Transcription of Dr. Lincoln Avery for the show Keeping Knees Healthy #219
Lisa: This next individual is a friend of mine that I’ve known for a little while and I guess first I knew him as my surgeon. He is Dr. Lincoln Avery, I call him Linc, an orthopedic surgeon at Maine Medical Partners Orthopedics and Sports Medicine. He is the division leader of Sports Medicine. Thanks so much for coming in and talking to me today.
Linc: It’s nice to be here, Lisa.
Lisa: Thanks for fixing my knee all those years ago.
Linc: It’s nice to see you not limping too much.
Lisa: Yeah, right. I know that’s always the thing if you’re the person who does the fixing and then the person breaks again then it makes you not look quite as good at your job, right?
Linc: Exactly.
Lisa: Yeah, but I’m not limping. My knee has worked perfectly fine. I’m interested in talking to you about knees and in part, I know that this is one of your specialties is the knee, in part because it really has been … it can be very disabling for people. In my line of work and I’m talking more older people, when I try to get people to be active and they say well, I want to be active but I have this knee injury and I can’t do a lot of walking, never mind running. We can’t even get to that next level of fitness. We can’t even get to just the basic level of wellness and some of these injuries started when they were younger and that’s where you come in. You can actually help people with their wellness by helping stave off some problems as they get older.
Linc: There’s a full range, you can have … A very common scenario I see are people that come in middle age, they’re very heavy and they’re trying to lose weight because obviously they’re working on their overall wellness. The first thing they do is start to jog or go for long walks and because they’re heavy their knees wear out sooner and now you’ve got a bad knee and you’re heavy and you can’t exercise. They see someone who’s a surgeon, says okay, you need to lose weight and do this, this and that and they’re saying well, how am I supposed to do that? Some of it is how do you modify things and keep people going while they get to that goal and then the other part, okay, if you’ve had an injury how do we get you back as good, if not better than before and very often we can get you back better to let you get back to those activities that you love doing.
Lisa: I have a special interest in, not only because I had my own knee issues, but in the knee because my daughter had an ACL tear when she was in high school and she went through this enormous rehab process and now they’re doing work with ACL rupture prevention. I like where this is going. I like that we’re actually getting to the kids before they end up having these catastrophic potentially, let’s call it, career ending even though they’re in high school but definitely life impacting kind of injury. Talk to me about that.
Linc: It’s really interesting because there was a real epidemic of female greater than male ACL tears. If you look back 10 years ago, particularly in basketball, basketball is like 10 to 1 female versus male, soccer was twice as much. There were sports where women were clearly getting injured, tearing ACL specifically. Everyone started to research this and going oh, is it because their hips are wider or is it hormonal changes or different center of balance, et cetera, et cetera. There are all sorts of theories and it looks like what’s happened is that it’s a neuromuscular control issue and partly related to the width of the pelvis that women have over men but that their hips are weak and so that they set up bad biomechanics.
What you’re referring to is that there’s a program where you can actually prophylactically treat athletes to use their knee in a correct biomechanical way that drastically in the order of 80-90% decreases the risk of an ACL tear. It can become motor memory and obviously, very, very effective and preventative.
Lisa: Where did this epidemic come from? I’m assuming that it’s not like there’s something different about biomechanics that shifted over the last so many years.
Linc: Yeah. You look around, what are some of the things that are different versus when I was growing up as a kid? Number one, there’s much greater female participation and number two is sports are starting earlier, particularly families are really devoting themselves to having their child get often year-round coaching and experience in one sport to really focus on that. The levels of injuries are harder and higher for that age group than they were 10 years ago and we’ve got a greater mix of female athletes.
Lisa: As I’m thinking about my own daughter who had her ACL injury, she had her injury in lacrosse but she is a three-season athlete. She is also a soccer player and a swimmer. She wasn’t … We didn’t have her doing, except for swimming, which shouldn’t have an impact on the knee, we didn’t have her doing the same sport year round but her father had an ACL injury. Does genetics ever play a part?
Linc: We’re not really aware of that, that there’s an ACL tearing gene at this point, no.
