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Hello everybody, and welcome to 
the Doctors for Running podcast 

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where we, a group of doctors of 
physical therapy, discussed the 

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art and science of running and 
the stuff that we put on our 

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feet. 
Today at the round table, we 

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have Doctor David Salas and 
myself. 

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I'm Nathan Brown. 
So it's just the two of us. 

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You are stuck with two I I was 
going to say sad NBA fans, but 

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things have been turning around 
for the Warriors lately. 

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So you you're probably a happier
guy or having a weird emotional 

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reality right now. 
And I'm just sad because Chris 

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Middleton is gone. 
I get it was the right time, but

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it does make me a little sad. 
Yeah, yeah. 

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You know, sports teams, 
sometimes they they can act a 

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little bit like a Patella. 
Sometimes it just needs a little

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lift, you know, and Jimmy Butler
is providing that right now. 

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So same thing. 
Things are all new. 

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I can promise you that none of 
you came here to hear us talk 

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about our NBA fandom and the 
NBA, but you may be interested 

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to hear us talk about Patel 
femoral pain syndrome, which is 

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what the is going to be mainly 
on the docket today. 

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We're going to be talking about 
what is the definition of Patel 

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femoral pain syndrome and what 
may people be referring to it 

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as. 
We're going to talk about the 

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science of it and what may be 
some of the pain generating 

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structures, talk about some of 
the common ways to rehabilitate,

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things to consider and are 
things like changing the way you

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move, gate retraining, gate 
mechanics. 

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I'm thinking about other factors
that may contribute to this, 

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this pain syndrome. 
How can you go about treating it

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and what are the biggest bang 
for your buck? 

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That's where we're going to be 
going today. 

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But before we go there, David, 
are there any shoes right now 

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that you've been testing or 
you're going to get ready for 

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review soon that you want to 
bring up and talk about? 

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Yeah, I mean, the majority of 
them I can't talk about, you 

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know, but that's old news. 
The current 1 though, that I 

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can't talk about is the Cloud 
Surfer. 

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Next kind of a fun shoe 
continuation of the the Cloud 

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Go, which I didn't actually 
realize that until I was reading

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the Running Warehouse summary 
and I was like, oh, that kind of

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makes sense. 
They made some changes. 

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I think it is a different shoe 
than the Cloud Go, but there are

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enough similarities where I 
could kind of see that being a a

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continuation of the line to some
degree. 

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But it's fun. 
Yeah, just wrote the review this

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morning that should be coming 
out shortly or maybe even before

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this airs, so. 
Where do you where do you see 

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that shoe fitting lineup wise or
is it a shoe that could do 

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everything for somebody? 
A little bit of everything, you 

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know, it's definitely firmer, 
like I mean, even even for on 

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this shoes pretty firm, but 
there's still just enough 

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cushioning like on didn't 
publish their stack height, but 

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running warehouse has it at a 
3731 for 6mm. 

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So there's a decent amount of 
foam still, but it's but that 

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but it is firm, you know, and 
it's it's got kind of a pretty 

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modest heel bevel, little bit of
a sharper toe spring up front 

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and the foam has a good little 
bit of bounce to it when you 

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load it. 
So it does have some 

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versatility. 
It weighs in in the low 9 oz. 

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So it's like you can kind of do 
a little bit of everything. 

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You know, it's definitely, and 
it feels that way, like the 

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upper is a little bit more 
streamlined too. 

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Platform itself is a little bit 
stiffer. 

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There's a little bit of give to 
it, but it's still pretty stiff.

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Whereas like the Cloud Surfer is
kind of like that traditional 

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training shoot you. 
Yeah, where I feel like this 

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one, it's like, OK, like I could
do some tempo runs, I could do 

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some long runs, assuming you're 
OK with it being that firm. 

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But yeah, I feel like there's a 
little bit more versatility to 

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it. 
You know, it's not like you put 

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it on, you're like, oh, I'm just
only going to run daily miles. 

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Like you could turn it up a 
little bit. 

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I think it's interesting that 
they both both the cloud surfer 

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and then the cloud surfer next 
are in the cloud surfer 

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category. 
But I they are very different 

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because that cloud surfer, the 
original 1 from on was the first

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shoe that was like remarkably 
soft from on, like remarkably. 

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And then you have this on the 
cloud surfer next, which is 

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again more back to that firmer 
feel. 

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So it's. 
Just interesting, I think from a

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in the same world from a naming 
standpoint. 

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I, I don't have confirmation on 
this, but I think it's the 

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midsole makeup and geometry. 
So with them using the cloud 

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tech phase, that kind of 
indicates the surfer line versus

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like there's no speed board. 
It's just like that new midsole 

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that they're working with where 
the. 

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Clouds are like angled instead 
of. 

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I think that's why it's like in 
the surfer lineage, but it's not

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in and of itself. 
They're they're they're not 

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doing a great job of 
differentiating it though. 

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You know, where it's like, yeah.
And I thought surfer next 

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initially in my head, I thought 
it was going to be this like 

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hyper responsive, super bouncy 
shoe kind of by the name. 

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And the idea of like, oh, this 
is the training shoe and this is

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the light fast 1. 
And I was like, I didn't quite 

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get that, but it was still 
really nice. 

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I I did have good things to say 
about it. 

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And I think it will serve a, you
know, a good population of 

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people for those that want that 
firmer feel. 

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But yeah, it just, it was a 
little bit misleading, I think 

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for myself. 
Yeah. 

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Well, cool. 
So what I'm going to do next is 

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we're going to start 
transitioning into our 

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conversation on Patel femoral 
pain syndrome. 

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I'm going to start giving us a 
breakdown of the anatomy. 

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And then David, after that, I'm 
going to pitch it over to you to

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talk about what is Patel femoral
pain syndrome and what may we 

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mean by that term, because there
are there are lots of things 

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that people use that term to 
refer to. 

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So we want to get on the same 
page about that. 

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But when we think about the knee
joint, there's a couple things 

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that we should know. 1 is that 
in regard to the region or body 

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part that has the most running 
related injuries for runners, it

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is the knee. 
Over 50% of running related 

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injuries happen at the knee and 
30% of the reason why people 

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seek care for running related 
injury up to 30%, some studies 

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show less than that as well are 
because they have the symptoms 

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of Patel femoral pain syndrome 
or that becomes their diagnosis.

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So this is a very prevalent 
thing that happens in the 

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running community and that's why
we wanted to spend time talking 

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about it. 
When it comes to the knee joint 

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itself, there's actually kind of
two joints, maybe even three if 

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you want to categorize a third 
one that within the knee joint 

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you have the tibio femoral 
joint. 

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So that's the two big bones 
coming together, your femur 

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coming down from your thigh, the
tibia being your big shin bone, 

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those articulate together and 
then you have the patellofemoral

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joint, which is that floating 
the kind of kneecap structure 

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that articulates with the femur.
It kind of floats on top of 

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there. 
That's connected from the 

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quadriceps tendon that goes into
the top part of your kneecap or 

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the Patella, and then it goes 
down into the tibial tuberosity 

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or part of that shin bone. 
A few other structures that I 

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think are worth just kind of 
wrapping your mind around are 

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the fact that the tibia and the 
femur come together between 

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there are two menisci and then 
all the holding the knee 

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together are a bunch of 
ligaments. 

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So you have these ligaments 
inside your knee called the ACL 

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and PCL. 
They're called your cruciates. 

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They cross each other. 
Then on the outside of the knee,

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you have collateral ligaments, 
which are just thickening of an 

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entire sheath that surrounds 
your entire knee. 

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Every joint has this capsule of 
a thick fibrous tissue. 

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And within our knee we have this
capsule that surrounds the whole

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thing. 
And then we have some 

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thickenings with the MCL on the 
inside of your knee, the LCL on 

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the outside of your knee. 
I think additionally, something 

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that's important to know is that
the knee, because it's a joint, 

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it articulates at what's called 
hyaline cartilage or articular 

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cartilage, very smooth surfaces 
that glide really well on each 

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other. 
These exist both at the tibia 

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femoral joint and the Patel 
femoral joint. 

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And we're going to talk a little
bit more about cartilage as we 

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move on in this conversation. 
But it's important to remember 

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that the cartilage also exists. 
And then under that cartilage is

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bone. 
Any other anatomical things 

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that, oh, I should say, The 
third joint that sometimes 

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people may put at the knee is 
what's called the proximal 

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proximal tib fib joint. 
And so that's right at the top 

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of your shin, there's 2 bones 
that kind of come together. 

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There's not a lot of motion 
there. 

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There's some translation that 
happens at that joint, but 

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typically that translation is 
more associated with ankle 

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motions than it is with the 
knee. 

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So we're not going to really 
talk about it much, but some 

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people may be like, well, what 
was that third, that third? 

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I was kind of curious. 
I was like, what is it? 

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Yeah, what is the if? 
I looked a little cheeky on 

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video there as where I was like,
yes I do. 

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Yeah, and that's why I don't 
really, I don't really put it 

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there, but somebody may. 
And so I didn't want to leave it

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out. 
Obviously too. 

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On the outside of the knee is 
your idiot iliotibial band that 

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comes down and attaches to the 
fibular head. 

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Also flat flows into part of the
Patella and lots of different 

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regions on the outside. 
Gertie's tubercle on the on the 

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tibia. 
So there's lots of different 

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things going on at the knee, but
it's a nice little hinge joint, 

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flexes and extends. 
It's got a little bit of 

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rotation to it, which will come 
into part of our conversation as

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well. 
So I'm going to give you an 

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opportunity. 
Is there anything about anatomy 

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that you want to add, or do you 
want to just start talking 

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about? 
What do you think of when you 

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think of patellofemoral pain, 
and what do other people may 

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sometimes refer to it as? 
Yeah. 

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So when we look at it, I think 
anatomically, I think you hit it

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pretty well. 
I'm not really sure there's much

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I can add there. 
That was a pretty good summary, 

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but when? 
3 minutes too much. 

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No, no, that was good. 
That was a compact like that was

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a crash course in the anatomy 
right there. 

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I was pretty solid. 
I was like, oh, Dang, that EDD 

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is paying off there. 
OK, I see. 

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Like. 
For those of you that I don't 

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know, Nate's working on an 
educational doctorate here, so. 

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Should I should defend? 
I don't want to put it too 

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public but potentially defending
and finishing up end of March 

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so. 
Yeah, yeah, I got to see 

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Professor Nate there for like 5 
seconds. 

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I was pretty impressed. 
Or three minutes, not 5 seconds.

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But no, I think you hit it 
pretty well. 

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I think it's kind of funny when 
we look at patellofemoral pain 

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syndrome, as common as it can 
be, it also is a little bit 

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diffuse and kind of hard to 
define. 

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And there's a lot of people 
within our own field that will 

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kind of butt heads a little bit 
on what is patellofemoral pain 

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syndrome and what are the true 
pain generating structures and 

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what's actually going on at the 
knee. 

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And because of this kind of 
mystification of the joint, 

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it's, it can be hard to, there's
a lot going on at the knee like 

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you just identified. 
And in a lot of pathologies, you

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have a very specific structure 
you can point it to. 

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And we'll, we'll get to this 
later. 

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But like we were talking before 
coming on, like one of the 

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things that can all get brought 
up pretty frequently when we 

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talk about the knee is like 
patellar tendinopathies and 

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things like that. 
That's not exactly what this is,

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right? 
Like that is a tendinopathy of 

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the patellar tendon itself. 
When you're looking at Patella 

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femoral pain syndrome, I'm 
usually looking more 

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specifically kind of at the 
Patella and the surrounding 

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connective tissue there. 
And so usually it's kind of a 

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broad based anterior, anterior 
being in the front knee pain, 

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and sometimes even within the 
retro patellar space where 

226
00:10:49,360 --> 00:10:51,840
you're looking at the Patella 
itself. 

