Kaizen Health and Wellness
Spotlight Series
Spotlight Series Topic: The Ultimate Guide to ACL Injuries and Recovery
Guest Name: Dr. Jason Sullivan
Guest Credentials: MD
Discussion Details: In this comprehensive interview, Dr. Jason Sullivan, an expert in sports medicine and orthopedic surgery, shares insights on ACL injuries, surgical options, recovery processes, and the latest advancements in treatment. Perfect for athletes, patients, and healthcare professionals seeking in-depth knowledge about ACL management.
Benefit of Watching
- ACL injury mechanisms and prevalence
- Surgical options: graft types and techniques
- Post-op care: bracing, CPM, and rehab
- Biologics and emerging treatments for ACL
- Psychological impact of sports injuries
Address of guest’s business:
6001 Westown Pkwy,
West Des Moines, IA 50266
Dr. Jason Sullivan: Hey, thank you very much, Brian, for having me. I appreciate it.
Dr. Bryan M. Ladd: Yeah, absolutely. I’m really looking forward to this. So, Dr. Sullivan, I thought we’d take a deep dive today and talk about everything ACL.
Dr. Jason Sullivan: So, I’m in, man. And you got to call me Jason, by the way. You got to call me Jason.
Dr. Bryan M. Ladd: I can do that. I can do that. Well, let’s let’s hop right in. Um, ACL is a big topic. I know, especially with athletes, it’s something that I think is in the back of their mind. Everyone hopes that they don’t have to go through it, but we see it a lot. Tell us a little bit about your experience with with ACL’s with surgery. How many how many do you see a year?
Dr. Jason Sullivan: It’s a good question. I don’t know that we’ve ever counted. I think you know I I probably fix around 100 or more a year. And it the interesting thing is like for me all these injuries are devastating for who’s in front of you to some degree, but the ACL injury uh emotionally seems like it’s one of the bigger hits to to the patient that you’re seeing, you know, and a lot of times it’s teenagers, high school athletes, collegiate athletes, even, you know, people in our age range who are, you know, they’re trying to stay active. They’re trying to reach a goal and maybe they’ve reached it, maybe they haven’t. Um, and then something happens, right? they they have an injury and there’s always usually it always starts with a little bit of doubt like something happened here but I think I’m okay you know and and so then when they come to see us in clinic either they have an MRI they don’t and it’s very difficult to navigate how much do you already understand about your injury um the people that come in knowing they have an ACL tear are usually easier to kind of set the the table as to hey where are we going from here but those that don’t know it yet it it is quite a shock you know so it’s a delicate conversation that takes a lot of time in clinic But it is something I’m passionate about partly because you get to see them 9 to 12 months later and a lot of these kids are local or adults are local and then you get to see them, you know, they go from at the bottom and then all of a sudden they’re they’re smiling, they’re at the top, they’re back to where they wanted to be. And so it’s a very gratifying u thing to take care of, but it is initially like you kind of feel it yourself. You’re like this is, you know, you kind of wear it around the rest of the day because it’s a big deal to them, you know.
Dr. Bryan M. Ladd: Yeah. I’m I’m really glad you brought that up because that’s something I’ve talked I’ve seen it a lot lately. I mean, I’ve seen it throughout my career, but just become more and more aware of that the longer I practice, right? You know, there’s such a mental aspect whether you know, regardless of surgery, but the ACL is definitely it’s it’s a huge impact on people and I think it’s that like that doubt of, you know, what’s their life going to look like afterwards and especially for the young athletes like you talked about, are they going to get back to playing the sport that they, you know, that they were before? And some of those athletes have scholarships on the line. So, you know, are they going to be able to get back to a level where they can play and still earn that scholarship? And I think, you know, like you said, you can kind of feel the weight of that sometimes.
Dr. Jason Sullivan: Yeah, 100%. I’m guessing that you um ahead of time when you do some prehab with them and things like that, I’m guessing a lot of what you do is kind of walk them through like, hey, here’s what it’s going to be. And then it’s probably a little bit of like uh psychology and coaching, right? And and and getting them first of all, you mourn the injury, right? And then once you get past that, then you start talking about how do we build from here? And I I routinely send most of my kids for some semblance of prehab, you know, local or wherever they plan to go for PT because I think establishing that rapport with someone like yourself, um is a huge deal heading into surgery. It’s one less question mark, you know, when they head into that big day. Um and then we know the mental component might even be at the end of the road um the thing that holds people back more than the physical component. I don’t know if you see that yourself, but
Dr. Bryan M. Ladd: Oh yeah, for sure. Yeah. Yeah. I have uh I’ll I’ll never forget this. This is when you know for everyone that’s listening and for yourself, Jason, out of school, I got a commission in the Navy as a physical therapist. And so I did that for 5 years. I’ll never forget I was it was in Okinawa, Japan working with this recon marine. So pretty high level Marine and ACL patient. And I said, “Okay, well today we’re going to do some hop testing, single leg hops. We’re going to see where you’re at.” And I said, “All right, just line up.” We had this this doorway where we kind of that was the starting line and then had it marked out and uh he wouldn’t go and I couldn’t figure out why. I’m like come on dude like let’s go. Let’s get it. Get on the road. Like this is a big deal. You know, you’ve been rehabbing this thing. Let’s go. Let’s get it. And he he was just kind of sweating bullets there. And uh he finally just looked up at me and he said, “Sir, I’d rather get shot at than jump on this leg right now.” I was like, “Yeah, I was it kind of like that kind of took me back. I was like, whoa.” like, you know, I don’t think I had ever really thought about it like that until he said that and I was like, “Wow, that’s that’s pretty intense.”
