Jared Poweell: Bill Vicenzino. Welcome to the show man.
Bill Vicenzino: Oh, well done, thank you very much. We're always off to a good start when you get my surname right well done. Thank you very much.
Bill Vicenzino: Thanks. Thanks. Thanks for thanks for inviting me on for a chat over this interesting condition. hopefully, there's something for
the audience. You know, for them. And yeah, thanks very much that it's a very interesting topic. I think we've had this chat offline that we're both kind of pretty excited about having a bit of an natter over. We've both got experiences from treating people with it. So let's go.
Jared Powell: Yeah. So the the condition of interest is is patellofemoral pain. But before we get into it, Bill. who are you, mate? For all the
for the 3 people that don't know who you are. Who are you? And what do you do, Bill?
Bill Vicenzino: I'm an old physiotherapy professor is about to retire, so entering my 60 fifth year. So I graduated as a Physio at the University of Queensland in 1990. A lot of you weren't born then, and over the next 10 years I worked in private practice, but in hospital, mainly in private practice, and did my sports and musculoskeletal post graduate degrees at Curtin in Perth, which was a very
a very good experience, one I'd recommend to other people. That was about 10 years of that. We had a 2 children over there and had a practice, and then we decided to come back with family on Brisbane, where I worked some locums. And
Bill Vicenzino: then.
Bill Vicenzino: yeah, I started off as a clinical tutor down in the clinic at Uq. Seeing patients teaching students did some lectures, and before long I was well, Lance to me, and curtain with my appetite for research. And then tony Wright, who became my supervisor and Gwen Joe were really keen to progress Phds and research. And so I was wanna one of their Phd students. Tony Wright's Phd student did that while I worked. And
Bill Vicenzino: then I basically promoted through the ranks in 2,000. I got my Ph d.
Bill Vicenzino: Not long after that II had a rapid promotion, because I was very lucky and
Bill Vicenzino: unfortunate that I could win grants successfully. One of the grants that I got was an individual grant of telephone pain and philophosis which we'll talk about and I've I've got interest in Tennessee. And oh, later, Lepro, but tending off the generally, there's there's a lot of my papers in that area.
Bill Vicenzino: I would have never dreamed I was talking to students that started up with the Masters program the other day. We're talking about where we're going to, where we've come from. And I reflected that I would never have dreamed I was in that position in that classroom talking to my last class for a semester
Bill Vicenzino: as a professor of physiotherapy, having had such wonderful collaborations with, many, many of our leading experts in our field. So yeah.
Bill Vicenzino: my message to anyone is is, yeah. Heavy. 5, 10 year plan. But it can go many, many places you wouldn't dream of. So I'm I'm rambling on a bit. I'm sorry about that, so II find myself now as a professor of sports physiotherapy at the University of Queensland. I'm a director of the Masters physiotherapy program. And I have a Phd students, research programs, etc., etc., which you'd expect for an academic.
Not unfortunately, last decade is so less and less clinical contact. As other administrative duties take over. And I just get too old. And I need a bit more sleep.
Jared Powell: Yeah relatable mate. No, if
Jared Powell: you've I can speak for a lot of people when I say that. you know we've all come through reading your work and congratulations on the career that you've had. Bill. You've been a wonderful contributor to the profession, so
Jared Powell: I'll have a drink on behalf of you. What is it? Thursday today? Tomorrow? Not Bill. I can't drink till Friday. I'll have a little sip of beer tomorrow, not in in toast to to your marvelous career, mate.
Bill Vicenzino: Thank you very much. Thank you very much. Yes, it it is. It is a. It has been a privilege, and it's also a great learning experience to work with a lot of physiotherapists, physiotherapy students and graduates. So very bright people. So
Jared Powell: yeah, I've probably learned more than I've taught. So yep, thanks. That's how you. That's how you say you want to be. Yeah. You always want to be in a room where you're not the smartest person I think I know I know exactly what. Well, some of the people I've collaborated with I'm definitely learning. And yeah, and it doesn't matter how smart you, I think
Bill Vicenzino: reflection and learning a lot more than being smart. Yeah. Anyway, that's probably another podcast working, just wax on and everyone go to sleep. Let's get to the point here. So
Jared Powell: So the point the point is, Bill, you're the number 3 expert, according to expertscape, on patellofemoral pain, and you're the number 2 expert, according to expertscape on tennis elbow. Lateral epicondylalgia or whatever you wanna call it. And you've got a h index of a ridiculous 93, which is absurd really to be nearing the triple figures. So
Jared Powell: Congratulations, mate again.
Bill Vicenzino: Yeah, I don't follow my h-index. So a lot of that stuff. But so thanks for that. I haven't looked at up for ages. I haven't had to put in for promotion documents, anything we need that shit. The the and you forgot to mention in tendinopathy. I think I'm number 3. I was number one for tennis elbow. But Luke Heels up at up the coast. They near you is taking that off me. We collaborate a lot, so I don't know how he sneaked ahead.
Bill Vicenzino: The good thing to the good thing, probably, for your audience is that the number one and 2 for ptellofemoral pain is Michael Rathleff number one, we? We collaborate still collaborate quite a lot about on this condition. And
Bill Vicenzino: and I think Christian Barton is probably the other person up there. He's also someone we collaborate with. So I've I've kind of got an insight into their mind. So hopefully we can. We can give some but no, hopefully it's top level
Jared Powell: it will be man, it will be. Don't worry. So on patellophemeral pain. Let's let's go right to the start
Jared Powell: in terms of diagnostic label. What do we call this thing? Is it patell, ephemeral pain? Is it anterior knee, pain, knee, cap, pain, patellophemeral pain, syndrome?
Jared Powell: What do we call the thing? Is syndrome. A a banished word these days. What's the what's the preferred label?
Bill Vicenzino: What is in a name, When I graduate is Chondromalacia patellae a. But we've pretty much moved away from that because you couldn't visualize. Well, Chondromalacia patellae are just fancy way of saying soft
Bill Vicenzino: cottage at the Patella. We moved away from that, saying, well, if you don't visualize it, you can't say that we almost come full circle and recognize that probably the subcontrol bone. Is
Bill Vicenzino: anything on the patella going to be sensitive? It's going to be underneath the
Bill Vicenzino: cartilage surface, and for it to be provoked. It probably needs to have softening of the cartilage, but we call it, I think, quite fairly patellofemoral pain, I mean, if you've done a scope, and you've poked the cartilage and it's soft, and you can see the fishery. Well, you're probably okay to call it Chondromalacia patellae. That's a surgical thing. But telephony syndrome. We use syndrome for a long time, because
Bill Vicenzino: I don't know. Maybe it just makes it sound like a medical term and important, but I'm not never too sure why we called it syndrome, or why we call a lot of things syndrome. So we elected to call it patellofemoral pain. That's a consensus type thing. It takes away any ambiguity.
Bill Vicenzino: yeah, diagnostically. There's nothing fancy about it. Spine at the anterior part of your knee around the knee, cap.
