Ep. 68: Ron Clinton – When Knee Pain is not a Knee Problem

44% of knee pain has its origin elsewhere.

Do you know anyone with knee pain? It feels like there are so many people who just kind of program themselves for it. It’s ‘part of getting old’ for them. So of course, the body listens.

We already know that even when there’s actual, mechanical damage, knee pain is not the guaranteed result. And we also know that even when there is pain, it can be managed and improved with many holistic techniques, so surgery or injections are far from the only solution.

And of course, sometimes the knees are not even the cause of knee pain…

Ron Clinton is a physiotherapist with 35 years of experience and an authority on all things knees and spine. He helps people identify and deal with the root causes of their pain and often resolves even the most difficult cases without the need for surgery.

In this episode, you’ll discover:

  • Why being diagnosed with osteoarthritis is not an automatic sentence to a life of pain.
  • Why it’s so important to examine a person holistically and not just focus on the joint that hurts.
  • How spine issues become knee issues, and how to approach that.
  • Hands-on work: The questions you can ask yourself to quickly figure out what might be causing your pain.

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Show notes & links

The show notes are written in chronological order.

  • Ron Clinton’s website: kneeandspinept.com
    • get in touch with Ron and get a free copy of his book: ClintonRonPT [at] Gmail.com
  • Ron Clinton’s book: Self-Manage Knee Pain: 52 Tips Before Considering Injections or Surgery [get it here]
  • Hashimoto, S., Hirokado, M., & Takasaki, H. (2019). The most common classification in the mechanical diagnosis and therapy for patients with a primary complaint of non-acute knee pain was Spinal Derangement: a retrospective chart review. The Journal of manual & manipulative therapy27(1), 33–42. [read it here]
  • Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). J Man Manip Ther. 2020;28(4):222-230. [read it here]
  • Episode 48: Eileen Kopsaftis – The Secrets of Coping With Pain in the Healing Process
  • Horga LM, Hirschmann AC, Henckel J, et al. Prevalence of abnormal findings in 230 knees of asymptomatic adults using 3.0 T MRI. Skeletal Radiol. 2020;49(7):1099-1107. [read it here]
  • McMurdo ME, Rennie LM. Improvements in quadriceps strength with regular seated exercise in the institutionalized elderly. Arch Phys Med Rehabil. 1994;75(5):600-603. [read it here]
  • Dr. Sanjay Gupta on Alzheimer’s Disease Risk [discover more here]
  • Episode 3: David Hanscom, MD – A Holistic Approach to Dealing with Pain and Anxiety
  • Dr. Dean Ornish on heart disease and Alzheimer’s [discover more here]
  • The McKenzie Institute®, USA | A scientifically proven assessment process that will identify the best treatment solution for back, neck, and extremity problems.
  • The McKenzie Institute® International

00:00 – excerpt from the episode
00:41 – intro (listen to discover a little more about your host. Martin will tell you a new lesser-known fact about Dr. Maya)

01:17
Dr. Maya Novak:
There are injuries that need immediate attention and help, and then sometimes we think that we’re injured but perhaps we’re not or the root cause of the problem is not the part of the body part that is causing us trouble. That’s why it’s really important to ask the right questions and to find health providers who know how to look at the big picture. And one of those experts is today’s guest.
I’m joined by Ron Clinton who’s been passionately practicing and educating physical therapy for over 35 years. He has authored several books, including “Self-Manage Knee Pain: 52 Tips Before Considering Injections or Surgery” and “How to Prevent Burnout and Achieve Personal Well Being”. He’s recognized as a leading authority in his field. He regularly facilitates seminars for physical therapists and shares his extensive knowledge with business and industry leaders. Referred by local spinal surgeons and pain specialists, the most challenging cases are entrusted to Ron and his dedicated team due to their exceptional success rate. And that’s why I’m so excited to be talking to him today. So, Ron, welcome!

02:33
Ron Clinton:
Thank you very much, Maya. It's really a privilege to be on your program I've listened to so many of your podcasts and they're always very entertaining and enlightening.

02:45
Dr. Maya Novak:
Well I am really happy that you are a guest today because we're going to be covering a really important topic and I think that potentially it's going to be really eye opening for a lot of people that the body part that is hurting perhaps is not really the cause of what is happening. But before we go into that… So let me ask you this, when you were growing up, did you envision that you're going to be a physical therapist or how did you get into the field?

03:16
Ron Clinton:
I never envisioned being a physical therapist. I had never heard of physical therapy, but a very serendipitous thing happened. After high school, I took a gap year. You know, the kids today take a year and go to Europe or travel or whatever. Well, I didn't have the option to do that. I had to work. I worked in a factory so that I could get enough money to go to college and buy a car. I didn't have a car. In that year, I decided I really had to buckle down and study hard, so I went to community college. I really didn't know what I wanted to do. At that time, it was around the Vietnam era, and I realized I might be drafted. That would mean they could send me anywhere and have me do anything. So I thought, maybe I'll enlist. I had read some books over that gap year by a military surgeon who went to Laos, Cambodia, and Vietnam and served the people there. He decided after his tour of duty to stay there and open free clinics for the people. I was really impressed by his commitment to service. I had a little bit of interest in medicine, so I thought I would enlist, maybe as a medic. I had an appointment with a recruiter. I got there a few minutes early, and he was with another person. He said, "Why don't you go in this room over here? There's a lot of literature you can look at, and I'll be with you in a couple of minutes." So I went in and saw a book on careers in the service. I thought I was going to be a medic, but I decided to take a look. As I started leafing through the book, I found physical therapy. It was like an aha moment. I loved exercise, had always been involved in sports, and loved games of any kind. Physical movement and medicine together made sense. That's how I got into physical therapy. I had to take a bunch of prerequisites at Wayne State University in Detroit. Once I got through those, I got into PT school. I've been doing it ever since, and I still love it today.

