:24

      Yes. So, uh, in addition to those problems, we also see muscle and tendon problems. In particular, we see issues with, uh, the tendons on the side of the hip, and, and this is actually not just in, in older individuals, but all individuals. The main abductor of the hip is the gluteus medius, which you can sort of make, uh, you could see coming out. It, it sits on the, the back of the pelvis, it, and attaches at the edge on the lateral or the outside s- of the femur. And these muscles help to-

   5. PAPeter Attia28:59

      Is that glute med and min?

   6. ACAdam Cohen29:01

      Yes. Correct.

   7. PAPeter Attia29:01

      Yeah.

   8. ACAdam Cohen29:02

      And-

   9. PAPeter Attia29:02

      And glute max is not shown here.

   10. ACAdam Cohen29:04

       Correct. The glute max comes across here and attaches a little bit lower down on the femur, and that's not depicted here. So this muscle's incredibly important. In fact, we, we consider this to be the rotator cuff of the hip.

   11. PAPeter Attia29:18

       Just those two?

   12. ACAdam Cohen29:19

       Uh, just those two, correct, the gluteus medius and the gluteus minimus. And it has a very similar profile, and just as in the rotator cuff, it starts to degenerate after a certain age.

   13. PAPeter Attia29:29

       Mm.

   14. ACAdam Cohen29:29

       Same thing happens in the hip. Um, this will, weakness of the gluteus medius is very difficult because it's incredibly painful. Uh, it doesn't have great healing potential. We also see this in endurance athletes as well from the repetitive stress, and we also see this in unstable patients because those muscles are trying to dynamically keep the ball in the socket, so they are working harder. Ballet dancers in particular have incredibly large gluteus medius, minimus, powerful. Part of the reason is because they're asked to do a lot to stabilize the hip. So we see tears there all the time, and we often approach that just like a rotator cuff.

   15. PAPeter Attia30:12

       So, so are most of the injuries you see here underuse or overuse? It sounds like they're mostly underuse.

   16. ACAdam Cohen30:18

       Um, I don't, I don't think so.

   17. PAPeter Attia30:20

       Yeah.

   18. ACAdam Cohen30:20

       I, I, I, it, I think it's, it depends. So the older we get, it doesn't necessarily matter whether it's overuse or underuse. These things will happen because that is just the normal trajectory of tendon problems, tendon pathology. The tendon cells, over time, start to degenerate just like all of our cells-

   19. PAPeter Attia30:43

       Mm

   20. ACAdam Cohen30:43

       ... and they go through process of senescence like all tissue, and those senescent cells produce those factors that lead to degeneration of the tendon-

   21. PAPeter Attia30:55

       Mm

   22. ACAdam Cohen30:56

       ... causes inflammation, incredible amount of pain, and it's hard to treat. It's hard to reverse the process. Now, if you knew it was happening before it started, would you be able to do anything? We don't have that ability yet, but that's what we're, that's what we're trying to figure out, how to intervene before these injuries take place.

   23. PAPeter Attia31:19

       There's

7. 31:20 – 37:16

   The importance of muscular strength around the hips for injury prevention

   1. PAPeter Attia31:20

      two things that jump into my mind here. The first is the obvious need for, I, I hate to use the word physical therapy, because that really gets misconstrued a lot, but basically deliberate exercise that strengthens those muscles. I, I mean, uh, when I used to be a cyclist, um, one of the challenges of that, versus any sport truly, is y- you're, you're sort of in one plane, one dimension, right? So you get very, very strong quads, glutes, and hams. Your glute med, uh, and, uh, min do very little. You're not really doing any abduction of the hip, and as such, you get a very tight tensor fasciae latae. A lot of cyclists get really bad IT band pain, um, because they just lack that strength there. And so an obvious way to fix this, which I was very lucky that I was able to fix this non-surgically, 'cause I was having debilitating IT band pain, was simply doing a lot of strengthening for the, uh, the, the hip abductors. So that at least suggested to me that you could be preventive in some way.

   2. ACAdam Cohen32:29

      If I had any muscle that needed to be worked on, and I had to pick one muscle group, it would be that muscle group, starting from early teens.

   3. PAPeter Attia32:37

      Mm-hmm.

   4. ACAdam Cohen32:38

      It is implicated in so many lower extremity injuries, um, at the hip and the knee. A, a weak gluteus medius, weak abductors, um, are, can cause a lot of injury, and I do believe that the stronger they are... It's almost like bones. The, the higher the bone density you get early on-

   5. PAPeter Attia32:59

      Yep

   6. ACAdam Cohen32:59

      ... then-

   7. PAPeter Attia33:00

      The higher your glider-

   8. ACAdam Cohen33:02

      That's right

   9. PAPeter Attia33:02

      ... the longer it rides.

   10. ACAdam Cohen33:03

       That's right.

   11. PAPeter Attia33:03

       Yeah.

   12. ACAdam Cohen33:03

       Because it's going to degenerate. It is just going to happen. And so the stronger and healthier the tendon is at a starting point, um, this is, this is sort of how I think about this. Um, first of all, not only are you likely to have less injury, and I'm talking about ACL injuries too, I'm talking about-

   13. PAPeter Attia33:24

       Knee injury, it holds back to valgus.

   14. ACAdam Cohen33:26

       Yes.

   15. PAPeter Attia33:26

       Everything that-

   16. ACAdam Cohen33:26

       Exactly

   17. PAPeter Attia33:26

       ... we're gonna talk about in the knee.

   18. ACAdam Cohen33:28

       Exactly. Uh, hip fractures, which we started to talk about a little in the elderly, that too. These muscles are incredibly strong. And the, and the hip flexors too. There was a study done out of South Korea that looked... It was, it was an imperfect study, but it was pretty decent. They took a group of, I think it was, it was retrospectively evaluated, but they took CAT scans of people who were in for a hip fracture, a femoral neck fracture, elderly population, and they measured the volume of their psoas muscle. So this is the psoas muscle, and this is the iliacus. Together they make the iliopsoas muscle, attaches here.

   19. PAPeter Attia34:08

       And this is what picks your leg up.

   20. ACAdam Cohen34:10

       That's what lifts your leg up. So if you're, you stumble, you pick your leg up to save yourself. They, the volume of that muscle was significantly smaller than that of an aged matched control group who were getting CAT scans for other reasons. Now, we don't know why they were getting CAT scans, so that's, you know, it's a little bit confounding. But, um, it showed that there was a significant decrease in volume in those patients who have hip fractures. So we know that hip muscle strength, so the important to get the, the abductors strong, the hip flexors strong. The adductors... You see, the problem with the hip flexors is that we're always sitting. So even if they're strong, they're often tight, because we're, we're always in this position. So it's important to see how, how your hip flexors are, make sure that they're flexible, 'cause a- an imbalance in the, in the flexibility of that muscle group will also impact the antagonistic muscles in the back, the, the gluteus maximus, which extend the hip, and the hamstrings, which also extend the hip. So these are... You know, it's fine balance, but if I could work on anything to help prevent these things later, I think this is a good place to start.

   21. PAPeter Attia35:26

       The other thing that I've really migrated to over the past decade is I've become very obsessed with, with all of these muscles, in particular those, uh, hip adductors, is the importance of training them not just in concentric phase, but also eccentrically. So there are these exercises we do in, in a training, uh, I don't know, for lack of a better word, philosophy, dynamic neuromuscular stabilization, DNS. Uh, there's a position called DNS Star. I was just doing it this morning. So I, I'm doing this stuff most days. And you're laying on your side. Uh, so if I'm on my right side, you know, my right elbow is down. It's sort of like a plank, but you're on the knee, and your hips are up, and you're extending yourself forward as you're putting the hip back. So you are eccentrically loading the adductor as you go back, and then you're concentrically loading it as you bring yourself back up. Now- [laughs] For anybody who's done this, uh, and we've demonstrated these things in other exercise videos, I mean, five reps of this slowly, you feel like someone is jamming an ice pick into those muscles.

   22. ACAdam Cohen36:40

       Mm-hmm.

   23. PAPeter Attia36:41

       It is remarkable how difficult it is. But you don't need to do a lot. I mean-

   24. ACAdam Cohen36:45

       Right

   25. PAPeter Attia36:46

       ... just doing a little bit-

   26. ACAdam Cohen36:47

       Right

   27. PAPeter Attia36:47

       ... of that stuff every day-

   28. ACAdam Cohen36:48

       Right

   29. PAPeter Attia36:49

       ... does so much in terms of lower body maintenance.