Dr. Jason Sullivan: Yeah. I don’t think you could put yourself in their shoes until you you know, you have gone through it yourself. And I’m fortunate enough not to have had a big injury. I don’t know if you’ve had a big orthopedic injury, but it it’s like it’s it’s it’s it takes a long time to get whole again, you know?
Dr. Bryan M. Ladd: Right. Yeah. Yeah. Yeah. I was going to say I’ve not had I’ve had some injuries. Nothing I’ve had had to have surgery for. And so, you know, I obviously I’ve seen it over the last 12 years, but haven’t had to like live that. So, yeah. Yeah. Yeah. Yeah. Kind of walk us through say, you know, a patient has an injury, they’re coming to you, I guess you can outline it whether, you know, whether they know they’ve got an ACL tear or whether or not, but kind of walk us through the process. What’s that look for look like for a patient?
Dr. Jason Sullivan: Yeah. So, typically we’ll see someone within a week or so of their injury. They may have been somewhere else. They may have come in with imaging. Let’s let’s say that we we know it’s an ACL injury. I always start by kind of sitting talking to them, understanding, you know, where are they coming from? You know, where do they go to school? What do they like to do? What’s their occupation to try and figure out, okay, you know, what kind of activities is this person involved in and what’s important to them? And then we kind of walk down through a physical examination and, you know, whether they’re if they’re two weeks out, a lot of times people come in and say, “Hey, my knee’s feeling better.” You know, as you probably know, right? like the swelling goes away, they can walk, you can even run in a straight line without your ACL, but it’s that next cutting pivoting event that you’re trying to avoid a pivot shift or something that would cause further harm, right? So, you kind of walk them through the physical exam, you let them know, hey, this, you know, your ACL feels unstable. You have the MRI as well, but to me, there’s like in my head, like it’s like, okay, we have an ACL tear. What else do we have going on here? Right? So we know that with ACL tears 40 50% or higher have some type of other pathology whether it be a medial or lateral meniscus tear the shock absorbers on the inside or outside of your knee. The MCL the ligament on the inside of your knee is commonly stretched and rarely needs any type of surgery unless it’s a really bad complete tear off your tibia. So we usually treat those conservatively. But the meniscus come in all sorts of varieties. So there are some meniscus tears that are simple and you’re like hey that you’re going to lose a little meniscus tissue and your ACL surgery is going to carry on like normal and then there are big meniscus tears where hey we need to salvage this meniscus and repair this and so your recovery in the first 2 3 months is going to look a lot different than if it was just your ACL. So everyone comes in and they have had a friend or or someone they know that has had an ACL surgery and they’re always comparing it to that. But I I caution them. I’m like, I really think that this is not a one-sizefits-all injury and it is completely individualized, you know. So, we start by kind of breaking that down and do not compare yourself to anyone else. And and then we kind of outline, okay, in my mind, an ACL tear is a surgical problem for the cutting pivot activities you want to do. If you’re 75 years old and you somehow sustain ACL injury, you know, we’ll talk about are there some strategies we can avoid surgery here, but I even have some six-year-olds that come in and say, I was skiing. I tore my ACL. Don’t tell me I’m too old. We’re fixing this, you know. So, I’m guessing in your experience, you see most of these get surgery and and progress on.
Dr. Bryan M. Ladd: Yeah. Yeah, for sure. I think there’s a the large percentage of that. And I was going to ask you even, you know, is there a certain certain patient demographic? Obviously, the older patient, like you mentioned, might not be a good fit, but there is there a time where a younger patient might not be a good fit for an ACL repair?
Dr. Jason Sullivan: I’ve had a few construction kids that will come in and they’ll say like their parents will be like they they love this sport. This is their senior year. Can they, you know, they’re they’re on the bench for the basketball team. Can they go back in a brace and get through the year? And I think in the right scenario, you can kind of work with them and say, “Hey, here’s your risks.” You know, I’m never someone who says like you can absolutely not do this. I think I’m an adviser more or less is the way I look at it, right?
Dr. Bryan M. Ladd: Yeah.
Dr. Jason Sullivan: Unless you’re in charge of a team, contractually in charge of a team like Drake University, I take care of their athletes. Like I feel I feel almost contractually obliged to be like, “Hey, we’re not playing tennis on an ACL injury here.” And if a high school kid comes to me, the parents are like, “They have four more weeks. They’ve been rehabbing the sneak. What can we do? We can kind of work within a a time frame there.” But I do think the data shows that the longer you go before you have an ACL reconstruction, the greater chance there is of disruption of some type of cartilage injury, making a meniscus tear worse. And to me, those are the things that probably lead to arthritis more so than the ACL reconstruction itself. And so we’re really restoring the ACL so you can get back to activity, but also to protect those vital structures that keep your cartilage healthy in your knee. So when you’re 60, 70, 80, you’re living a great life. You’re active and you’re able to do all those things.
Dr. Bryan M. Ladd: Yeah. And I think that’s a something you just touched on was a big question that we always get too is, you know, am I am I doomed to have arthritis now that I’ve had this ACL tear?