05:55
Dr. Maya Novak:
So that was really the perfect combo for you - like you said, let's move and let's practice medicine. So let's put this together, and here we are. So one of your specialties is knee problems.

06:05
Ron Clinton:
Yep, love it.

06:07
Dr. Maya Novak:
And I think it's almost safe to say that the majority of people have some sort of experience with that. A few weeks ago, I was talking with a friend who had potentially stepped awkwardly or something happened, so they thought something was off. One of the sentences that really stuck with me during that conversation, and also because I've heard it so many times, was, "I'm at a certain age, so my body is, I guess, kind of falling apart." It was followed by, "Well, I hope that I don't need surgery." What do you think about that? Are any problems connected to age or not?

06:57
Ron Clinton:
Okay, so the fact that with age we tend to develop arthritis in our joints is a well-known fact. But sometimes that arthritis, which is osteoarthritis, is not the crippling type of rheumatoid arthritis that is a systemic problem. This is a joint problem that is very common with aging and is normal. However, some people experience accelerated degeneration of a particular joint, like the knee, maybe because of being significantly overweight or having had a previous injury or surgery. This can accelerate the condition, and maybe one knee is bad while the other one is okay. Arthritis in and of itself is not necessarily alarming. When doctors say you have degenerative arthritis, it makes everybody nervous and scared because they think of it as a terrible disease that will keep getting worse. But the fact is that people with arthritic problems in their knees can get better. In fact, the Arthritis Foundation always recommends exercise for people with arthritis, so it's not inevitable. Women tend to get it a little more than men. One of the issues with women is that the pelvic angle is wider, which creates a different angle at the knee and can cause more knee problems. For example, you see a lot of young female soccer players who get torn ACLs because of that. Running in and of itself is not bad for the knees. Many studies, even in the last couple of years, have pointed this out. I've been running for over 40 years and have run marathons. I participate in the Senior Olympics here in Michigan, doing the running events, and I've never had a knee problem. I might have had a little knee discomfort, but it didn't last and went away. Running isn't bad for the knees. If you are significantly overweight, I wouldn't recommend starting with running; there are other approaches to take. It's not inevitable that with age you're going to get problems with your knees or any other joint. There are many variables to take into account, and even if you do have arthritis, lots of things can be done for it on a very conservative basis.

10:03
Dr. Maya Novak:
Yeah, so you kind of said that that yes, it can be connected to age. So what is your experience, what age are we talking about? Are these people now in their thirties or are these people in the 60s, 70s? What is it, or can we even say it really depends on the lifestyle and everything, so it can start earlier or later?

10:26
Ron Clinton:
Yes, in general, if we take the age group of 40 to 50, you might start to see some changes. Let's say the average person might see some, and in each generation after that, you're probably going to tend to see more. But it doesn't necessarily mean you're going to have problems. In one study that was done, they looked at 230 knees, and the average age was 44. These people did not have symptoms in their knees, and amazingly, 97% of them had changes in their knees, like arthritic changes, meniscus tears, or cartilage damage, but they weren't having any pain. It can be very confusing when you get an MRI or an x-ray, and they say you have arthritis. You might wonder if it is really a problem for you or not. That's where it is helpful to get a physical therapy evaluation and treatment because, lots of times, a lot can be done before considering more invasive things like injections or surgery.

11:56
Dr. Maya Novak:
Yes, It's Interesting what you're saying and I've heard of many of these kind of studies. So there are changes that can be seen, but there is no pain. There are no problems. So it does lead to a question about beliefs as well, right? Because my thinking and my experience is if we believe that something is going to happen to us at a certain age it is more likely that we're going to be starting experiencing something. And if we believe that, “Well I'm going to be completely fine until I die,” it might be. You know the body might react differently. What is your experience with that?

12:36
Ron Clinton:
You know, I've had people come in, maybe in their late 30s or early 40s, and they'll talk about how it must be age, saying, "Wow, it must be age, I'm getting older," and they're focused on this concept that this is the beginning of the end, so to speak. It's really part of my approach with patients to gently help them modify that belief going forward. I try to give examples of either patients or studies that have been done. One study I like to refer to with patients is one they did with 90-plus-year-old people who were in assisted living facilities. They divided them into two groups, about one hundred people in total. They tested their strength in their quad muscles, the biggest muscle in the front of the thigh. They tested the strength in both groups. One group was sent away and told to come back in eight weeks for another strength test, while the other group did strength training three times a week to strengthen their quad muscles. Eight weeks later, the patients who didn't do anything showed no change, but the ones who did the exercise improved their strength by over 100%. Those were people 90-plus years old. Often, that's a wake-up call: if a 90-year-old can do it, they certainly can. I might give examples like that, or if I have a patient in mind, I might tell them about something they accomplished despite having arthritis, just like the person I'm speaking with.

14:40
Dr. Maya Novak:
Yeah, so it's really also about how it's never too late.

14:45
Ron Clinton:
Yes.

14:45
Dr. Maya Novak:
So it doesn't matter if you are thirty, forty, fifty, sixty, seventy, eighty… ninety. It's never too late to start something and to improve how your body acts and reacts.

14:56
Ron Clinton:
Right. Exactly.

14:57
Dr. Maya Novak:
So how about, those patients or maybe someone right now is listening and they’re saying “But, Ron, you know what? You don't really understand I have what is called that bone-on-bone.” So when a person has this bone on bone situation, is the only option a total knee replacement? You know a lot of times people think that this is the only option. What is your insight into this?