   30. ACAdam Cohen36:52

       Right.
8. 37:16 – 42:27

   Hip fractures due to osteopenia and osteoporosis

   1. PAPeter Attia37:16

      talk a little bit about, um, fractures. So, um, I guess w- let's put aside just kind of the, you know, the 25-year-old skiing accident, freak acc- you know, it's like-

   2. ACAdam Cohen37:28

      Right

   3. PAPeter Attia37:28

      ... you're gonna see that all day long. But let's talk about the more predictable and far more catastrophic fractures to quality of life-

   4. ACAdam Cohen37:35

      Sure

   5. PAPeter Attia37:35

      ... which are these fractures of the femoral neck that are occurring in people due to osteoporosis and osteopenia. Now, I, I talk about these stats all the time, and nobody believes them 'cause they're-

   6. ACAdam Cohen37:45

      Right

   7. PAPeter Attia37:45

      ... so absurd, but-

   8. ACAdam Cohen37:46

      Right

   9. PAPeter Attia37:46

      ... if you're 65 or older-

   10. ACAdam Cohen37:49

       Right

   11. PAPeter Attia37:49

       ... and you fracture that hip, depending on the study, 15 to 30% one-year mortality.

   12. ACAdam Cohen37:56

       Right.

   13. PAPeter Attia37:57

       Can you explain why that is? Like, h- how do these people present to you, and why is it so-

   14. ACAdam Cohen38:01

       Right

   15. PAPeter Attia38:01

       ... challenging to take care of that opera- to take care of that fracture?

   16. ACAdam Cohen38:05

       I think part of the, a, a large percentage of those people, it's usually another disease that has, um, overtaken their lives. And so they may have advanced stage cancer, uh, they may have advanced renal disease, and it's almost the last event that-

   17. PAPeter Attia38:24

       The last straw. Yeah.

   18. ACAdam Cohen38:25

       It's the last straw.

   19. PAPeter Attia38:25

       The hospitalization alone is just-

   20. ACAdam Cohen38:27

       That's right

   21. PAPeter Attia38:27

       ... catastrophic.

   22. ACAdam Cohen38:28

       That, that's right. And so it's, and it's very hard to, uh, when you're elderly and if, and you don't... First of all, you break your hip, you come to the hospital, y- there has to be some medical management to make sure that it's safe to proceed with surgery, and everybody who has a hip fracture needs surgery. You can't treat this non-operatively. It would be essentially a death sentence to do so, um, because the goal is to mobilize as quickly as possible. Because for even the people who don't have, who, and you know, the mortality of 20 to 30% within the first year, you know, that's been a stable number for decades. I mean, every time-

   23. PAPeter Attia39:09

       It is

   24. ACAdam Cohen39:09

       ... they look at, look at it, that's a stable number, and that's within one year. So our goal is to get you up-

   25. PAPeter Attia39:14

       A- and, and Adam, how much-

   26. ACAdam Cohen39:15

       Yeah

   27. PAPeter Attia39:15

       ... of that is really acute? It's pulmonary emboli, fat emboli, you know, MI because of surgery, versus, you know, two weeks out-

   28. ACAdam Cohen39:25

       Yeah

   29. PAPeter Attia39:25

       ... they're okay, but then they fail to thrive, and they die within the year.

   30. ACAdam Cohen39:29

       It really is spread out. Uh, the, and the, the management of these patients is very important early on. So we like to get a full team on board, right, a geriatric specialist. You, you need a team approach because you need them medically optimized before surgery so that they could safely go through the surgery.
9. 42:27 – 59:27

   The utility of biological therapies like stem cells and platelet-rich plasma (PRP)

   1. PAPeter Attia42:28

      What is it about the hip? Well, let, let me, uh, reframe my question. Um, as you were talking earlier about sort of the degeneration of the hip, obviously the first thing that comes to my mind, and I'm sure everybody's mind listening to this, is where do stem cells play a role here?

   2. ACAdam Cohen42:45

      Sure.

   3. PAPeter Attia42:45

      Now, we're gonna talk about stem cells through all of these joints, but we might as well start here. Um, when I hear that the tendons of those muscles and those muscles themselves are going to weaken, when I hear that my cartilage is going to weaken, when I hear that the, you know, the, um, osseous structure of the bone is going to weaken, all of these things make me wish I could just have newer and younger cells there.

   4. ACAdam Cohen43:14

      Right.

   5. PAPeter Attia43:15

      So w- what do we know about the utility of stem cell therapy here? W- what's the state of the art today?

   6. ACAdam Cohen43:22

      Right. So, um, y- you know, this is a, this is a great conversation, and there's a lot of layers to this conversation, 'cause there's, you know, the dark side and the, and the bright side of this. Uh, the... You know, when we talk about orthobiologics, um, or biologics in general, basically biologics, they're... It's a, it's a class of therapies that i- that are using your own natural resources to promote healing. So you're using a biologic product to encourage healing of diseased or injured tissue. So the most commonly used ones are blood, specifically platelets; bone marrow, bone marrow aspirate concentrate it's called; and also fat. So if we sort of go through those three, just to start there, um, the, we... For PRP, what are we doing? So we take your-

   7. PAPeter Attia44:18

      Platelet-rich plasma

   8. ACAdam Cohen44:19

      ... platelet-rich plasma. We take your blood, we draw it, and we take it down the hall, and we spin it in a centrifuge, and the centrifuge machine will separate out the different elements of the blood based on the density of those elements. So after you're done spinning it, you have a layer called the plasma layer, which is rich in plasma and platelets, and it separates out the red blood cells and a lot of the, the white blood cells. Now, you could spin it twice. You could do two-spin technique. You can spin it so that you're keeping some of the white blood cells. So we've categorized it into leukocyte-rich PRP and leukocyte-poor PRP. And this is a very simplified way that we think about it right now, and there's certainly, if we fast-forward 10 years from now, this will be a ridiculous conversation, because we just are sort of in our infancy of understanding what we're doing here. So the principle is we take those platelets which are involved in healing. We know this because if you cut yourself, the first thing that happens is the platelets come to the surface to form a blood clot and to form a scar, and then you heal. So platelets are associated with an incredible amount of growth factors and healing factors, including the 800 to 1,000 proteins within the plasma, and you inject that into tendon, a joint with arthritis, muscle, and see what happens. So the, the problem is, is that as a physician, you are, you are allowed to do that procedure, right? So there's no, there's no rule that can't say that anybody comes in and they say, "I have this injury. Can I have PR- Can I have stem cells?" And you say, "Oh, sure. Let me give you PRP," and I spin it, and I inject it. So, b- but what does the, what does the actual science say about what's actually working? And what we've learned is that it works for some things pretty decently and other things not well at all, and we can only go by our randomized controlled trials and, and systematic reviews of randomized c- controlled trials to find out what seems to work.

   9. PAPeter Attia46:37

      So what are the, what are those best case scenarios?

   10. ACAdam Cohen46:39

       So tennis elbow seems to work with PRP. There's good data to suggest, like tier one data, maybe tier two data, that suggests that it works for tennis elbow. It works pretty decently for gluteus medius tears. And for tendons, that's about it. Some will argue maybe in the hamstring tendon it works, but I'm not convinced.

   11. PAPeter Attia46:59

       And just to be sure, are you talking specifically about PRP?

   12. ACAdam Cohen47:02

       Yeah.

   13. PAPeter Attia47:02

       Or are you talking about the broader umbrella of stem cells?

   14. ACAdam Cohen47:06

       Broader umbrella of stem cells don't seem to work, and I think it's important to bring up a v- a very important part, which is these aren't stem cells, and I think that's one of the major problems, is that there is no stem cell therapy anywhere, unless-

   15. PAPeter Attia47:24

       So when you go to Mexico and get stem cell therapy, what are you actually getting?

   16. ACAdam Cohen47:29

       I don't know, but they're not stem cells. I mean, the only stem cell... I mean, I can only speak what's happening in the United States, but the only stem cell ther- therapies approved in the United States are for, you know, leukemia, lympho- l- you know, blood disorders, blood diseases. There is no stem cell. In fact, the FDA has a big warning page with a video that explains there are no stem cells. Stem cells implies that I'm gonna inject cells into you, and those cells are pluripotent. They have the ability to become something else.

   17. PAPeter Attia48:02

       Mm-hmm.