You know it's it's provoked by things that load your patellofemoral joints. So squatting stairs up and down sustained sitting may in pro in later stages. But essentially it's activities that load the patellofemoral joint
Bill Vicenzino: And this pain that pain is at the interior knee joint.
Bill Vicenzino: Now you need to have some.
Bill Vicenzino: You need to be a bit careful on examining, to make sure that it's you know that it's not the patella tend and the fat pad, and
Bill Vicenzino: and you know you've got a myriad other things down at the patel attendant at the table. Tuberosity as well. So
Bill Vicenzino: you need to. You need to differentially diagnose. You need to knock out those things set up probably more obvious. So acute injuries. It's generally
Bill Vicenzino: we consider it as a non acute injury. You know an overuse type injury.
Bill Vicenzino: So there's no acute inciting event.
Bill Vicenzino: So you rule out ligamentous instability miniscule issues. If you came clinically and I guess minuscule issues come with a different presentation.
Bill Vicenzino: I like to think of it just stepping back a bit. So that's patellofemoral from paying the consensus statement is paying around the knee cap
Bill Vicenzino: loading the patellofemoral joint
Bill Vicenzino: creates the pain. And you've excluded. You've excluded other potential sources will need pain. Yeah, yeah, so that that's kind of how we'd go about it. I like to think of it as a
Bill Vicenzino: probably a knee extensor disorder. And so there's a myriad of those, and when you come to managing them they're probably not managed that much differently. There's some nuances, but you pick them up on testing patients ability to manage that extensive mechanism. So of the need. So anyway, digressing a bit. But we probably come back to that to treatment. But yeah, patellofemoral, pretty simple clinical diagnosis. There's none of the things that have been. You know, the special test that have come about the grinding and the I've even forgotten the name for now. But Clark,
Jared Powell: Clark's test.
Bill Vicenzino: Yeah. Clarks test. Yes, that's it. Yeah. Those those are not helpful at all.
Jared Powell: People have studied the capacity barrack to Bill. Do do that damrod in the face, and II fully back them into do that.
Bill Vicenzino: and if you want to overdose the condition cause. That's a condition you can treat. Well. Go ahead.
Jared Powell: Just in preparing. I left all my homework pretty light, Bill. I had a look at Michael Ross's
Jared Powell: rath lifts work today, and he's got this nice little modified single leg squat for 45 seconds
Jared Powell: that you hold in 60 degrees knee flexion. And if you, if you get pain
Jared Powell: within that in 45 s, it's a pretty good diagnostic tech test for anterior knee pain. Not so much patellofemoral pain, specifically, so really easy to sort of doing. Clinic.
Bill Vicenzino: Yeah, yeah, that yeah, he his population. He had a great. He's he did a great for his Ph. D. He just got a group of students, adolescents, and quite a few of them, and follow them. And so, because it was done by distance. Couldn't examine all of them. Some of them got examined when they got into your knee pine. But yeah, they refer to anterior and Knee pain. And in this group it can be a number of different things that are that are going on there. But patellofemoral
Bill Vicenzino: when I did, the diagnostics on subgroups. patellofemoral pain seems to be the one that's most common and that yeah, that it's it's a really great way of provoking. The extensive mechanism. And yes. That that test. I think they use that more as an outcome measure. Like to see whether you've improved. But
Jared Powell: yeah, and it does. It does differentiate. Well, I think you found between people with and without anterior knee pain. But it's just a for me. It just seems a lot more
Jared Powell: real world test versus compressing someone's patella in soup on saying, Does that hurt cause? Mine would hurt right now?
Bill Vicenzino: Well, when they toured it in the undergraduate because we did it way back. Then. Everyone's Nick have hurt and g10, I don't have the patellofemoral. Yeah, back then.
Jared Powell: Yeah, this this specificity must be anyway. So so patellofemoral pain, we're happy with that
Jared Powell: clinical testing. There's a bunch of things we can do, but it's mainly affected by a squat or any low to the femoral joint. What about
Jared Powell: pathophysiology? Actually, before we get into Pathophys Bill? I want to talk about natural course of the condition or natural history of the condition if we were to. If we were to leave someone who comes in with patellofemoral pain, and we just say, just
Jared Powell: don't worry about it. Continue on doing what you want to do to avoid things that hurt, do things that feel good. Will they get better in time, or will they? Will they suffer with pain for years?
Bill Vicenzino: Yeah. It. It's unfortunate on a nice natural history. There's a number of studies, some old ones, and some more recent ones, that you can expect one in 4 people that have had this pain, and as an adolescent, to have significant problems. A lot more have ongoing issues that they can manage, but significant problems in about 25% of people.
Bill Vicenzino: So it's probably not fair for the Gp. All the physio. Any healthcare practitioners say it's self limiting. You know it's it can come as part of this growing pain scenario in a young child.
And it's probably not wise to say it's it's naturally
Bill Vicenzino: I'm going to resolve by itself. because there's a high probability it won't so something needs to be done about. We do know that the longer you've had it the more severe it is.
Bill Vicenzino: They're prognostic factors.
Bill Vicenzino: poor prognostic factors that you it's going to be around for a lot longer, and it's going to be a lot more severe than notice that.
Bill Vicenzino: haven't had a severe pain for shorter durations. Yeah.
Jared Powell: yeah. The troubling the study that I am aware of was that if you're an adolescent
Jared Powell: and you're diagnosed with patellofemoral pain, there's a strong chance. You're still going to have pain 2 years later, and then, as you mentioned as you alluded to, there's a strong chance. They're going to have pain, one in 4 people into their 40 s. As well. And that's a
Jared Powell: that's a really troubling conversation to have with a teenager.
Bill Vicenzino: Yeah, yeah, yes. Well, it's something that you want to never navigate pretty carefully, because.
Bill Vicenzino: unfortunately, there are a lot of things that we can get onto knee extension as next size later on. But there are a lot of things that propagated by
Bill Vicenzino: general population, and I'll tell you an experience I had in the gym in wanica New Zealand late last year. But
Bill Vicenzino: th, you know, there's a lot propagated. So you gotta be careful how you bring that up. You should. Yeah, I I'd recommend bringing up in light of this is something that you know. Learning how to manage. This is is going to be very good for you in the long term, because it's gonna be that kind of a
Bill Vicenzino: adventure for people that have this rather than talking about cures or not cures. Yeah, we do know when we get to treatment that there are some good treatments over 3 months that can get quite good success rates in in that shortish mid term.
Jared Powell: Yeah, you you've had patellofemoral pain. I've had it as well. I've had it on and off for 15 years, and
Jared Powell: it afflicts me for 6 weeks or back things off. Stop squatting. Do some, some of this, some of that stop running, do more bike.
Jared Powell: And then, 6 weeks later, I'm usually better again. So whilst it may be recurrent in nature, it doesn't seem to be getting worse to me. Each episode seems to pass without too much fuss. And so you can manage.