Lisa: I think about knees in general because they are this big hinge joint. You can injure your hip and get away with it. If you injure your foot you can be put on crutches for a little while but you can limp around quite a long time on a bad knee and just keep doing damage on top of damage on top of damage. What has your experience been with this?
Linc: As you said, the knee’s a very vulnerable joint. It’s in the middle of these two long lever arms so it’s exposed, it doesn’t have a lot of bony protection, it’s all soft tissue holding it together. Between leverage or contact, it’s very often the first thing to go but because it’s a weight-bearing joint. Hips and feet injuries can be just as debilitating, they’re just not as traumatic because when someone limps in and they can’t move their leg you can see it across the room. You really need that 98-100% of your knee to really be competitive and so, it seems to be a very sensitive joint in terms of what it can tolerate and what it can’t tolerate.
Lisa: It also seems in the patients that I care for that weight has a tremendous impact on the knee and even fluctuation of 10 pounds or so can change the way that somebody experiences perhaps an old injury.
Linc: Yeah, that’s really true. It comes down to basic biomechanics. These muscles are pulling at well over body weight loads to make these legs work and if, for example, going up and down stairs you put three to five times your body weight across your kneecap. If you’re 20 pounds overweight that’s 100 pounds more. That little kneecap, it’s only the size of a half dollar seeing across the whole contact area. Weight is a huge thing and very often I’ve had patients that it sounds easy, lose 20 pounds but if they’re 250 and they get down to 230 and they say you know what, my knee feels better already. Very often that’s motivating and really makes them not only hang in there but take it to the next level in terms of what they’re doing to drop their weight and get more active.
Lisa: When we think of surgeons and I actually have to talk my patients through this often because when I say, I’d like to refer you to an orthopedic surgeon, they automatically believe that I’m sending them towards the knife but that is not true. What you’re describing is let’s not have somebody go through surgery unless you absolutely need to. Let’s try everything to get you to a place of better biomechanics before we go that route.
Linc: Absolutely. Yes, I’m an orthopedic surgeon but I’m specialized in sports medicine. Sports medicine isn’t just sports medicine surgery, it’s preventative medicine, it’s performance medicine in terms of how can you make someone who isn’t injured achieve a better level with sports. These are all aspects of sports medicine.
Lisa: The sports medicine program at Maine Medical Center actually came to be just after I went through my own residency with the family medicine program and it is affiliated with the family medicine program which I find interesting because it’s acknowledging that primary care doctors do have a touch point within the sports medicine field and you’re working with family practice doctors and primary care providers as you’re providing sports medicine care.
Linc: Oh yes. Bill Dexter has been around for 20 years with the family medicine sports program and he and I have literally moved in to the same house at this point because of that interaction. We both are trying to get patients better, not necessarily with surgery but with hands on care, modification of physical therapy, medications, all sorts of new biologics that are being done in terms of injections and other treatments. Surgery is clearly the last resort.
Now there are times where it’s very obvious that it’s the only way to go with the traumatic injury. As you said, an athlete with an ACL tear, there’s no studies that really say you’re going to do very well with that bracing or whatever if you want to stay at the same level. Anything we can do to prevent surgery and to get people functional is clearly the right way to go.
Lisa: With ACLs, there is the possibility that if somebody doesn’t want to return to, say, a high level of play, if they don’t want to go back to being a skier you could decide not to repair an ACL if it wasn’t completely ruptured, is that right?
Linc: In that case, yes. The ACL is a stabilizer for sports that require plant and pivot changing direction quickly activities, jumping down on the knee, decelerating, those kinds of things. My famous story is I have a patient who I met in the late 1980s who’s a marathon runner and he tore his ACL with a fluke injury at home that was unrelated but all he does is run distance. He talked to me about hey, I don’t want to do ball sports, I don’t want to do agility sports. I’m not a big hiker. I just like high mileage asphalt running. I said sure, let’s try it and see what happens.
I saw him probably five years ago for a different issue and I said hey, would you mind if I get an x-ray on your knee. I want to see what’s going on, just update that. He looked great. There were no arthritic changes. He hadn’t had any instability. He was coping simply because he wasn’t doing activities that he needed an ACL with.