   18. ACAdam Cohen48:02

       And those cells are now going to become your cartilage. They're now going to become your tendon. That doesn't happen. In fact, right now what seems to be happening-

   19. PAPeter Attia48:12

       What's the identity of the stem cell? I- in other words, um, what is the signature that allows that doctor to know or at least believe they have a stem cell? Because these are not autologous typically at these clinics, right? Aren't they, uh-

   20. ACAdam Cohen48:28

       Are we talking about Mexico or-

   21. PAPeter Attia48:31

       I only say that because everybody-

   22. ACAdam Cohen48:32

       Yeah

   23. PAPeter Attia48:32

       ... I know is basically going abroad. Although I know some people that have done this here. You know, they tear-

   24. ACAdam Cohen48:37

       Right

   25. PAPeter Attia48:37

       ... the rotator cuff, and they, you know, and they go-

   26. ACAdam Cohen48:39

       Right

   27. PAPeter Attia48:39

       ... and get stem cells, uh, injected, and-

   28. ACAdam Cohen48:42

       Right

   29. PAPeter Attia48:42

       ... six months later, the rotator cuff is fine without surgery.

   30. ACAdam Cohen48:45

       Right.
10. 59:27 – 1:00:34

    Cortisone as a treatment to delay the need for surgical intervention

    1. PAPeter Attia59:27

       Before we leave the hip, uh, what is the role of cortisone as a treatment to delay the need for surgical intervention? Is it particularly efficacious, or do you not muck around with it?

    2. ACAdam Cohen59:40

       Uh, I, I don't love it because we, we worry about what it's doing to the cartilage. Listen, I think because it's such a successful operation, I'm less... I'm more opt to push for the hip replacement in the appropriate patient than a cortisone injection because satisfaction rate 90, 95% for hip replacement surgery with low complication rate. That's not to say that I don't do it or I wouldn't do it, 'cause there's certain circumstances that I would. I would give hyaluronic acid in the hip also. Although it's not FDA-approved, it, it can be used off-label for that application. There's some studies to suggest that the gel can help. Um, but they're, it's still... We're still trying to find out, figure out a better way. But we also know that if you give an injection right before a hip replacement, there's an increased risk of infection. So we know that there's something about this that, uh, we need to be cautious about.

11. 1:00:34 – 1:04:09

    Anatomy of the knee

    1. PAPeter Attia1:00:34

       Anything else about the hip before we move down to the knee?

    2. ACAdam Cohen1:00:37

       Um, no, because I think even in the knee, we're gonna be talking a little bit about the hip too.

    3. PAPeter Attia1:00:41

       Okay, Adam, so let's, let's talk about the knee. Um-

    4. ACAdam Cohen1:00:44

       Sure

    5. PAPeter Attia1:00:45

       ... again, I think most people listening to this can at least relate briefly to some bout of knee pain. Um, so w- walk us through the anatomy of the knee.

    6. ACAdam Cohen1:00:55

       Sure. So the knee is a bit different than the hip joint. Uh, it is, uh, it is more unstable than the hip joint. The hip joint is a true ball-and-socket joint, and the knee joint is inherently more unstable. So when we look at a knee, what are we looking at? If you look at the front of your knee, you often see that rounded, uh, area in the front. That's your kneecap or patella. The quadricep tendon attaches to the top of the patella right here, and then that tendon continues on as the patellar tendon and attaches to the bone here at the, at the tibia. Um, if we were to fold that over, what we're looking at is the undersurface of the, of the kneecap, and this is the patella, and this is the cartilage on the patella. And all joints, like we spoke about, have cartilage. All joints are made up of cartilage, so the end of all of the bones allow that to glide smoothly on the surface. So we're always interested in maintaining the cartilage because once that disappears, we have trouble. So if we were to flex the knee a little further, what we can see are ligaments in the knee. So I don't know if you can see that well, but here's the anterior cruciate ligament, posterior cruciate ligament. They're called cruciate ligaments 'cause they cross. And then we have on the side the collateral ligaments, so this is the medial collateral ligament. This is a right knee, and this is the lateral collateral ligament. And then if we were to fold it over, and you were to look directly there, you would see two semicircular structures that are called the menisci. And you have two menisci, medial and lateral menisci. If I move the model away, and we look at the picture here, you could see those cruciate ligaments a little better. This is the anterior cruciate ligament, posterior cruciate ligament, and we see the collaterals. This picture is without the kneecap there. You could also see the menisci or meniscus. And the main role of the meniscus is to distribute force across that knee, and they're imperative to maintain the surface of the joint, the cartilage, uh, from wearing down. And the ligaments provide stability to the joint and are, are... the anterior cruciate ligament is a commonly torn ligament.

    7. PAPeter Attia1:03:16

       And just, again, to orient people here, you are looking at the right leg.

    8. ACAdam Cohen1:03:21

       Correct.

    9. PAPeter Attia1:03:22

       Yeah.

    10. ACAdam Cohen1:03:22

        Correct.

    11. PAPeter Attia1:03:22

        So the fibula is that little small bone on the outside, and that's where we see both its attachment to the tibia, which is the platform on which the knee sits, and also you have the lateral collateral ligament attaching there. Yes?

    12. ACAdam Cohen1:03:38

        Correct. Correct.

    13. PAPeter Attia1:03:40

        So the menisci collectively make up the bulk of the cartilage surface of the tibial plateau then?

    14. ACAdam Cohen1:03:46

        It does. It, it, uh, it, it... the function of it is to distribute stress, and it distributes about 30% of the load of the knee through the joint. So without that meniscus there, you end up having point loading or edge loading, and it will cause degeneration of the cartilage w- pretty rapidly if it's removed.

12. 1:04:09 – 1:08:39

    Are activities like running that amplify forces bad for the knee?

    1. PAPeter Attia1:04:09

       You know, I, I always hear people talk about how running and walking, you know, they amplify forces at the knee. So I've heard people say when you're running, you're experiencing eight times your, the force of your body weight at the knee. Is, A, A, am I remembering people say that correctly, and if so, why is that the case?

    2. ACAdam Cohen1:04:27

       It, it, that is correct. And so be- because, so it depends which joint you're talking about. So if we're talking about the kneecap, the amount of load that the kneecap sees with activities like squatting and lunging. If you do not even a deep squat, just a regular squat, the pressure behind the kneecap is about seven times greater.

    3. PAPeter Attia1:04:48

       Than the weight on your back.

    4. ACAdam Cohen1:04:49

       That's right. That's right. Exactly. So the, the cartilage has an incredible responsibility here. Um, and I think it's really, I think the mo- one of the most important conversations that I have with patients, 'cause I get the s- similar questions often, which is things like, "Is running bad for me? Is, is this activity good for my knee or bad for my knee?" Because you'll read a different report-

    5. PAPeter Attia1:05:13

       Yeah

    6. ACAdam Cohen1:05:13

       ... in the news all the time. Running's good. Running's bad. Uh, the truth is we s- we kind of know the answer to this in general. That is, no activity is horrible for cartilage. If I put your leg in a cast, and we then look at your cartilage in a couple weeks, the content of that matrix is going to be significantly depressed.

    7. PAPeter Attia1:05:38

       Right. Nothing's worse for you than inactivity.

    8. ACAdam Cohen1:05:40

       Right. But it's a, it's an inverted U-shaped curve, right?

    9. PAPeter Attia1:05:44

       But it's not symmetric. It's like that, where more and more and more activity, probably better and better and better, but then you can go too far, and it falls off.

    10. ACAdam Cohen1:05:53

        Right.

    11. PAPeter Attia1:05:53

        But it's not, it's not a perfect U where it's-

    12. ACAdam Cohen1:05:56

        Right

    13. PAPeter Attia1:05:56

        ... pure Goldilocks, where you wanna be right in the middle of doing nothing and doing a lot.

    14. ACAdam Cohen1:06:01

        Because we'll never know because we do- because it's dependent on a particular individual and so many factors. So we know that chondrocytes respond to activity. They feel the stress, and they make more matrix. They make all of the proteins within cartilage. So a, a chondrocyte that's being pressured is happy. A chondrocyte that's not being pressured isn't gonna do anything, and eventually it's gonna break down.

    15. PAPeter Attia1:06:28

        And biomechanics have to matter here.

    16. ACAdam Cohen1:06:31

        They do.