227
00:10:51,840 --> 00:10:54,920
And then the little gap that you
have in between, let's say you 

228
00:10:54,920 --> 00:10:57,680
have your big femur, your tibia,
and then you have that floating 

229
00:10:57,680 --> 00:10:59,800
kneecap right in the middle. 
And then there's a little bit of

230
00:10:59,800 --> 00:11:01,840
space in between there. 
And so sometimes people get this

231
00:11:02,080 --> 00:11:05,920
irritation and pain on the 
underside of that or even on the

232
00:11:05,920 --> 00:11:08,880
inside wedge of that. 
And so when you kind of get 

233
00:11:08,880 --> 00:11:12,160
those like weird broad based 
kind of front of the knee pains,

234
00:11:12,160 --> 00:11:16,120
that's kind of what I usually 
think of as Patella femoral pain

235
00:11:16,120 --> 00:11:20,760
syndrome versus a traditional 
tendonopathy or ligamentous 

236
00:11:20,760 --> 00:11:24,480
injury or something like that. 
I totally agree because I think 

237
00:11:25,000 --> 00:11:28,720
when when people come in and 
they end up in my mind having 

238
00:11:28,720 --> 00:11:31,720
that kind of diagnosis of 
patelifemoral pain syndrome, 

239
00:11:32,520 --> 00:11:36,600
there usually isn't a palpably 
tender structure like like the 

240
00:11:36,600 --> 00:11:40,240
patellar tendon is super tender 
to palpation or if they have 

241
00:11:40,240 --> 00:11:42,960
really inflamed fat pads. 
I kind of categorize that 

242
00:11:42,960 --> 00:11:46,840
differently from patelifemoral 
pain syndrome, which I find to 

243
00:11:46,840 --> 00:11:50,000
be, yeah, like you said, more 
retro patellar deep to that 

244
00:11:50,000 --> 00:11:51,720
kneecap. 
In that space between. 

245
00:11:51,720 --> 00:11:54,160
There's kind of just this. 
I'll find sometimes it's more 

246
00:11:54,160 --> 00:11:57,160
medial, sometimes it's in the 
middle and it's just kind of 

247
00:11:57,160 --> 00:11:59,080
there. 
But they can't, like they can't 

248
00:11:59,080 --> 00:12:02,880
point to it, they can't push it.
Oftentimes that's what I 

249
00:12:03,280 --> 00:12:05,440
categorize as Patel femoral pain
syndrome. 

250
00:12:05,720 --> 00:12:08,640
But that categorization, even 
when I give it to people, I'm 

251
00:12:08,640 --> 00:12:11,920
not telling them it's this 
structure that's causing you the

252
00:12:11,920 --> 00:12:14,480
discomfort because I went 
through a lot of those 

253
00:12:14,480 --> 00:12:17,800
structures that are in the knee.
And with this syndrome, it's 

254
00:12:17,800 --> 00:12:22,440
ultimately a result of when your
capacity and your loading don't 

255
00:12:22,440 --> 00:12:24,560
match up. 
And so the amount of loading 

256
00:12:24,560 --> 00:12:28,080
that you had in that Patel 
femoral space is exceeding what 

257
00:12:28,080 --> 00:12:31,280
the capacity is at that time. 
And then that may lead to 

258
00:12:31,280 --> 00:12:32,600
irritation of a number of 
things. 

259
00:12:32,880 --> 00:12:35,000
I think it could. 
There was some studies that 

260
00:12:35,000 --> 00:12:38,680
showed that the edema not within
the cartilage, but the bone 

261
00:12:38,680 --> 00:12:40,960
underneath the cartilage, 
there's edema there that causes 

262
00:12:40,960 --> 00:12:43,200
some discomfort on that backside
of the Patella. 

263
00:12:43,520 --> 00:12:46,720
That was one theory. 
It also can be that membrane, 

264
00:12:46,720 --> 00:12:49,280
that kind of capsule that I 
talked about getting irritated. 

265
00:12:49,760 --> 00:12:52,200
And I think that makes a lot of 
sense because of what we know 

266
00:12:52,200 --> 00:12:55,080
about how much loading there is 
related to running. 

267
00:12:55,280 --> 00:12:58,520
And yes, we adapt to the load 
that we put on our body. 

268
00:12:58,760 --> 00:13:01,960
But at some point, if you have a
decreased capacity and your load

269
00:13:01,960 --> 00:13:03,760
exceeds that, you can start to 
have discomfort. 

270
00:13:04,040 --> 00:13:07,040
They did some math in a study. 
I'd wrote it down because I 

271
00:13:07,040 --> 00:13:09,160
thought it was interesting to 
think about how much loading 

272
00:13:09,160 --> 00:13:10,640
happens to your knee when you 
run. 

273
00:13:11,080 --> 00:13:14,240
And I want to be clear before I 
read these numbers, loading is 

274
00:13:14,240 --> 00:13:16,840
not bad. 
In fact, loading in your knee 

275
00:13:16,840 --> 00:13:19,560
joints. 
We have a whole podcast on this 

276
00:13:19,840 --> 00:13:23,480
actually helps prevent 
degeneration of your knee. 

277
00:13:24,120 --> 00:13:27,880
It's running recreationally as 
protective for knee joint 

278
00:13:27,880 --> 00:13:29,440
health. 
But anyway, listen to the amount

279
00:13:29,440 --> 00:13:33,560
of loading that happens if 
somebody is running 160 steps 

280
00:13:33,560 --> 00:13:36,240
per minute, which is potentially
conservative with some people 

281
00:13:36,240 --> 00:13:37,760
having a higher cadence than 
that. 

282
00:13:38,440 --> 00:13:41,400
And each time you step, there's 
about four times your body 

283
00:13:41,400 --> 00:13:43,520
weight that goes through the 
patellofemoral joint. 

284
00:13:44,000 --> 00:13:48,040
That is 320 body weights per 
minute going through that joint 

285
00:13:48,400 --> 00:13:51,480
and 19,200 body weights per 
hour. 

286
00:13:51,880 --> 00:13:54,960
And then you extrapolate that 
further in the number of runs 

287
00:13:54,960 --> 00:13:57,920
that you do in a week. 
That's a lot of loading that 

288
00:13:57,920 --> 00:14:03,200
that that joint needs to respond
to, recover from, heal from. 

289
00:14:03,200 --> 00:14:07,120
And it makes a lot of sense to 
me that it's possible that the 

290
00:14:07,840 --> 00:14:11,640
area underneath that cartilage 
can get a little bit of swelling

291
00:14:11,640 --> 00:14:14,200
as it's repairing itself. 
And that can lead to some of 

292
00:14:14,200 --> 00:14:16,640
that discomfort. 
And you need to be able to 

293
00:14:16,640 --> 00:14:18,200
manage kind of some of that 
load. 

294
00:14:19,320 --> 00:14:22,440
What's also important because I 
think sometimes people also 

295
00:14:22,440 --> 00:14:26,080
again, get scared that running 
maybe decreasing the health of 

296
00:14:26,080 --> 00:14:28,360
their cartilage. 
And then when their cartilage 

297
00:14:28,360 --> 00:14:30,680
starts breaking down, they're 
getting osteoarthritis and that 

298
00:14:30,680 --> 00:14:34,160
can lead to pain. 
What's really important is that 

299
00:14:34,800 --> 00:14:37,880
they, there's previous research 
that shows that there are not 

300
00:14:37,880 --> 00:14:39,720
nerve endings within our 
cartilage. 

301
00:14:40,240 --> 00:14:43,040
So if you have something like 
chondromalacia, let's say you 

302
00:14:43,040 --> 00:14:46,240
went, you had knee pain, you go 
to an MD, they're probably going

303
00:14:46,240 --> 00:14:48,680
to give you X-rays and that 
might show that there's some 

304
00:14:48,680 --> 00:14:52,400
sort of chondromalacia. 
But chondromalacia cannot be 

305
00:14:52,400 --> 00:14:55,680
really A cause for pain because 
the cartilage itself cannot be a

306
00:14:55,680 --> 00:14:57,920
pain receptor. 
There aren't free nerve endings 

307
00:14:58,160 --> 00:15:02,560
in those structures. 
And so I, what we do sometimes 

308
00:15:02,560 --> 00:15:05,480
is say, oh, no, running's 
leading to softened cartilage, 

309
00:15:05,480 --> 00:15:07,720
which is leading to my pain. 
I need to stop running. 

310
00:15:08,040 --> 00:15:11,560
And that's not the case. 
We need to be thinking a little 

311
00:15:11,560 --> 00:15:14,000
bit differently about this. 
And it's more about load 

312
00:15:14,000 --> 00:15:16,760
management so that you can 
continue to ramp up the amount 

313
00:15:16,760 --> 00:15:19,120
of loading that the tissues can 
tolerate. 

314
00:15:19,120 --> 00:15:22,600
Do you have anything to add? 
Yeah, because I I just rambled 

315
00:15:22,600 --> 00:15:23,880
for a bit. 
No, no, no. 

316
00:15:23,880 --> 00:15:28,040
It's a it's a very professional 
and a very doctorate level rant.

317
00:15:30,680 --> 00:15:33,160
I don't like I'm. 
Just gonna like for those of you

318
00:15:33,160 --> 00:15:36,240
that don't know our 
relationship, I will find 

319
00:15:36,240 --> 00:15:39,480
something to just troll him 
constantly about and then I will

320
00:15:39,480 --> 00:15:42,920
just lean into it for way too 
much time. 

321
00:15:47,360 --> 00:15:53,360
I lost my thought. 
No no. 

322
00:15:53,360 --> 00:15:56,640
OK. 
So for anything when you look at

323
00:15:56,920 --> 00:16:00,000
specifically in the physical 
therapy world, there is this is 

324
00:16:00,800 --> 00:16:03,520
going to be the one of the few 
times I bring up APTA here. 

325
00:16:03,520 --> 00:16:07,840
But there is a push to have 
clinical practice guidelines and

326
00:16:07,840 --> 00:16:11,080
things to follow and kind of 
have kind of a road map and kind

327
00:16:11,080 --> 00:16:14,200
of what is something, what are 
some things to look for? 

328
00:16:14,200 --> 00:16:16,400
What have some of the studies 
said about it, levels of 

329
00:16:16,400 --> 00:16:21,240
evidence going into everything 
between exercises to motor 

330
00:16:21,240 --> 00:16:24,120
control, gait training 
modalities, yadda, yadda, yadda.

331
00:16:24,120 --> 00:16:27,480
So those exist. 
If you guys want to go out and 

332
00:16:27,480 --> 00:16:30,360
find that that is public 
information, you can just 

333
00:16:30,360 --> 00:16:33,160
literally look up, you know, 
patellofemoral pain syndrome 

334
00:16:33,160 --> 00:16:35,520
clinical guidelines, boom, it'll
pop right up. 

335
00:16:35,920 --> 00:16:40,440
Usually JOSPT. 
That's Journal of Orthopedic and

336
00:16:40,440 --> 00:16:42,080
Sports Physical Therapy. 
Yep, there we go. 

337
00:16:42,080 --> 00:16:45,280
Yep. 
Sometimes I'm so used to 

338
00:16:45,280 --> 00:16:47,600
referring to things as acronyms 
that I'm like, what? 