Lisa: The ACL, the anterior cruciate ligament, is one of four ligaments in the knee that can cause, potentially cause problems. There are also problems with the meniscus which is a cushioning element of the knee.
Linc: Yeah, the menisci are C-shaped cartilages separate from the joint cartilage that are like the lip of a dish. They support the edges of the joint. They take about a third of the load that each knuckle bears in weight bearing in the knee. Then essentially, they’re shock absorbers with a small amount of stabilizing function but because they’re shock absorbers, just like a shock in a car they can wear out or rip or tear or get injured.
Lisa: Again, this is the sort of thing that sometimes if there’s a tear sometimes people notice it, sometimes they don’t, sometimes you fix it and sometimes you don’t depending upon what type of activities people want to participate in and the severity of it.
Linc: Activities and the tear itself. These tears can occur in any conceivable geometry and location on the meniscus and for example, a horizontal tear which is a tear like you’re slicing a bagel and just literally slicing a portion of the meniscus so it’s almost like a mouth. Very often patients can tolerate that and go on with life with no change in arthritis and no significant change in function. Now they’re not playing for the NBA but they’re doing recreational sports, they’re working out, they’re active, they can ride a bike around the world. There’s lots of activities you can do and never have symptoms. Those are the type of people that we try not to operate on unless they’re having pain that’s frustrating for the patient in terms of not doing the things they want to do.
Lisa: When we think about the knee we have to think about the other parts of the body. We have to think about maybe whether the muscles, maybe the hamstrings aren’t quite right. Maybe the gluteus muscles aren’t quite right. How do you when you’re doing an exam on a patient, walk me through your mental process.
Linc: The mental process actually backs up to the history so taking a good history and listening to what the problem is, how active was the patient, what is it they’re trying to do, what are they really describing. It may be a knee symptom but as you listen to it it’s clear that maybe something else could be going on. You watch … I’ll have a patient walk down the hall and just watch how are they using their feet, how are they using their ankles, how are they using their hips. We test their joint mobility. We test their joint strength above and below the knee itself just because these all can be a big factor.
Just like we are talking about with the ACL and hip weakness and lack of hip control, very often standard old kneecap pain, housemaid’s knee or very common teenage girl malady where your knees track a little abnormally and get pain in the front of the knee, hip strengthening can make a huge difference in those symptoms. It’s just one example of how knee bones are connected to the hip bone, et cetera.
Lisa: What I’ve noticed in my own experience with physical therapy and other modalities is that orthopedics and sports medicine have increasingly been borrowing from various other practices. The physical therapist I had seen it’s not just exercises. It’s not just flexibility work. She’s actually doing some hands on manipulation of my joint. This is interesting that there has been this evolution that you’re able to say oh, this works over here so let’s bring it in and use it over here to get the patient better.
Linc: Yeah. I’ve seen that as well that the good therapists now are very hands on and it seems to make a difference. It makes a difference in terms of appropriate mobility of all the tissues and a complicated joint. It makes a difference in terms of flexibility preventing injury. It makes a difference in terms of particularly for me a surgeon the cases that I send to a physical therapist they’re at risk for scar tissue. Scar tissue very often can be prevented by a knowledgeable physical therapist that can sense when that’s working, when it’s happening and loosen that up with hands on work and there’s a whole subculture of … There are all these semi-medieval smooth metal tools that are used to really literally distend and stretch some of these tissues very aggressively.
That is a real science and it’s made a real difference particularly with soft tissue injuries like IT band tendonitis which is a common running malady, the kneecap we talked about Achilles tendonitis, et cetera, et cetera. Yes, I think that certainly is a field that has grown within the culture of physical therapists.
Lisa: They’re also using things like ultrasound and electrical current. It’s really been amazing to see what types of things are being brought in to accelerate tissue healing, which is different than I guess when I was first a medical student, the whole idea was RICE. It was rest, ice, compression and elevation. Some of which seems like it still works in some situations but not always and not in every situation.
