Your Knees, Ankles, and Hips Are Ready for a Second Act — How New Orthopedics Is Sending Athletes Back to Sport

Ageless Athlete Podcast - Dr Kevin Stone
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Kush: [00:00:00] Dr. Stone. I always like to start off with this question, which is where are you right now and what did you have for breakfast this morning? 

Dr Stone: I am in my happy space. It's number one. Uh, and that's because I'm at the Stone Clinic in San Francisco and on Mondays I see patients and interact with our research team.

In preparation for Tuesdays where we do surgical repair of injured athletes and people with arthritis. And I start out my day, uh, on Monday mornings out on the coast, and usually ride my bike in towards Mo Valley and then, uh, come over to the city. So, uh, it's a good way to start off every Monday. 

Kush: Oh, that's lovely.

So do you ride your bike from your place all the way to over to Mill Valley 

Dr Stone: and then come into the city? 

Kush: Oh, that's excellent. What a what a what a beautiful energetic way to set the tone for the day and the week. Yep. And, uh, as we were just, [00:01:00] uh, discussing, it's a, it's a gorgeous day in San Francisco. I I bet that made you a ride in just that much more nourishing, 

Dr Stone: it makes it even better because I ride to Sausalito and then I take a small motorboat that I keep there.

To the city. So I get the best of both worlds where we live here riding in the hills in beautiful part of the Bay Area and using San Francisco Bay as much as possible. 

Kush: Incredible. Yeah. This is, , this is just using one's environment to one's full advantage, even when one is commuting. Of course.

Excellent. Dr. Stone, it is so refreshing to. Talk with someone who actually lives what they teach. You are moving, you are playing, you're staying active, and you're not just disseminating all of it in theory. So before we dive into the details, for listeners who might not know you yet, [00:02:00] could you give us a quick snapshot of what you do at the Stone Clinic?

And the kinds of people you help. 

Dr Stone: Sure. So I'm fortunate to be an orthopedic surgeon and I divide my life between clinical practice where I'm treating primarily knee, shoulder, and ankle patients, usually injured athletes or people with arthritis. And I also, uh, run a public nonprofit research foundation called Stone Research, which you can find information about it, stone research.org.

And then I, my third part of my life is that I invent products and devices and things that would help people and help the field of orthopedic surgery help people stay active. So I get divide my life three ways that way and every day, every patient that I see, every surgical technique that we do, the focus is how do we make it a little bit better every single time?

So there's no [00:03:00] single standard procedure in a sense. I don't believe in that. I think there's almost everything we can do. We can make better, and that the science around making them better is, is a key part of how I practice. And that's why the Public Research Foundation is intimately connected to the Stone Clinic so that almost every patient, uh, is entered into one research outcome study or another.

And the reason for that is that I don't believe that a doctor. Should do something to, or put something in a patient that they either don't know the outcome of or aren't trying to study or improve the outcome. And so all the things that we're doing in terms of new surgical techniques around treating, preventing curing arthritis, or accelerating healing, all of these are being entered into a research database.

All of them are being exposed to different things that are happening in our field to see if we can make them better.

Kush: [00:04:00] I love it, Dr. Stone. Yeah, your work sounds comprehensive So I can see that you are continuously innovating and the part about your work, which is particularly attractive to listeners of this podcast, lifelong athletes, people who wanna keep moving till the day they cannot move anymore.

So could you give us also a snapshot of the type of people who. You are most likely to help. 

Dr Stone: Sure. So I see athletes of all ages and so there's the high school and college athlete who tears their meniscus the way I did when I was in college and, uh, tears their ACL or dissipates their shoulder or the sort of the typical sports injuries that we see in young athletes.

And then there's also the, all the middle aged folks, the folks who had their meniscus taken [00:05:00] out when they were in high school or college or injured their knee then and then are starting to develop arthritis. And then I have a wide range of patients who are referred from pickleball these days because our 50 to 80 year olds are picking up pickleball at an enormously rapid rate, and they're unfortunately not prepared for how ballistic that sport is.

So I see lots of Achilles ruptures and shoulder tear, rotator cuff tears and other injuries from pickleball. So we see a wide range of athletes. All of them have the goal of, Hey, look, how do I stay playing my sport? Or I've been told I can't run, or I've been told I need a knee replacement, or I've been told things that are, Not as conducive to keeping playing the way they'd like to. And that's our job. you know, we're very focused on how we keep people playing for a lifetime, how we keep them engaged in sport, which we think is just the key to a lifetime of happiness. 