15:26
Ron Clinton:
Yes, this is a very interesting topic. I had two patients in the last year or so that I'd like to tell you about. One of them is named Harriet. She had been told she had bone on bone in her knee and had gone to a couple of different surgeons for opinions. She came to me because I had treated her for her low back a few years prior, and she wanted another opinion. We started working with her and got her on a good program. She was making some progress but was already scheduled for surgery. We discharged her with a home program, and she kept doing it. She still had some time before her surgery date, so she kept working the program. One day, I got a call from her, and she said, "You know, my knee is so much better. I've canceled the surgery." She still has bone on bone, but she isn't having the surgery. The other patient had bone on bone in both knees. I'm actually seeing him right now again for his lower back, but I treated him for his knees about six to eight months ago. He had been having injections and came to me because I had treated his wife in the past. His wife was having a lot of physical problems, and he's the primary caregiver, so he really didn't want to go through surgery and rehab. He thought, "Let's see what we can find out." We went through the McKenzie program, which I'm certified in, and we got him on a program such that he hasn't needed any more knee injections. He is committed to not having surgery because he can control the symptoms with exercise. That's both knees, and both of them were told to be bone on bone. So, it doesn't necessarily mean that if you have bone on bone, you need surgery. You should have an evaluation to see if, number one, you can be treated with the McKenzie approach or even regular physical therapy and get better. Or, could the problem be coming from another area of the body, such as the low back? There are people all over the country trained in the McKenzie method, not just myself. We have the training to clear the spine and make sure that it's not involved in the problem.

18:42
Dr. Maya Novak:
So for those people who are not familiar with these bone on bone situations, can you just quickly explain what does that mean? Does this mean that there is no cartilage, or what is bone on bone?

18:56
Ron Clinton:
Yeah, pretty much that's what it means. It's like everything is kind of worn down in the in the joint itself and theoretically it should be a situation where it would be just impossible to do very much with that. People come in with a lot of discomfort, but for whatever reason we really don't understand how sometimes the exercises that we do with the McKenzie method seem to be able to allow people to get more movement and less pain in their affected knee, and kind of get on with their life. Despite what is obviously damaged tissue on X-ray or and MRI.

19:45
Dr. Maya Novak:
Yeah, so you mentioned the McKenzie method a few times and you said that it's different than physical therapy. So what is the difference? Can you explain a bit so that we know what we are talking about?

19:59
Ron Clinton:
Yes, well, it is part of regular physical therapy, and the difference in terms of the way we evaluate a patient, it is a little bit different from some of the standard approaches. For example, before we start an evaluation let’s say with a knee patient, we do what we call baseline measurements. A baseline measurement for a knee pain patient would be something like walking on stairs. We have them walk on a few stairs and ask how much discomfort do you have? We might ask them to squat and see how much discomfort they feel and how far they can squat. We might ask them to walk at a slow pace and then at a faster pace. These are things we can test or check before and after. Then we do what is called a directional preference assessment. This means we test movements in one direction repetitively. We do several movements of a joint in one direction and then retest the baseline measurements. If they are no better or worse, we know that's not the direction we want to go. But if the baselines are better, we know we might be onto something in terms of an exercise. We will give that patient an exercise in the directional preference of movement that we identified in the evaluation as a trial home program. If they come back on the next visit and say, "I can walk better on stairs now, I can squat a little better, I can walk a little bit faster without pain," then we can continue to progress that program. We usually notice these results quite quickly when we are assessing a patient. It doesn't always take us too many visits to figure this out, especially if it's going to help them. Not every single patient is going to respond. I don't think there's anything in the world that's a magic bullet for everybody, but a lot of patients who have failed other physical therapy have done very well with the McKenzie method. I see a lot of those kinds of patients coming from doctors who know and are supportive of the McKenzie method.

22:39
Dr. Maya Novak:
Well you said a really important thing right at the end. You know patients who failed with other physical therapy approaches. So it's really important for people to also know and understand that if you failed once with one physiotherapist it doesn't mean that physiotherapy is not for you. You just have to find another a therapist with a different kind of approach. And nothing is lost right? So it's really important that we remind ourselves that if something didn't work once that doesn't mean that it's not going to work in a different kind of way with a different kind of person.

23:21
Ron Clinton:
Exactly and just I just want to say that in in general, physical therapy is very good for knee problems and a lot of problems with the knee will get better with regular physical therapy. It's some of the more stubborn ones that don't get totally better or don't get better at all that may respond to the McKenzie Method. So I'm a big promoter of the field of physical therapy as a conservative way to start interventions with a musculoskeletal problem, but having been certified in the McKenzie method since 1997 and seeing such good results with so many people who have failed other courses of PT, I'm just a big proponent of the McKenzie method.

24:16
Dr. Maya Novak:
Yes. My experience - because in the last decade or twelve years since I broke my right ankle I've had quite a few experiences with physical therapists and my experience is that those physiotherapists who are the most passionate about their field and are really interested in their clients, in their patients, in the field itself are usually the ones that can help the most people. On the other hand, I also had experience with physiotherapists who don't care really and they put you on some machines and it's like, well, you do this and at home you can do a few of those exercises and that's it. And usually, how I respond with those who are not really interested in me and my problems is also don't respond really well.

25:15
Ron Clinton:
No, no, you know physical therapy has to be individualized. You know I wrote this book on burnout years ago and sometimes when people get burned out in their field, in a lot of cases physical therapists are in situations where they might work for a big company and they have 20-some patients on their schedule, and they're just coming at them one after the other, and they just don't have the time to individually work with them. But in the past a lot of people would say, “Oh let's see, I've got another knee on my schedule,” or another back or they refer to it by the diagnosis. But it's a person with a back problem. It's a person with a knee problem and there are so many factors that impact that knee problem. Let's say that a person has psychological, emotional… all these different factors really need to be taken into account. So you ideally have to take a holistic approach and assess the whole patient in relation to their knee problem. For example…

26:30
Dr. Maya Novak:
Yes, it's not just, “Well number five come in.” It's really more than that…

26:38
Ron Clinton:
Yeah, unfortunately that happens. I think it's a consequence sometimes of overload of clients for these people and it's not that they personally are that way all the time, but if they've had to do this for a few years it's really wearing on them going forward.