339
00:16:47,600 --> 00:16:49,400
Is the actual. 
What does it actually mean? 

340
00:16:49,480 --> 00:16:50,880
Yeah, 100. 
Percent. 

341
00:16:51,280 --> 00:16:53,920
But anyways, like some of the 
things with patellofemoral pain 

342
00:16:53,920 --> 00:16:56,080
syndrome, like we were saying, 
you can be kind of broad based 

343
00:16:56,080 --> 00:16:58,840
as far as like OK, what is 
actually happening there. 

344
00:16:58,840 --> 00:17:01,680
And it's like, I think he did a 
really good job of kind of 

345
00:17:01,680 --> 00:17:04,599
summarizing that it's kind of an
issue between load and capacity.

346
00:17:05,359 --> 00:17:07,760
But some of the things that are 
believed to kind of be some of 

347
00:17:07,760 --> 00:17:11,359
the things that started #1 is 
like overuse, right? 

348
00:17:11,359 --> 00:17:13,520
You're just doing too much and 
it gets something gets 

349
00:17:13,520 --> 00:17:16,160
irritated. 
But there are some reasons to 

350
00:17:16,160 --> 00:17:18,280
believe too. 
Like, let's say you don't have 

351
00:17:18,280 --> 00:17:20,280
the proper strength to be doing 
what you're doing. 

352
00:17:20,680 --> 00:17:24,240
And so that's just a mechanical 
issue there, like you just can't

353
00:17:24,240 --> 00:17:26,079
produce the force. 
Something's getting irritated. 

354
00:17:26,359 --> 00:17:29,240
Sometimes it can be a motor 
control issue where it's maybe 

355
00:17:29,240 --> 00:17:31,800
not a strength issue, but the 
way you're moving on a given 

356
00:17:31,800 --> 00:17:37,120
area is creating irritation 
within that joint or joints as 

357
00:17:37,120 --> 00:17:41,240
we can say. 
And and then sometimes it can be

358
00:17:41,240 --> 00:17:43,400
a strength issue elsewhere as 
well. 

359
00:17:43,400 --> 00:17:47,720
So like a lot of times, I'm sure
if you've seen APT for things 

360
00:17:47,720 --> 00:17:50,640
that are similar, they will tell
you like, oh, let's look at your

361
00:17:50,640 --> 00:17:52,120
hips. 
Oh, you have no hip strength. 

362
00:17:52,120 --> 00:17:54,360
Maybe we should work on that 
because that can be protective 

363
00:17:54,360 --> 00:17:58,160
for your knee as well. 
So I think there's a lot of kind

364
00:17:58,160 --> 00:18:02,400
of differential diagnosis and a 
lot of kind of screening when 

365
00:18:02,400 --> 00:18:06,000
you're on the on the clinician 
side of things to be careful and

366
00:18:06,000 --> 00:18:08,080
look for. 
And it's not as simple of just 

367
00:18:08,840 --> 00:18:11,200
OK, let me take a look at your 
knee range of motion, OK, range 

368
00:18:11,200 --> 00:18:14,160
of motion looks OK, let's look 
at your quad MMTI don't know, 

369
00:18:14,160 --> 00:18:17,280
your quad looks pretty strong. 
Like, I don't know what's going 

370
00:18:17,280 --> 00:18:18,600
on. 
It's not, it's not that simple, 

371
00:18:18,600 --> 00:18:20,920
right? 
Like, and so I think it's good 

372
00:18:20,920 --> 00:18:22,640
to look at it. 
Oh, and the other thing could be

373
00:18:22,640 --> 00:18:25,120
potential mobility issues as 
well. 

374
00:18:25,120 --> 00:18:27,880
If things aren't gliding well or
they're not able to elongate and

375
00:18:27,880 --> 00:18:30,160
certain things and that can 
create also a passive tension on

376
00:18:30,160 --> 00:18:32,720
something. 
And repetitive tension can get 

377
00:18:32,720 --> 00:18:35,040
irritating after a while if it's
not able to move through a 

378
00:18:35,040 --> 00:18:36,920
normal range of motion 
dynamically. 

379
00:18:36,920 --> 00:18:40,440
So that is my rant. 
That's great. 

380
00:18:40,440 --> 00:18:42,920
Yeah, very much less 
professional. 

381
00:18:42,920 --> 00:18:49,440
Yes, as as I like to keep it. 
Gosh, now I just played into 

382
00:18:49,440 --> 00:18:53,800
your own troll of me, you know, 
so I, I think what can be so 

383
00:18:53,800 --> 00:18:57,840
frustrating about Patel moral 
pain is it kind of comes out of 

384
00:18:57,840 --> 00:19:00,400
nowhere. 
A lot of times runners are like,

385
00:19:00,400 --> 00:19:03,520
and even myself, if I've, when 
I've dealt with it, it's like it

386
00:19:03,520 --> 00:19:06,720
doesn't feel like I did anything
different, doesn't feel like I 

387
00:19:06,720 --> 00:19:08,760
did anything crazy. 
And all of a sudden my knee is 

388
00:19:08,760 --> 00:19:11,280
just bugging me. 
And I think that's where kind of

389
00:19:11,280 --> 00:19:15,600
this, the scales balance of load
on one side and capacity on the 

390
00:19:15,600 --> 00:19:19,200
other side can be a helpful 
thing to not underestimate the 

391
00:19:19,200 --> 00:19:23,160
power of one of the factors that
can lead into this. 

392
00:19:23,400 --> 00:19:25,640
As I was preparing for this, I 
went back and looked at an 

393
00:19:25,640 --> 00:19:31,520
article from 2020 and it it laid
out some nice like things that 

394
00:19:31,520 --> 00:19:34,960
impact load and capacity. 
So some of them for load that we

395
00:19:34,960 --> 00:19:38,760
may not give enough credence to 
is if you start to add more 

396
00:19:38,760 --> 00:19:42,200
speed into your workouts, you 
have more speed work in there. 

397
00:19:42,440 --> 00:19:45,600
The amount of load on your knee 
goes significantly higher. 

398
00:19:45,680 --> 00:19:48,040
Obviously mileage, that's 
another one that's a little bit 

399
00:19:48,040 --> 00:19:49,840
more obvious. 
If you increase your mileage, 

400
00:19:50,240 --> 00:19:53,120
you're going to have more load 
as we go back to like some of 

401
00:19:53,120 --> 00:19:56,320
those numbers of how many body 
weights per minute and and per 

402
00:19:56,320 --> 00:19:58,800
mile. 
And then you look at if you're 

403
00:19:58,800 --> 00:20:02,360
running uphill compared to flat,
that increases loading. 

404
00:20:02,360 --> 00:20:05,520
Joint loading on the knee joint 
going downhill significantly 

405
00:20:05,520 --> 00:20:07,400
increases Patel femoral joint 
loading. 

406
00:20:07,880 --> 00:20:10,920
And then we're going to talk 
about footwear later, but some 

407
00:20:10,920 --> 00:20:13,400
footwear can increase the amount
of loading on the Patel femoral 

408
00:20:13,400 --> 00:20:16,200
joint. 
Your gait mechanics and how your

409
00:20:16,200 --> 00:20:20,120
knee is tracking in the frontal 
meaning like from the front and 

410
00:20:20,120 --> 00:20:24,080
from the side can have an impact
on the amount of Patel femoral 

411
00:20:24,080 --> 00:20:26,760
loading. 
And then if you're doing other 

412
00:20:26,760 --> 00:20:29,000
activities, maybe you're like, 
you know what, I'm going to go 

413
00:20:29,000 --> 00:20:31,800
play with my kids, you know, a 
couple times a week, or I'm 

414
00:20:31,800 --> 00:20:34,040
going to go on an extra hike, or
I'm going to actually add in 

415
00:20:34,040 --> 00:20:36,280
some strengthening or I'm going 
to add in some plyometrics. 

416
00:20:36,560 --> 00:20:40,160
That additional amount of 
exercise or activity is more 

417
00:20:40,160 --> 00:20:41,720
load that the knee needs to 
handle. 

418
00:20:41,800 --> 00:20:44,120
And then on the other side of 
the scale is capacity. 

419
00:20:44,520 --> 00:20:47,440
And these are ones that are 
sometimes harder, excuse me to 

420
00:20:47,440 --> 00:20:52,200
quantify, but there's some of 
the very basic 98% of our 

421
00:20:52,200 --> 00:20:53,880
health. 
So like if you have increased 

422
00:20:53,880 --> 00:20:57,080
stress or anxiety, your capacity
is going to go down. 

423
00:20:57,080 --> 00:21:01,040
If you have less sleep, your 
capacity is going to go down. 

424
00:21:01,280 --> 00:21:04,800
If you have fatigue or 
depression or kinesiophobia or 

425
00:21:04,800 --> 00:21:07,920
fear of movement, poor 
nutrition, all of those things 

426
00:21:07,920 --> 00:21:11,280
can lead to a decreased capacity
for that tissue to handle load 

427
00:21:11,280 --> 00:21:16,040
at a given time. 
Great example for me was when I 

428
00:21:16,040 --> 00:21:20,000
was trained for my first 
marathon and things were going 

429
00:21:20,000 --> 00:21:23,480
great and halfway through our 
training, we had our first son 

430
00:21:23,520 --> 00:21:28,160
Henry, which was great. 
And then my stress and anxiety 

431
00:21:28,160 --> 00:21:31,240
went up trying to learn how to 
take care of a human and my 

432
00:21:31,240 --> 00:21:35,480
sleep went way down and I 
actually wasn't in a an increase

433
00:21:35,480 --> 00:21:40,800
in loading, but I let I ended up
having a significant injury that

434
00:21:40,800 --> 00:21:42,440
really Hanford the rest of my 
training. 

435
00:21:42,800 --> 00:21:46,920
And so your capacity, if that 
scale gets really tipped in One 

436
00:21:46,920 --> 00:21:50,200
Direction, even if you haven't 
changed your load, you can be 

437
00:21:50,200 --> 00:21:52,120
predisposing yourself to some 
injuries. 

438
00:21:54,200 --> 00:21:58,160
What I want to move on to next 
is to say, OK, now you have this

439
00:21:58,160 --> 00:22:01,480
tough moral pain syndrome. 
What does the rehabilitation 

440
00:22:01,480 --> 00:22:03,680
process look like? 
What are some things that you 

441
00:22:03,680 --> 00:22:07,800
can maybe start on your own? 
When do you need to go see APT? 

442
00:22:08,000 --> 00:22:09,280
What's kind of your perspective 
there? 

443
00:22:09,720 --> 00:22:12,640
Yeah, I think that's a great 
thing to bring up and transition

444
00:22:12,640 --> 00:22:14,680
to. 
You know, I was going to make a 

445
00:22:14,680 --> 00:22:16,680
cheeky professional comment, but
I'm not going. 

446
00:22:16,800 --> 00:22:24,280
I'm going to refrain myself. 
I think it's when it starts 

447
00:22:24,280 --> 00:22:28,000
affecting the things you want to
do, obviously. 

448
00:22:28,000 --> 00:22:30,800
So, IE if it's running and you 
can't run, I mean, that's that's

449
00:22:30,800 --> 00:22:34,000
one thing there, but sometimes 
it's other things as well. 