Bill Vicenzino: It's a classic. It's one of the classic, you know. It's a bit like tendons and middle age. This boom bust type thing, you know. Yeah,
Bill Vicenzino: you. We're all busy, and so you get excise in when you can, and then you don't. And then all of a sudden, you have time, and you know you learn to moderate it. You learn to identify. So you don't really hurt yourself badly. And and then you go again. Yeah.
Jared Powell: so what's underpinning it all, Bill, what's what's causing the pain? What are the what are the mechanisms that play? Is it a classic nosey, septic type of pain. Is there a nosey plastic element? Is there something structural that we need to be aware of? Are there psychological factors at role in terms of moderating outcomes, or or perpetuating the course of the condition. Where are we at? Do we know? Do we not know?
Jared Powell: Tell me, mate, tell me you're the oracle. You're the sage.
Bill Vicenzino: It's a answer easy question to answer. Yes. Still, leave up. Totally. Yeah. Okay. So
Bill Vicenzino: so no, deceptively, there are some very pain sensitive structures. Scott died, got his brother to athletic surgeons, got his brother to probe without an anesthetic through enough scope. Probi's knee.
Bill Vicenzino: no pain at all at the patella's surface, maybe a little bit of sensation on the femoral condyle.
Bill Vicenzino: So now, if you yeah, that's starting to get discomfortable. But the fat pad. Yeah, he was swearing. He was saying. Apparently there's a video of it at a conference that I that I got told about that where he was quite unhappy about being probe there. So locally. There are tissues around the patellofemoral joint, and don't forget we talk about Patel. But the the femoral surface, the femal condyle is not uncommonly the one that's got
Bill Vicenzino: degenerative or osteo. 3 changes in it. And so you know the tissues around the snow, even in the fat pad, tend to be the ones that get sensitized.
Bill Vicenzino: yeah. And then the subcontrol bone, which I didn't pro. But we do know through imaging that you do get. You know that bone bruising. You get that hyper signal in that area which denotes that there's increased activity, likely increase pressure, and no susceptors. A stimuli. So there are reasons why you can have. There are no susceptive reasons there pain, sensitive structures that could be signalling off pain.
Bill Vicenzino: probably, if you if I looked back
Bill Vicenzino: and look at all the literature. And there's been, and we we doing a scoping review on this. We were looking at all the qualitative data as well.
Bill Vicenzino: I'd say I'm gonna go way to the other side of things. And the social context, which not surprisingly because we're looking at adolescent to the early adulthood, the social context comes up a lot when we start asking people about this problem, this condition, and how it affects them.
Bill Vicenzino: You know, from having to care for others. And they've got the problem so they can't do exercises, and they can't bend or go up and downstairs to the child that wants to, you know. Be part of the peer group and do the sport and can't keep up. And things like that.
Bill Vicenzino: Th that comes up so many times that II think so. We we talk about psycho social. But I think we should be talking so show psycho the social aspects of it. Are something that comes up
Bill Vicenzino: time and time again, these qualitative interviews, all these focus groups that you read about the in the papers and the ones we've done ourselves. So you've got local notceptive drivers for sure. And we know almost all these conditions are brought on by a bout of overload
Bill Vicenzino: But why so long? Well, we've got to look at the social context within which they exist which is not uncommon for a lot of other conditions like back pain, you know, will thinking like that now.
Bill Vicenzino: in terms of pain mechanisms. You know, we do have some studies that show there's local sensitization mechanically, and some that show there are remote, and so therefore widespread sensitization. But that's not
Bill Vicenzino: uniform. I mean, we've done some studies where we were unable to find it. When we blinded the examiner we were unable to to actually find remote sensitization. So
Bill Vicenzino: I'm wary of saying that it's
Bill Vicenzino: it's, you know, that central nervous system processing is gone awry
Bill Vicenzino: as a statement for patella thermal pain patients. So I and a lot more work needs to be done on that. We did a consensus statement where I think the the research has decided, more research needs to be done on that. We're not too sure what it means. Clinically, patients didn't think
Bill Vicenzino: much of it at all. Actually, I didn't. I didn't the patient to into we interviewed? Yeah, or did they do surveys? They? They didn't think much of that.
Bill Vicenzino: they are more interested in and and clinically, things like pain, self efficacy from me. Memory, Kinesi phobia. You know, those kind of psychological construct that we are becoming more aware of in in a muscular skill, conditions that tend to be perpetuated. So like
Bill Vicenzino: this, the quick answer would have been for me to say, we don't know, and I've done giving you a long answer, said that we might know some little insights for some patients, but I don't think anyone could stand up and say we know exactly
Bill Vicenzino: why this problem exists. Well, why it exists may not be as difficult in the first
Bill Vicenzino: little while, maybe 6 months a year, but as it progresses out, it's more complicated.
Jared Powell: Hmm, so yeah, that's that's my impression to the social stuff that you mentioned is is fascinating. That seems to be important. That seems to be the best thing or the the thing that we seem to neglect the most in in healthcare, which is which is something that I've I've found that the context, the environment, the social aspects, and the psychological all of it. Let's say psycho, social, socio, psychological. It's
Jared Powell: it's
Jared Powell: I know it's fashionable to say that it's important, and I sort of I feel like I'm making a bit of a meme out of myself when I do say it, but it does seem to come up every single time you dig into the literature, and II fully grant that there's probably a no susceptive process going on there, certainly, initially. But and maybe it turns into a no see plastic type condition when there's some aberrant firing of of no exception, even in the absence of
Jared Powell: any structural damage. But there's got to be some sort of psychological social. moderating role. The
Bill Vicenzino: yeah, yeah, I, yeah, that has to be. Yeah, we did a lot better than I did in a short of time. Yes,
Bill Vicenzino: I don't think if too far off the off the point there. I think a lot more work needs to be done to understand fully. And when it comes to management.
Bill Vicenzino: yeah, you look at the local. But you really do have to consider like when you prescribe exercise, you need to know the context. I mean, when we're when we are looking at a a futures workshop where we had some patients in the room that were mums had kids, and we had vignettes which they talked about, and we gave some of the vignettes in our child, and they they had to work, and they had to look after the house, and the husband had 2 jobs, etc., etc.
Bill Vicenzino: You know it comes up that. Well, when do you do exercises and etc., etc.? How do you still have to run around up and down the stairs in the house, and etc., etc. So
Bill Vicenzino: you know, even if we're dealing with the local
Bill Vicenzino: muscle and whatever you want to do locally. You do have to consider the rest of it because it it's not in isolation. Not an isolation door. And invariably you'll probably give these people exercises. If you, if you aiming to do a decent job like I said, it's an extensive mechanism mechanism, disorder.
Bill Vicenzino: The extension mechanism will not be good it'll be it'll it'll be in need of some work. Exercise will do that. Well, you you need to structure your program so that people can do it. So when and where and how? Yeah.