Kush: Your mission resonates strongly because it's not [00:06:00] just helping people regain day-to-day functions.

It's about helping them regain. The joy that they find when they're out there doing the activities they love. So it really is a quality of life change that you are enabling or at least you are helping maintain. So people listening to this podcast, I think they will want to listen in strongly because.

Yes, these people have had their shift injuries, the type of stuff you described. Yeah. Torn meniscus of course, but also, worn out cartilages where the standard treatment might have been, Hey, let's go and get that joint replaced. from your front row seat, Dr. Stone. So what is actually possible today in.

for repairing or even regenerating joints. So [00:07:00] what can orthopedics do today that wasn't a realistic even 10 years ago? 

Dr Stone: So in a broad sense, in the past when you saw a doctor with a torn tissue, whether it's torn meniscus or other tissues in the knee, joint, shoulder, ankle. They'd often take out the tissue and then inject cortisone or try to keep you going until you come back to me when you're ready for your knee replacement or live with your pain until you're older, or the whole field was around removing damaged tissue.

That's changed dramatically. Now, we're in what I call the anabolic era of orthopedics, which means that instead of taking tissues out, we put tissues back in and we stimulate them to heal. So a great example is the meniscus cartilage injured about a million times per year. In the United States alone, more than 90% of these things are taken out, or the tissue is trimmed.

The rest [00:08:00] are repaired and very few are replaced, and we developed the technology and that a lot of the techniques for replacing the meniscus cartilage using a donor allograft tissue. In the past, we also u invented and developed the collagen scaffold for regrowing the tissue that's not currently on the market, but it's about to come back.

But the meniscus tissues are available to replace the meniscus. So all these people who've been. Playing, and impacting on their knee without a meniscus and developing arthritis. We think the moment the tissue comes out, it should be replaced. And then we think for those who develop pain, we can put a meniscus back in and help them restore their sports and diminish their pain.

So remember I told you that we're in an academic environment here as well, so we published a paper on people over the age of 50. Who were told to have either a total knee or a partial knee replacement, artificial replacement for [00:09:00] their arthritis, and as long as they still had some joint space remaining, we went ahead if they wanted us to and put back in a new meniscus and grafted their damaged articular cartilage to regrow it.

And when we looked at and track 85 of these patients over the course of 25 years. About 42% of them got about eight and a half years of relief from the biologic replacement before they had to have partial or total knee replacement. And the other 48 of them, 48% of them never went on to having that partial or total knee in the two to 25 year outcome study that we did.

So we know now that we can do a biologic joint replacement. Often when we thought we had to do an artificial joint replacement. Now, the other side to that is that because of robotics, we now can do partial knee [00:10:00] replacements so much better than we could ever do them in the past. So many of the patients referred for a total knee replacement actually don't need a total knee replacement.

They can have a partial or a biologic, and then those that do need a total knee replacement. Because of the precision of robotics, we can now get rid of the, of the bone smith that we used to use, that limited people's return to impact sports. So we now can permit, uh, people to go back to running and playing tennis on their total knee replacement, which in the past we weren't really able to do.

So there have been these amazing improvements that we've been part of as other as both inventors and participants in this wonderful era. Of having new tools to get people back to sport. And it's not just the knee joint, the ankle joint has come along in dramatic ways as well. Uh, the shoulder is not quite as, uh, advanced as the ankle and knee are in [00:11:00] our options for biologic treatments.

But still, even there, there are some better tools than we ever had before. 

Kush: Wow. Dr. Stone. Yeah, you threw out a few different things at us and I'm gonna try to see if I can, go down further with some of the things you talked about. So going back to that illustration you provided, which is somebody who comes to you, and they may have a combination of things happening with their need.

So let's stick, let's stick with the knee illustration. So we talked about. A meniscus that might be torn. We also talked about cartilage that had eroded, so the meniscus bit, I understand, but are you telling us that there is a possibility that people who have, let's say, lost all cartilage where, and they hear, That their knee is bone on bone. So those people also have possibilities [00:12:00] here that allow them to regain full function without the need for their knees being replaced. 