27:01
Dr. Maya Novak:
Yes, we are all just people, right? With our own personal lives and our own personal experiences.

27:08
Ron Clinton:
Exactly.

27:08
Dr. Maya Novak:
So a few minutes ago you touched on that a knee problem is not necessarily a knee problem. Can we dive a bit into this? When is a knee problem not a knee problem?

27:25
Dr. Maya Novak:
We'll continue in just a moment. I wanted to quickly jump in for two things. First, thank you for tuning in. And second, I’m sure you have at least one friend, colleague, or family member who would very much appreciate this episode. So share it with them and help us spread the word. Now let’s continue…

27:46
Ron Clinton:
Okay, I wanted to share with you two cases that I had pretty much at the same time last year. They happened to be two women with the same first name, Barb, and they are both retired nurses. The first Barb is an 83-year-old woman who is a dynamo. This woman is so active and energetic that you wouldn't believe she was 83. One day, she was having dinner with friends, and when she got up, she had this terrific knee pain. Being a medical person, she wanted to address it right away. She went to the doctor, saw a specialist, got an x-ray, and was told she had bone on bone. The traditional medical thinking was to do a knee replacement. She had the knee replacement, went through physical therapy, but still had the pain. Then she went to a pain management specialist, who did a nerve block, but that didn't work. She saw another pain management specialist who offered a very expensive treatment, but that also did not help. Eventually, she came to see me, and I did my McKenzie screening evaluation. For lower extremity problems, I start by looking at the low back, alignment, leg lengths, and any rotation in the spine. We determined that the pain was referred from her low back, even though she had no back pain whatsoever. I saw her for seven visits, and she completely recovered. Last winter, she went to Florida and told me she was back to walking three miles a day without pain. She probably did not need that surgery; her pain was due to her low back. The second Barb is younger, 65 years old. She was a former patient of mine for a back problem, but this time she had a really intense knee problem that was debilitating. She was having trouble finding a comfortable position and walking, with stairs being almost impossible. She came in with a referral for treatment. During her evaluation, she mentioned that she had seen an orthopedist, who did an x-ray but didn't see anything that would explain the amount of pain she was having. The physician assistant couldn't figure out what was causing her pain and didn't even suggest looking at the low back. When she came to see me, I evaluated her low back, and sure enough, even though she wasn't having back pain, the source of her knee pain was her back. We treated her back, and she got better. We didn't do anything specific to her knee, just as with the first Barb. These cases indicate that many times, the back can be the referral source for knee problems.

31:46
Dr. Maya Novak:
Yes, and this is not the first time that I'm hearing something like that. I mean last year when I had a conversation with Eileen Kopsaftis who is also a PT, a really good PT, she was also explaining how she had a patient with a neck problem, but the root cause was his ankle. Everything is connected. So let me ask you this, what percentage would you say of people who have problems with knees actually have problems with their lower back?

32:37
Ron Clinton:
Yes, this is really interesting. A couple of studies were done by McKenzie-trained clinicians. In one of these studies, they took about 320 patients who came in with a primary complaint of arm pain or leg pain. Of those patients, 43.5% were found to have their primary origin in the low back. Their primary complaint was extremity symptoms, but the main problem was in the spine. Another study focused solely on knees, conducted in Japan. They had 101 patients with a primary complaint of knee pain, and in 44% of the cases, almost exactly the same percentage, the spine was found to be the primary source of the problem. I'd like to mention a couple of cases I had recently involving ankle area pain, specifically ankle tendonitis. I had two patients with this issue at the same time, and it was really amazing. One patient had had ankle tendonitis for seven years and had gone through two previous courses of physical therapy. We were able to determine that the back was actually the source of the problem. The other patient had about a three-year history of ankle tendonitis pain. That was the diagnosis they were given because it was pain in the area of the ankle tendons, but it was not the correct diagnosis. The low back proved to be the source. One of the instructors in the courses I’ve taken at McKenzie made a statement that was a real eye-opener and was very true because it would have applied to me before I had the McKenzie training: "Diagnoses have seen you, but you haven't seen them." This means that if you treated knee pain and it was actually the back, you treated the wrong problem. The diagnosis was there, presented in a sense in front of you, but you didn't pick it up because you didn't have the training to identify it. I always keep that in mind. The McKenzie method is really good at finding those back issues that masquerade as extremity issues. For example, a patient came in with "pickleball elbow." Many people are playing pickleball these days, and there are articles about pickleball elbow. It turned out her pickleball elbow was actually a neck problem. We treated her neck, and her elbow got better. This happens all the time.

35:57
Dr. Maya Novak:
Yeah, it’s almost like a fifty-fifty chance, no? What I'm hearing from you from my perspective is, ”Okay, there is fifty-fifty chance that maybe it's my knee or maybe actually it's not my knee.” So it's really important that we have this discussion because like I said at the beginningthis is probably really eye opening for so many people. I know that it is for me because such a high percentage of maybe it's your knee, but maybe it's your lower back? I mean it's just wow.

36:30
Ron Clinton:
Yeah, and the advice that I would give to someone if they are in a situation where maybe they have a lot of knee pain and maybe they've tried therapy and it didn't work is, if they can't get to a McKenzie therapist and they were going for injections or something, could they say to the surgeon “Are you absolutely sure it's not coming from my back or my hip? That it’s not a referred to pain? Are you absolutely sure because if it was found out later that it was when they eventually got to a McKenzie therapist, that wouldn't look too good that you operated on the wrong body part.”