450
00:22:34,000 --> 00:22:36,640
It's like if you have a hard 
time going downstairs and you're

451
00:22:36,640 --> 00:22:39,480
like, shoot, man, I can't like 
every time I go down those 

452
00:22:39,480 --> 00:22:41,480
things, like I just get that 
pain right on the front of my 

453
00:22:41,480 --> 00:22:44,520
knee. 
I can't figure out what it is or

454
00:22:44,520 --> 00:22:47,320
even immobility can do it. 
Let's say you're sitting at your

455
00:22:47,320 --> 00:22:49,560
computer desk and you're 
working, you're doing things. 

456
00:22:49,560 --> 00:22:51,880
And then it's like you try to 
get up and move around every 

457
00:22:51,880 --> 00:22:54,240
once in a while, but every time 
you do, your knee hurts, you 

458
00:22:54,240 --> 00:22:55,920
know? 
And so you and we call that a 

459
00:22:55,920 --> 00:22:57,680
theater sign. 
You go, you sit down, you watch 

460
00:22:57,680 --> 00:23:01,280
a movie, you get up. 
It's like, you know, which can 

461
00:23:01,280 --> 00:23:04,360
be consistent with other knee 
injuries as well, but you know, 

462
00:23:04,360 --> 00:23:07,840
basic screening things for 
yourself and looking at just how

463
00:23:07,840 --> 00:23:10,520
are you doing, right? 
I mean, most of the time with 

464
00:23:10,520 --> 00:23:12,760
patellofemoral pain syndrome, 
you're going to get it with 

465
00:23:12,840 --> 00:23:17,240
things that have some level of 
loaded knee flexion and, or 

466
00:23:17,240 --> 00:23:20,360
immobility. 
And so IE the things that have 

467
00:23:20,360 --> 00:23:23,160
loaded knee flexion are things 
like running, squatting, 

468
00:23:23,160 --> 00:23:26,320
stepping up onto curbs, coming 
off of stairs, right? 

469
00:23:26,320 --> 00:23:29,080
Like things like that, 
especially in unilateral 

470
00:23:29,080 --> 00:23:31,360
situations, right? 
Like when that leg is isolated 

471
00:23:31,360 --> 00:23:34,520
and it doesn't have help. 
So I think if you're starting to

472
00:23:34,520 --> 00:23:37,080
notice some of those daily 
issues and you're starting to 

473
00:23:37,080 --> 00:23:39,280
think about it more and more, 
it's not just like a, oh, shoot,

474
00:23:39,280 --> 00:23:41,680
I wonder what happened? 
You know, sometimes things just 

475
00:23:41,680 --> 00:23:45,080
go away, sometimes they don't. 
So when things don't and it 

476
00:23:45,080 --> 00:23:47,480
starts to become a recurring 
theme and you're like, I don't 

477
00:23:47,480 --> 00:23:48,960
know about this, something's 
weird. 

478
00:23:49,280 --> 00:23:51,240
That's probably the time when 
you should probably start 

479
00:23:51,240 --> 00:23:55,000
looking for a professional. 
On the professional side of 

480
00:23:55,000 --> 00:23:57,280
things. 
I think when you look at a 

481
00:23:57,280 --> 00:23:59,120
patient, I think you do have to 
be. 

482
00:23:59,120 --> 00:24:01,680
I think PTS in general tend to 
be a little bit more holistic 

483
00:24:01,880 --> 00:24:06,680
thinking in the medical 
practice, but nothing is ever as

484
00:24:06,680 --> 00:24:07,960
simple. 
And I kind of alluded to this 

485
00:24:07,960 --> 00:24:10,200
already. 
It's not just the knee, you 

486
00:24:10,200 --> 00:24:12,040
know? 
And so you have to kind of look 

487
00:24:12,040 --> 00:24:14,320
at the whole body and then look 
at the impairments that are 

488
00:24:14,320 --> 00:24:16,760
present, look at some of the 
secondary factors like you 

489
00:24:16,760 --> 00:24:19,920
brought up, stress, sleep. 
I think kinesiophobia is a 

490
00:24:19,920 --> 00:24:22,760
really important one, and I'm 
happy you brought that up. 

491
00:24:23,720 --> 00:24:26,120
It's a very fancy word. 
I was very happy to hear that. 

492
00:24:29,240 --> 00:24:33,240
But but your fear of movement, 
your fear of your own body can 

493
00:24:33,240 --> 00:24:35,240
really accentuate that nervous 
system. 

494
00:24:35,240 --> 00:24:38,040
And that can have pretty massive
effects that I don't think 

495
00:24:38,040 --> 00:24:43,320
people give enough credit for. 
Truly trolling aside like that 

496
00:24:43,320 --> 00:24:47,160
is something that I think if you
are afraid to move your body, 

497
00:24:47,160 --> 00:24:48,560
then everything's gonna be 
hurting. 

498
00:24:48,560 --> 00:24:50,040
Everything's gonna be a little 
extra sensitive. 

499
00:24:50,040 --> 00:24:54,800
Your nerves are gonna respond to
that, you know, and I think for 

500
00:24:54,800 --> 00:24:57,720
those that have a lot of 
anxieties around training, 

501
00:24:57,720 --> 00:24:59,920
especially if they have a 
history of a lot of injuries, 

502
00:24:59,920 --> 00:25:03,040
that can play a role that can 
play a very real role. 

503
00:25:04,120 --> 00:25:06,120
So I'm happy you did bring that 
up truthfully. 

504
00:25:07,040 --> 00:25:10,720
But looking at it as a from a 
clinician, I think it is good to

505
00:25:10,720 --> 00:25:13,040
look at the the body you have in
front of you. 

506
00:25:13,760 --> 00:25:15,160
We always say the two joint 
rule, right? 

507
00:25:15,160 --> 00:25:17,720
Look above, look below. 
You know, clear out anything 

508
00:25:17,720 --> 00:25:19,000
else. 
Is there anything neurologic 

509
00:25:19,000 --> 00:25:22,040
going on? 
Is there any in the PT world 

510
00:25:22,040 --> 00:25:23,720
there's like special tests and 
things like that? 

511
00:25:23,720 --> 00:25:25,640
Is there something 
differentially going on? 

512
00:25:25,640 --> 00:25:28,200
Is there like something in the 
meniscus that might be a little 

513
00:25:28,200 --> 00:25:31,240
irritated because also loaded 
knee flex positions and then 

514
00:25:31,240 --> 00:25:34,360
this guy don't always like that 
if they're irritated and just 

515
00:25:34,360 --> 00:25:36,040
looking around like is there 
mobility? 

516
00:25:36,040 --> 00:25:38,760
Are things moving well? 
Is the foot and ankle moving 

517
00:25:38,760 --> 00:25:39,720
well? 
If that's not moving well, 

518
00:25:39,720 --> 00:25:41,400
you're going to have a lot more 
load going through that thing, 

519
00:25:41,400 --> 00:25:42,440
right? 
Like you're not going to 

520
00:25:42,440 --> 00:25:45,960
dissipate forces as well. 
So just things like that to 

521
00:25:45,960 --> 00:25:49,000
really kind of look all around, 
make sure you have good 

522
00:25:49,000 --> 00:25:52,520
mobility, make sure you have 
flexibility where it matters, 

523
00:25:52,600 --> 00:25:56,160
whether it's the calf complex, 
the hip flexors, the quads, and 

524
00:25:56,160 --> 00:25:58,240
then making sure that you have 
the base amount of strength to 

525
00:25:58,240 --> 00:26:01,160
do the things that you want to 
do as well, because that is 

526
00:26:01,160 --> 00:26:03,800
important, right? 
And again, not just the quads, 

527
00:26:03,800 --> 00:26:07,480
not just the hamstrings, not 
just the shins we're looking at 

528
00:26:07,480 --> 00:26:10,000
above and below there too. 
Like how is your calf strength? 

529
00:26:10,000 --> 00:26:13,720
How is your, you know, your 
glute Max, your glute Mead, you 

530
00:26:13,720 --> 00:26:15,880
know, a lot of people always 
focus on the glutamine, but it's

531
00:26:15,880 --> 00:26:18,720
like your glutamax is a crap ton
of stabilization as well. 

532
00:26:18,720 --> 00:26:21,160
Like, why are why are people not
taking naps? 

533
00:26:21,320 --> 00:26:25,280
Yeah. 
So things like that, just making

534
00:26:25,280 --> 00:26:27,840
sure that you have a good 
supporting structure to do the 

535
00:26:27,840 --> 00:26:29,880
tasks that you're asking your 
body to do. 

536
00:26:29,880 --> 00:26:32,800
And a good PT will go through a 
screen and look through 

537
00:26:32,800 --> 00:26:36,720
everything and then they'll let 
you know, like, hey, like I like

538
00:26:36,720 --> 00:26:38,760
this, this and this, but we 
could probably work on this, 

539
00:26:38,760 --> 00:26:42,320
this and this. 
And I think that's kind of step 

540
00:26:42,320 --> 00:26:44,560
one is kind of control the 
controllable, see where that's 

541
00:26:44,560 --> 00:26:46,760
at. 
And then to take a good look 

542
00:26:46,760 --> 00:26:48,760
screening wise at the activity 
of the individual. 

543
00:26:48,760 --> 00:26:51,800
Like you were saying earlier, 
like where is there any increase

544
00:26:51,800 --> 00:26:53,560
in activity? 
Was there anything that was 

545
00:26:53,560 --> 00:26:56,640
added in that was a different 
stimulus, be it physical or not?

546
00:26:56,640 --> 00:26:59,000
You know, if they started a new 
job and they just moved to town,

547
00:26:59,000 --> 00:27:00,040
they're going to be pretty 
stressed out. 

548
00:27:00,360 --> 00:27:05,120
So it's like things like that 
and being able to look and just 

549
00:27:05,120 --> 00:27:07,320
take that step back and again, 
just look at it very 

550
00:27:07,320 --> 00:27:10,080
holistically because this is 
kind of a weird injury where 

551
00:27:10,080 --> 00:27:13,440
it's kind of diffuse. 
And it's frustrating for the 

552
00:27:13,440 --> 00:27:15,560
patients too. 
When someone goes poking around 

553
00:27:15,560 --> 00:27:17,680
and they're doing it and they're
moving it around and nothing's 

554
00:27:17,680 --> 00:27:20,160
really recreating it very well. 
And it's like, sorry, I don't 

555
00:27:20,160 --> 00:27:22,200
really know what to tell you. 
I could like, I, I wish I could 

556
00:27:22,200 --> 00:27:24,040
just tell you this was the 
issue. 

557
00:27:24,040 --> 00:27:26,520
That is what hurts. 
We do this, that gets better, 

558
00:27:27,040 --> 00:27:29,120
right? 
And sometimes it's not as black 

559
00:27:29,120 --> 00:27:33,920
and white as that. 
So that is my rants on the 

560
00:27:34,160 --> 00:27:38,320
patient and clinician side of 
the starting steps of this. 

561
00:27:39,400 --> 00:27:40,760
Yeah. 
And I, I agree with like 

562
00:27:40,760 --> 00:27:43,080
everything you said because I 
think something you mentioned 

563
00:27:43,080 --> 00:27:47,040
even earlier too or whenever it 
was you talked about, you know, 

564
00:27:47,040 --> 00:27:49,080
and then you're going to test 
their quad and do a manual 

565
00:27:49,080 --> 00:27:50,560
muscle test and that's going to 
look good. 

566
00:27:50,560 --> 00:27:52,240
And it's like what is going on 
here? 

567
00:27:52,720 --> 00:27:56,560
And I think a couple things that
are helpful to know. 1 is that 

568
00:27:56,760 --> 00:27:59,760
kind of unequivocally, even 
regardless of your starting 

569
00:27:59,760 --> 00:28:02,840
Strength position, they found 
that doing strengthening of your

570
00:28:02,840 --> 00:28:05,320
quadriceps and of your gluteal 
muscles helps. 