Dr. Jason Sullivan: And so that’s I mean the a lot of the data says that, you know, maybe graph choice matters a little bit, maybe what other injuries happened at the time matter a little bit, but I think that probably the initial insult and the the bone bruise that you have that may set off a cascade 10 or 20 years later that leads to some cartilage thinning. Um, and there’s some inflammatory markers that that are triggered in an ACL setting and the knee doesn’t like that. And so there may be some things that are set in process that don’t manifest for 15 or 20 years. But I think all in all with some newer techniques, I think we’re doing well enough that you can see people potentially not develop arthritis with an ACL tear.
Dr. Bryan M. Ladd: Nice. So let’s keep walking down. You know, patient comes in, we’ve determined done the physical exam, we’ve determined there’s an ACL tear. Yeah. What’s next from there?
Dr. Jason Sullivan: So the big the big question uh that we need to get through is you know what do we use for this reconstruction? Traditionally I say there’s there’s basically four things you can use if we’re talking about a reconstruction and we can get into the idea of repair and discuss that a little bit if you’d want to at some point but let’s say we’re doing a reconstruction using something else to make a new ACL. In my hands 90 to 95% of the time I’m usually recogni uh recommending autographed meaning using their own tissue. And there’s three different autographs that I think are all valuable in different context. So you have the hamstring tendons or tendon, you have the quad tendon, and then you have the patellar tendon. And so I use all three intentionally because I realized pretty early on and being in LA, it’s a very concier world. And people do their own research and they don’t really want to be told what to do. So if someone comes in and says, you know, hey, I did my research and I want a quad tenant ACL. It’s a good graft. you can have a great result with a quad tennon ACL. So why would I why would I bicker with them? You know, I have my biases in certain context, young kids, cutting pivoting athletes. I have a bias in my middle-aged, you know, group that not doing cutting pivoting activities anymore. I think it opens up the the variety a little bit more. And then in your 60-year-olds, if they’re like, hey, I don’t want a graft harvest, then you think, okay, the fourth type is allograft. That’s using someone else’s tissue. And I think it’s perfectly reasonable in that context. So, I think you have to be versatile in this world. And so, I kind of like to I like to understand new techniques. And I think we have it all down to where if you pick one of three graphs, like you’re getting the same kind of procedure because what people don’t realize is what’s really important is getting the an anatomy restored, right? You can put any graph you want in and if you put the tunnels in in the in the incorrect position, they’re going to have some type of impingement or they’re not going to have rotational stability of their knee. So, I think really getting the tunnels right and going to a doctor you trust is the most important thing. I think graft is probably way further down the list, but it seems to be the thing that we get to and we spend the most time on.
Dr. Bryan M. Ladd: Yeah, I would agree. Everyone wants to talk about uh the their graft type and just, you know, I’m sure orthopedic surgeons, physical therapists are this way, too. They’ve all got their favorites and what they like to see. Why don’t we since we’re on the topic, why don’t we take a deep dive into those and talk about the pros and cons of each and you know when you might recommend one versus the other.
Dr. Jason Sullivan: Yeah, it’s interesting. I came to town 13 years ago. Someone asked me, this is when patellar tendon and hamstring were probably the two most commonly utilized graphs and they someone was like, “Hey, what do you prefer to use?” And I was like, “Well, for a young cutting pivot athlete, I think patellar tendon is is I like it. I think it’s really nice. I think it gives you nice stability and I think that anterior knee pain was a little bit over um overserved and I think if you close the tendon in layers and bone graft in where you took the the plug from I think they do really well and the person who told me he’s like hey you’ll you’ll never see an ACL in this town without opinion is a very hamstring dominant town I said all right well I’ll try my best I said I like hamstring too you know I don’t have a problem with it so what I tell people is this I say uh the the the patellar tendon the plus side of the patellar tendon is we can take the size the tissue that we want. And we know in studies that cross-sectional diameter matters in terms of retar rates. If you get a 7 mm graft, you probably have a higher likelihood of a rerupture than if you get a 10 mm graft in diameter. So, I like that element of the patellar tendon procedure. You also take bone plugs on either end. And so if you figure out how to work with whatever length the guitar tendon is, sometimes they’re a little mismatch, but if you’re if you’re clever with it, you can get it anchored on either side and you can get bone to bone healing, which gives the patient maybe a little sense of increased stability initially. The downside is if if you care about your incision, you will have a a 5 to 6 cm, you know, longitudinal incision front of your knee. And I’d say one in 20 people have anterior knee pain or patellar tendinitis and things like that. I think it usually runs its course and burns itself out. But that’s what I kind of tell them as my brief spiel on patellar tendon. Hamstring tendon, I say you can do one of two things. You can either harvest both hamstrings and quadruple them over or you can take one slip of hamstring and burrito it and fold it over four times. And in either event, you usually get your way to an 8 mm graft or maybe a nine. And that’s perfectly adequate for most people. There are sometimes you harvest the hamstring and you’re just a little dissatisfied with this is a little smaller than I was hoping it would be. And so that’s when maybe you need to augment it with allograft or whatever it may be, but you can still get them to where you want to be. The downside of taking the hamstring is that you can have some weakness with flexion of your knee at like a really high flexion angle, but no one’s really doing that functionally. Who’s flexing their knee past 120°? You know, no one. So, no one really knows that unless they’re really in tune with their body. And every once in a while, people will kind of recurrently pull that hamstring and feel it in the back of their thigh, but it’s a pretty benign graph to take. I don’t like taking it sometimes when there’s a significant injury to the medial side of the knee, like an MCL, because I think the hamstring is a secondary stabilizer of your MCL. So, like if you have a grade three, a really bad MCL, and it’s really unstable, then I I sometimes I think twice. But it’s a it’s a really good graft, too, and I’ve had plenty of patients do awesome with it. The third graft is the quad tendon which honestly is becoming very popular. I think most guys coming out of sports fellowship training are seeing a lot of quad and so they’re doing a lot of quad. The advantage of the quad tendon is you can take a 10 uh mm strip and it the cross-sectional area is greater probably than that of the patellar tendon. So tensile wise is probably a little stronger. It’s all soft tissue. So you have to put it in the sockets and you have to allow that bone to soft tissue healing to happen. But you can actually brace across it with a with a piece of rope as well and really stabilize that knee. So that’s a nice part of the procedure. The downside of the quad is if you look at long-term studies, some even out to a year, especially in females, the way they land and the the way they absorb stress with their quad can still be altered even out to a year or so, but long-term studies show that they eventually get there and and normalizes. So quad atrophy would to be the biggest thing you worry about because obviously you’re taking, you know, a 6 and 1/2 or 7 cm strip of that central part of the quad. So that that’s kind of the general conversation I have. And then I usually ask them, I say, “Hey, tell me what you’ve learned.” Because I’d say 50% or more have have, you know, they’ve been reading, they’ve been doing the research. And I I I like that because then we have an informed conversation and there’s no reason to argue about these things. Like my job is to tell them the pros and cons. And to a certain degree they can they can choose what they want if if if they have strong convictions.