Jared Powell: yeah, that speaks to exercise burden. And that's that's another big, big, big interest that I have where we. We have this
Jared Powell: preconceived bias. To think that sort of more is better. And we just there's this dose response relationship between alright, if I just give you 10 exercises. You'll get stronger quickly, and you'll get better, quicker
Jared Powell: kind of not as simple as that. Look. We'll get into treatment in a in a minute. I'm gonna I'm gonna shelve that for just for 1 s, because we're gonna get sidetracked, Bill. But I wanna try and anchor anchor us to these talking points, because they're very, very important that I pick your brain on every single topic. Path of physiology. So I wanna talk about the old school. I'm saying this in inverted commas, old school.
Jared Powell: lateral tracking of the patella, the weak vmo, the tight itb. So this is stuff when I say, old school. This was still current and in vogue when I graduated 13 years ago.
Jared Powell: which is a while ago. But it's not, you know. It's not the 1,900 eightys bill like like someone else here. So
Jared Powell: where are we at with lateral tracking of the patella? Is it a plausible pathophysiological mechanism of injury? Or is it completely being thrown in the bin? Where are we at?
Bill Vicenzino: Hmm, okay, where are we? So probably for the audience in British Sportsmans, and 2017 Chris Powell's, and a group from the Patel Female con International Consensus group
Bill Vicenzino: put together over a number of retreats, a flow chart on the pathobiome mechanical aspects of this condition.
Now
Bill Vicenzino: this.
Bill Vicenzino: almost all the literature is cross, sectional. So very little of this is longitude, and so we don't know whether it's causative or just something that's there anyway.
Bill Vicenzino: And the other thing is is that
Bill Vicenzino: in joined in that is that we don't quite have that last link between elevated patella thermal joint loading which could be due due to increased telephone joint reaction forces and or decrease the telephone or joint contact area. Those 2 things seem to be at play with the telephone. When you look at cross sectional studies that elevate to telephone or joint loading in the cart, which and bind stress that goes with that.
Bill Vicenzino: But then the leap to pain is is a leap. It's like, because we've done cross sectional studies, you know. We can only say they're different on that elevated telephone joint loading.
Bill Vicenzino: We'll go down deeper into the Patella firm will join line. That's the dec the decrease pitel firm will join contact area. Chris put together. What's kind of a nice way of looking at it. So the contact areas where you think about those things like, you know, tracking due to muscle, imbalance.
Bill Vicenzino: excessive rotation. So the Feamer and Tivia, you know, written acular tightness. So wheel looseness, you know, Admiral Patel firm, join anatomy, shallow grooves, etc. They may lead to mail tracking or mel alignment, but in any event it's
Bill Vicenzino: possible they lead to, you know, reduce contact area compared to
Bill Vicenzino: those that don't have the telephone pain.
Bill Vicenzino: Then if you go to react joint reaction force as well in adults. There seems to be some differences in hip kinematics.
Bill Vicenzino: I don't believe so. III don't follow this research, but I do. They are. There is a smack review that says there are some
Bill Vicenzino: foot changes that are different in those with telephony pain than not.
Bill Vicenzino: And then you got reaction forces measured through kinematic studies. And all those infer react, increased telephone joint reaction forces.
Bill Vicenzino: And so you know, it's kind of if you look at the model he's got. That's kind of nicely laid out, the biggest
Bill Vicenzino: and we had. We had quite an argument over this. The biggest contentious issue is at the top. It's an arrow to patellofemoral pain. and I argue it should not be that it. It's kind of like
Bill Vicenzino: should be a.
Bill Vicenzino: This elevator. Joint loading is different in these people and these people, which which is different to saying it.
Bill Vicenzino: it links to. Yeah. So so in a roundabout way, I it's it's it's not impossible. It is impossible to measure muscle imbalance in the clinic. You know you can't feel it. The Mg. Like in a lab measuring in the lab. You need to have really high skills. Do it properly and to pick it up. You know.
Bill Vicenzino: laxity of tissues. Well, we're not talking of unstable joints. We're not talking about a dislocating patella, which is a different thing. We're talking about. People got paternal pain. They're stable joints.
Bill Vicenzino: you know, being able to quantify that that the patellas out of place, whether it's tied on one side? Not you know. If anyone yeah, you just couldn't give credence that it's plausible. They would be reliable and valid markers clinically. So I think if it does exist, we can't measure it. So
Bill Vicenzino: You know, I tend to.
Bill Vicenzino: II tend to sit on the fence, you know. I mean, if you had a measure that you knew
Bill Vicenzino: could measure it even in a laboratory, and you could show that it was causative.
Bill Vicenzino: That's one thing. You've got the measure that can do that. But I'm not convinced we got the measure to do it, so we can't say that it doesn't happen
Bill Vicenzino: because we don't have the measure. That's valid enough to show that it might happen
Bill Vicenzino: so.
Bill Vicenzino: It's probably not wise to think of it as maltracking malalignment. And the interesting thing is, when we talked to patients with the telephone pain we asked them to. We had a draft for Mark Matthew's study, a draft advice brochure, and asked them to give us feedback on it. We had such Nosycev nocebic
Bill Vicenzino: information on that, like, you know, we talked about maltracking. We talked about increased pressures, and that. And the patients just said, Oh.
Bill Vicenzino: do you really think so we step back and get, oh, shit! We didn't have that written in there. We we basically just taken the best of everyone else's right as a draft to it was, where do you go? You look at what everyone else is publishing, so all will fashion this up into this 2, sided I, full fold up. Bro, that we're going to give everyone that's yeah bit of education. So they know about their condition. So yeah, you you need to be a bit careful about how you present this material.
Bill Vicenzino: To people. Because I hook on yeah, we want to hook onto something. We want to hook on that onto. You know, we want hook onto this little part of my body is not right. And so we need to fix that because that that gives you a focus that gives you some. Yeah, some focus, some reason.
Bill Vicenzino: And that's okay, if you can validly say that. But
Bill Vicenzino: but if you don't, if you can't vitally say it, then you're giving someone some really false ideas which there is no solution. So you've already set them up to fail so very cautious about
Bill Vicenzino: after my experiences in focus groups and and and in my own experience of my taking my daughter software specialist and and myself very careful about how you say stuff to people, and therefore, yeah, so
Bill Vicenzino: do we know that it's there or not? It's very hard to say whether it's there or not. Now, tracking, that is lateral deviation. And maybe we shouldn't
Bill Vicenzino: it? We shouldn't say that we shouldn't accept it as a fact.
Jared Powell: Yeah, more work to be done, a lot more work by the sounds of it. So it does seem to afflict
Jared Powell: patellofemoral pain afflicts females more than males. So
Jared Powell: you know, it's not beyond the realms of of possibility to think that there is some anatomical
Jared Powell: underpinning. You know, the Q angle of emails is famously greater than in than in males which might lead to some sort of
Jared Powell: issue at the Patella femoral joint. So I think it's plausible to think that there, there may be some sort of
Jared Powell: the telephone rule, force type issue that's underpinning the development of pain. But, as you said, we don't, we don't. That's all speculative, right? It's all conjectural knowledge. At this point we don't have anything to say whether it is definitively
Jared Powell: this that's causing the pain or or isn't causing the pain.