Dr Stone: Yeah, so the guideline in the knee joint is bone on bone. If you're, if the x-ray shows bone on bone, then there's not enough space usually.

To replace it with biologic tissues. In that case, most of those people are only bone on bone in one compartment, and so they can have a partial knee replacement, which is a procedure done robotically, takes about one hour. It's an outpatient procedure. You come into the clinic the next day and start your exercises right away.

98% of those patients between three and four months will say it's a forgotten knee. We've had patients go back to running across the United States on these things so it can return them to having a normal feeling knee. Now, if they have cartilage damage, remember there's two [00:13:00] types of cartilage in the knee that the articular cartilage, that white shiny surface.

When you crack open the chicken leg, that's what when you get arthritis, it's wearing that down to the bone. The second type of cartilage is meniscus cartilage, the shock absorber inside the knee. So when they wear down the articular cartilage, the bearing surface, that can now be regrown in many instances.

And we do that all inside the knee. We take some of their own bone and cartilage, create a paste out of it, and then we're able to paste that uh, material back onto their damaged area inside the knee. And we're just doing a number of studies right now in various animal models to see if we can improve that pace Graft.

With various growth factors, cells and jelly, and a host of factors that augment healing. But right now we can do a pretty good pace for many people who have warned part of their articular cartilage down. So the answer is yes. don't be told, don't live with the advice of wait and fill your [00:14:00] knee replacement.

There are a lot of things that can be done now to get you back and playing sports. Now, I will tell you that almost every one of these procedures, these days, the results are improved by adding injections of lubrication and growth factors to them. So a dramatic change in our practice in many people's practices over the last decade has been when we do a surgical repair, how do we augment it to get it to heal fast?

So let me explain. So if I ask any patient a year after their knee surgery, what was the worst thing about it? They never say it was the pain. They almost always say it took them a year to come back from the muscle injury or from get their muscle atrophy back or their tissues strong enough. You know, why does it take collagen fibers a year to mature?

So it turns out we can accelerate some of that healing, doing a host of things and, we're driven on the research side to [00:15:00] figure out how we make. That acceleration worked better. 

Kush: Dr. Stone, you're blowing my mind. I did not know that. It is not possible to regrow old cartilage. I thought once your cartilage was worn out, it was done.

is this something which is new? Is it proven? Is it becoming more, Just more, valid as a confirmed type of treatment and it is more than just experimental. 

Dr Stone: Yeah, so we've published both, uh, two to seven year follow-up studies in peer review journals. We also published two to 25 year follow-up study on the biologic reconstruction of knee joints.

I lecture around the world at various meetings and just gave a talk at the International Cartilage Repair Society meeting. Boston. I think cartilage regeneration is an accepted technology now. every, there are lots of different [00:16:00] approaches towards cartilage repair. We feel confident in the way that we do it using a base graft technique as we think is the best one for almost all the situations that we see is probably the only one indicated in arthritis.

There are a number of other techniques. Indicated in what's called an isolated chondral defect, when you have a small hole in the cartilage and there are different ways to plug those holes, but in the setting of arthritis, the pace graft technique seems to be the best and the only one really indicated there.

Kush: And just to be clear, uh, Dr. Stone, are we just talking about cartilage in the knee here or are you also saying that the cartilage in other joints, that. But mentioned like the ankle, shoulder, et cetera, those can also be grown the same way. 

Dr Stone: So our experience with cartilage degeneration is primarily in the knee and in the ankle.

There's an excellent foot surgeon at my surgical center. I've taught him how to do the cartilage procedure for the various toe joints [00:17:00] that he operates on. So I know that it is done in other joints as well. The shoulder and hip have been extremely difficult because of their shape and their anatomy. so I can't offer, uh, and I don't operate on hips.

I can't offer that same optimism to the shoulder, but knee and ankle are definitely treatable with cartilage degeneration techniques. and we're optimistic that we'll get better and better at these. 

Kush: Wow, so incredible. Let me ask you this, rather. General question so folks have a sense of how innovative and how just life changing these treatments can be.

So can I ask you to hazard just a guess? Just, back of the envelope guest with, if they're a hundred knee replacement. Surgeries that happen, let's say each day, how many of them would be preventable? Still [00:18:00] allowing the candidate to regain full function with the type of intervention you are talking about?