    17. PAPeter Attia1:06:31

        In other words, you know, you, you watch an Ethiopian runner. Y- you know, you watch Kipchoge running a marathon, and you realize, okay- Clearly there's a lot of force there based on his velocity. For him to have the stride length that he has, he is hitting that ground so hard, and that ground is hitting him back so hard, and that's what's allowing him to stay in the air long enough to travel the distance-

    18. ACAdam Cohen1:06:55

        Right

    19. PAPeter Attia1:06:55

        ... he travels. And sure, he's not the heaviest guy in the world. He probably weighs a buck 20 soaking wet, but again, if he's feeling eight times that, we're close to 1,000 pounds-

    20. ACAdam Cohen1:07:05

        Right

    21. PAPeter Attia1:07:05

        ... every time. But his mechanics are perfect.

    22. ACAdam Cohen1:07:09

        It's, I think it's all mechanics.

    23. PAPeter Attia1:07:12

        Yeah.

    24. ACAdam Cohen1:07:12

        Well, I mean, that's exaggeration, but it's mostly mechanics. Y- if you have good mechanical alignment we call it, that is if we draw a line from the center of your hip to the center of your ankle, and we do this regularly, and it goes right through the center of the knee, there's a good chance you're gonna be okay.

    25. PAPeter Attia1:07:31

        Center of hip meaning where the femoral head meets the acetabulum.

    26. ACAdam Cohen1:07:36

        Right, the center of the ball.

    27. PAPeter Attia1:07:38

        Center of the ball. Drops, you should be able to drop a plumb line-

    28. ACAdam Cohen1:07:41

        Correct

    29. PAPeter Attia1:07:41

        ... that goes, that cuts the patellar tendon and the patellar bone in half.

    30. ACAdam Cohen1:07:46

        Correct.
13. 1:08:39 – 1:14:09

    Risk of future knee issues and arthritis following an ACL tear or other substantial knee injury

    1. ACAdam Cohen1:08:40

       once the knee is unstable, just focusing on the knee, let's say you have an, let's say you have an ACL tear, and then you measure the compressive force of that cartilage before and after an ACL tear, so like a normal knee-

    2. PAPeter Attia1:08:53

       Yeah

    3. ACAdam Cohen1:08:53

       ... and then your contralateral knee, the amount that the cartilage gets compressed in an ACL-deficient knee is substantially greater than an ACL-intact knee.

    4. PAPeter Attia1:09:04

       Hmm.

    5. ACAdam Cohen1:09:05

       If you reconstruct that ligament, it still doesn't come back to normal. There's something that happens once a, the knee is injured where the loads through that joint change, and sometimes permanently.

    6. PAPeter Attia1:09:19

       So is that why, or is it the case, I think I used to believe this was the case, if you have an ACL injury, you do increase your risk of arthritis later in life?

    7. ACAdam Cohen1:09:28

       You do.

    8. PAPeter Attia1:09:29

       Is that partly why?

    9. ACAdam Cohen1:09:30

       Yes.

    10. PAPeter Attia1:09:30

        Because you never fully get the chondrocytes back?

    11. ACAdam Cohen1:09:32

        Correct. Correct. So there's a, I think there are a couple issues here that obviously we don't fully understand, but the first thing I'll say is that a lot of it is baked in the cake at that injury, and any injury where there's sheer stress on an ACL, and I think we should talk about the biomechanics of the ACL injury, but when you have that event on any joint, w- in f- the stats are that in about 15 to 20 years, half of the people who have an ACL tear, whether it's reconstructed or not, have signs of arthritis.

    12. PAPeter Attia1:10:09

        No difference if you reconstruct or not?

    13. ACAdam Cohen1:10:12

        It's debatable. There are some studies that show that if you've had your ACL reconstructed, you have a greater chance-

    14. PAPeter Attia1:10:19

        Yes

    15. ACAdam Cohen1:10:19

        ... of arthritis.

    16. PAPeter Attia1:10:19

        Those, those are the literature I'm sort of-

    17. ACAdam Cohen1:10:20

        Yeah

    18. PAPeter Attia1:10:20

        ... familiar with.

    19. ACAdam Cohen1:10:21

        And that's because you're, you're active, right? So you are now able to do things.

    20. PAPeter Attia1:10:28

        Mm. Very good point.

    21. ACAdam Cohen1:10:29

        Because your knee is stable.

    22. PAPeter Attia1:10:31

        So there haven't been any RCTs that have said randomized to repair, no repair, and let's see what happens.

    23. ACAdam Cohen1:10:37

        No. It's too hard to do. There's, you know, there's a, there was a fate study I think in the '90s where they look at the fate of doing ACL surgery, not doing ACL surgery, but you can't randomize it.

    24. PAPeter Attia1:10:47

        Yeah.

    25. ACAdam Cohen1:10:48

        So, but it show, that's, that's where that data comes from, where that you may end up having more arthritis if you have it reconstructed. I'm not necessarily saying that you shouldn't reconstruct it by any means. You need to... You know, why do we do, why do we do ACL surgery? We do ACL surgery because we wanna protect the meniscus, 'cause if your knee's flopping around, your meniscus is gonna tear. If your knee is flopping around, you're not gonna be able to play the sports you enjoy doing. So by all means, it's worth the risk of arthritis. The other thing is, it's not everybody has an ACL tear.

    26. PAPeter Attia1:11:18

        Yeah, one in five.

    27. ACAdam Cohen1:11:19

        Not everyone who has a... Right.

    28. PAPeter Attia1:11:21

        Yeah.

    29. ACAdam Cohen1:11:21

        So, but to that point, I mean, I'll just use my own example. When I was, I was hit by a car when I was 14 years old. I had an ACL tear and a meniscus tear. It was, this is the, this is the '80s. I had knee surgery that week, but nobody did anything. You just went in and looked, and I came out and said-

    30. PAPeter Attia1:11:42

        What do you mean they went in and looked?
14. 1:14:09 – 1:25:52

    How the ACL injury happens and how it is repaired

    1. PAPeter Attia1:14:09

       uh, let's talk a little bit about how the injury happens-

    2. ACAdam Cohen1:14:11

       Sure

    3. PAPeter Attia1:14:11

       ... and then I wanna understand kind of how it's repaired.

    4. ACAdam Cohen1:14:13

       Yeah. So in general, there's, there's sort of the c- ACL contact ACL injury and non-contact ACL injuries, and the majority are non-contact. Uh, some are also indirect contact. We also categorize them that way. And, and women have a higher risk, females have a higher risk of ACL tear than men. Um, and we think there, there's, and there's a lot of factors.

    5. PAPeter Attia1:14:35

       Just the strength difference?

    6. ACAdam Cohen1:14:37

       It's, that's one of the reasons. It's a neuromuscular control. So early in, in puberty, uh, boys tend to, during the, the spurt, tend to have testosterone, and that affects muscle growth, and in, in females, that's delayed. And if you look at sort of the neuromuscular control factors specifically, we have patients, well, you know, you jump off, uh, this is pre-injury, just so we evaluate why are they greater risk? You have them jump off a box and see how they land. And in general, at that age, uh, females are more likely to land with a valgus knee-

    7. PAPeter Attia1:15:16

       Mm-hmm

    8. ACAdam Cohen1:15:17

       ... with an adducted hip, right? The leg goes in. That is, you have weak gluteus medius, over tight sh- over imbalance with the adductors. So they land with their knees in valgus, oftentimes with a very straight extended leg, slightly flexed, and a little bit pronated. Um, so one of the sort of programs we're trying to implement, which is incredibly difficult to do, are injury prevention programs where we can, we can take individuals and see risk, stratify them based on risk to see, you know, we do l- uh, landing error scoring system and see how people, and we mark them and say, "Okay, you need special neuromuscular training."

    9. PAPeter Attia1:16:04

       What percent, I know that this answer can't be known, but just to speculate, what percent of ACL tears do you think could have been prevented if the individual was maximally, uh, strong, had, had the highest amount of their genetic potential for neuromuscular control going into it? So even though-

    10. ACAdam Cohen1:16:20

        Yeah

    11. PAPeter Attia1:16:20

        ... virtually all ACL injuries-

    12. ACAdam Cohen1:16:22

        Yeah

    13. PAPeter Attia1:16:22

        ... I assume, are acute injuries-

    14. ACAdam Cohen1:16:24

        Yeah

    15. PAPeter Attia1:16:24

        ... um, how many of them do you think are on, on top of a chronic weakness?