Bill Vicenzino: Yeah, you raise a good point, I mean, I think, back to my early days and clinic in the mid eighties and
Bill Vicenzino: there's there's a different, definite phenotype. There's a definite like, it's generally female, it's generally adolescent. It generally comes with the knock knees or the or flat feet. It's it's a perception in my brain that's very kind of consolidated, because that was my experience, and I don't think it's a an unusual experience. I think the issue
Bill Vicenzino: becomes when we then take that phenotype and then try to make some theories about why they're manifesting pain.
Bill Vicenzino: I think that is where we run into strife in the business. It's okay to say you've got that phenotype. So I'm gonna predict you might have this kind of presentation pain wise and that might help us. Now, you know, making some apologies when you first see the person start asking some questions, but we gotta be careful not to jump.
Bill Vicenzino: you know, to wanting to correct them as the sole way in which we're going to address this before, you know, doing further examination and being careful about going down a slippery slope.
Jared Powell: Do you have any theories, Bill? Of? Why, females are more afflicted?
Bill Vicenzino: No,
Bill Vicenzino: no. And as you mentioned this, I should've looked up some of the research.
Bill Vicenzino: somewhere in the back of my mind. I think females tend to be weaker at the hips than males.
Bill Vicenzino: But correcting that doesn't, doesn't correlate with correcting the telephone pain from memory. Don't quote me on that.
Bill Vicenzino: No, I don't have a theory. Why, it's more than females and males. It's just an observation. Maybe it is because of the
Bill Vicenzino: the alignment issue. And pelvis. One thing, I wondered, though there there is this thing, though, generally speaking.
Bill Vicenzino: women like in the eighties, even women were not, and young girls were not.
Bill Vicenzino: We're not given the same.
Bill Vicenzino: They they weren't. They weren't as active physically, and that, you know, come to menstruation and that and development. They kind of withdrew a lot more and didn't keep on
Bill Vicenzino: active participation as a group, you know, there's some that did. But and so I wonder whether you know now, with the equal
Bill Vicenzino: opportunity or increasing opportunity to stay active and be active and be strong, and and all that stuff, and and being less of a gender bias, and that. I wonder if it's I wonder if that in the end shows us
Bill Vicenzino: something, you know, decades to come.
Bill Vicenzino: whether things get worse or better due to just physical conditioning and exposure. You know, graduated levels as you're growing and developing. So I that's an interesting question. I haven't really given that much thought.
Bill Vicenzino: I should have but it's an observation, and it's held up in literature that women especially. Females! Adolescents are more prone to this, you recruit for studies, and it's easily you're going to get higher proportions of of of females or women. In in in your cohort.
Jared Powell: Yeah, it's I think it's 4 to one in terms of the the prevalence, which is, which is high. You know, we're both happy. So like it doesn't affect males as well. But it it is interesting, and it's something to think about in terms of what is there underpinning that that development of Patel family?
Bill Vicenzino: It's it's interesting because I I've got a clear memory in my mind of a couple of families I treated early on in my clinic. I don't know why, but
Bill Vicenzino: I can remember the mother sitting there, the child that I was consulting there, and the other younger child over there.
Bill Vicenzino: and the mother's gone. She's got my problem, and I don't want her to have it. The mother's ran 40, and she's trying to get it. What can we do about it?
Bill Vicenzino: And you know she goes. The interesting thing was this example that I remember is
Bill Vicenzino: at that stage I was giving everyone foot offices, if they even hinted like the pronating, and I got the down the road to make them, because at that stage I wasn't doing them myself and you know, these people would get better. We can talk about some of the procedures we use to get to that decision of using them. But these patients have come back and bring up. You know the check up. Yeah, going good. It's better, a lot less plain, etc. Then one day we'll get a phone call. A month is panicking, just seeing the surgeon and the surgeon just told them. Still, bullshit.
Bill Vicenzino: they're not better. And there were crashes around them, and yet they'd been up until that point
Bill Vicenzino: feeling a lot better, and the surgeon says it's not to do with that. And then, you know, they get shaken. So it's kind of like
Bill Vicenzino: it's.
Bill Vicenzino: you know. Mum, child, I went off the trail a bit, but basically almost like that social context. You have a young female patient in front of you. Maybe it's good idea to ask
Bill Vicenzino: if the mother isn't there. Maybe this is good idea to ask Mom about her and her mother, and to just get a sense of the
Bill Vicenzino: the thinking in that little bubble, that family grouping of what they make of this, how much of an impostors on life. What can't I? Can they do? And parents wanna help their kids? So Mom felt like, you don't do those running up and down hills, you back off and do something else. Well, you know, she's gonna support the child and not doing it as well. Because and so
Bill Vicenzino: the context, I think th that. That's why I meant that's one of the things I meant about context before. You probably do need to understand in the young female more of the family
Bill Vicenzino: context in terms of yeah, the the lineage, the the familiar, the family history.
Jared Powell: generational patellofemoral Pain
Jared Powell: Bill used. I don't know if you had it, but used to be a pretty common thing in their practice at Mannington. Perth, yeah, yeah, right there you go. Let's go of something. Just come to me, Bill, and and just tell me if you don't wanna
Jared Powell: speak to this. But crepitus.
Jared Powell: So you know, lots of people come in. They're really worried about the crepus. This sound that their their knee makes when they flex and extended, or whatever, and they're often terrified by my my knees, make a lot of noises when I squat and show yours do Bill? The problem, maybe that I don't have seen what Scott, mate, you're a machine, but
Jared Powell: what do we say about Crepus? Do we just say, don't worry about it. I think Claire Claire Patel on Twitter has done a lot of work. Or ex has done a lot of work on this. What do we say about Crepus?
Bill Vicenzino: We're all clear Patella. She's got a real name. But Rob, running to add conferences. She's like Madonna. She's instantiated just into a her handle. Yep, yep, yep, yeah. I look. I think if you got someone in front of you. That's an older person. And yeah, they've got evidence that they might have
Bill Vicenzino: osteoarthritis. That's one kind of prepidus, and that's you know, for those that haven't felt. A joint that is like crepitus, like bumping over a gravel road. Kind of crippled us. You could feel it. You could hear
Bill Vicenzino: the telephone ones are really like that. They generally crack some stuff out of a joint, and you get a bit of you know point of range. You get through a point of range, and it does that.
Bill Vicenzino: I've never, ever thought that was a major issue. II know I've worked with some colleagues that make a big deal about that that you know. That's the anti season to articulate cottage degeneration.
Bill Vicenzino: There's no evidence of that. No evidence of all at all that, and I think
Bill Vicenzino: I think Natalie Collins did a
Bill Vicenzino: I think some study that we did. She did. A secondary analysis presented at a conference.