571
00:28:05,400 --> 00:28:07,640
So whether or not they're strong
or. 

572
00:28:07,760 --> 00:28:09,160
You should put a cab out there, 
yeah. 

573
00:28:09,360 --> 00:28:11,640
Yeah, like I. 
Think 5 out of five strength 

574
00:28:11,640 --> 00:28:15,840
means quote UN quote normal 
strength for like normal tasks, 

575
00:28:15,840 --> 00:28:18,240
right? 
Like, like it's a very basic, 

576
00:28:18,240 --> 00:28:22,640
quick and dirty screen to make 
sure that there isn't any major 

577
00:28:22,880 --> 00:28:25,480
abnormalities, right? 
That doesn't necessarily mean 

578
00:28:25,480 --> 00:28:29,840
that you have the strength to go
bomb a downhill down a mountain,

579
00:28:29,840 --> 00:28:30,960
right? 
Like right? 

580
00:28:31,000 --> 00:28:33,160
That is run 40 miles a week. 
Yeah. 

581
00:28:33,200 --> 00:28:37,240
So the caveat there. 
Yeah, and I I think too. 

582
00:28:37,360 --> 00:28:38,800
And I think you'd agree with me 
here. 

583
00:28:38,920 --> 00:28:43,280
As professionals, we're limited 
by the tests that we can perform

584
00:28:43,440 --> 00:28:47,040
with the technology we have. 
So we may have just our hands or

585
00:28:47,040 --> 00:28:50,240
we might have a a dynamometer. 
We can test how many pounds of 

586
00:28:50,240 --> 00:28:52,400
force you can produce with like 
a maximal push. 

587
00:28:52,640 --> 00:28:55,320
Some people are going to have 
these isokinetic machines. 

588
00:28:55,320 --> 00:28:57,800
So they can test, you know, the 
amount of force you can do at a 

589
00:28:57,800 --> 00:29:00,240
certain speed. 
There's lots of different types 

590
00:29:00,240 --> 00:29:02,480
of technology and they test 
different things. 

591
00:29:02,600 --> 00:29:05,960
So I know for me, I've never 
really had more for most of my 

592
00:29:05,960 --> 00:29:09,960
career than my hands or a 
dynamometer and that it just 

593
00:29:09,960 --> 00:29:13,640
gives you like Max force output.
But when we're running, we don't

594
00:29:13,640 --> 00:29:15,960
really use Max force output 
ever. 

595
00:29:16,040 --> 00:29:18,560
We're doing these quick 
repetitive contractions of our 

596
00:29:18,560 --> 00:29:21,000
quadriceps and our glutes and 
it's coordinated. 

597
00:29:21,160 --> 00:29:22,960
So it like has to do with 
coordination, it has to do with 

598
00:29:22,960 --> 00:29:25,360
power, it has to do with this 
fatigue ability. 

599
00:29:25,680 --> 00:29:27,280
And we don't really get to 
measure that. 

600
00:29:27,560 --> 00:29:30,520
And I think that's why some of 
these things like even if you 

601
00:29:30,520 --> 00:29:34,240
don't have numbers that show 
that you're weak or it doesn't 

602
00:29:34,680 --> 00:29:38,280
pop out on you when you're doing
your clinical testing, it's 

603
00:29:38,280 --> 00:29:40,680
still a good thing to probably 
work on this stuff with 

604
00:29:40,680 --> 00:29:42,640
specificity towards the 
activity. 

605
00:29:43,680 --> 00:29:47,280
And yeah, so I think I think 
those are some important things 

606
00:29:47,640 --> 00:29:49,840
to consider. 
And I was, I was also just going

607
00:29:49,840 --> 00:29:53,000
to reiterate the idea of the 
entire kinetic chain checking 

608
00:29:53,000 --> 00:29:56,000
above and below and making sure 
that the knee is sandwiched 

609
00:29:56,000 --> 00:29:58,560
between two different joints 
that can move in a lot of 

610
00:29:58,560 --> 00:30:01,000
different planes. 
And the knee is meant to go like

611
00:30:01,560 --> 00:30:04,520
forward and backward and it can 
rotate a little bit at the shin,

612
00:30:04,720 --> 00:30:06,080
but that's not what it's made to
do. 

613
00:30:06,400 --> 00:30:09,440
And so it's kind of at the 
liberty of your, your hip joint 

614
00:30:09,720 --> 00:30:12,640
and your foot joint. 
And having somebody help guide 

615
00:30:12,640 --> 00:30:14,160
you through some of that could 
be helpful. 

616
00:30:14,440 --> 00:30:17,160
Yeah, like if any of my patients
are listening to this, like a 

617
00:30:17,160 --> 00:30:18,880
lot of times I say it's just a 
middleman. 

618
00:30:18,880 --> 00:30:20,760
It just does whatever the hip 
and the ankle tell it to. 

619
00:30:20,800 --> 00:30:23,640
Like it's. 
Just yeah, it's good. 

620
00:30:23,840 --> 00:30:27,160
Yeah. 
I think in that vein, right, 

621
00:30:27,280 --> 00:30:29,880
right there, I think it brings 
us to kind of this question 

622
00:30:30,280 --> 00:30:36,960
about mechanics and what is the 
value of understanding your 

623
00:30:37,120 --> 00:30:40,320
running gate mechanics or your 
squat mechanics or your single 

624
00:30:40,320 --> 00:30:44,240
leg step down mechanics and how 
that may or may not influence 

625
00:30:44,880 --> 00:30:47,440
Patel moral pain syndrome. 
Yeah, I think that's great that 

626
00:30:47,440 --> 00:30:49,840
you brought that up. 
I think there's some big glaring

627
00:30:49,840 --> 00:30:56,000
things to look at, but I think 
generally speaking, I I like to 

628
00:30:56,000 --> 00:31:00,400
use the quote UN quote normal or
the thing that I'm relating 

629
00:31:00,400 --> 00:31:02,920
something back to as they're 
normal. 

630
00:31:03,480 --> 00:31:06,040
So if they have an asymptomatic 
side and a symptomatic side, 

631
00:31:06,040 --> 00:31:08,240
well, what do things look like 
on the asymptomatic side, unless

632
00:31:08,240 --> 00:31:11,160
it's something glaring, right? 
Like, and we know this with like

633
00:31:11,160 --> 00:31:13,120
gait retraining, right? 
Like if you go and you 

634
00:31:13,120 --> 00:31:15,880
completely change up the way 
someone runs, sometimes it 

635
00:31:15,880 --> 00:31:18,160
predisposes them to another 
injury on something else. 

636
00:31:18,400 --> 00:31:21,120
Yeah. 
And so unless there's something 

637
00:31:21,120 --> 00:31:25,600
just massively off, you know, 
then I I really don't go in that

638
00:31:26,000 --> 00:31:29,400
Ave. as much. 
But let's say if we look at a 

639
00:31:29,400 --> 00:31:33,560
step down and in for those 
listening, you usually will have

640
00:31:33,560 --> 00:31:37,400
a box, I don't know, give or 
take 6 to 8 inches. 

641
00:31:37,400 --> 00:31:41,160
Yeah, someone's going to put you
on it one foot and have you take

642
00:31:41,160 --> 00:31:43,240
a step down to the side and or 
forward. 

643
00:31:43,560 --> 00:31:44,960
And then we're. 
They're going to look at the 

644
00:31:44,960 --> 00:31:48,840
knee that you're standing on on 
the box and see how it acts as 

645
00:31:48,840 --> 00:31:52,440
you lower down that other leg. 
And they're going to tell you 

646
00:31:52,440 --> 00:31:54,760
whether they'll probably look at
how you do it first without 

647
00:31:54,760 --> 00:31:57,360
telling you anything. 
And if your leg looks super 

648
00:31:57,360 --> 00:32:00,520
squirrely, it's rolling in, the 
whole thing has a giant valgus 

649
00:32:00,520 --> 00:32:02,680
on it, it's like, OK, maybe we 
don't have very good control 

650
00:32:02,680 --> 00:32:07,600
over our leg, you know, But if 
when you're running and you have

651
00:32:07,600 --> 00:32:10,400
that much load, going through 
some degree of internal rotation

652
00:32:10,400 --> 00:32:12,880
is necessary to have a little 
bit of shock absorption. 

653
00:32:14,280 --> 00:32:17,200
A lot of it is controlling 
external forces that are placed 

654
00:32:17,200 --> 00:32:18,960
on you from gravity and the 
amount of forces you're putting 

655
00:32:18,960 --> 00:32:22,360
into the ground. 
So I, I don't demonize some of 

656
00:32:22,360 --> 00:32:25,000
those movements as much as some 
other P TS may. 

657
00:32:25,760 --> 00:32:28,320
But at the same time, I just 
want to make sure it's not 

658
00:32:28,320 --> 00:32:30,840
glaring because if it's really 
rolling in, like, OK, yeah, 

659
00:32:30,840 --> 00:32:32,560
that's put in some massive 
pressure through that thing. 

660
00:32:32,560 --> 00:32:35,680
We don't want that. 
But if it happens a little bit 

661
00:32:35,720 --> 00:32:38,400
and it's and it looks different 
between the two sides, like 

662
00:32:38,400 --> 00:32:42,520
maybe one it's really rolling in
and the other one's fine or one 

663
00:32:42,520 --> 00:32:44,200
it rolls in a tiny bit, but it's
fine. 

664
00:32:44,200 --> 00:32:46,440
And the other one it rolls in 
about the same, but it's 

665
00:32:46,440 --> 00:32:48,280
shaking. 
You know, like it's like, OK, 

666
00:32:48,360 --> 00:32:51,480
well, maybe they don't have the 
proper stability needed and 

667
00:32:51,480 --> 00:32:55,200
maybe it's not so much of, you 
know, a what am I looking for 

668
00:32:55,200 --> 00:32:56,600
here? 
Like a motor control issue as 

669
00:32:56,600 --> 00:32:58,120
much as it is just a pure 
strength issue in that 

670
00:32:58,120 --> 00:33:00,640
situation. 
So kind of teasing out little 

671
00:33:00,640 --> 00:33:02,280
things. 
And same goes for like running. 

672
00:33:02,280 --> 00:33:04,280
If you see them and they're 
running and they take a step on 

673
00:33:04,280 --> 00:33:07,360
that standing leg and that hip 
or that knee or something, it 

674
00:33:07,360 --> 00:33:09,960
just drops, you know, and they 
just have no control. 

675
00:33:09,960 --> 00:33:12,040
Or they just flex up that knee a
lot more. 

676
00:33:12,040 --> 00:33:14,280
Like they're just having a hard 
time holding themselves up 

677
00:33:14,280 --> 00:33:16,800
through that side, whether it's 
the hip or the knee or the calf.

678
00:33:16,800 --> 00:33:18,480
And they're not pushing off very
well. 

679
00:33:19,920 --> 00:33:21,440
And the other can go too as 
well. 

680
00:33:21,440 --> 00:33:24,760
Like looking at maybe that looks
OK, but like maybe they're just 

681
00:33:24,760 --> 00:33:26,160
a little bit tighter on that 
side. 

682
00:33:26,160 --> 00:33:29,040
They just can't extend that hip 
and they, their stride length is

683
00:33:29,040 --> 00:33:31,600
altering and it just looks 
funky. 