Dr. Bryan M. Ladd: Yeah, absolutely. I think even when people come into physical therapy like they’re they’re well informed nowadays like everything’s on the internet and you can find it pretty quickly. So I like that take. I like that take on it. So once we’ve picked the graph out, we’ve decided surgery is the option. Kind of walk us through walk us through surgery day and then what that looks like immediately afterwards.
Dr. Jason Sullivan: Yeah. So so surgery day for them, you know, it’s a big event. It’s uh for us it’s about an hour procedure or less, but they have to get there early. They have to get there checked in. We once they’re situated with an IV, we our anesthesiologist get get them a nerve block called an adductor canal block. And then they also do what’s called an IPAC block, which is blocking kind of the the capsule in the back of the knee. And to the best of our knowledge, that does a pretty good job of covering the knee while not knocking out the quad. So most of my ACLs, I want them putting full weight down right away in a brace afterwards. So we fit them for that brace as well and we put them in that after surgery. So I usually keep them straight in that brace, let them put full weight down with crutches and then they come see us about a week or so later. We kind of look at the dressing, refit the brace and everything. Therapy starts right away after that. In the meantime, they’ve been using a CPM machine and doing some heel slides and some quad exercises. And then they’re already plugged in with their therapist typically with prehab. So then they get they get rolling right away there. and um and then it’s kind of off to the races. The scenario that’s hard is when you found a meniscus tear you didn’t expect or something was a little worse than you thought and you do a meniscus repair and then you say that tissue is pretty delicate and we’re going to have to take a little bit of weight off it. And so sometimes a month of weight, you know, minimal weight bearing and then after that kind of slowly progressing to being full weight bearing by, you know, 2 to 3 months is necessary. And that that really uh hinders people’s ability just to get around, go to class, go to work. But we think it might be necessary in some context of a meniscus repair for success of that repair. Um those are the kind of the big things we discuss. Uh it tends to day surgery tends to go pretty smoothly. Usually they they get their mind around it pretty quick. It’s one of those it’s the biggest shock when it happens, but it’s also the people that like the human ability to flip the switch and be like, “All right, ready to go.” And a lot of credit is to you guys because you do a lot of counseling behind the scenes to say, “Hey, you can do this. You know, we’re going to get you through this.” And so with a team behind them, it goes a lot better.
Dr. Bryan M. Ladd: Absolutely. There’s two things you you talked about there that I I want to hit on a little bit. It sounds like you’re in favor of them, but I see I see it go both ways here. One was the brace and then CPM. So I’ve seen some surgeons where they’re like, “Nope, research says, “No, we don’t need that brace. Knees stable. Let’s go.” And I’ve seen others that are the opposite. It’s like, “Well, you know, maybe maybe they don’t need it. the surgery is good, but it’s more of an indicator for other people. I don’t know. What’s your take on that? What’s the research show? What do you what are your thoughts there? And then the second one Oh, yeah. Go ahead. We we’ll hit the second one next.