Dr Stone: Yeah, so there are different ways of looking at that. There are about 450,000 total artificial total knee replacements done in the US each year. It's said by one study in England that 80% of those could have an alternative treatment, meaning a partial knee replacement or a biologic intervention. So there's a substantial number of people who when told to have a knee replacement or told to wait for their knee replacement.

Should look at what their other options are. It just, you need to know that, you need to know the bias of your surgeon. So I'm biased. we've spent years developing these biologic techniques and these robotic partial knee replacement and total knee replacement techniques. So we're, and we've spent years working with athletes A, we're all athletes here as well, so we're [00:19:00] very biased towards the side of helping people play sport.

Helping people just treat the part that's injured and not take more risk of replacing uninjured parts of the knee. And we're also humbled by the fact that we know that if we do a full artificial knee replacement, it's not really a normal knee and it's not. They have a failure rate and we like to do things where we can bail out if there's something that goes wrong or they doesn't last 'em as long as they want.

Once you do a full artificial knee replacement, it's very difficult to revise it properly. So we're biased towards biologic interventions towards partial knee replacements. In the ankle towards cartilage grafting, in avoiding fusion in ankle replacement. Just speak to that ankle for a minute. So many of the people we see from around the world have been told after their trauma to their ankle that they had only two options, an ankle fusion or an [00:20:00] ankle joint replacement.

And we've learned over the years that if we just go in and recreate that ankle joint, even in very difficult arthritic ankles. We can get a biologic healing response that works quite well for patients. So it's a great example where we all thought there was nothing that we could do, but we now know that we can biologically treat these ankles that otherwise look destroyed.

It's very different than the knee joint, by the way. Once the knee joint is truly destroyed and bone on bone, we have to use artificial materials. But there's something quite unique about the ankle. Let me explain that a little bit more. You're walking around with your entire body loading on that tiny little ankle joint only on one side with each step, and yet the ankle never becomes arthritic unless it was injured, unless you had trauma fracture or dislocations and stability.

The ankle just never becomes arthritic on its own. There's something unique about [00:21:00] ankle cartilage, and so we can take very damaged arthritic ankles. Regrow cartilage in them when we otherwise didn't think we could and we can't in a knee joint when it's so severely there. So we're learning about the unique aspects.

All cartilage is not cartilage. They're all a little bit unique. And every individual's unique as well. What their goals are and their desires, their healing ability, their likelihood form scar tissue. People are remarkably unique. We don't see that there's any standard procedure. We don't think there's any standard patient.

We think everybody really needs a thoughtful, individualized approach. And people respond very differently. So if you're the patient, I would tell you explore your physician's biases. Just ask straight out. Uh, people ask me all the time and I tell them all the time. And if the physician's biases match your own biases and your own desires, then you're probably, uh, you know, heading down the right path.

But if you're heading down a [00:22:00] path or your goals are to play one sport or be able to run or be able to climb, and your physician's attitude is, no, don't ever do that, you're probably in the wrong hands. So I think exploring that understanding that really helps you get the kind of care that you want to get.

Kush: Appreciate that. I mean, I think most people listening would say that their bias is for sure, for being able to regain full function of their injured. and they would wanna work with a specialist who will help them get there. But to what you said, there are different paths to getting there, and different paths have different levels of surgical trauma and different levels of long-term effectiveness.

However, what I can see from the approach that you have, perhaps your approach is less invasive. And may be more promising because of some of the data that you shared. [00:23:00] For sure. The fact that the recovery times and just the time under surgery, those right away seem just,more palatable than going in for a total joint replacement.

And because this term is going to be. To this conversation. I think yeah, I think it would be. Who us, for me to ask you like right away. So what is a biologic replacement or scaffold, I think is the term you use and how is that really different from the simple, uh, trim it and go, approach with arthroscopy?

That has traditionally been, I think the, uh, the mechanism. 

Dr Stone: So arthroscopy is the tool for looking inside the joint. And then what you do when you're there is either you can take tissue out, you can smooth tissue down, or you can put tissue back or repair a tissue. And [00:24:00] so what we like to do whenever possible, a biologic joint replacement means that if you're missing your meniscus or you're missing your articular cartilage, or you're missing your ligaments, or they're torn, we want to either repair, regrow, or replace those tissues.