    16. ACAdam Cohen1:16:30

        So the only way I can get close to sort of answering that question is there have been studies that looked at injur- injury prevention programs and then followed those people. And the number that has come out of the literature is that you need to treat 90 people to save one ACL. So the number needed to treat.

    17. PAPeter Attia1:16:51

        Mm-hmm.

    18. ACAdam Cohen1:16:52

        But I think that also-

    19. PAPeter Attia1:16:54

        It probably speaks to how hard it is to treat.

    20. ACAdam Cohen1:16:56

        Yeah. And right.

    21. PAPeter Attia1:16:57

        How, how hard it is to prevent.

    22. ACAdam Cohen1:16:58

        Also, but it's potentially also decreasing risks of other injuries, too.

    23. PAPeter Attia1:17:03

        Yeah.

    24. ACAdam Cohen1:17:04

        So it's not just ACLs when you strengthen the glutes and you... So let me show you sort of the mechanism. So when... I'm gonna move the kneecap out of the way. So this is the... So this is a right knee, so this is the outside of a right knee. What happens when you land in a valgus position is like this, right? So you land with the leg a little bit like this. What this does, we call this condylar lift off, right? So that's why you often see MCL tears, 'cause this gets stretched. The condyle lifts off of the surface, and that surface on the inside of the knee, this is called the medial part of the knee, is very congruent. It's the most congruent part of the knee. The lateral side, the surface of the tibia is convex. It's very unstable in general. So now you're only bearing weight basically on the unstable non-congruent part of the knee. When you've land, when your foot lands in pronation, by nature, the tibia internally rotates slightly. At the same time that happens, the quadricep pulls, and then it shifts out of place. The only thing that typically will help that is that the hamstring on the back has the opposing force. So if you land with a flexed knee, it can help stabilize the knee. Did that make sense?

    25. PAPeter Attia1:18:31

        Yeah. Unfortunately, this is gonna be something where people listening to us on audio will have no idea what we're talking about. It, you really have to see the model in 3D.

    26. ACAdam Cohen1:18:40

        Right.

    27. PAPeter Attia1:18:41

        Um, and the, the inju- the way you just described it, you could experience that if you fell, for example.

    28. ACAdam Cohen1:18:49

        Correct.

    29. PAPeter Attia1:18:50

        Is that also what's happening in a ski injury? Uh, where I get, I just seem to see more people-

    30. ACAdam Cohen1:18:55

        Yeah
15. 1:25:52 – 1:28:22

    Arthritis of the knee

    1. PAPeter Attia1:25:52

       again, x-ray tells a big story here. I'm as-

    2. ACAdam Cohen1:25:55

       Yeah

    3. PAPeter Attia1:25:55

       ... I've seen my knee on x-ray. I've got, you know, I'm fortunate I don't have arthritis, so I've got a big clear space between the femoral condyle and the tibial plateau. Um, how narrow does that need to be before you would make the diagnosis of arthritis, and how correlated is the reduction in that space with symptoms?

    4. ACAdam Cohen1:26:15

       It's not correlated well, and even when I say arthritis, it's hard to define. So the, uh, the way I think about it is there's arthritis, and then there's symptomatic arthritis. So you can have cartilage loss, and we consider that, quote-unquote, arthritis, but it very often isn't symptomatic. And so when we really think about arthritis, it's a whole joint disease. The cartilage starts to break down, an inflammatory reaction happens. The synovium, which is on the inside of the knee, also gets inflamed. The bone under the cartilage goes through changes. So the arthritis that you're worried about, that I'm worried about, is that whole joint arthritis. Not so worried about narrowing of the cartilage-

    5. PAPeter Attia1:27:02

       I see

    6. ACAdam Cohen1:27:03

       ... in isolation. It's the-

    7. PAPeter Attia1:27:05

       It's much more systemic-

    8. ACAdam Cohen1:27:06

       Correct

    9. PAPeter Attia1:27:06

       ... to the knee as a system.

    10. ACAdam Cohen1:27:07

        It's a, it's like a biologic process. We're really trying to avoid... And I see them come in, they were perfectly normal. I see people with horrible-looking knees who come into my office, they say, "My knee started hurting last week. I've never had a knee problem before." I get an x-ray, and there is no cartilage left, and they won't believe me. They said, "But I don't have arthritis." I say, "I know you didn't know you have arthritis, but now you do."

    11. PAPeter Attia1:27:34

        So what tipped that person over? Because clearly-

    12. ACAdam Cohen1:27:37

        Yeah

    13. PAPeter Attia1:27:37

        ... if you took that x-ray a year, a year ago, it would look-

    14. ACAdam Cohen1:27:40

        It would-

    15. PAPeter Attia1:27:40

        ... almost as bad, if not the same

    16. ACAdam Cohen1:27:42

        Exactly the s- same.

    17. PAPeter Attia1:27:42

        What flipped the switch?

    18. ACAdam Cohen1:27:43

        Same. It's usually a traumatic event. It's usually a stumble. It's usually nothing. It's like, "I lifted something heavy and twisted funny. I felt a little something." Maybe the meniscus tears a little more.

    19. PAPeter Attia1:27:53

        Mm.

    20. ACAdam Cohen1:27:54

        Right? So it's, it's a very slow process. The chondrocytes have been not doing their thing. The cartilage is worn away, but it's been such a low burn that it hasn't tipped the scale into a very painful process, and then it goes over the, overboard, and it's hard to bring it back at that point, 'cause there's not really any healthy cartilage left, and those are the... That's very difficult. It's a very difficult problem, and those people get knee replacements.

    21. PAPeter Attia1:28:21

        Before we

16. 1:28:22 – 1:38:16

    Meniscus tears: how they happen and when surgery is appropriate

    1. PAPeter Attia1:28:22

       go to knee replacements, let's talk about the meniscal tear.

    2. ACAdam Cohen1:28:24

       Yeah.

    3. PAPeter Attia1:28:24

       This is such a controversial area.

    4. ACAdam Cohen1:28:26

       Right.

    5. PAPeter Attia1:28:27

       I assume there have been sham surgery studies-

    6. ACAdam Cohen1:28:30

       Right

    7. PAPeter Attia1:28:30

       ... that have been done.

    8. ACAdam Cohen1:28:30

       Correct.

    9. PAPeter Attia1:28:31

       What do we know about meniscal, isolated meniscal tears?

    10. ACAdam Cohen1:28:33

        Yeah, so I think the, just the, the principle is, is if you have a meniscus tear, and you don't have arthritis, you need to strongly consider fixing that meniscus, because that's what's keeping us from getting arthritis.

    11. PAPeter Attia1:28:48

        And the meniscal tear means separation from the tibial plateau? Is that what the tear means, or is it a tear across the surface?

    12. ACAdam Cohen1:28:57

        So here we have a cross-section of the knee. This is the lateral meniscus here, and this is the medial meniscus here. So if we were to look at the model, that's what we would be looking at. So there are different types of meniscus tears. There are tears that are at the periphery, where there's very good blood flow, and in those types of tears, you can sew it back together, and should. There are tears that go all the way across, and then this piece can flip. That's called a bucket-handle tear, and that often will lock the knee.

    13. PAPeter Attia1:29:41

        The inner piece or the outer piece flips?

    14. ACAdam Cohen1:29:43

        The inner piece. The outer piece is connected to the capsule.

    15. PAPeter Attia1:29:47

        Mm-hmm.

    16. ACAdam Cohen1:29:48

        There are tears that we call radial tears, that go through here. Occasionally, if it's close enough to the rim, you could put sutures there, but sometimes you just need to trim it, where you take out the torn piece of meniscus, and you just leave what remains. So that's the difference between a meniscus repair and a meniscectomy. So when we talk about-

    17. PAPeter Attia1:30:09

        And the, and the bucket handle, you repair primarily?

    18. ACAdam Cohen1:30:12

        Yes. You put it back to where it is, and you sew it back together.

    19. PAPeter Attia1:30:16

        So all the controversy around meniscal surgery that is no better than a sham surgery, is it based on a particular one of those, or is it based on the fact that these studies didn't stratify for those?

    20. ACAdam Cohen1:30:31

        Right. So i- it's, it's a specific type of tear. So in general, we wanna save the meniscus when we can. So if you're young, and you have a meniscus tear, and you heard that sham surgery's no better than, that's not you. You need to have your meniscus fixed if it can be fixed. If you have degeneration of the knee already, if you have arthritis, let's say you have advanced arthritis of the knee- And your doctor gets you-

    21. PAPeter Attia1:30:59

        And again, sorry to interrupt, I wanna come back to this point.