Dr. Jason Sullivan: So bracing I I I think that um for me posttop bracing immediately is a way of uh it’s a way of kind of slowing the patient down holding them back preventing the oops you know I was asleep I got out of bed I had to go to the bathroom I took a misstep I didn’t have a brace on I’m post op day two to some extent it’s protecting the patient from themselves maybe I don’t like to use it longer than we need to and the second they have quad control and can do a straight leg raise and they can demonstrate in clinic with you. They can walk. They can come out of the brace. If they have a meniscus tear, I think that the brace is still a nice reminder, hey, you know, we’re going to be nonweight bearing for a little while here. I have an injury. And it’s just a constant kind of proprioceptive feedback like, okay, you know, we’re protecting this leg for a little longer. I think I I could be wrong. I think most people post op after an ACL surgery use a brace right away. Now, when you brace longterm is probably maybe the more controversial thing. return to sport braces and things like that. I usually offer some semblance of a return to sport brace like you’d see like a quarterback wearing on their, you know, on their plant leg, you know, for a D-end coming in. I say, “Hey, this isn’t going to prevent a retear.” If you play a contact sport, if you’re on a if you’re on the the O line or the D line, there’s zero downside in using this. It’s going to help protect you in the in the coronal plane from like an MCL injury or, you know, it’ll just protect you from one variable. And some people are like, “Hey, I want to go hiking.” and then they’re they’re 4 months out from an ACL. And I’m like, they probably could, but it’s uneven ground. You know, maybe that’s when they use the the the smaller brace. But I’ve kind of gone away from telling people they have to do that because I don’t think we have any evidence it prevents recurrence. And most high level athletes like they look at me and they’re like, “Dude, I’m not using this. I’m not I’m not when I go back, I’m not wearing this.” And so then it’s kind of like okay I you hear enough people tell you that and you kind of say okay you know but by the same token I do think and you tell me if you’ve noticed this but I do think that when I 13 years ago I was like at 6 months hey go for it do whatever you want to do but honestly like I feel like as we advance we have more objective measures of when someone can return and I think it’s more like an 8 nmonth injury you know if you look at the pros and high level collegiates like sometimes 9 months to a year so I think maybe we’re protecting people for longer And that bridge of having a brace maybe when they go back is no longer as as necessary as we may once have thought it to be.
Dr. Bryan M. Ladd: Yeah. I just had that conversation with a patient uh the other day, you know, they said this is going to be 6 months. And I said, well, actually, you know, you’re going to be feeling great by 6 months, but research now is showing if we can push that out to 9 months or longer, like you said, 9 months to a year, you know, our rate of reinjury is much lower than if we return to sport at that six-month mark. So, yeah, I I agree. And uh yeah, like I would say, like you said, most of the surgeons I’ve worked with will will do immediate post op bracing, especially for the first couple weeks. And like you said, the the meniscus tear is a whole different story. Like that that really changes the game. Yeah. So, um yeah, and I’ fast forwarding then to return to sport, I’ve seen that go both ways where, you know, especially linemen bracing. I’ve seen quarterbacks as well. Um, just kind of depends, but seems like we’ve kind of shifted away from, you know, needing that brace long term.
Dr. Jason Sullivan: I think you’re probably right. I mean, at least that’s the dynamic I’ve seen. And it mostly comes patient driven, you know, like you’re not going to if someone tells you they’re not going to wear it no matter what you tell them. Okay. Well, let’s let Okay, let’s work around this, you know. So, um, I think you’re going to get to the CPM thing, too.
Dr. Bryan M. Ladd: The question on that CPM. That was my other question.
Dr. Jason Sullivan: Yeah. So, honestly, there’s zero there’s no scientific evidence you need a CPM after after an ACL. For me, it’s it’s that bridge for the first two weeks. I think cartilage likes motion. Okay? And so, it’s a way of every day guaranteeing uh a couple times a day for a half an hour that the knee joints moving. And I tell them, hey, here’s what extension is, and we got to ensure extension, but it’s gets working on their flexion. I think also a lot of patients feel like I’m just sitting around. I’m I’m lazy. I’m not doing anything. So, I feel like they feel like they’re enrolled in their own care that way. Um, and they can’t come see you every day. You know, that’s not a feasible thing. For the first uh for the first 7 to 14 days, I do that. And then, you know, with some cold compression and things like that, I think it um for me, patients tend to like it and and we’ve been able to keep it cost effective for them. Uh, and so, honestly, I’ve stuck with it. But there are no studies that show that like if you don’t use a CPM, you’re not a bad doctor. If you do use one, maybe you’re not paying attention to literature that says it doesn’t matter. But honestly, to me, it’s something that um seems to set up nicely for my patients. I’ve just stuck with it.
Dr. Bryan M. Ladd: Yeah. Yeah. It’s Yeah. I It’s funny that you mentioned that because I would say a majority of physical therapists that I know are against CPMs, but a majority of the patients that come in absolutely love them and they enjoy using them. So, I don’t I don’t see what the harm is either. If it’s if it’s helpful, I don’t think they’re hurting anything. So, why not get that get the joint?
Dr. Jason Sullivan: I mean if it if it becomes where it’s not cost effective uh then yeah you you got to ditch it but uh if you can work out some agreement with the uh companies you know and say hey my patient doesn’t see more than x out of pocket you know and and then it seems to be like okay I don’t see a downside you know
Dr. Bryan M. Ladd: yeah yeah and like you said too you know motion’s lotion and so getting that joint moving kind of feeding some of that tissue even the course I was telling you about before we started this podcast the neurodynamics course they were talking about fluid dynamics within nerves and how they, you know, they like fluid and so getting some of that that movement in there, too. So, it’s that tissue is it’s meant to have it in there and
Dr. Jason Sullivan: Yeah. And movement’s one way to do it. So, Yep.%
Dr. Bryan M. Ladd: Yeah. So, let’s talk about, you know, postsurgery. We’ve kind of talked about we’re getting people up. We’re getting weight bearing through that limb. Um, which I think uh I’m obviously for that, but uh patient wise, it seems like I don’t know if people have quite caught up to that. A lot of people are surprised, I think, that we’re getting people up uh right away. We’re putting weight through it. We’re moving.