Bill Vicenzino: and I'd have to look it up. But I think there's some work done which essentially shows that it really is not predictive of severity or anything. So I wouldn't. Yeah, the crepus is interesting.
Bill Vicenzino: but I would differentiate. I like this real, you know. Preparation where you get the clunking in the gravel road, bumpy corrugation type thing, and you can hear it. You can feel it as opposed to the patella firm ones, even my knee, and probably yours. You get mine snaps more than it kind of snaps, cracks, and then couple of rips, and it's all good to go
Bill Vicenzino: and no no sequelae afterwards. II wouldn't recommend people get that worried about that. I'd be more worried that you unable to develop good force generation in your quadriceps muscle.
I mean, if it's
Bill Vicenzino: impeding your ability to generate good force. Well, then, maybe I'd I'd be concerned about it then. So how relevant is it to the things that are important to keep the knee healthy.
Jared Powell: Well, said mate, well said even even though I caught you off guard. Well done, so let's go, Bill. I knew we'd we'd wander off track here, mate, but we've got to. We've got to talk about treatment here. So
Jared Powell: a a every single clinical practice guideline that you read on Patel a female sub pain, it says, do hip and knee, strengthening exercises, so that's usually glutel exercises at the hip and quadricep strengthening exercises
at the name do we address both? Do we address one or the other? Is the name more important is the hit more important, or or neither do we just sit around and firm. Roll the Itb, what is the what's the value of strengthening exercise these days?
Bill Vicenzino: I'm gonna I'm gonna digress a little bit. I II turned up to Michael Rathliff had some award for getting some experts together in a room, and Copenhagen a few years ago I was lucky to be invited, and
Bill Vicenzino: I was introduced to this fellow that said he had the the largest RCT.
Bill Vicenzino: On patellofemoral pain. And again, oh, that's interesting. So you've got more more than 219 subjects in your group, because I won't know. Okay? Good. So I still have the log of the the largest sausage in the world. But you know, II say that just because I do stuff like that. But basically
Bill Vicenzino: his study was to look at quads versus hamstrings, and to his credit it is the biggest study that's done that and there's no difference, no, no difference. And you can't predict who's gonna benefit from either doing hips or or quadriceps. So same same result. And that's kind of come out in the literature that you can exercise either, or which I guess brings us to the question. So are you going to do both? Are you going to do one? So
Bill Vicenzino: my approach to that is, you do get some people that are really pain, averse and sensitized.
Bill Vicenzino: either sensitize to pain averse. Anyway, they don't like the idea of really whacking a lot of weight through their neat. So in those instances, why not really get the butt going abduction, adduction, external rotation, particularly extension. Really work them hard to get them, you know, comfortable with heavy load.
Well, it's relative to them, and then gradually build in some some knee work, and you could start as easily as isometrics with most people. As long as you get a point in range which isn't painful. You can load up, you know, on a knee extension machine or a war squat whatever and then gradually, you know, start to get them into isotonics and higher loads. So
Bill Vicenzino: How could you decide if they're too sensitive at the knee. perhaps go to the to the hip?
Bill Vicenzino: Otherwise there's no real guidance, I think.
Bill Vicenzino: III do believe. Hmm! I have a feeling that it is a knee. Extensive disorder. I teach my students for the last 5 to 10 years. When I teach knees
Bill Vicenzino: teach well, when I lead the sessions, the learning sessions, activities for the knee.
Bill Vicenzino: I I actually I like. I urge him to think of it as a knee. Extensive disorder.
Bill Vicenzino: It is going to be painful and inhibited. So how can we load this knee extensor so that we can get maximum force generation? And eventually, you know, the endurance of power, whatever is needed for the activity. They want to do well without pissing the patient off essentially, bring him along in the journey. And so, yeah, Chris, power to do a nice little biomechanical analysis study in
Bill Vicenzino: physical therapy or joss journal of orthopedic sports, physical therapy. Where he shows that you know, if you load the knee on any extensive machine up to about 40 degrees, you're less likely to generate
Bill Vicenzino: joint reaction forces which are provocative in terms of just the load. And if you do squats down to about, you know, 60 degrees. So really small squats with heavy loads you're unlikely to to bring. I think that's the right way, right? You unlikely to bring the the kneecap into much loading that creates pain that is painful. And so you can load people. That's a nice little
Bill Vicenzino: biomechanical modeling study. He did, and he bases it a bit on some of his Fmri study or MRI studies he did on a couple of cases. So it's a nice little research to work I like I like. I've just said then I hope I've got that the right way around. II would look at a patient's ability to extend the knee. If it's painful in certain ranges, I would just limit the quads extension excise around those ranges.
Bill Vicenzino: You know you, you'll still, and, if need be, if that range is quite substantial. Isometrics generally are quite well tolerated. And if not, well, go to the hip. So stepping back a bit. The exercise you're doing? Yes, it's for the telephone pain condition. But
Bill Vicenzino: ideally, I would think you've asked the patient. What is it that this kneecap pain, this knee problem, is preventing you from doing or really compromising what you wanting to do, and then focus on what that sport that activities it may well just be. You know, I got a walk, a lot of stays work, or I've got a squat, a lot at work, or whatever it is, break that down and then exercise the muscles which are
Bill Vicenzino: You need to build conditioning into, get them to the stage where they can do those activities with a lot in reserve. So therefore, you know, they can do those activities before they really load the joint excessively. So
Bill Vicenzino: you know, what is it that you want to do with these patients? And we do know that either all is going to be beneficial in this group. So you've got you got ability to play around of that and justifiably say to the patient that this has been shown to work?
Jared Powell: Yup, yeah, exactly. There's there's quantitative evidence that this this is an effective intervention, although we don't know how and why. Bill. So before before we go there, let me just let me just step back a bit.
Bill Vicenzino: I know you're keen to ask about that, so won't forget that
Bill Vicenzino: we did a network metal analysis as well. I'm on the author group Maris Winters is the lead author, and he's the mathematical whiz on it. Bayesian statistics, and you know, smoky mirrors and all that stuff. But basically education comes up. So you, you take all the studies, a, a systematic review, and then you compare them. And essentially, education comes up.
Bill Vicenzino: Yeah, better than doing nothing. Exercise a bit better than ex education. Education full of those, is a bit better than exercise or education alone.
Bill Vicenzino: If you then start adding in, you know, patella stuff.
Bill Vicenzino: you get a better result. But if you do everything education, exercise for teletaping and photothoses. You'll get the best effect over 3 months.
Bill Vicenzino: We couldn't find enough data out to 12 months and the data we did find nothing really is any better than than what would be a natural history, or wait and see. So
Bill Vicenzino: everything we know works well. It's quantifiable at 3 months outcomes.
Bill Vicenzino: So after that it's not as good
Bill Vicenzino: it may well be. And so before I go away from that we'll probably come back to the foot of those afterwards. So we we we'll go on to where you wanted to go, Jared. Sorry, I'm sure, just on strengthening. So
Jared Powell: hip exercises, work, knee exercises, work both in isolation and together. How do they work, Bill? Do? Are they getting you stronger? And is that a valid mediator of recovery?