    22. ACAdam Cohen1:31:01

        No, sure.

    23. PAPeter Attia1:31:02

        The diagnosis is made how of arthritis? 'Cause it's clearly-

    24. ACAdam Cohen1:31:06

        Right

    25. PAPeter Attia1:31:06

        ... no longer just a radiographic-

    26. ACAdam Cohen1:31:07

        Right

    27. PAPeter Attia1:31:07

        ... diagnosis.

    28. ACAdam Cohen1:31:08

        Well, if it is even with a radiographic diagnosis, because that's what the studies use to say this is-

    29. PAPeter Attia1:31:14

        I see

    30. ACAdam Cohen1:31:14

        ... ineffective.
17. 1:38:16 – 1:49:41

    Total knee replacement: when it’s appropriate and how the recovery process compares to hip replacement

    1. PAPeter Attia1:38:16

       So what are the indications, then, for the total knee replacement?

    2. ACAdam Cohen1:38:20

       So if someone comes in and they have advanced arthritis, that is all compartments of their knee, the medial compartment, the lateral compartment, the patellofemoral compartment, or really two severely degenerative compartments, and they've failed conservative treatment, it's a conversation to have. What is failed conservative treatment? Have we tried PT? Have we tried injections? Have we tried a steroid, hyaluronic acid, potentially PRP, if they're interested, um, bracing? And they, their quality of life is so poor that they want to have something done, we talk about knee replacement.

    3. PAPeter Attia1:38:58

       Do you have a sense of how often body weight is a driver of this arthritis? In other words, you know, I don't know what the numbers are today, but it's roughly a third of the country would have a BMI over 30.

    4. ACAdam Cohen1:39:10

       Right.

    5. PAPeter Attia1:39:10

       Uh, many of those people don't have a BMI over 30 because they're overly muscled, right? Um, although I'm not sure that the knee cares how much that weight is muscle versus fat. So just in terms of excess weight, how often is that driving the problem?

    6. ACAdam Cohen1:39:24

       It's driving it a lot, which is why I show them the chart of this is what you do-- this is four times body weight when you do this. This is seven times body weight when you do this. Just walking up the stairs, or down the stairs, even-

    7. PAPeter Attia1:39:35

       Down the stairs is even worse.

    8. ACAdam Cohen1:39:36

       Right. And I say, "If you lose five pounds, I don't, you know, let's start small. This is how much weight you're taking off your knee if you multiply that." I said, "If you can lose this amount of weight, you may not want a knee replacement, and you may not need one." And so I never tell someone when it's time for them to have a knee replacement. They're gonna tell me, "Listen, I can't do this anymore. I want something." And as long as they're healthy enough to have the surgery, it's reasonable. But obviously, you know, the, the satisfaction rate after knee replacement is different than hip replacement, and it's just an inherently less stable joint. And so it's, it's harder to feel like it's a normal knee. People feel like it's a normal hip, but they don't feel like it's a normal knee when it's replaced, so.

    9. PAPeter Attia1:40:17

       So this is probably a decent diagram to show the anatomy of the knee replacement, huh?

    10. ACAdam Cohen1:40:22

        So I have a model for that.

    11. PAPeter Attia1:40:24

        Ah, perfect.

    12. ACAdam Cohen1:40:26

        So this is a model of a replaced knee. I'm gonna take off this portion, flex the knee, and what we see here is fake knee replacement, but basically has three components. Before we put those components on, we make cuts in the surface of the distal femur. We make a cut in the surface of the proximal tibia, and that matches an implant that fits right on that surface, and same with the tibial surface. And that is made of the high molecular weight polyethylene. And then also occasionally, we also will replace the surface of the kneecap with a plastic button, and that's your new knee.

    13. PAPeter Attia1:41:17

        And do you, do you sometimes keep the native patella if it's fine?

    14. ACAdam Cohen1:41:22

        Yeah, occasionally. Sometimes, you know, there's some people who, it's called resurfacing the patella, and some people who don't resurface the patella.

    15. PAPeter Attia1:41:28

        Okay.

    16. ACAdam Cohen1:41:28

        And the studies show that there's probably not a difference. In Europe, I think they hardly ever resurface the patella. It's more common in the United States. But I know a lot of surgeons who don't, and I do sometimes. I do most of the time, but sometimes I don't. The reason I do it most of the time is because if there's significant arthritis there, and I'm there, I'm too afraid that they're gonna have pain after, because a lot of people after knee replacement still are, eighty-five percent satisfaction means that fifteen percent are dissatisfied. And if I haven't replaced the patella, I'm thinking to myself, "Maybe I should have replaced the patella, too."

    17. PAPeter Attia1:41:59

        How long does this operation take?

    18. ACAdam Cohen1:42:01

        Uh, it depends. Anywhere from an hour to two hours, depending on the complexity of the surgery.

    19. PAPeter Attia1:42:06

        And how big is the incision? It's straight-- It's a midline incision?

    20. ACAdam Cohen1:42:09

        It's a midline incision, anywhere from ten centimeters. It depends on the knee. It's, it's, it goes from here to here.

    21. PAPeter Attia1:42:15

        And unlike the hip, which we talked about earlier, where the difference between what happens today and twenty years ago is night and day, and these patients are, they just feel amazing, um, these patients still struggle post-operatively.

    22. ACAdam Cohen1:42:27

        Yes. Less so. We learned a lot during COVID that you can do these outpatient very s- safely.

    23. PAPeter Attia1:42:32

        Mm.

    24. ACAdam Cohen1:42:33

        And, uh, there, the, the technology is improving with total knee replacements, too, where the incisions can be a little smaller. I do-

    25. PAPeter Attia1:42:40

        What's the dominant source of pain? Is it the incisional pain? I assume it's much more the bone pain of what you've had to resurface, isn't it?

    26. ACAdam Cohen1:42:46

        Right. So none of that's changed.

    27. PAPeter Attia1:42:48

        Yeah.

    28. ACAdam Cohen1:42:48

        But the perioperative management of the pain has changed. We give injections into the capsule during the surgery. There's other nerve blocks that are used. We send them home with pumps to get them through that initial stage.

    29. PAPeter Attia1:43:03

        What is the time to recovery for a motivated patient who has a knee replacement, and what are the limitations? I should have asked the same question, by the way, on the hip replacement, so we can do that after.

    30. ACAdam Cohen1:43:16

        Right.
18. 1:49:41 – 1:53:42

    Surgical vs. non-surgical approaches to various knee injuries

    1. PAPeter Attia1:49:41

       any other knee pains that you look at that are quantifiably not surgical, where you say, "Boy, you, operating on you would be a mistake"?

    2. ACAdam Cohen1:49:51

       Right. So, you know, in general, the, the, it's injury-dependent often. There are some injuries where there is, there's no doubt about it, you have to have surgery. If you rupture your patellar tendon or your quadriceps tendon, I don't, is, the conservative treatment is to do surgery because y- your leg will not work unless we reconnect the tendon, right?

    3. PAPeter Attia1:50:11

       Is the patellar tendon typically ruptured above or below the patella?

    4. ACAdam Cohen1:50:15

       So the quadriceps tendon is... Oh, we could use this s- picture. So this is the quadriceps tendon.

    5. PAPeter Attia1:50:24

       Mm-hmm.

    6. ACAdam Cohen1:50:24

       And this is the-

    7. PAPeter Attia1:50:25

       Oh, the patellar tendon is the below. Got it

    8. ACAdam Cohen1:50:26

       Yeah. So if either one of these is ruptured, the patella will go with the unruptured side.

    9. PAPeter Attia1:50:31

       Yeah.

    10. ACAdam Cohen1:50:31

        They're not connected anymore. You have to fix that, otherwise it-

    11. PAPeter Attia1:50:34

        You can't ex- it's very hard to extend the knee.

    12. ACAdam Cohen1:50:35

        You can't.

    13. PAPeter Attia1:50:36

        Yeah.

    14. ACAdam Cohen1:50:36

        You can't do it. I mean, essentially, you can't do it.

    15. PAPeter Attia1:50:39

        Okay.