Dr. Jason Sullivan: I think if you set that as an expectation, you know, if you we do a lot of uh when I leave the room, I usually tell them, “Hey, my PA here who’s with me every day is going to spend five or 10 more minutes talking about the intricacies of, you know, the first seven days after surgery and all that.” And so, we usually hammer it as an expectation. And so, then I think they’re like, then they they think they can trust it. You know, there’s a few people that come in and very guarded, but um the weightbearing thing seems to once they do it once or twice, they don’t seem to be, you know, and then I I have some kids that come in for the postop, no crutches in sight, skipping down the hall, ready to be done with the brace. So, you know, everyone, my absolute best patients are the lucky non-compliant patients. I don’t know if that makes sense to you, but um the ones that just, you know, something with their biology, it happens sooner. They kind of make their own rules up and like they’re off to the races and they’re happy, right? And I can’t explain it, but
Dr. Bryan M. Ladd: Yeah. Yeah. It’s that patient that’s like it’s like they’re not following a single thing and they’re doing phenomenal.
Dr. Jason Sullivan: Yeah. They’re absolutely killing it. Yeah. Happens all the time.
Dr. Bryan M. Ladd: So, you know, we’re going to get physical therapy started. We’re going to get that quad control back. But then what’s it look like? What’s the care? you know, they’re going to see us every day or not every day, but they’re going to see us several times a week there. So, what’s the follow-up care with you look like after?
Dr. Jason Sullivan: So, I see everybody um eight or nine days after surgery. I see everyone then at usually 5 to 6 weeks, 3 months, and then typically 6 months. If someone’s struggling, we see them through, you know, we see them at 9 months. Most people at their 3-month visit are looking at me like, I can’t golf. I can’t What are you saying here? And so if we kind of outline the next 3 to 6 months with them, you know, I I don’t want to charge them for a visit. I say, “Hey, if you have any issues, just come on in. We can talk or send me a task and we can call you, but I don’t routinely make people see me at 6, especially my adults that are like active enthusiasts, but not necessarily getting back to a team sport. My team sport, you know, usually the coach or the AD or someone wants a blessing, right, of some variety. And so then it’s always good to do that. But it’s gotten trickier because usually when I see people at six when they look great, I’m like, all right, let’s hey, let’s go for it. But now I’m kind of like, okay, you know, the risk of reinjury injury to your other knee is higher now than it would be in another 6 weeks, you know? So, what do you think about? And so, I try and frame it like some people think like it’s a failure of modern medicine. Like, how could I not be back at 3 months? Why is it taking longer now? I think we just know so much more. you know, we have so many metrics of objectively measuring their strength and doing these return to sport tests and all that and you could speak to those things. I’m sure even at a year sometimes you’re like, well, they still have a deficit, you know, but let’s, you know, at some point you just got to cut it loose and go for it.
Dr. Bryan M. Ladd: Right. Right. Yeah. And that’s where what you talked about earlier, too. Like everyone’s different and you can’t cookie cutter, you can’t cookie cutter the the surgery, you can’t cookie cutter the rehab. Everyone’s so much different and their progress is different. And I think the hard part is uh a lot of people see these professional athletes getting back to playing very very quickly. You know, I think of like Adrian Peterson and so that that’s the one that always comes up, you know, right?
Dr. Jason Sullivan: You just don’t you don’t know what else was used, you know, in conjunction. I get asked all the time about, you know, what can I do to speed this up? What peptide do I need to take? Do you get asked about peptides all the time?
Dr. Bryan M. Ladd: Absolutely. Yep.
Dr. Jason Sullivan: Okay. And I, you know, it’s it’s an intriguing, you know, there are effective peptides out there already. We know that, right? GLP-1s, right? I mean, that’s a perfect example. I mean, it it targets something and it does what it’s meant to do. The ones for like building muscle and, you know, anabolic activity, I don’t understand them as much. So, I tell them, hey, at your own risk, you can do whatever you want. I just I’m always a little wary of the cheat codes. I don’t understand them enough yet. I don’t know if we have enough science. They’re not regulated, but I’m sure someone’s going to figure this thing out and it’s going to get more advanced.
Dr. Bryan M. Ladd: Yeah, that Yeah, like BPC 157 is the one that people ask me about a lot and you know, probably get three questions a day about that. And I I try and do some research on it and then I I just can’t find the peer-reviewed like level one stuff that or level two that we’re used to like kind of quoting or or relying on. And so I’m kind of like, okay, level evidence isn’t there yet. It’s promising, but we don’t know enough for me to professionally say you should do it.
Dr. Jason Sullivan: Right. Right. And then it’s just like the GLPs, they’re so easy to get and seem to be pretty affordable. And so I think that’s a hard thing, too. People can just readily readily go get them. You know, you don’t need a prescription in some cases. So it’s
Dr. Bryan M. Ladd: wasn’t it you had to see a doctor to get on one and now it’s it’s a little bit of the wild west. like things that aren’t regulated, you know, there you just got to proceed with a little bit of caution, but not that it could work perfectly for someone. I just I don’t know enough to tell people to to do it or not do it.
Dr. Jason Sullivan: And the orthopedic our academy recommendation is is uh we don’t have a formal one yet on on on regular incorporating that. So I have some patients asking, hey, can you give me some HGH after surgery? And theoretically, I’m like, “God, that sounds like an amazing idea,” you know, but uh conceptually phase forward to your patients, you don’t know if that’s going to cause some type of pituitary tumor or what what are the downside, you know, problems that you could be causing just to get someone to heal up a month sooner. I’m not willing willing to take that risk lacking the expertise. So, I kind of stay out of those conversations.