684
00:33:32,120 --> 00:33:34,920
You know, sometimes that can be 
it as well, where like maybe 

685
00:33:34,960 --> 00:33:38,160
things are moving OK from a 
strength standpoint, but they're

686
00:33:38,160 --> 00:33:40,680
not moving OK from a range 
standpoint. 

687
00:33:40,680 --> 00:33:43,640
And that's not necessarily 
something that they could get on

688
00:33:43,640 --> 00:33:46,400
a table where it's like, OK, lay
down, bend your knee. 

689
00:33:46,400 --> 00:33:48,400
Looks like you got 130°. 
I don't know. 

690
00:33:48,400 --> 00:33:50,560
It looks good. 
I don't have to tell you. 

691
00:33:50,920 --> 00:33:54,000
So when you look at some of 
those more functional 

692
00:33:54,000 --> 00:33:57,040
translations in our world, 
functional limitations, right? 

693
00:33:57,040 --> 00:34:00,160
Like find the thing that is 
limiting for you that you can 

694
00:34:00,160 --> 00:34:03,800
kind of pick something up on and
then compare and contrast and 

695
00:34:03,800 --> 00:34:06,600
look and see if there's any 
differences that are worth 

696
00:34:06,600 --> 00:34:08,920
noting and anything that's worth
working on. 

697
00:34:09,440 --> 00:34:11,920
And that's going to require some
level of trust with your 

698
00:34:11,920 --> 00:34:16,560
clinician as well, who you're 
working with and any clinician 

699
00:34:16,560 --> 00:34:19,120
that you're working with, don't 
be afraid to ask questions. 

700
00:34:19,120 --> 00:34:21,639
If they are a good clinician, 
they'll be happy to answer all 

701
00:34:21,639 --> 00:34:23,520
questions. 
And if there's a gap in the 

702
00:34:23,520 --> 00:34:25,679
knowledge or something they just
aren't quite sure about, they 

703
00:34:25,679 --> 00:34:27,800
should be able to tell you that 
too, you know? 

704
00:34:27,800 --> 00:34:28,880
Yeah. 
Hopefully they're honest with 

705
00:34:28,920 --> 00:34:31,080
you. 
Yeah, yeah, I, I'd like to know 

706
00:34:31,080 --> 00:34:31,840
that. 
I'm brutally honest. 

707
00:34:32,080 --> 00:34:37,120
But like, yeah, yeah, I try to 
be very, very transparent as a 

708
00:34:37,120 --> 00:34:38,600
clinician. 
Same. 

709
00:34:39,360 --> 00:34:42,880
But yeah, looking at things from
those lenses and angles and just

710
00:34:42,880 --> 00:34:47,120
trying to trying to just widen 
that lens, essentially look at 

711
00:34:47,120 --> 00:34:50,800
everything, Don't leave stones 
unturned and find what is it 

712
00:34:50,800 --> 00:34:52,120
that you're having a hard time 
with. 

713
00:34:52,120 --> 00:34:54,440
OK, well let's look at it. 
Let's figure this thing out 

714
00:34:54,440 --> 00:34:57,080
because sometimes every once in 
a while you get someone who 

715
00:34:57,080 --> 00:34:58,760
comes in, oh, I'm great with 
everything. 

716
00:34:58,760 --> 00:35:03,760
It's just when I do this, it's 
like, cool, let's look at it. 

717
00:35:03,760 --> 00:35:05,840
Let's figure it out. 
Does that matter? 

718
00:35:05,840 --> 00:35:07,200
Like, is that something that's 
important to you? 

719
00:35:07,200 --> 00:35:08,520
It is. 
OK, let's look. 

720
00:35:08,640 --> 00:35:10,800
Because I mean, it could be a 
sampling as simple as like 

721
00:35:10,800 --> 00:35:13,200
getting into a slightly deep 
squat for gardening, right? 

722
00:35:13,200 --> 00:35:16,560
It might not be running. 
So just random things looking at

723
00:35:16,560 --> 00:35:18,640
all of this stuff. 
I think I have a few thoughts 

724
00:35:18,640 --> 00:35:21,520
regarding mechanics. 
Some of them are within like a 

725
00:35:21,960 --> 00:35:25,000
diagnostic analysis that side of
thing. 

726
00:35:25,000 --> 00:35:27,520
And then there's like the 
exercise and treatment side and 

727
00:35:27,520 --> 00:35:31,000
kind of load management. 
So if I start on the first side 

728
00:35:31,360 --> 00:35:33,920
of some of the assessment, you 
talked about how you can do some

729
00:35:33,920 --> 00:35:36,120
of these assessments. 
And then I'm going to talk 

730
00:35:36,120 --> 00:35:39,200
specifically about running gate 
analysis and because I use 3D 

731
00:35:39,200 --> 00:35:41,320
running analysis with the 
runners that I work with. 

732
00:35:41,880 --> 00:35:47,280
And right now the evidence 
shocker isn't super clear about 

733
00:35:47,280 --> 00:35:50,960
the association of running 
mechanics and certain specific 

734
00:35:50,960 --> 00:35:53,320
injuries. 
There's some theory that if in 

735
00:35:53,320 --> 00:35:55,440
the front, like looking at 
someone from the front, if their

736
00:35:55,440 --> 00:35:59,400
knee like you said, is coming in
and rolling in one way or 

737
00:35:59,400 --> 00:36:04,240
another, both rotation and into 
adduction of the hip, that could

738
00:36:04,240 --> 00:36:07,160
increase the amount of loading 
at the Patel femoral joint. 

739
00:36:07,680 --> 00:36:12,080
The research on big groups isn't
super clear part of the question

740
00:36:12,600 --> 00:36:14,040
right? 
And because some people had just

741
00:36:14,040 --> 00:36:15,600
have that mechanics. 
Look at Connor Manse. 

742
00:36:15,600 --> 00:36:17,120
Yep. 
Well, everyone does too. 

743
00:36:17,200 --> 00:36:19,880
That's why I made the caveat of 
like some internal rotations 

744
00:36:19,880 --> 00:36:22,160
normal, right? 
Like you're going to have some 

745
00:36:22,160 --> 00:36:25,320
of it like, and yes, like I was 
really happy with some of my 

746
00:36:25,320 --> 00:36:28,040
early rotations looking at like 
valgus in the knee. 

747
00:36:28,040 --> 00:36:30,120
And for a lot of sports you have
to, you're playing basketball, 

748
00:36:30,120 --> 00:36:31,760
you're making a cut. 
Like you're going to have to put

749
00:36:31,760 --> 00:36:33,160
a load through the knee in a 
valgus moment. 

750
00:36:33,160 --> 00:36:35,520
Like people got to be good at 
that to some degree, depending 

751
00:36:35,520 --> 00:36:38,120
on what the tasks are that 
you're trying to ask it to do. 

752
00:36:38,120 --> 00:36:40,640
So that's why I try not to 
demonize it too much. 

753
00:36:40,760 --> 00:36:43,360
And what's so important with 
that too is if somebody has been

754
00:36:43,360 --> 00:36:48,360
running that way for 15 years, 
your body adapts to the load 

755
00:36:48,360 --> 00:36:51,000
that you put on it. 
And so it's not like that's the 

756
00:36:51,000 --> 00:36:54,040
thing that's tipping them over 
the edge necessarily. 

757
00:36:54,440 --> 00:36:57,200
They may have had a change in 
their mechanics for some reason.

758
00:36:57,200 --> 00:36:59,400
And that's where I think 
sometimes there's individual 

759
00:36:59,400 --> 00:37:02,760
application to modifying the 
amount of frontal plane motion 

760
00:37:02,760 --> 00:37:06,360
that somebody's having. 
Additionally, maybe if you do 

761
00:37:06,360 --> 00:37:09,200
change that, you can change some
of the external load that's 

762
00:37:09,200 --> 00:37:11,840
going on their body. 
But I, I think it's important to

763
00:37:11,840 --> 00:37:14,360
remember that if you run a 
certain way, don't let someone 

764
00:37:14,360 --> 00:37:16,120
tell you you're running with 
terrible form. 

765
00:37:16,440 --> 00:37:18,920
And because if your body has 
been running that way for a long

766
00:37:18,920 --> 00:37:22,560
time, it's adapting to that type
of running and your tissues have

767
00:37:22,560 --> 00:37:24,960
to adapt to it. 
But again, there may be 

768
00:37:24,960 --> 00:37:26,320
instances where you can apply 
that. 

769
00:37:26,600 --> 00:37:29,200
I think where there's a little 
bit more credence sometimes is 

770
00:37:29,200 --> 00:37:32,160
looking from the side, we call 
that the sagittal plane, and 

771
00:37:32,160 --> 00:37:35,080
looking at how much forward 
translation of the knee is 

772
00:37:35,080 --> 00:37:36,680
happening with your running 
mechanics. 

773
00:37:37,640 --> 00:37:40,320
If you have a lot of anterior 
knee translation, the further 

774
00:37:40,320 --> 00:37:43,520
that knee comes out and forward 
in front of your like in front 

775
00:37:43,520 --> 00:37:46,440
of your toes during the running 
cycle, that just does increase 

776
00:37:46,440 --> 00:37:48,680
the amount of loading. 
That doesn't mean you can't go 

777
00:37:48,680 --> 00:37:51,200
back to running that way for 
like for the rest of your life, 

778
00:37:51,200 --> 00:37:54,880
But in this moment where you 
have high irritability and a 

779
00:37:54,880 --> 00:37:57,760
simple change of getting your 
foot off the ground more 

780
00:37:57,760 --> 00:38:00,560
frequently by increasing your 
cadence has been shown to 

781
00:38:00,560 --> 00:38:03,000
decrease overall. 
Patel femoral joint loading. 

782
00:38:03,240 --> 00:38:05,200
So if you're someone who's 
running with a really low 

783
00:38:05,200 --> 00:38:07,880
cadence, maybe you look on your 
watch and it's like in the one 

784
00:38:07,880 --> 00:38:11,240
50s, maybe you look at 
increasing your cadence by 5 to 

785
00:38:11,240 --> 00:38:13,840
10%. 
I, I tend to recommend doing 

786
00:38:13,840 --> 00:38:18,360
this with a provider who can 
like understand what these gate 

787
00:38:18,360 --> 00:38:20,640
mechanics are going to mean for 
the rest of your body. 

788
00:38:21,080 --> 00:38:26,640
That's, I think that's important
running into another injury that

789
00:38:26,640 --> 00:38:30,120
that's the tricky part. 
I do think cadence of 5% 

790
00:38:30,120 --> 00:38:33,240
increase from yourself selected 
overall decreases loading on 

791
00:38:33,240 --> 00:38:35,680
pretty much everything. 
So that's probably a safe one to

792
00:38:35,680 --> 00:38:38,640
try by yourself. 
But even when you do that, I 

793
00:38:38,640 --> 00:38:41,640
recommend backing yourself down 
before you just like keep going.

794
00:38:41,640 --> 00:38:45,720
But anyway, I think under the 
supervision of a provider who 

795
00:38:45,720 --> 00:38:49,760
understands the game mechanics, 
doing some minor changes in the 

796
00:38:49,760 --> 00:38:53,600
short term can be helpful to 
decrease that load versus 

797
00:38:53,600 --> 00:38:57,280
capacity scales. 
Similarly, I think that doing 

798
00:38:57,280 --> 00:38:59,800
exercises differently, like 
let's say you're someone who's 

799
00:38:59,800 --> 00:39:02,560
hurting with squatting, but you 
want to strengthen with your 

800
00:39:02,560 --> 00:39:04,280
feet on the ground and do single
leg stuff. 