37:12
Dr. Maya Novak:
Yes. And I think that you recall a conversation that I had with Dr. David Hanscom, the retired spinal surgeon.

37:22
Ron Clinton:
Yes.

37:22
Dr. Maya Novak:
He was sharing the same thing, right? It's yeah, we are cutting people but actually there is no problem right? So I think that we can always go back to cutting, but let's try and do everything else. The whole mind body. We cannot ignore that emotions and thoughts also have a really huge role in how our body reacts. So yes, we can always cut, but before that let's try something else.

37:56
Ron Clinton:
Absolutely and I know Dr. Hanscom said 70% of back surgeries probably don't need to be done, and if you look at it country by country, United States does way more back surgeries than any other country per 100.000 people. It's just it's like an industry here.

38:23
Dr. Maya Novak:
Yes, like let's just cut everything, let's open everybody up. So before you mentioned inflammation and body weight. How much of a connection is there between lifestyle and inflammation and knee pain and body weight and all of this?

38:47
Ron Clinton:
Yes, the medical profession has not identified inflammation as such a big issue as it really is. Researchers are identifying it as a major issue but it hasn't trickled down to the average MD in a lot of cases. They say that medical research that is absolutely effective and true takes 14 to 17 years to get into the mainstream so that people start practicing it. But with inflammation, I mentioned this a little bit in the book that that I wrote, there are definitely foods that are inflammatory such as fried foods, processed foods, packaged foods that have 45 ingredients and those types of things they tend to be all inflammatory. And fruits, vegetables, whole grains are anti-inflammatory. So part of a holistic approach would be to talk about diet with people. Some are not ready for making a big change in their diet. But it really would be part of a holistic approach to treating a condition like inflammation in the body that contributes to pain. Being overweight has its own issue that fat cells can also produce inflammation and so that's a big issue. Part of a good treatment program would be weight management through exercise, modified diet, that type of thing The other thing about inflammation I'd like to mention is a special I just viewed on television. It was by Sanjay Gupta who is a MD Neurosurgeon, he's the medical correspondent for CNN and he did a study or a program on Alzheimer’s and I bring this up because it's related to inflammation. There's a doctor out in California you may have heard of, Dean Ornish.

41:13
Dr. Maya Novak:
Yes.

41:13
Ron Clinton:
He has a holistic program and he published research several years ago that you can reverse heart disease by following his program and now he has a program related to Alzheimer’s and I think it's pretty much the same program. And they have shown that you can reverse Alzheimer’s. They had a patient who they saw five years ago and today and she's over 80 um, and she has reversed Alzheimer’s. The program involves, exercise and big dietary changes. You pretty much go, vegetarian or vegan. So exercise, diet, relaxation techniques, meditation and relaxation methods and trying to have good social relationships, getting proper rest and that type of things. Very holistic approach and they're seeing these patients turn their lives around and actually reverse the inflammation. They feel that a lot of the Alzheimer’s is due to inflammation and it can actually be turned around if you're ready to commit to doing that.

42:34
Dr. Maya Novak:
If you're ready to commit to doing that. Yes, this is the most important message. But I think that people who really are in pain and who really want to get rid of that pain, sometimes you really have to be pushed into the corner. And then we go back and fight back. Like, “Okay, no, I've had it, I have to change something.” So inflammation and being overweight. It kind of is a more straight line in understanding. But what about those people who are not overweight but they are still experiencing knee pain? What do you say to patients like that or what does research say about patients who don't have problems with weight?

43:27
Ron Clinton:
Well, there can be so many factors. There can be so many lifestyle factors that impact knee problems, like working in one position all the time. Some people have jobs where they might be in a squatting position with their knees bent all the time, or others are on their feet all the time, bending and twisting. Those kinds of factors can contribute to knee pain, even without being overweight, plus previous injuries when they were younger. A lot of times, I'll ask patients if they've had any major knee issues, and they won't think of anything. Then maybe the next day, they'll come in and say, "Well, you know, when I was eighteen, I remember I fell and landed on my knee." Those traumatic injuries can later start early arthritis development and related problems. So there can be many factors that contribute to it. The key thing, I think, is if you're young and not overweight and you start having some knee pain, see if you can get a referral to a PT. They can try to identify if you have some lack of motion that can be stretched out, or lack of strength, or alignment issues in the pelvis. You can nip things in the bud and get on a program that can prevent problems from developing in the future. It's better to jump on it as quickly as possible before it turns into something more complicated.

45:27
Dr. Maya Novak:
Yes, absolutely. You know I really cannot ignore the topic so I'm again coming back to emotions and thoughts because they have a big impact on how our body reacts. So let me first ask you, what is your experience with this, the mind body connections? How people are thinking, what they are feeling or also just stressful life all of these things. What is your experience with that?

45:59
Ron Clinton:
Yeah, well, going back many years, I've had a big interest in holistic health. I remember seeing Dr. John Travis in person—he's known as the father of wellness. I went to some seminars on holistic health and thought, "This has got to be my way of living, holistic living." Way back in the early '80s, I was on the Metropolitan Detroit Holistic Health Association Board of Directors. I worked at Henry Ford Hospital in Detroit, where we had a program called the Quality of Life Optimal Health Program. It was very holistic and involved classes for employees and community members on relaxation and stress management. I taught a smoking cessation class and a stress management class for six weeks, three hours a night. With that background, I bring a holistic approach to my patients. I try to assess them holistically, and when I identify that there is a stress component to their situation, I utilize some type of stress management intervention. Typically, I start with diaphragm breathing, which is the simplest and easiest thing to implement in terms of relaxation. One of my past teachers made a statement that I actually put on a poster because I feel it's so important: "Relaxation is the base of all natural healing." We have to have that as our foundation. If we don't have that foundation and we're dealing with all kinds of other factors, our own healing is hard to achieve the best possible result. So, based on various stress management techniques that I've learned over the years, I use those as needed with patients who are having those issues. We know that if someone is under stress, you can usually add a point or two to their intensity level on a 0 to 10 scale. If we can eliminate that stress, then we can start peeling away at the other layers of the pain with regular physical therapy techniques.