Dr. Bryan M. Ladd: Right. Yeah. What about things like PRP? Is that something that you do in your practice? And is that something that potentially with ACL or meniscus tear can be beneficial?
Dr. Jason Sullivan: Yeah, good questions. We we do PRP at DMOS. I I do PRP for a few re good reasons. I think I think early arthritis, it’s probably a little better than a cortisone or viscosupplementation injection, but fractionally. I think partial tears maybe there’s a role for things. Maybe a partial UCL tear, maybe a partial uh rotator cuff tear. So I do them and honestly I start by being fiscally responsible for patients because insurance doesn’t cover this and so um you have to charge out of pocket and then you know you have do you do have stem cell clinics in town um that do this too. Um I think we do it responsibly for a meniscus repair or a tear I and an ACL tear we don’t have any evidence yet that um you need to be doing this or telling people that they need to do this. Uh, now ACL repair, the thing I kind of mentioned at the beginning, I I know enough about it. I could execute the procedure. I haven’t done it yet because I just don’t know who am I going to choose to do that for because I think the retear rates are a little higher. But in repair, you use the PL, you know, PRP and a collagen scaffold and biologics to have both ends of the the the tissue kind of reopposed and then you let the body do its thing. But there the niche for that is very small. It’s kind of like non-cont athlete older cartilage has to look good and then your retear rates are are no better than you know a recon and they fall short in many measures. So it’s coming it’s interesting stuff and that you use patients biology for that. So that’s kind of a promising that’s probably the most promising aspect of the biologics field in the ACL is you know can you get some of these ACLs to to regenerate and become as good as they once were.
Dr. Bryan M. Ladd: And just to clarify, for a repair, you’re looking more at like a like a partial ACL tear versus a full.
Dr. Jason Sullivan: So, it can be a full, but you need you need like 10 to 15 mm of the stump off of the tibia to be intact. Got it? Because you got to put stitches through that and through the femoral part and have them envelope into this scaffold. To me, it’s like when I go in there, some of these ACLs, it looks like a bomb went off and you know that it’s probably not a great idea. And then some you’re like, you know, there’s 30% still here. Maybe, you know, most of the posterolateral bundles intact. A lot of people don’t know there’s two bundles of the ACL. And so maybe one of the bundles looks pretty good. So there could be a role for for that patient. It’s always nice to know ahead of time when you’re going in. It’s a little stickier when you’re like, “Hey, I’m going to have my repair guy here and my recon guy here and I’m have all these reps around and we’re going to decide.” So too many variables and I don’t like uh wasting other people’s time. I usually like a plan A and a plan B and we move and that that works well for me efficiently. So I I still haven’t figured out the role for repair yet, but I think that we need longer term studies, but it’ll be interesting to see where those go in the next 5 or 10 years.
Dr. Bryan M. Ladd: Yeah, I’m glad you mentioned that, too, cuz I was going to ask, you know, can you even see that on an MRI? Sometimes it seems like things hide on MRIs and so you might not know till you get in there anyways. And so which which way you going to go?
Dr. Jason Sullivan: Yeah, it’s tricky. I think it’s a lot of game time decision, you know, and then I would probably do it in the first patient that comes to me and says, I want a repair. I look at their MRI, it seems reasonable. We would, you know, try it, but it’d have to be middle-aged, adult, non-cont. The bar would have to be low. And our I think our retear rates on reconstruction are pretty good these days. Like they’re, you know, you’re going to have your failures if you do enough of them. And if you put the ACL in the right spot, you might actually have more failures because the graft is actually seeing the strain that it should see. I think sometimes conventionally like 20 20 years ago some of the techniques were a little more vertical and I don’t think the graph was actually seeing as much strain. So I think maybe retire rates were less but you probably weren’t controlling as much and so rotationally you get more meniscus injuries post ACL the ACL looks good but you have these big flip bucket-handle tears of the meniscus and you can’t figure out why. It’s probably because the ACL isn’t constraining the knee as good as you want it to. So I think if you do get an anatomic, you have to be prepared for you’re going to have a couple failures out there because you got someone back to the level they’re at and the graft is seeing all of that strain that it should be seen.
Dr. Bryan M. Ladd: In your experience as well, are most of your patients getting back to high level activities and able to play the sports that they want to play without any hindrance there?
Dr. Jason Sullivan: Yeah, I mean by and large I would uh these things like ruin my day. So I haven’t I haven’t been that depressed lately. So I I feel like yes, I mean um absolutely like the expectation is that they are by 9 months to a year they’re back to where they want to be. Whether they’re at that level right away probably doesn’t matter as much as like their trajectory and if they get there. Uh but yeah, I mean my uh uh my expectation I tell them right away like we we want you to get back to the level you were at and then we accept any you know risks that happen at that point because things are going to happen on a turf field playing soccer as a female athlete right but if you can get them back and they feel great then I think their chances have normalized to you know less than you know 3 4% or whatever and then that’s that’s the whole goal you want them to be back very few people fall short and sometimes if they fall short. It’s It’s almost like an they did an an internal check and they’re like, “This what I was doing isn’t that important to me and here’s where I’m headed.” So, they just pivot and go in a different direction and that’s fine, too.
Dr. Bryan M. Ladd: What’s your take on turf fields versus natural grass fields?