And so, you know, I'll see somebody that needs everything. So tomorrow I'll do a biologic knee reconstruction where the patient needs a new meniscus, cartilage put in, needs a new ACL and an extra articular graft to control their rotation, new needs. their damaged articular cartilage grafted. So we'll use a pace graft technique in order to do that, and we'll do that all in an outpatient surgical environment.

And then they'll come into the clinic the next day and start their rehabilitation program. So that's what a biologic knee replacement is. On the other hand, if we see somebody that has worn their knee joint down to bone on bone has no joint space on one side, then in that case we'll often do a partial knee replacement.

[00:25:00] That's when we use a robot, but a middle cap over the end of the femur and a little tray on the tibia, just only on the side that they've damaged it. And that can either be on the medial side, the lateral side, or just at the patellofemoral joint. See a lot of people with anterior knee pain, when they develop severe arthritis, the kneecap, then we can just surf, resurface that area and not touch the rest of the knee.

So in the knee joint, those are the common things In the ankle, in the achilles tendon is a nice one to talk about that we haven't mentioned yet. So, so many Achilles ruptures get open surgery, and we've learned over the last decade, a couple of decades, that they really don't need open surgery. We can repair those ruptured achilles tendons with what's called a percutaneous technique, where we weave a suture underneath the skin and never make an incision open incision there.

And so we don't lose that natural, normal blood clot that forms around the ruptured ends of the utility tendon. So these are techniques and, and [00:26:00] biases that we're, we're able to bring repair methodology to damaged and missing tissue.

Kush: Amazing. Again, just for people who are listening who might immediately be interested in exploring this type of intervention, yeah. Can you provide to us. What the current landscape is of being able to find a clinic. Let's say somebody's interested and they are not able to, find time with you either because of calendars or they, maybe they just happen to live in a different place.

Far away. Are these procedures becoming more and more common? So if somebody lives in let's Australia or Canada, or a different part of the us, can they find somebody? Who can help them, uh, evaluate if a biologic replacement is indeed, viable for them? 

Dr Stone: Sure. So for information, they can look on our [00:27:00] website@stoneclinic.com and go under videos, or if they want to consultation, they can go under consults.

And we do lots of these remote consults for people from all over the world. They can also look, if they're interested in the research part of it, they can look@stoneresearch.org and get information about the research aspects. And I think, you know, most of our patients are looking at chat, GBT and other AI methodologies of looking up biologic knee replacement or avoiding total knee replacement.

And that usually will lead them to surgeons who have that kind of bias. So I think the tools are out there. I spend my time running around the world lecturing and creating surgical videos and trying to teach. the methodologies that we develop and, so there are a lot of us who are passionate about trying to move this field forward.

And it's exciting, it's fun. It's, we get to take care of people who are just like us, who want to keep playing. Beautiful. 



Kush: yes, it is correct that a lot of information is at our fingertips now, but sometimes that also, adds to the [00:28:00] confusion. As the noise of, uh, where to go for a, across the source. So yes, we'll put links and people are encouraged to visit your website I know you publish regularly and, uh, they can, assess based on the information you have provided.



Kush: so what I'm understanding is that, each person is different. The treatment that you will advise will be different? Yes, there likely are situations when a total joint replacement is indeed warranted, but those will be more rare than was advised even just a few years ago. one other, area I would love for you to help unpack for us is, so when it comes to, again, these joints, the ankles and the knees, but also the, the shoulders and the hips.

There are a lot of buzzwords that have, uh, come up in the last, several years, one years [00:29:00] of stem cells, one years of PRP. I'm sure you also hear of Others in the medical community and also your patients talking about these terms. So can you help us separate what is real and what is the hire?

And yeah, are these other therapies generally helping people today? 

Dr Stone: So the answer is yes, they are helpful. And let me explain though, again, my bias. For your listeners so that they can sort through the various therapies that they're being asked to have in their own joints or their own body. So in general, you need to know that you as the patient sitting there, no matter what your age, have billions of stem cells within your body.

They're called pericytes. These are cells that live on the walls of vessels and when you have an injury. Even a simple injury falling down on that sidewalk and banging your knee or [00:30:00] your muscle or football injury, there's a siren. Call out to your body's own stem cells to rush to that site of injury and direct the healing response, and that's how normal healing works.