48:36
Dr. Maya Novak:
Yes, it's absolutely so important that we do remind ourselves that yes, doing all sorts of exercises and physical work is important. But also, if we are ignoring the stress of every single day or having any kind of emotional turmoil happening or thinking how I'm never going to get better and all sorts of stuff, then of course the body will react in a different kind of way than if we think differently. If we are working on our emotional state. And speaking about the emotional state… You know how some injuries are easier and more quickly resolved, but then there are some injuries that take a long time. We can talk about not just weeks, we can talk about months, we can talk sometimes years. So what do you say or what do you suggest to your patients? How can they approach it from this psychological side?. How to be better equipped to be able to do this marathon of healing an injury?

49:56
Ron Clinton:
Yeah, so in physical therapy, because of insurances, we usually only get a certain amount of time with the patient. In many cases, it can be fairly short, depending on their insurance coverage. I like to try to equip the patient with as many skills as possible in the time that we have. I refer to it as their toolkit. The tools could be exercises, relaxation techniques, stress management techniques, and referrals to other healthcare professionals. Sometimes, as they say, it takes a village to get people well. I was recently treating a military guy who had spent time in Afghanistan. He came in with an ankle injury diagnosis, but on evaluation, he also had knee problems and back problems. We were treating all of that at one time. He also had PTSD and was being treated for that with a psychologist. I was helping him with his physical pain, which we were able to get under extremely good control, and at the same time, he was getting assistance with the PTSD. Over several weeks, this put him in a very positive space going forward because he was able to significantly reduce his physical pain and improve on the psychological end as well. That's totally out of my field to deal with something like PTSD, but it's important to know when to refer people to other specialty areas so they can get the total help they need.

52:09
Dr. Maya Novak:
Yes, and it really takes a village right? It takes a village to raise a child, but it also takes a village to heal the injury.

52:17
Ron Clinton:
Yes!

52:18
Dr. Maya Novak:
So don't expect a certain health provider to have all the answers, right? I mean they have their specialty but we do have to build our circle of people who are supporting us and helping us through this.

52:39
Ron Clinton:
Yeah, and another thing that I find that is very healing for a lot of patients is when you sit down with them and you try not to be rushed. And you really truly listen to them. I've had patients that said, “You know, you're the first person that really has explained what my condition is.” And an evaluation can be a treatment. You don't have to do anything in terms of exercise with that patient. But if you approach the evaluation in that manner of being totally present with that person, listening to them completely and making sure that you understand what they are telling you, that in and of itself may be the first time that's happened with some of them and can be a healing factor in and of itself.

53:43
Dr. Maya Novak:
Absolutely. Being heard. This can be really the most healing thing because sometimes everything that is happening internally with us, of course the body is screaming with all of this pain and sometimes we just need to be heard. Because no one else is asking us, “So how are you really feeling today, tell me more about that?” Really simple questions but they can make the whole difference in someone's journey.

54:14
Ron Clinton:
Yeah, and is there's a funny story of, a guy. He goes to a friend and he's just telling him all his problems, and this friend is really listening and listening but he never really says anything back to him. And the guy walks away and the next day he sees him and he says, “Boy, you know it really helped to talk to you about this problem!”[chuckles] But really the person didn't say anything to him. He just really listened to him.

54:46
Dr. Maya Novak:
Yes, sometimes we just have to put it out there. Whatever is happening, just let it out. Let it out. Now, talking about listening but also asking the right questions. At the beginning I said ask questions speak to different kind of health providers. But there are also some questions that we can ask ourselves to evaluate if we really need any kind of knee replacement or surgery. And before we started recording we talked about how you have a set of questions that you can share with listeners that will help them determine if they need any kind of um procedure or not. Would it be okay if we go into this right now?

55:40
Ron Clinton:
Yes, sure.

55:42
Dr. Maya Novak:
So can you share? I don't know how many questions you have, if this is 5 or 10, but can you share what are they about and how to evaluate if I need a procedure on my knees or not?

55:59
Ron Clinton:
Okay. Well, I think we can start with a couple of questions related to activities. For example, if you are a person with a knee problem, are your symptoms constant or intermittent? If they are intermittent, there is a potential that those symptoms could be coming from your back. Before considering any kind of injection or surgery, you should make sure that the spine is cleared as a potential source for the problem. Another situation would be if your knee feels better with walking but worse with sitting. This would indicate a good chance that the problem is from the back because movement helps it, and a sedentary position worsens it. A lot of people with low back problems find that sitting is an issue, so if sitting makes your knee worse, you could potentially have a low back issue. Playing off that concept, let's say your knee always gets worse when you sit down after maybe half an hour or 45 minutes. The next time you sit down for that length of time, try sitting in a firmer chair, sit up straight, and maybe place a cushion behind your back. If it takes a lot longer for the discomfort to develop or it doesn't develop at all, then you can almost be assured that a back problem is definitely contributing to the knee pain. There may be some issue with the knee, but the back is maybe a primary contributor to your knee pain. Other situations, like the intermittent nature of the pain, can also provide clues. If rest helps and then being on your feet and doing more tasks makes it worse, it could be either knee-related or back-related. But anytime it's intermittent, I would definitely consider the back as a potential source of the problem. If you find that bending your knee relieves your pain, like bringing your knee up to your chest and squeezing your leg, it might indicate a direct knee problem. Similarly, if you sit and straighten your knee several times and hold it for five or ten seconds, and it gets a little better, that might indicate a knee problem that could be treated effectively. Those are probably the main simple things that people could check themselves easily to see if they might be leaning in one direction or another regarding the source of their pain. Ideally, a full examination can usually determine quite easily if it's either the back or the knee and in what direction the knee needs to move for treatment.