    16. ACAdam Cohen1:50:39

        So that has to be fixed. For a lot of problems, you can try conservative management, right? Meniscus tears, occasionally you could try conservative management. There are even people who don't necessarily need an ACL reconstruction. There are people who have ACL tears who cope well without reconstruction, and we talk about that possibility. If someone does not participate in Level 1 sports, they don't do pivoting or rotational types of activities, then, and they, they can, you can bike without an ACL tear. You can, you can run without an ACL tear. So even that potentially-

    17. PAPeter Attia1:51:16

        With, with an ACL tear?

    18. ACAdam Cohen1:51:17

        With an ACL tear.

    19. PAPeter Attia1:51:18

        Yeah. Yeah.

    20. ACAdam Cohen1:51:19

        You can. So, and there are a lot of people who cope quite well. I did from the age of 15 to 30, and I was fairly active, with occasional swelling here and there.

    21. PAPeter Attia1:51:27

        And during those 16 years that you had the ACL tear, outside of the acute phase, how many times did you lose stability, or did your knee go out?

    22. ACAdam Cohen1:51:36

        Dozens, dozens, dozens. But I tend-

    23. PAPeter Attia1:51:39

        Were you causing more injury? Were you increasing the risk of arthritis through that activity-

    24. ACAdam Cohen1:51:43

        Absolutely

    25. PAPeter Attia1:51:44

        ... through the instability? Yeah.

    26. ACAdam Cohen1:51:44

        Which is amazing that I don't.

    27. PAPeter Attia1:51:45

        So it's, it's very similar to the subluxed shoulder, right?

    28. ACAdam Cohen1:51:48

        Yes.

    29. PAPeter Attia1:51:48

        The more you sublux, the more you increase the risk of arthritis.

    30. ACAdam Cohen1:51:51

        Right, right.
19. 1:53:42 – 1:58:50

    Achilles tendon: tendinitis, rupture of the Achilles tendon, and prevention strategies

    1. PAPeter Attia1:53:42

       All right. So the, uh, the foot and ankle are very complicated, and, um, uh, the number of bones here and the number of ligaments is simply staggering. Uh, obviously, we're not going to, y- you know, provide a master's class on this due to the complexity of it, but let's kinda focus on the big picture here, um, which is what are the areas, w- what, what part of the anatomy do we need to understand to really get a sense of where people have pain here?

    2. ACAdam Cohen1:54:12

       Sure. Um, well, it, it depends obviously on, on the population we're talking about. So if we just talk about athletes for a second, uh, people who are very active and, and, for example, run a lot, we're, we're interested in a number of things. Um, let's focus on the top picture here. This is, uh, this is the heel bone, and this is where the Achilles tendon attaches to the bone, and we do see a lot of Achilles tendonitis, uh, and that's a very difficult problem, 'cause there are not a lot of great treatment options. Um, surgery doesn't do great with tendinopathy of the Achilles tendon, and only when it's ruptured is there sort of more, more of a, a plan on how to address it. Um, interestingly, I don't think there's a increased incidence of tendon ruptures in the setting of tendinopathy. We don't really-

    3. PAPeter Attia1:54:58

       Interesting

    4. ACAdam Cohen1:54:58

       ... see that.

    5. PAPeter Attia1:54:59

       So tendinopathy would just present as pain there.

    6. ACAdam Cohen1:55:03

       Mm-hmm.

    7. PAPeter Attia1:55:03

       But that doesn't necessarily increase the risk of rupture.

    8. ACAdam Cohen1:55:06

       My reading of the literature up to date, and I don't do a lot of foot and ankle surgery, that's been my, uh, understanding, and I've treated lots of people over the years with Achilles tendonitis, and I don't remember ever a case where they came back, "Oh, I, I, look at that, I ruptured it."

    9. PAPeter Attia1:55:20

       Interesting. While we're on the topic of rupture How much of a concern are fluoroquinolones? Everybody asks me this question.

    10. ACAdam Cohen1:55:26

        Hmm.

    11. PAPeter Attia1:55:26

        I don't really know the answer, so-

    12. ACAdam Cohen1:55:28

        Right

    13. PAPeter Attia1:55:28

        ... you know, ciprofloxacin, drugs, leva- Levaquin, uh, these antibiotics.

    14. ACAdam Cohen1:55:32

        Yeah.

    15. PAPeter Attia1:55:33

        I know that, you know, we're told that they slightly increase the risk of a subsequent rupture. How big is that increase in risk?

    16. ACAdam Cohen1:55:38

        Yeah.

    17. PAPeter Attia1:55:39

        And for how long does it preside after the antibiotic?

    18. ACAdam Cohen1:55:41

        I don't know the length of how long it presides, but I do know that, and I'm, mine is sort of a sampling error because I see it.

    19. PAPeter Attia1:55:47

        You see the cases.

    20. ACAdam Cohen1:55:48

        I see it more than you do, so because that's who's coming in. And, uh, I've seen it after one dose, so I don't, I don't know how to guide people.

    21. PAPeter Attia1:55:58

        How long after a dose? Someone has a dose, and then they-

    22. ACAdam Cohen1:56:00

        Within a week or two I've seen it. So, and it, it usually, so this is what I tell people. It's not a reason not to take the medication, but if you start to feel anything, you have to stop and rest [laughs] because I feel like that is one of those situations when-

    23. PAPeter Attia1:56:12

        Are there warning signs to an Achilles rupture?

    24. ACAdam Cohen1:56:15

        Uh, they, they start to develop pain, and that's when I stop, but I don't know-

    25. PAPeter Attia1:56:19

        Then we just, but, but it's not tendinopathy.

    26. ACAdam Cohen1:56:21

        It's some, it's some-

    27. PAPeter Attia1:56:21

        So what's the pain?

    28. ACAdam Cohen1:56:22

        It's some im- I don't know what the mechanism is for it that would... There is some sort of tendon inflammation that's happening, but I'm not, I'm not sure.

    29. PAPeter Attia1:56:32

        Okay, that's a little disconcerting.

    30. ACAdam Cohen1:56:33

        Yeah.
20. 1:58:50 – 2:01:32

    Anatomy of the ankle and foot

    1. PAPeter Attia1:58:50

       Okay, so let's go over some of the bony structures here.

    2. ACAdam Cohen1:58:54

       Hmm.

    3. PAPeter Attia1:58:54

       Maybe it's easier to look at that model, huh?

    4. ACAdam Cohen1:58:55

       Sure. So this is the, the ankle joint proper, which is this, this is the leg bone or the tibia. It joins here with the talus, um, on the, and al- also along with the fibula. So these three bones make up the ankle joint, um, and the surface is coated in cartilage just like all the other joints we talked about. The talus then articulates with the navicular bone here, and then there cuneiforms, the cuboid bone on the outside, the metatarsals, the phalanges. If we turn it to the side, this is the inner side of the ankle. This is the, the medial malleolus, and along this area is where the tendons, uh, that help to maintain your arch rest. So if we were to look at the tendons of the ankle, this, on the bottom image is the medial aspect of the ankle, and this is the posterior tibialis tendon, which is incredibly important for maintaining your arch. Uh, and then we also have the flexor hallucis longus here, which goes to the first toe, and these are the flexors for the, for the digits as well. Uh, if we look at the, uh, ligaments on the medial aspect of the ankle, we see here, this is the medial malleolus. This broad ligament is the deltoid ligament, and then we have this, uh, spring ligament here. And this is the plantar fascia as well, which helps to maintain your arch. And these are important structures to examine, uh, to make sure that the, the plantar fascia, which helps to maintain the arch, is competent, and that the posterior tibialis tendon is also working. So it's important to go through, um, walking on your toes, walk on your heels, see how the gait, uh, progression is managed.

    5. PAPeter Attia2:00:51

       Yeah, and all of these things we'll show in the exam-

    6. ACAdam Cohen2:00:53

       Yeah

    7. PAPeter Attia2:00:53

       ... of course.

    8. ACAdam Cohen2:00:54

       [smacks lips] On the outside of the ankle, or the lateral part of the ankle, where this is where the fibula is, this is where most ankle sprains happen. So there, this is the main ligament that's injured. It's called the ATFL, or anterior talofibular ligament. And then we have the calcaneofibular ligament, posterior talofibular ligament, which is not as often sprained. And then we have this ligament up here which connects the fibula to the tibia, and when people have high ankle sprains, this is often the ligament that's injured. Whenever someone has an ankle sprain- It's conservative treatment, and most people get

21. 2:01:32 – 2:13:17

    Common injuries to the ankle and foot

    1. ACAdam Cohen2:01:32

       better, but not everybody.