Bill Vicenzino: So they do get you stronger. So if we look at mark Matthews Fox study, we did. Has 2 20 or something some something like that do. I mentioned it was the largest study done for telephone. Find physical therapy. Sorry. Capital letters, Bill. So basically his study looked at
Bill Vicenzino: hip exercises which were given in a clinic 3 days a week for 4 weeks. 4 or 6 weeks, 4 weeks, I think it was by a therapist to meet it out. They were all rubber band excise, really strong excise. We all, as authors investigated, tried a session, and it was categorically hard work with doms later on. So it was kind of like
Bill Vicenzino: Denmark. So we had
Bill Vicenzino: thing. So basically, one group did that. Another group got given authorities and the group that got authorized. He's got some food exercises as well. So we had hip exercise with versa, foot intervention, and we showed that there's really no difference between those 2.
Bill Vicenzino: That study of Marx was trying to see whether or not those that got better in the foot ofoses compared to the hip size. Was that because I had something in their foot that was different, and we had some ability measures in there, some postural measures in there.
Bill Vicenzino: and no, we did. We could not find any foot measures that would predict those that got better, you know, most improvement with the
Bill Vicenzino: so the next thing was that was that primary aim. But we always had in mind. We've got this like 100 odd people doing exercise, you know. Can we predict who benefits from exercise was, we've taken yeah range of measures. At the beginning we take isometric abduction, adduction, external rotation on us, also on fixed hand, held dynamometers. So we did good structural measurement, abduction, adduction, external rotation in the hip
Bill Vicenzino: at baseline. And we did that at 6 weeks as well. We also took, because we know nowadays we're getting a lot more aware of psychological factors. We ask them the anxiety, anxiety, and depression scales pain, catastrophizing scale and Tampa scale of
Bill Vicenzino: Kinesi phobia. Now, the one thing we didn't do, which II really think, was a mistake. But we had a shit load of measures, and we we had to go with something. This pain, self-efficacy. But we'll park that for now. Because intended opt that we find in glutral tend of the pain. Self-efficacy is probably one of the mediators, one of the mechanisms for which education next size might work.
Bill Vicenzino: So to develop the story bit more. So Shannon Holden did the analysis for us on on Mark's data set. So she was independent. And we're wanting to know. And whether those any changes in strength
Bill Vicenzino: with exercise compared to a foc's, any changes in strength or any changes in psychological characteristics that mediated, that were responsible for the differences we saw between hip exercises and forces.
Bill Vicenzino: And we looked at Couse, and we looked at as an outcome. We looked at couse and pain free squats. So we picked, you know,
Bill Vicenzino: really specific telephone pain activities. These were not the primary outcomes from our Fox trial, our fox trial, their primary outcome was a global rating of change. In other words, are you better? Same or worse, which I believe is probably the the best outcome. That's that's story for another podcast anyway. For this study, we measured patel specific, a physical test, pain, free squats and and the coup's the telephone will scale in the coup's.
Bill Vicenzino: So we found that you know the exercises actually did improve strength.
Bill Vicenzino: We also found that, you know, hip abduction adduction was improved with the photo postings as well. So license metric
Bill Vicenzino: strength improve for both groups. External rotation, though, was a little bit better, significantly. So in the Hip Exercise group. So the Hip exercise group was a little bit stronger, and then from memory, I'll just pull it up because I didn't open it up, because I never can remember these things
Bill Vicenzino: on on the treatment effect. External rotation and anxiety were better with the exercises. Don't know why anxiety was better, but none of the others. Other measures we took
Bill Vicenzino: differentiate were better on
Bill Vicenzino: hipx sizes versus photothe. So that's you know. One of the first things you want to see in a mediation analysis is that your your mediator is different.
Bill Vicenzino: Between treatment. So we got rotation. So then we also do another part of the study, which then shows that any of these changes that occur due to these treatments. So now look at the effect. Does that
Bill Vicenzino: make any difference on the outcomes? On? Not not not the effects at 3 months, but the outcomes at 3 months and basically paying catastrophizing tempered by Tampa scale with the 2 only ones that were kind of with only 2 outcomes that were different
Bill Vicenzino: from baseline to the end. So
Bill Vicenzino: it's probably a complicated way to come to what the mediation analysis is. And in essence we really
Bill Vicenzino: were unable to show that those strength changes, all those psychological changes, none of those were responsible for
Bill Vicenzino: mediating, though, in other words, they're not the mechanism by which we observed improvement in these patients.
Bill Vicenzino: or differences between the groups and these patients. So we have a bit of a conundrum. We do
Bill Vicenzino: We can't improve, we can improve. So you know you give someone hip exercises the ones we gave and a foot of those. If you say in this person we can do both simultaneously, we know that external rotation will be stronger at 3 months, at 6 weeks and 3 months. We know that's going to happen.
Bill Vicenzino: but that increase in strength is not well, what we've shown here is not responsible for the changes in coup's pay, and being able to do more sit to stands or squats, or whatever I as step up. So whatever I said it was before as the as the outcome measure pain free squats. Yeah. So so we're at a bit of a quandary. And that's where I come back to the pain. Self-efficacy, because
Bill Vicenzino: pain, self efficacy, is a bit different to anxiety is a bit different to catastrophization and kinesiophobia. You know, it's it's more about being able to do more, being more efficacious. In the face of pain. So being able to get on with things playing self efficacy scale.
Bill Vicenzino: Whereas, you know, kinesiophobia is more about withdrawing from it, or care with it, catastrophizing to make more of it than what it is. And anxiety is just, you know, not knowing what the shit's happening and being anxiety anxious about it. So basically, maybe you know. Would it be nice to have pain, self-efficacy, like? I said.
Bill Vicenzino: And I'm not too sure there's that much difference between a lot of these muscular conditions that are over use in nature, these grumbling long term ones. We did show pain, self-efficacy as one mediator
Bill Vicenzino: for hip strengthening and education in in in a glitch will tend not to trial. So yeah, II guess you can tell a patient we know these things
Bill Vicenzino: will end up being better than doing nothing, or just education and nothing but we not quite sure why this happens, and I'm not. I'm not sure patient needs to know that. But I think the clinician needs to be when I reflect on it, think carefully about what has changed. And yeah, we don't know. Currently
Bill Vicenzino: is is my answer, which is a bit of a a null response. But it's better than what we had before we didn't know.
Jared Powell: Well, exactly. That's just the current state of play, Bill, and it's not just a patella femoral pain. It's every musculoskeletal condition we really don't know how and why exercise works. Well, there's one
Jared Powell: I didn't cash in down at Sydney. Uni did a mediation analysis on their low back pain. intervention, sensory motor training, and they found that I think it was
Jared Powell: back pain beliefs
Jared Powell: mediated almost the entire effect of this sensory motor training intervention for low back pain, so physical, biomechanical variables, such as strength, kinematics. All these kinds of things are rarely shown to be mediators of recovery. And it's
Bill Vicenzino: it's an interesting thing, because well, 2 things the study I talked about before in Holla, in Denmark.