Dr. Jason Sullivan: That’s funny you asked that. I get asked that a lot. I I I I inherently you think you have to think that we went to turf fields because basically they they’re they’re less maintenance in the long run, right? But there’s there’s also like less there’s less give. Like if you if if you plant on a outdoor grassy field in the you know in the EPL and a piece of sod comes up you’re probably not tearing your ACL. Like if you plant on a turf field like there’s only so much give you know. Uh so I think that I think the turf’s gotten better. I think that it used to be horrendous and I think it’s getting better and I think the evidence points towards it being very minimal if even obvious at all. When you just look at it you’re like there has to be some variance in the turf, right? like not everyone installs turf the same. Uh what’s the regulation? Have they replaced it every 5 years? How many pellets are on the field? There’s so many variables as opposed to grass is just kind of is what it is. So I think there’s more elements of surprise and and and so but that’s all you see anymore. So it’s it’s almost a moot point.
Dr. Bryan M. Ladd: Yeah, for sure. For the people listening, what would you look for when they’re looking for a surgeon, but also a physical therapist?
Dr. Jason Sullivan: Yeah, so those those are good questions. So, I think um for a surgeon, I go to someone you trust, right? I mean um word of mouth is a big deal. I I tell most people that’s like all I have like my my I’m not I don’t get a lot of patients through the ER. I’m not fixing a lot of broken bones anymore. So, these injuries are elective and everyone knows, you know, names in town and things like that. And so, go to go to someone that you trust that you you you’ve heard someone had a good experience with or you can look up their credentials. But honestly, Des Moines is a really good, it’s a good medical town. Like, I’d be lying to you if I told you I was the only one who should do an ACL in Des Moines. We have so many good ACL surgeons. So, go to someone you trust. And when you meet them, if you have a connection and you feel like they care about you and where what you’re trying to do, then then it’s a home run. I I think you want to go to someone that does the surgery frequently. And we all get annoyed with how many of these do you do, but you don’t necessarily have to ask that question, but you can kind of figure out when you’re talking to someone the process. Like if it’s a well-oiled machine, they’re thinking about it a lot, right? And the more details you get, the more nuances they’ve been through. So those are things I would look for. Like you you don’t want it to be something that’s they’re losing sleep over the night before, you know? You want it to be something that’s routine for them. And and then don’t don’t stress over the graft. Like if the surgeon you go to says, “Hey, I I use hamstring.” And and you like him, do it. You know, like he’s going to do a great he or she’s going to do a great job for you. To me, that that’s what’s important. like the team approach, feeling you have good rapport and understanding their background. Is it something they specialize in and they really enjoy? Because if they’re passionate about it, they’re going to care, right? And then as a physical therapist, that is like that’s a big deal in a way different perspective. So like you got to figure out, can I get along with this person for the next nine or you know 6 months, 5 months, right? I mean, can I have are we going to be able to to BS about anything in the world while we’re getting some work done? Do I like this person? And then like is this person kind of cutting edge? Are they reading about similar to the surgeon, are they reading about new techniques? You know, do they have goals outlined for me? You know, we always send like a like I try not to insult therapists like yourself in town. Like when I send a script, it has broad strokes, but like a lot of people are like, “Why didn’t you say you know three paragraph sorts of things?” I’m like, well, if I give them the diagnosis and the procedure we did and some parameters. If you go to a good therapist like and they know what they’re doing, like they’re going to have their own. You don’t want to over constrain a good therapist. You know, you you want them to kind of take it where they’re going to take it. And I tell everyone like you’re going to be better friends with your therapist every time I see you. Like, I hope this is your person because you’re going to see them twice a week. And so, those are things that I think are important, like figuring out like, are we on the same page here? Do they know my goals? Do I enjoy being around them? and am I are they holding me accountable because they can’t be with you all the time and if you don’t work at home as you know the results aren’t quite as good. Those are kind of the main things I would I would say that are important.
Dr. Bryan M. Ladd: Yeah, love it. I would agree. Jason, is there anything that we haven’t talked about that you want people to know?
Dr. Jason Sullivan: No, I mean this is a pretty pretty good all-encompassing discussion and uh No, I appreciate your time today. It’s been it’s been a lot of fun. We could I could talk the rest of the night to be honest. I I I love I love talking these things.
Dr. Bryan M. Ladd: Yeah. No, that’s great. I I agree. I could keep talking about it as well, but if people want to learn more about you, they want to find you, how can they do so?
Dr. Jason Sullivan: Simple. You can uh I mean, I’d give you my cell, but that might lead to lead to problems. I give most of my patients my cell that ask for it, which which is which honestly I guess I want people to know that like my thing is like I really don’t like when I go home at 5:00, the workday is not over. Like there’s all sorts of texts. I call people. I’m kind of always trying to do the right thing in a concierge fashion for people. You can schedule an appointment online through Luma at DMOS and ask for me or one of my PAs directly and then anyone who asks to schedule with me they can like there’s no like screening like you don’t have to go see primary care you don’t need a referral honestly I see people for shoulder knee hip primarily discomfort and so and elbow so I mean like I’m fairly accessible honestly I maybe I should be less accessible but I’m happy to see people anytime so they call DMOS schedule with me if they need but yeah that’s that’s kind of the main routes to get in and see us.
Dr. Bryan M. Ladd: Perfect. Well, I appreciate your time. I know you’re busy. Thank you for doing this.
Dr. Jason Sullivan: Well, hey, I thanks for inviting me. I appreciate it very much.