Linc: Yeah. I mean that’s the mantra for an acute injury but 10 days later, okay, where do we go from here? RICE isn’t really going to be as helpful for that. Again, that’s where a good therapist can be invaluable in terms of recognizing how hard to push a patient, what’s a good pain, what’s a bad pain, what mobility is going to be a step forward and what pushing and pain mobility is going to create enough pain and inflammation that’s a step backwards and going to lead to scar tissue for example.
It’s a tremendous art. I don’t really understand how they do it as well as they do it and I really appreciate it just because it is a little bit of a mystery to me. I can tell you that there are a number of really qualified people in this town and in this state that make a huge difference in terms of you take the same patient with the same malady or the same surgery and you can get totally 180 degree different results based on how they’re treated in recovery.
I’m a huge utilizer of physical therapy. I know there’s doctors that with routine, for example, knee arthroscopies, they’ll give the patient some home exercises and off they go and they never see them again and some of us should be able to do great. I get to see the people that didn’t do great who come to me and say, “Hey, what happened?” I find just anecdotally and in my own experience that PT is invaluable.
Lisa: I have two siblings that went into orthopedics which, of course, you know I have nine brothers and sisters and many of us are doctors but two of them happen to be orthopedic doctors which I find fascinating because one is a shoulder specialist and one is doing a sports medicine fellowship.
It’s a remarkably difficult field to actually get into. It is a very competitive field and it’s just blown up over the last, I would say, 20 years or so.
Linc: Certainly, in the last 10 years. I mean it’s been so popular that therefore, it’s become so competitive. The good part for me being on the other side that I’m in, it is some tremendously qualified people are making it through and really bringing a depth of knowledge and integrity which is really nice to see. Sports as I said earlier are much more ubiquitous now it seems, particularly through the ages, younger patients but also older patients. You can kid and say weekend warriors or whatever but people who are doing more activities much later into their life and this all part of sports medicine and so it’s easy to understand the appeal.
Lisa: What was your appeal?
Linc: The greatest satisfaction for me, number one, I understood it because I was an athlete or I’m still sort of an athlete but more importantly, the satisfaction of helping people, getting somebody back into the level of competition or even at a higher level than they were before they’re injured or before they develop symptoms, the smile on that person’s face, a shake of the hand at the final visit and the gratefulness. That’s what makes me go to work every morning.
Lisa: You describe yourself as was an athlete. Maybe you still are an athlete. What was your past and what is your present?
Linc: I was a big skier. I was a collegiate ski racer, winter time was important for me but all that … I was … baseball, football. I did a lot of cycling and some of these things that have just taken … I’m still active with skiing and ski patrol and things like that but obviously, I’ve got a real job so I can’t do it anywhere nearly as much as I want to and I probably need to.
Lisa: You also have worked with the US Ski Team?
Linc: I do.
Lisa: Tell me what that’s like to be living here in Maine and also working with the US Ski Team. What types of … Well, first of all, are there different injuries at a lower level than there are at a higher level of competition?
Linc: That’s a complex answer and again, I’ve seen some huge … I’ve been traveling with the US Ski Team since 1989 and the level of science has increased to the point that these athletes are just in tremendous shape when they used to be just getting in shape by skiing. I’m exaggerating a little bit but the conditioning, the workout, they’re working year round, they take it seriously, you don’t have to tell them at the end of the day and we’ve been up in the hill for six hours.
They then go to gym and lift and just incredibly motivated and in incredibly good shape. Male and female across the board, there’s been a huge increase in interest in that and that’s frankly why the US has been such a power in skiing in the last decade. There’ve been some real stars that have worked through the science of performance in terms of skiing-specific conditioning and it’s been fun to watch that.
The problem with that is they’re now competing at such a high level of speed and efficiency that when they do get hurt, when they do crash, it’s usually a bad one.
Lisa: We’ve also had some success with Olympians coming from our state which is interesting considering that we have a relatively small population and we’re relatively high up on the coast. What do you attribute that to?