59:47
Dr. Maya Novak:
Oh, I love these questions because they're really simple but they're really guiding the person through what is actually happening. So before we start panicking about, “Oh my goodness. Do I need surgery?” Just relax, sit down. Again, release these questions, write them down and think about this. So it's not necessary that we start panicking, “Oh I need surgery or I need something...”

01:00:14
Ron Clinton:
Absolutely.

01:00:14
Dr. Maya Novak:
But you very often mentioned it's almost like fifty-fifty, right? Maybe it’s knees. Maybe it's the back. When there is a problem in the back, what is the solution? Is the solution exercises for the back or what? What do we have to do or what do you do with your patients that helps?

01:00:43
Ron Clinton:
Okay, when it is back problems, the evaluation will usually tell us which direction of exercises will help relieve the symptoms. This can vary from person to person based on their physical abilities. There might be exercises that involve flexion of the spine, such as bringing the knees to the chest or bending forward, or extension of the spine, such as arching backward in a cobra-like position from yoga. There are many variations on these exercises, and there are many subtleties to them. The prescription for a particular patient could vary significantly from one person to another. During the back evaluation, if we determine that the knee problem is actually a back issue, we would put the patient on a trial program. They would go home doing either extension or flexion exercises. When they come back, we check if they are having better results with those baseline activities like stairs, squatting, and walking speed. Those are the typical exercises we use, but there are a lot of variations and subtleties in the exercises that are based on either extension or flexion.

01:02:32
Dr. Maya Novak:
Oh, and this is great. You know, you're mentioning exercises, and people go home, do the exercises, and come back, and we see how much they've progressed. Now, some people are really good at that. They do the exercises, really focus on getting well. But there are also those people who get the exercises, maybe do them once, and then come back saying, "Oh, this doesn't work for me." So, when you're talking about exercises - this was really interesting to me. Before we started recording, when we were talking over emails, you mentioned that the exercises that physical therapists provide for knee problems are actually called Therapeutic Exercise Prescription. It's not just "Here's some exercises, and that's it." It's actually a prescription. Can you explain a bit more why you call it that way and not just "Here's a bunch of exercises?"

01:03:43
Ron Clinton:
Yeah, so in medicine, if you go to the doctor for a checkup and you have high blood pressure for the first time, the doctor might start you on a 10-milligram dose of medication for hypertension and ask to see you in a month. When you come back in a month, the doctor might say, "Okay, I see some improvement, but it's not enough yet, so let's increase it to a 20-milligram tablet." They keep adjusting until they find the right dose for that person. It's the same thing in physical therapy. If a patient comes in and we determine that they need to do certain exercises, we might start them with one particular exercise: 10 repetitions, three times a day. If they come back and say, "I'm not worse, I'm a little bit better, but not that much," we might adjust it to two sets of 10, three times a day. If they're a little frail and we think it might be too much at one time, we might have them do 10 repetitions, five times a day. We have to look at the individual. I have people who come in and say, "I'm not an exerciser. I've never been an exerciser. I don't like exercise. Don't give me a bunch of exercises." And I say, "Okay, we can work with that. Don't worry." Keeping that in mind, I try to keep it as simple as possible and find an exercise that makes a difference for them. If it doesn't make a difference, they won't do it. You totally individualize each case. I typically ask them, "Do you think you can do this three times a day: morning, midday, and after dinner? Does that sound reasonable?" If they agree, I proceed. If it's too much, we can start lower. The patient needs to have confidence that the exercise will be effective. If you can demonstrate that to them, you get more adherence to the instructions. When they come back and they've improved, I encourage them, saying, "You're doing extremely well. Keep up with this program, and you can continue to make more progress." Even if they've not been an exerciser, they get motivated when they see results. I always try to make sure I show them something that works, whether it's reduced pain, improved alignment, or better walking on steps. If they can see that then they’ll be more motivated to do the program at home and that’s the goal. Because once they're done with PT, I don't want them to stop what they're doing. I develop a maintenance program for them, so they don't have to come back for another round because they weren't doing the exercises.

01:07:59
Dr. Maya Novak:
This was such a great explanation, Ron, because I've never heard it explained in a way like when you go to the doctor you get pills. You take those pills, you get back and the doctor checks you. I've never heard it so it's a great aha moment for me as well. Oh, it's actually really a prescription in a different kind of form, so this was great.

01:08:22
Ron Clinton:
Right.

01:08:22
Dr. Maya Novak:
Yes, so talking about surgery and knee replacement and those people who decide this is their only way out. Can we talk a bit about what are some possible complications of a total knee replacement. Just so that the people are a bit more aware of what they are going to go into, potentially.

01:08:49
Ron Clinton:
Yeah, sure. Most knee replacement surgeries go well, but there are percentages of people who have complications. Typically, the older you are, the more potential there is for complications. If you have heart issues like atrial fibrillation, there's a higher chance of problems. Over time, the prosthesis can loosen, and if that happens, you need a revision—meaning they take the old one out and put a new one in sooner than expected. They're supposed to last about 20 years, but if it gets loose, there's usually pain associated with that. Another occasional complication is an allergy to the metal. If that happens, you need a revision again. I learned from a patient that there is a test you can take before a total knee replacement to determine if you are allergic to the metal of that particular prosthesis. Some other complications include people saying “My walking feels different.” They might say, "It doesn't feel like my knee," or "I don't feel right." There can be blood clots post-op, and there are risks related to anesthesia, such as temporary post-operative memory loss. A lot of things can go wrong, but in the majority of cases, this does not happen. However, there is an overall 20% dissatisfaction rate with the outcomes of total knee replacements. To me, that's pretty high—one out of every five people is not totally happy with their outcome. That's unfortunate, and I wonder if a number of those have their back as the primary source of their problem, which was never identified early on. Like our patient Barb, who had a total knee replacement and wasn't happy with it because she still had pain. She went through all those other treatments before she found out that her back was the cause of the symptoms.