    2. PAPeter Attia2:01:33

       And is a sprain what degree of tear to that ligament?

    3. ACAdam Cohen2:01:38

       It could be any degree. If you have a sprain, that is, if you, your ankle twists and you have swelling, you've torn the ligament. The question is, is it a complete rupture of the ligament? And so we arbitrarily say this is a grade I, grade II high ankle. They're all tearing of the ligament. The degree to which they're torn or which they heal, um, will dictate the next step. So no, it's very rare to have a severe ankle sprain without any dislocation of a joint that would require surgery, except for some syndesmosis injuries up higher. Those often will require surgery. But for the run-of-the-mill twisting my ankle playing basketball, the treatment is conservative, strengthening, strengthen the peroneal muscles. Uh, but the... Doesn't necessarily mean everybody's going to recover, because sometimes what happens is the cartilage gets injured. And just like we talked about in the shoulder and the knee and the hip, any mechanical trauma to the joint puts you at increased risk for arthritis of that joint.

    4. PAPeter Attia2:02:44

       And which cartilage in particular, if for the, if you took the most common-

    5. ACAdam Cohen2:02:48

       Right

    6. PAPeter Attia2:02:48

       ... sprain.

    7. ACAdam Cohen2:02:50

       Right.

    8. PAPeter Attia2:02:50

       Um, which would be the fibul- the, the one-

    9. ACAdam Cohen2:02:55

       ATFL.

    10. PAPeter Attia2:02:56

        ATFL, yeah.

    11. ACAdam Cohen2:02:57

        So the anterior talofibular ligament connects the fibula to the talus.

    12. PAPeter Attia2:03:01

        The talus. Yep.

    13. ACAdam Cohen2:03:02

        And when that rotates this way, this does not rotate at all-

    14. PAPeter Attia2:03:05

        Yeah

    15. ACAdam Cohen2:03:06

        ... you will cause injury to the cartilage 'cause it abuts in this area.

    16. PAPeter Attia2:03:11

        Uh-huh. Yep, makes sense.

    17. ACAdam Cohen2:03:12

        Right? So you will see what we call osteochondral bone-

    18. PAPeter Attia2:03:15

        And if you did an MRI, would you see bone edema there-

    19. ACAdam Cohen2:03:18

        Yes

    20. PAPeter Attia2:03:18

        ... in that patient?

    21. ACAdam Cohen2:03:19

        Yes.

    22. PAPeter Attia2:03:19

        Mm-hmm.

    23. ACAdam Cohen2:03:20

        Yes. And so if someone is not recovering after an ankle sprain, I get an MRI, 'cause I wanna see what the cartilage looks like, to see if they've injured the bone, if they've injured their car- cartilage, and if anything else needs to be done.

    24. PAPeter Attia2:03:31

        And if there's a small fracture there, is it still conservative, put 'em in a boot?

    25. ACAdam Cohen2:03:36

        Um, fracture here or fracture here? If there's a crack in the cart-

    26. PAPeter Attia2:03:39

        There's a crack there

    27. ACAdam Cohen2:03:39

        ... depends. Depends if that piece is what we call stable or unstable. So you can have a crack in the cartilage and bone unit that is in place, in situ, and you could leave that alone, maybe give a boot. Um, if it, that piece is detached, then that's a different ball game.

    28. PAPeter Attia2:03:56

        Unstable.

    29. ACAdam Cohen2:03:57

        That's unstable.

    30. PAPeter Attia2:03:57

        And what about if you have a distal fibula fracture because the sprain is so bad that when their-
22. 2:13:17 – 2:18:40

    Tips for finding a good orthopedic surgeon

    1. PAPeter Attia2:13:18

       So taking a step back from all of this, if someone watching this is sort of in the process of interacting with, with the medical community, um, specifically the orthopedic community, how, how can they pick a good surgeon? What are, what are some of the tells that you're speaking with a good orthopedic surgeon versus someone who's a hack?

    2. ACAdam Cohen2:13:37

       It's a good question. I think you use the same judgment you have when you speak with anybody. You know, are they sitting down when you, when they walk in the room? Are they sitting down? Are they looking at you in the eye? Are they talking to you? Um, do you, do you feel like you're being rushed? I think that's a big sign. If you feel like you're being rushed, you probably are being rushed. Uh, and so just the ability to listen, to have someone that you're, you're li- is listening to you. Um, you know, I hear a lot of people come, and I've seen people all the time who they had surgery with someone, and they're seeing me about three months after their surgery, and they say to me, uh, I said, "Well, you really should ask that question of your surgeon, um, because they know what they did for you, and you..." If they're still in pain, for example. And they say to me, "Oh, yeah, but he's just a surgeon. He just does the surgery." I said, "Well-

    3. PAPeter Attia2:14:26

       [laughs] What do you think I am?

    4. ACAdam Cohen2:14:27

       "... I, I'm also just a surgeon. You know, you can ask him these questions. You, you're entitled to have a conversation with somebody." So I think that's a good... You're, you're not gonna know till you meet them, and, and some people m- some people mesh well with people, other people don't, and-

    5. PAPeter Attia2:14:41

       What, what are some questions that they can ask specifically to get a better sense of, um, y- y- you know, a person's competence, basically?

    6. ACAdam Cohen2:14:52

       Right. It's a, it's a good question. I think if, if you just have to... [lips smack] It's a, it's a good question. I think just, again, the rapport you're having with the person. Let's say for example, y- y- they say, "I think you need surgery." Just a simple question, "Are, are there alternatives?" Or, um, "What are the alternatives?" Or, "Why do you think I need surgery now, and I can't do non-o- you know, is there, are there any non-operative approaches to it?" Uh, and just the answer, right, you know, right off the bat, you could get a good sense if they're, if they're defensive about the res- defensive in their response, that's, you know, that may not be someone who's, who's right for you. Even if they, even if they're right and you do need surgery, doesn't mean you're not allowed to ask the question about alternatives. If someone comes in with a ruptured patellar tendon, and I'd say to them, "You need surgery," even though that visit could be four seconds, I could say, "Oh, you ruptured your patellar tendon. I'm scheduling you for surgery next week. I'll see you then." I'll be right in my assessment of what needs to be done, but that doesn't make me a good doctor or a good surgeon. You need to explain why that's the case, what to expect afterwards, so everybody deserves a conversation about these things.

    7. PAPeter Attia2:16:06

       Yeah, I, I, I, when, when I talk to people about this in general with, with, especially with surgical procedures, I feel like when a surgeon can't give you a clear breakdown of what the complications are-

    8. ACAdam Cohen2:16:18

       Mm-hmm

    9. PAPeter Attia2:16:18

       ... and what the probabilities are of those complications, especially in their hands.

    10. ACAdam Cohen2:16:22

        Right.

    11. PAPeter Attia2:16:23

        It's one thing to qu- quote the literature, but I wanna know, what is your risk of wound infection-

    12. ACAdam Cohen2:16:27

        Right

    13. PAPeter Attia2:16:27

        ... here? What's the probabil- how many times do your patients get wound infections?

    14. ACAdam Cohen2:16:31

        Right.

    15. PAPeter Attia2:16:31

        How many times do your patients require reoperation?

    16. ACAdam Cohen2:16:34

        Right.

    17. PAPeter Attia2:16:34

        How many times do your patients, uh, you know, still find themselves in pain a year out? All of those little things. And then the other question is, what will we do if? So if I'm still in pain in six months-

    18. ACAdam Cohen2:16:49

        Right. What's next?

    19. PAPeter Attia2:16:49

        ... what does your intuition tell you is going on, and how will we work that out?

    20. ACAdam Cohen2:16:52

        Right.

    21. PAPeter Attia2:16:52

        And in my experience, people who can't, surgeons who can't go through that thinking-

    22. ACAdam Cohen2:16:58

        Right

    23. PAPeter Attia2:16:59

        ... aren't very-

    24. ACAdam Cohen2:17:00

        Right

    25. PAPeter Attia2:17:00

        ... good at their job.

    26. ACAdam Cohen2:17:01

        Right.

    27. PAPeter Attia2:17:01

        And you're, you're, you're playing a little bit with-

    28. ACAdam Cohen2:17:04

        Right

    29. PAPeter Attia2:17:04

        ... fire when you-

    30. ACAdam Cohen2:17:05

        It's true

Episode duration: 2:18:40