Linc: With skiing obviously, the mountains, so that’s an easy one. There’s a lot of exposure. Skiing is difficult in the east, a lot of ice, a lot of conditions. They’re very similar to what racing is like all the time so we’ve seen a lot of New Englanders. Currently, there’s a girl from New Hampshire on the team, Kirsten Clark was from Raymond, Maine who you may be referring to. I think part of that is just being exposed to some really good performance-related mountains locally.
It depends on the sport. You take a summer sport like baseball, we have a hard time with that versus teams that are playing 365 outside down in Florida all year but the winter sports I think we tend to do well, water sports we tend to do well. Then in the indoor sports, it’s a wash.
Lisa: I remember when we brought Julia Clukey and I interviewed her, she essentially was alone in her sport. She came down and did a tryout thing here in Portland for the luge and she got the bug and she really had to be very independent and go off and her family supported her and basically, this became her life.
I wonder if there’s also some work ethic that also Maine is familiar with that even if you’re not, you don’t have a big mountain of skiers to ski with you but maybe there’s some frame of mind.
Linc: I think that may be true. New Englanders tend to be just because you’re dealing with adversity and weather and conditions, there’s a little bit of a chin up hardness to drive that but I do see that the whole family commitment that you referred to, that it’s not just the athlete. It’s the whole family saying, okay, we all need to get behind you and make this thing happen, not just financially but in terms of emotional support and time and every weekend going to tournaments or going to this, this and there.
I think that that’s some of the Maine spirit, the family unity and the sense of really protecting what’s around you and trying to achieve your goals.
Lisa: You’ve been in the business for how long now?
Linc: A long time.
Lisa: A long time, okay, good. We’ll go with that and you’ll probably be in the business maybe another?
Linc: Another 10 years anyway.
Lisa: Ten years anyway.
Linc: God willing, yup.
Lisa: What do you hope to see happen over that period of time?
Linc: In terms of what?
Lisa: Well, I guess you can answer the question anyway you want. I was thinking about sports medicine but how do you hope that things will move along?
Linc: Well, my first response to that is okay, what about in my field? It’s just so much exciting research is going on with what we call biologics where you’re recreating structures either through stem cells or viral engineering. Instead of us using, for example, a cadaver graft to replace an ACL, using a form of silk that is then impregnated with a virally engineered collagen-producing virus. You make an ACL without having to rob Peter to pay Paul that oh, by the way, it’s stronger than a native ACL and has all better qualities. Meniscal transplants right now are all we have to try to replace the meniscus but in the lab there are sponge scaffolds that can be impregnated again with the appropriate cells to grow a meniscus within that structure.
I would not be surprised that in the next 20 years, just as we’ve seen in cardiology where things have got progressively less invasive that who knows, I mean there may be a shot that you get to create a new ACL, regrow joint surface, total joint replacements may be a thing of the past. This is where all the really exciting stuff is in terms of my field.
Lisa: I’m hoping that my brother and my sister, the orthopedic surgeons, will be able to put a few more years in after you’re done and we’ll see some of those changes take place.
Linc: I’m sure they will.
Lisa: Linc, how can people find out about the work that you’re doing with Maine Medical Partners Orthopedics and Sports Medicine?
Linc: Maine Medical Center has a website, obviously, where we’re listed. We’re everywhere. I mean we’re on the sidelines covering games. We’re doing performance labs. We’re setting up a concussion clinics so there’s all sorts of resources that are available to high school kids and colleges very easily but certainly, the website or a good old phonebook and Google can do it.
Lisa: I appreciate the time that you’ve taken to come in and talk to us about sports medicine and the work that you’re doing. I especially appreciate the work that you did on my knee because I will say, this was a cartilage transplant so this was no easy and short fix. This was something you and I worked on together over the course of maybe two months I think.
Linc: It was unique. You were the first person I remember that we did as an outpatient so it was usually a two or three days stay in the hospital. You did great.
Lisa: Well, so did you and I’m not limping so that’s good. We’ve been speaking with Dr. Lincoln Avery who is an orthopedic surgeon at Maine Medical Partners Orthopedics and Sports Medicine, also the division leader over there. Thanks so much for keeping us all active and healthy here in the state of Maine.
Linc: Thank you Lisa for having me.