801
00:39:04,520 --> 00:39:08,280
Maybe you change how you do a 
squat or a lunge for the short 

802
00:39:08,280 --> 00:39:10,360
term to decrease Patel femoral 
loading. 

803
00:39:10,640 --> 00:39:13,080
I show this picture I drew it on
if you're. 

804
00:39:13,080 --> 00:39:15,280
Watching what you're doing over 
there, yeah. 

805
00:39:15,440 --> 00:39:19,760
I was writing this down the 
Chris Powers research route in 

806
00:39:19,760 --> 00:39:21,640
California. 
He's actually in Southern 

807
00:39:21,640 --> 00:39:24,880
California. 
He's down at USC, but he's done 

808
00:39:24,880 --> 00:39:28,560
some research to look at what 
are the joint compressive forces

809
00:39:28,560 --> 00:39:31,640
happening and can we just 
correlate that with clinical 

810
00:39:31,640 --> 00:39:34,360
measures that we can get with an
iPad that's like his, which I 

811
00:39:34,360 --> 00:39:37,520
really appreciate because it 
makes some of the decisions 

812
00:39:37,520 --> 00:39:41,720
about kinetics and forces a 
little bit more accessible to us

813
00:39:41,720 --> 00:39:44,080
as clinicians. 
But basically if you look at 

814
00:39:44,080 --> 00:39:47,560
this here we have from. 
Is this on the left side for 

815
00:39:47,560 --> 00:39:49,600
you, David? 
On the left side for me. 

816
00:39:49,760 --> 00:39:51,920
Yes. 
So from left to right you have 

817
00:39:51,920 --> 00:39:54,920
three different squat forms. 1 
is where the trunk is angled 

818
00:39:54,920 --> 00:39:58,320
forward more than the shin. 
The second one is where the shin

819
00:39:58,320 --> 00:40:00,080
and the trunk are angled about 
the same. 

820
00:40:00,320 --> 00:40:03,960
And then the third is where the 
shin is more more angled forward

821
00:40:03,960 --> 00:40:07,240
than the trunk. 
And the more you are to the 

822
00:40:07,240 --> 00:40:11,400
left, the less forces there are 
overall at the knee and the less

823
00:40:11,400 --> 00:40:14,080
joint compressive forces. 
Whereas more on the right it's 

824
00:40:14,080 --> 00:40:16,080
going to have higher joint 
compressive forces. 

825
00:40:16,800 --> 00:40:19,000
Doesn't mean that one squat is 
better than another. 

826
00:40:19,000 --> 00:40:21,440
It just means that it's going to
increase or decrease the amount 

827
00:40:21,440 --> 00:40:25,880
of loading at the knee. 
And if you are having like this 

828
00:40:25,880 --> 00:40:28,800
kind of more irritable Patel 
femoral pain syndrome, maybe you

829
00:40:28,800 --> 00:40:31,760
adopt A movement strategy for 
your exercises that's more like 

830
00:40:31,760 --> 00:40:34,240
the one on the left where your 
trunk is a little bit more 

831
00:40:34,240 --> 00:40:36,480
forward, your shins are much 
more vertical. 

832
00:40:36,800 --> 00:40:40,120
That can make a difference for 
just continuing activity without

833
00:40:40,200 --> 00:40:42,520
having super high loading 
through the joint. 

834
00:40:42,520 --> 00:40:44,880
So I think that's where 
mechanics can play a role too. 

835
00:40:44,880 --> 00:40:47,040
In a more like. 
Applied. 

836
00:40:47,160 --> 00:40:49,640
Not to cut you off, but even 
like barbell placement, like 

837
00:40:49,640 --> 00:40:53,080
front squat versus back squat 
versus X bar versus yeah. 

838
00:40:53,640 --> 00:40:56,480
And so when you have, let's say,
if we're talking to traditional 

839
00:40:56,480 --> 00:40:58,840
front squat, back squat, like 
front squats can be more 

840
00:40:58,840 --> 00:41:01,040
anterior on the front, that's 
going to load those squats a 

841
00:41:01,040 --> 00:41:02,920
little bit more. 
It's usually going to have a 

842
00:41:02,920 --> 00:41:04,960
little bit more of an upright 
posturing like you were saying, 

843
00:41:04,960 --> 00:41:08,480
like in order to balance it out 
and keep yourself up here versus

844
00:41:08,480 --> 00:41:10,960
like traditional back squat, I 
don't have enough space here. 

845
00:41:13,000 --> 00:41:15,800
But like when you have it racked
up on the spot of the scabula 

846
00:41:15,800 --> 00:41:19,120
there, if you're traditional 
high bar for the pure, for the 

847
00:41:19,200 --> 00:41:21,120
people that are out there that 
are super into weightlifting and

848
00:41:21,120 --> 00:41:23,520
it's high bar and low bar and 
whatever. 

849
00:41:23,520 --> 00:41:27,000
But anyways, posterior position 
back here, it's going to load 

850
00:41:27,000 --> 00:41:28,840
those glutes a little bit more, 
going to put you in a little bit

851
00:41:28,840 --> 00:41:30,080
more of a different position as 
well. 

852
00:41:30,080 --> 00:41:32,320
So that can also be a quick fix 
as well. 

853
00:41:32,320 --> 00:41:34,200
Not fixed. 
I don't want to fix, but that 

854
00:41:34,200 --> 00:41:38,760
can be a quick adjustment or 
modification if you are like, 

855
00:41:38,760 --> 00:41:40,760
Dang, it's just like, I just 
can't front squat very well. 

856
00:41:40,760 --> 00:41:42,760
But for some reason when I put 
on my back, it feels OK. 

857
00:41:43,120 --> 00:41:46,440
Hey, you're probably OK. 
What I want to move to next is 

858
00:41:46,520 --> 00:41:47,880
talking about tacos. 
What? 

859
00:41:47,880 --> 00:41:52,680
Most people? 
Yeah, tacos, of course I. 

860
00:41:53,200 --> 00:41:54,560
Sorry, that was unprofessional 
with me. 

861
00:41:55,680 --> 00:41:58,160
Well, I was going to say I went 
to Houston. 

862
00:41:58,280 --> 00:41:59,680
I went to Texas for the first 
time. 

863
00:41:59,680 --> 00:42:02,720
I got to meet our audio 
engineer, BJ for the first time 

864
00:42:02,720 --> 00:42:05,440
in person. 
He, Matt and I all were together

865
00:42:06,480 --> 00:42:12,440
for lunch and we got fajitas and
I almost, I'm so glad that I 

866
00:42:12,760 --> 00:42:16,200
didn't get tacos because then I 
don't have to compare Santa 

867
00:42:16,200 --> 00:42:19,480
Barbara tacos from David's 
wedding with like the meet up 

868
00:42:19,480 --> 00:42:22,880
with BJ and Texas tacos. 
I have fajitas, which I loved 

869
00:42:22,920 --> 00:42:25,400
and I have tacos which I loved 
and I don't have to pick a 

870
00:42:25,400 --> 00:42:27,120
favorite. 
I just love them both. 

871
00:42:27,400 --> 00:42:30,120
So what we're going to do 
though, is going to continue 

872
00:42:30,120 --> 00:42:33,720
talking about shoe footwear 
decisions now. 

873
00:42:34,160 --> 00:42:37,640
And we're not even going to 
belabor the fact that obviously 

874
00:42:37,640 --> 00:42:39,240
evidence isn't going to show us 
something. 

875
00:42:39,280 --> 00:42:41,960
We're going to talk about what 
we've learned about footwear, 

876
00:42:42,120 --> 00:42:44,600
the changes that it has in our 
mechanics, what sort of 

877
00:42:44,600 --> 00:42:48,440
considerations you may make 
knowing that this is not the 

878
00:42:48,440 --> 00:42:52,040
biggest change or the most 
accessible or feasible change to

879
00:42:52,040 --> 00:42:54,680
make because it would mean you 
might need to buy a whole new 

880
00:42:54,680 --> 00:42:56,520
pair of shoes. 
But if you are someone with a 

881
00:42:56,520 --> 00:42:59,840
lot of shoes available, we're 
going to talk about what sort of

882
00:42:59,840 --> 00:43:02,560
implications made different 
designs have for the amount of 

883
00:43:02,560 --> 00:43:06,200
Patel femoral joint loading for 
DALF, moral pain syndrome and 

884
00:43:06,320 --> 00:43:08,200
shoes. 
Yeah, it's such a loaded. 

885
00:43:08,200 --> 00:43:11,640
Question because there's so many
theoreticals and different 

886
00:43:11,640 --> 00:43:16,640
situations, I think it can be 
very, very individual dependent 

887
00:43:16,640 --> 00:43:19,640
on this. 
And the main reason being is 

888
00:43:19,640 --> 00:43:22,920
that certain shoe designs, you 
may have a slightly stiffer 

889
00:43:23,400 --> 00:43:25,480
range of motion that you go 
through being like, let's say 

890
00:43:25,480 --> 00:43:27,480
the high stack stiff rocker 
shoes. 

891
00:43:28,000 --> 00:43:30,680
You're not going to go through 
quite as much range of motion at

892
00:43:30,680 --> 00:43:34,200
the ankle and you're going to 
have a little bit more at the 

893
00:43:34,200 --> 00:43:36,840
hip and at the knee there. 
Traditionally speaking, that's 

894
00:43:36,840 --> 00:43:38,800
going to load your glutes and 
quads a little bit more. 

895
00:43:38,840 --> 00:43:42,720
But in some situations that's 
that can still help with the 

896
00:43:42,840 --> 00:43:45,280
telephone while pain syndrome. 
And the reason being is like, if

897
00:43:45,280 --> 00:43:47,520
it's coming because you can't 
move through a larger range of 

898
00:43:47,520 --> 00:43:49,720
motion. 
So like, let's say in the more 

899
00:43:49,720 --> 00:43:53,800
traditional traditional like 
lower stack shoes, little bit 

900
00:43:53,800 --> 00:43:55,880
more flexible design. 
I'm thinking like a Saucony 

901
00:43:55,880 --> 00:44:01,520
Canvara or an A traditional 
ultra or something like those 

902
00:44:01,520 --> 00:44:02,680
kinds of shoes. 
They're a little bit more 

903
00:44:02,680 --> 00:44:04,600
flexible designs. 
You move through larger ranges 

904
00:44:04,600 --> 00:44:06,320
of motion. 
Usually you're gonna have a 

905
00:44:06,320 --> 00:44:08,320
little bit more work at the 
ankle and in the calves. 

906
00:44:08,320 --> 00:44:10,680
In theory that would take some 
work away from the knees and the

907
00:44:10,680 --> 00:44:13,080
hips, right? 
But for some people like you do 

908
00:44:13,080 --> 00:44:14,440
go through larger ranges of 
motion. 

909
00:44:14,440 --> 00:44:17,720
So if you are someone that is 
sensitive to going through 

910
00:44:17,720 --> 00:44:20,600
larger ranges of motion, then 
maybe that thicker high stack 

911
00:44:20,600 --> 00:44:23,120
rocker profile. 
If you're someone that's like, 

912
00:44:23,880 --> 00:44:28,960
like you don't, you're not as 
sensitive to that, like, or you 

913
00:44:28,960 --> 00:44:31,080
need to stiffen up a little bit.
Yeah. 

914
00:44:31,080 --> 00:44:33,040
You go rocker. 
I'm losing myself here. 

915
00:44:34,560 --> 00:44:36,320
You're making sense to me. 
Yeah, but. 