01:11:32
Dr. Maya Novak:
Well, that's why we really have to research the right question and find the right health provider. Maybe not just one, maybe 2 or 3 to really be sure that we’ve covered all of the things before we go to get surgery. Because otherwise like you said, there was a surgery on the knee, but maybe the problem actually was the lower back. So it was completely unnecessary. But let's say those people who are not really happy or they had a failed knee surgery or failed total knee replacement, is there actually any kind of hope for them or that's it? You know, you've made your decision…

01:12:25
Ron Clinton:
Yeah, well actually I can give you a couple of examples of patients who had total knee replacements, had poor results, and it wasn't the back—it was still the knee. One patient that I am seeing right now, I'll see her tomorrow, had a total knee replacement a couple of years ago. She went through therapy and did not do well. So, a couple of years later, she came in, and she was averaging a 5 out of 10 pain, which is pretty high to be averaging every day. She would get spikes higher than that. She was another retired nurse—I've had a stretch of retired nurses—and she was very discouraged and depressed. She only did this because her husband asked her to. He found out about me from our high school newsletter that did a little story about me and my book. She said this was her last resort. We started doing the evaluation and determined it was not the back but the knee. We did the knee evaluation and found some interesting things. She had some alignment issues in her pelvis that made one leg longer than the other, which can create an imbalance of pressure on the knee. We also identified an exercise for the knee that gave her relief. It was amazing—on her first visit, she was this depressed individual, but she came back the next visit as a new person. She had energy in her face, could walk a little better, and had hope that she could make further improvements. She was very encouraged, and we're trying to finish up her course of therapy now.

01:14:57
Dr. Maya Novak:
Fantastic. So those people who potentially want to explore a bit more or they need help from a McKenzie trained therapist and right now they're going to go online, they're going to search and then potentially maybe they're going to realize there is no one really near. What would you suggest to those people who cannot find or cannot come and visit you or they cannot find any McKenzie trained therapists. What would you suggest to them?

01:15:34
Ron Clinton:
Well, one option is I have created a course that is a self-treatment course and a self-evaluation course and it's on the Teachable platform. It's called Self Manage Knee Pain. And it's self-manage-knee-pain.teachable.com and there are 2 modules that people can look at for free I really feel it's equal to about 10 visits of pt and it probably costs one visit. So it’s good for somebody in a rural area who can't get to pt, but if people are in Southeast Michigan they can locate me and the the websites that they can go to are the mckenzieinstituteusa.org and mckenzieinstitute.org for international. So you can find a McKenzie therapist anyplace in the world.

01:16:38
Dr. Maya Novak:
Oh that's great. Um, but those who really want to get in contact with you, where can people find more about your work, call you make, an appointment… Can you share a bit about this?

01:16:54
Ron Clinton:
Yeah, my email is ClintonRonPT [at] Gmail.com and if you’d like a free copy of my book you can send me an email and I'll send you a copy. My website is kneeandspinept.com. It's currently under revision and it should be up by the end of the week, but there's a lot of information online about myself and the programs that we use, you know, the McKenzie programs, and there's some testimonials there from clients.

01:17:29
Dr. Maya Novak:
Perfect. So when this is going to be released your website is going to be up and running, so it's not going to be another week. So people can go to your website and get all the information that they need.

01:17:41
Ron Clinton:
Yes, absolutely.

01:17:43
Dr. Maya Novak:
Perfect. Oh, Ron that was fantastic, really eye opening, and before we say goodbye I have one more question that is an out of the box, fun question, not connected to knees. So my question is: if you held an exhibition in a museum and the paintings and pictures would be snippets of your whole life, what would the exhibition be called and what would you like for the visitors to get out of it?

01:18:19
Ron Clinton:
Yeah, that is the most interesting question I think I've ever been asked. In terms of the title I would title it Lifelong Learning and the highlights around the room would be Read, Study, Learn, Listen, Grow and Serve. And that's what I would say is what I have tried to do over my life is. Continue to study and learn and grow and serve people because it's a grace to me to be able to be in the position to help people. And my mission is to get this information out to as many people as possible about their options before having to go through something like injections or surgery through the book and the course.
And the book is free. It's on Amazon, but I'm making it free for just about anybody who wants it just so that we get that information out there and people all over the world can get to a practitioner that can really help them avoid injections or surgery.

01:19:52
Dr. Maya Novak:
Yeah, well Ron I do feel that today I did visit a bit of this exhibition and I'm very grateful for that because it was very eye opening.
And I think that people are going to really love all this information because it's so helpful. So thank you so much for being here and thank you so much for being so passionate about your work.

01:20:19
Ron Clinton:
And thank you for having me. It's been a great experience meeting you and talking with you.

01:20:27
Dr. Maya Novak:
This wraps up today’s Mindful Injury Recovery Talk with Ron Clinton. To access show notes, links, and transcript of today’s conversation go to mayanovak.com/podcast and click on episode 68. While being on the website, go on and discover more about The Mindful Injury Recovery Method, and find my book Heal Beyond Expectations on Amazon. Until next time – keep evolving, blooming, and healing.

Love and gratitude xx
Dr. Maya

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