Bill Vicenzino: They also did some mediation analysis and weren't able to show strength media that the improvements.
Bill Vicenzino: But also we, we're starting to find out. This is study recently that show that you you don't need to. Was this Foster, you know, as long as you don't even have to, dear to him. As long as you do some exercise it doesn't matter the volume, the intensity it. It's just as long as you do some. And so.
Bill Vicenzino: you know, I wonder about pain, self-efficacy, because I think that's definitely an attended OP. The trial. We did a lot of education, trying to explain to people what the condition is. You know, we had an MRI that showed it was attending opiate. So that's anxiety relieving already. So you kinda got a diagnosis. And I told us when we review when we did some follow up qualitative stuff. They told us that was a really good thing, even if they got a wait and see group.
I felt at least I got a diagnosis, and I could be reassured on that. So you reassure them. Nothing's really wrong. You then teach them ways in which they can move with less pain.
Bill Vicenzino: And they often tend to free frequently. Le feel less pain frequently. And so that's the other mediator that we found in that study is a pain frequency, seem to be a mediator, and also the ability that
Bill Vicenzino: patient, specific function score those 3 things were the mediators. So the ability. I read that as if we've reassured them, it's okay to move, and they've been able to do more Psfs pain. So efficacy went up. And they had less frequent pain. And you know.
Bill Vicenzino: our education is about that our education rules is, look you need to keep moving. We know musculoskeletal tissues. You don't move your wrists, and you're going to deteriorate. That's just a given so you need to keep moving. Now, we also know that if you really flog yourself.
Bill Vicenzino: you know, you're gonna get boom bus cycles, and it's painful, and you don't. Then you don't like to do the exercise. So just be sensible about it right? Realize what things hurt. You. Just get a walk around them. You know.
Bill Vicenzino: like we give them tips. So for patella feral pain you in the education you give them the tips. Okay, they'll probably tell you it hurts when I go for hikes up and down hills. Okay, let's get you walking on on flats. Let's increase your speed on flats. Now let's just try gentler slopes, and let's just do it within your capacity and gradually spread it out.
Bill Vicenzino: So patience will generally give you the insights you need to meter out. We're along the load spectrum. You need to set them off for those things, and you know I do wonder whether it's all about.
Bill Vicenzino: you know, less frequent pain, and then being able to do will be efficacious.
Bill Vicenzino: Do more, or do the same or do more with less pain, or or
Bill Vicenzino: do the same with list pain that kind of thing like moving in pain. I wonder whether that's what we're doing?
Jared Powell: I love it, bill education, manipulating load. It's sort of all what it's about, isn't it? And and at all times trying to empower and promote optimism and movement is, gonna be good for you. We just have to find the right dose in the right type, and not sort of getting into that hole. It hurts when you never, never squap below 90 degrees again, or never bloody. Sit with your legs cross or never. You know all these things which we sort of we can say
Bill Vicenzino: you forget that you say in a console all that that creaky need that you've got is not good, you know. Just get away from all that crap and empower the person I have. Can I tell you a story? I don't want to drag this out, but I was in that in Monica last year I went for 10 days or so.
Bill Vicenzino: And I found a gym. That 24, 7 h gym, and like I end up going almost every day or every other day. And this is gentleman. They use account residues well into seventies, if not ids.
Bill Vicenzino: big tool strapping guy. And I've noticed him, I said, Get I doing? Because he is really whacking it. He's doing the hit, and he's doing all the white slack they start tomorrow. I'm going good on you. Might I wanna be like you when I grow up and I'm sitting down ripping out some quads like I've just done some squats. I've gone over to the quad extension machine, I'm really, you know, grunting, trying to force out. 8 sits each individually comes over to me, goes. Oh, Mike.
Bill Vicenzino: he shouldn't be doin that. You're gonna really that really stuffs up your cartridge. And then I'm going. So then I started talk to him. He's an all black. He's a he's one of the famous, all blacks from way back.
Bill Vicenzino: And you know he's had reconstruction, surgery, and totally and all kinds of stuff, and you know, he he said. Oh, the surgeon, that's obviously the god surgeon for Rugby over and keep, he said. You'll never do that, and I'm going. Oh, Mike, that's not true. I'm my knees have been better and offloaded like all the Jesus. And so it's quite interesting, like you've got. And he, I would imagine. Like, you know, he's an elderly gentleman.
Bill Vicenzino: Everyone knew him right in the gym. Everyone's like an item. Have a chat to him. So he's yeah, he's gone around telling people in that gym back off that son. And so this, this issue, I think, is in this social context. Yeah, we really do need to think carefully how we relate these things, especially when we don't have the evidence, for it'd be a different thing if we had evidence for it. But I don't think we do or we don't.
Bill Vicenzino: Yeah, I agree. So in that case you are on the side of optimism. Bro, I think so. I think so. And be sensible right? If you're finding like, it's really hurting. And it hurts the next day. Well, you've just done too much. Yeah, work around it.
Jared Powell: So for for international listeners at all, black is someone who's played for the New Zealand Rugby Union team, which is act is the greatest sporting team of all time in terms of winning percentage, which is phenomenal. And anyway, so those guys are the our heroes over in New Zealand as they should be. Bill, who doesn't know who doesn't know the All blacks? Iconic? Yeah, exactly. But just, you know, include everyone, Bill.
Mate. I've taken enough of your time
Jared Powell: Bill. Thank you so much, mate, thank you for today, and also thank you for your years of service. II think you gotta still stay active in the research sphere. Is that right for a bit?
Bill Vicenzino: Yes, yes, II stopped turning up for classes in the middle of the year. Then, after that I've got some great collaborations and research and Phd. Students that I'd like to still keep active with, because I'm not that old, but old enough to hand over the teaching and stuff to youngest. Yes, so I'll I'm still gonna be. You're not gonna get rid of me. I'm still gonna be around for few years, God willing. Yes.
Jared Powell: nonetheless, I'm still gonna raise a glass for you tomorrow, mate. Thanks thanks very much for your time, Bill, can we find you on Twitter? Where are you? Where are you active?
Bill Vicenzino: Oh, yeah, I'm yeah, Twitter. I when I get busy at teaching, not so much. But at Bill underscore vich and zeno I think just got make sure you spell which in Zena, right? It doesn't come up, and I'm on Instagram. I like Instagram. We've got pictures, and II guess I tend to be the
Bill Vicenzino: look at the pictures in the paper rather than read, so Instagram is one which are probably more on
I'll probably dare say, be more on twitter
Bill Vicenzino: once I once I hang up the duster and chalk.
Jared Powell: Look forward to it, Bill. Thanks for your time, mate.
Bill Vicenzino: You're welcome, Mate.