916
00:44:36,720 --> 00:44:39,040
If. 
You need to unload the quads a 

917
00:44:39,040 --> 00:44:41,680
little bit and it's more of a 
strength, a true strength issue.

918
00:44:41,680 --> 00:44:43,280
And you're like, OK, I need to 
switch this up. 

919
00:44:43,280 --> 00:44:45,160
You can go switch design to 
something that's a little bit 

920
00:44:45,160 --> 00:44:49,120
more, you know, dominant on the 
calf and in the ankle complex. 

921
00:44:49,480 --> 00:44:53,680
I am not as well tuned to 
lecturing as you can see this 

922
00:44:53,680 --> 00:44:56,040
is. 
The worst I don't I don't like 

923
00:44:56,040 --> 00:44:58,160
this troll. 
This is not my favorite troll, 

924
00:44:58,920 --> 00:45:00,160
which is fine. 
That's the point. 

925
00:45:00,160 --> 00:45:04,160
That's why you troll me. 
But I, I've the only thing I'll 

926
00:45:04,160 --> 00:45:07,120
add into this, because I agree 
with everything you you've said,

927
00:45:07,120 --> 00:45:11,760
is that there's some evidence to
show that those really high 

928
00:45:11,760 --> 00:45:14,520
stack shoes that are really 
compliant, those smooshy things 

929
00:45:15,040 --> 00:45:17,800
decrease the amount of motion we
don't go through at our joints 

930
00:45:17,800 --> 00:45:19,960
because it's not as stable of a 
platform. 

931
00:45:19,960 --> 00:45:21,560
So we kind of reflexively 
stiffen. 

932
00:45:21,720 --> 00:45:25,120
And like you said, if you're 
not, if you're doing poor with 

933
00:45:25,160 --> 00:45:28,400
more knee flexion as you go 
through your running gate, those

934
00:45:28,520 --> 00:45:31,400
higher profile shoes which are 
going to be more rockered might 

935
00:45:31,400 --> 00:45:33,880
be your better choice, even 
though the rocker technically 

936
00:45:33,880 --> 00:45:38,200
also shift slowed up. 
So it literally is one of those 

937
00:45:38,240 --> 00:45:42,400
like you just got to go try it 
and see what your situation is. 

938
00:45:42,680 --> 00:45:46,120
Or it like let's say you're 
working with your or even you're

939
00:45:46,120 --> 00:45:48,640
by yourself and you notice that 
it's like you don't get your 

940
00:45:48,640 --> 00:45:51,320
pain until you're like, I'm 
doing a single leg sit to stand 

941
00:45:51,320 --> 00:45:53,000
or something. 
And it's not till deeper. 

942
00:45:53,320 --> 00:45:55,720
You probably could go to a shoe 
that allows you to go through 

943
00:45:55,720 --> 00:45:59,000
more flexion, that has more 4 
foot flexibility and a little 

944
00:45:59,000 --> 00:46:01,320
less stack. 
But if you're getting that pain 

945
00:46:01,320 --> 00:46:04,280
right away, maybe you'd be 
thinking about a shoe that gives

946
00:46:04,280 --> 00:46:06,320
you a little bit more stiffness 
up top. 

947
00:46:06,320 --> 00:46:09,360
So yeah. 
So how's that for a non answer 

948
00:46:09,360 --> 00:46:11,120
everybody? 
It depends. 

949
00:46:11,200 --> 00:46:13,800
It depends on how it presents 
for you. 

950
00:46:15,240 --> 00:46:19,560
So before we wrap things up, do 
you have any other things you 

951
00:46:19,560 --> 00:46:22,080
want to add about Patel Femoral 
pain syndrome? 

952
00:46:22,720 --> 00:46:26,520
No, just that it's diffuse. 
And it's a little odd and we 

953
00:46:26,520 --> 00:46:30,520
fully acknowledge that. 
And I think anyone who has read 

954
00:46:30,520 --> 00:46:33,800
up on it or is exposed to it, 
which would be most P TS, I 

955
00:46:33,800 --> 00:46:38,280
would assume, yeah, it could be 
a frustrating 1. 

956
00:46:38,480 --> 00:46:41,280
So if you're listening to this 
and you're frustrated, it can be

957
00:46:41,280 --> 00:46:42,960
frustrating for both parties 
sometimes. 

958
00:46:43,560 --> 00:46:46,560
And so a lot of it is figuring 
things out and working through 

959
00:46:46,560 --> 00:46:50,400
it together. 
It's not as straightforward as 

960
00:46:50,400 --> 00:46:52,520
some of the other pathologies 
that are out there. 

961
00:46:53,000 --> 00:46:56,720
That's probably my closing 
thoughts on that, But tacos. 

962
00:46:56,960 --> 00:47:01,440
Can help tacos always help From 
California. 

963
00:47:02,040 --> 00:47:05,360
I don't know, man, I'm. 
Not I'm not a hater of like 

964
00:47:05,360 --> 00:47:08,280
regionality here, you know, I 
can fully acknowledge. 

965
00:47:08,280 --> 00:47:10,280
I'm sure Texas has some good 
tacos. 

966
00:47:10,280 --> 00:47:14,840
So when I asked you like, hey, 
who has the better talkers and 

967
00:47:14,840 --> 00:47:19,440
you went and skipped out on me, 
I'm like, I was a little hurt, 

968
00:47:19,440 --> 00:47:21,360
I'm not going to lie. 
Wow. 

969
00:47:21,440 --> 00:47:25,560
We'll have to go back to Texas. 
Then yeah, I guess I can't even 

970
00:47:25,560 --> 00:47:28,440
remember what I was going to 
add, so maybe we'll just wrap 

971
00:47:28,440 --> 00:47:30,240
things up. 
Does that sound good? 

972
00:47:30,240 --> 00:47:32,200
Sounds good. 
I can't remember the thing I was

973
00:47:32,520 --> 00:47:35,560
going to say. 
Oh yeah, this is what it was. 

974
00:47:35,560 --> 00:47:40,400
I wanted to just reiterate that 
this can be, as you said, a 

975
00:47:40,400 --> 00:47:43,640
frustrating and a nagging thing.
That doesn't mean you need to go

976
00:47:43,640 --> 00:47:46,320
get imaging. 
There are very few instances 

977
00:47:46,480 --> 00:47:49,240
where this is going to be some 
sort of like major degenerative 

978
00:47:49,480 --> 00:47:51,560
condition. 
The signs and symptoms would be 

979
00:47:51,560 --> 00:47:54,840
very different for 
osteoarthritis than they are for

980
00:47:54,840 --> 00:47:58,000
Patel femoral pain syndrome. 
And this is one of those 

981
00:47:58,000 --> 00:48:02,560
conditions where it's like, I 
have a major bias here, but I 

982
00:48:02,560 --> 00:48:06,120
wouldn't waste your time going 
to someone who doesn't do 

983
00:48:06,120 --> 00:48:08,880
rehabilitation. 
Go to someone who does rehab 

984
00:48:08,880 --> 00:48:11,600
first for this because you're 
going to probably have to pay 

985
00:48:11,600 --> 00:48:13,640
for an X-ray that's going to 
tell you something about your 

986
00:48:13,640 --> 00:48:15,920
knee that you didn't want to 
hear but doesn't have really 

987
00:48:15,960 --> 00:48:18,480
actually have anything to do 
with your condition. 

988
00:48:18,480 --> 00:48:22,000
So go to the go to the rehab 
specialist 1st. 

989
00:48:22,360 --> 00:48:26,560
And I think that you'll not 
necessarily get better at the 

990
00:48:26,560 --> 00:48:28,760
snap of a fingers, but you're 
going to get on the right track 

991
00:48:28,760 --> 00:48:30,080
quicker. 
Sounds like you had something 

992
00:48:30,080 --> 00:48:31,840
else that popped up for you. 
Yeah, I think in most 

993
00:48:31,840 --> 00:48:33,280
situations. 
That applies. 

994
00:48:33,280 --> 00:48:37,000
I'm happy you brought that up. 
I was just Speaking of like 

995
00:48:37,120 --> 00:48:39,640
frustrating and inconspicuous 
and other stuff. 

996
00:48:40,680 --> 00:48:43,120
Is is Giannis back? 
Is he is he healthy? 

997
00:48:43,440 --> 00:48:44,920
I know he didn't play in the All
Star game. 

998
00:48:44,920 --> 00:48:45,840
Yeah. 
How's he doing? 

999
00:48:45,840 --> 00:48:47,560
Yeah, He he's been, he's been 
back. 

1000
00:48:47,560 --> 00:48:50,760
He's been playing. 
OK, So I'm not a Giannis hater. 

1001
00:48:52,560 --> 00:48:53,560
Yeah. 
You just troll me. 

1002
00:48:53,600 --> 00:48:54,400
I just troll you. 
He's a. 

1003
00:48:54,600 --> 00:48:56,000
He's a. 
Fantastic player. 

1004
00:48:56,480 --> 00:48:58,320
He's a good person. 
From what I can tell, he's an 

1005
00:48:58,320 --> 00:49:00,720
easy guy to root for. 
Yeah, he is. 

1006
00:49:01,040 --> 00:49:02,520
He is. 
Yeah, we'll see. 

1007
00:49:02,520 --> 00:49:05,440
I think final take and then I'm 
going to close things up. 

1008
00:49:06,480 --> 00:49:12,640
This feels like a potential make
or break year for Giannis's, 

1009
00:49:12,640 --> 00:49:14,600
like finishing his career with 
the Bucs. 

1010
00:49:15,840 --> 00:49:17,520
It's just the feeling I have 
this. 

1011
00:49:17,520 --> 00:49:21,680
I could be totally wrong, but I 
think that they made a lot of 

1012
00:49:21,680 --> 00:49:24,720
changes to try to continue to 
make the Bucs competitive in the

1013
00:49:24,720 --> 00:49:27,960
process. 
You lose Drew and you lose Chris

1014
00:49:27,960 --> 00:49:32,680
Middleton and you get Dame and 
now we have Kyle Kuzma. 

1015
00:49:32,680 --> 00:49:38,600
But I think what's challenging, 
what's challenging is those two 

1016
00:49:38,600 --> 00:49:41,360
guys were part of the 
championship run and you see 

1017
00:49:41,360 --> 00:49:44,880
Drew and he joins A-Team. 
They go win a championship and 

1018
00:49:45,240 --> 00:49:46,360
Drew. 
'S just a great. 

1019
00:49:46,360 --> 00:49:48,720
Guy to have on the team. 
So they're doing some 

1020
00:49:48,720 --> 00:49:51,320
experiments and if it doesn't 
work out this year, if they can 

1021
00:49:51,320 --> 00:49:54,280
at least make like the Eastern 
Conference finals, I wouldn't 

1022
00:49:54,360 --> 00:50:00,080
blame I wouldn't blame Giannis 
or be that surprised if he ended

1023
00:50:00,080 --> 00:50:03,120
up trying something else, as 
much as I want him to stay here 

1024
00:50:03,120 --> 00:50:05,520
forever. 
So with that said, I'm going to 

1025
00:50:05,520 --> 00:50:07,280
wrap things up. 
We are going to close things 

1026
00:50:07,280 --> 00:50:09,520
down. 
If you want to have us cover 

1027
00:50:09,520 --> 00:50:12,520
anything else with doctors 
Running, you can send us an 

1028
00:50:12,600 --> 00:50:15,600
e-mail at 
doctorsrunning@gmail.com. 

1029
00:50:15,840 --> 00:50:17,920
Thank you for joining us in the 
podcast and we'll see you next 

1030
00:50:17,920 --> 00:50:18,040
time.