So as a physician, especially one interested in these biologic therapies, my job is to figure out what to. Do to accelerate your healing response. Now, traditionally what we used is physical therapy, soft tissue massage, ice, heat elevation, and then surgical repair to try to get these tissues to heal. And what we have now is an ability to inject factors that accelerate your body's response to make that healing occur.

So what are the factors? Number one, there are lots of these factors in your own blood, and so we use your blood to take [00:31:00] your platelets and get them to release these granules that have lots of growth factors in them. And those growth factors work both locally to help the healing, reduce inflammation, stimulate new collagen production, reduce inflammation, and they also work to.

Recruit your body's own stem cells to that set of injury. You can choose to add additional cells from your bone marrow, from fat, someone else's bone marrow, or fat from birth tissues. All of those things are potentially helpful at increasing the healing response, but the reality is what we wanna focus on.

Is the most potent recruitment factor for your body's own cells. So when you go somewhere and they say, Hey, we're gonna inject 1 million cells or 10 million cells of [00:32:00] whatever, you should be sitting there thinking, Hey, it's not really the number of cells you are going to inject because those cells probably die or probably don't stay at the site of injury very long.

What I really want you to inject. Is the most potent recruitment factor for my body's own cells. 'cause I'm sitting here with billions of stem cells ready to respond to this injury. So many of our patients and people we see from around the world have gone to Mexico, have gone to wherever to get cells grown in tissue culture and then inject it into them.

I think they've wasted their money because it's not the number of cells, it's really the recoupment package. So that's where I think the field is today. Our research is on how we do that more potently, and I think you wanna use the most cost effective, therapies and injections that work best for your individual [00:33:00] problem.

And then you want to potentiate that injection. Meaning, how do you make that thing work better? And you do that with exercise with soft tissue, massage with energy. So the shockwave therapies that add energy to these injections augment how they heal and make them heal better. So in general, every time we're doing a injection of these factors into someone's injured tissue or arthritic knee, we're almost always encouraging them to stare on long enough to do.

Shockwave therapy type approach or other approach, soft tissue massage therapy, whatever they can do in order to augment that healing response. So stay tuned is what I would tell your listeners. be very cost effective. however, these injections if done safely, can be quite helpful in a lot of circumstances.

Kush: Dr. Stone, I mean, you've just dispelled this huge myth about just. [00:34:00] Yeah, it's not the quantity of the stem cells that's going to make that difference. Your body already has all these other stem cells waiting as receptacle. So, yes, I think that's, that's really pointedly helpful right there.

I'm trying to understand or make sense of all these different possibilities, maybe almost this buffet of, Treatment options, and maybe it's not a buffet. So I think maybe I should ask a very simple question first. So, in your clinic, do you also provide RPS and stem cell therapies to patients, or do you Yes.

Every day. 

Dr Stone: It's a big, it's a big part of both helping people avoid surgery, help people accelerate their healing from an injury or from surgery, or help people have a surgery work better. 

Kush: Perfect. So let's use a, like a real world example. Let's say you have,a 50-year-old skier or runner who walks into your clinic [00:35:00] with, with pain, with knee pain.

How would you go about helping this person, 

and helping them? Sort through either, examine different options or combining these different options to allow them to move past pain and get back to full long-term health of their knee. 

Dr Stone: Well, first thing is a good history, understanding how they get injured and what the symptoms are.

A very careful physical exam to understand their gait, their mechanics, their walking and running gait. their range of motion, where they hurt, how the tissues feel, how loose they are, whether they're unstable. Most of those factors just by careful physical exam and history. X-rays and MRI are almost universal in part of making the diagnosis.

We do that right here in the clinic so we can have clear pictures of exactly what the injury is and a physical therapy [00:36:00] assessment of the patient as well. 'cause we learn so much from physical therapists and athletic trainers, uh, and things that we sometimes don't pick up ourselves or the patients tell them or that they see from their perspective.

So the entire team. Looking at somebody, a 50-year-old walking in with a particular problem has gotta come together to understand what's the injury, what's the right path to get that person back? What are their goals? How are we gonna get them there? The other thing is that trying to help people see their injury as an opportunity.

So bad luck, you injured your knee, but we have all these resources to help you, you know, treat yourself like a pro athlete to treat themselves. Use this injury become bitter faster and stronger, as we like to say, than you've been in years. So if we're gonna spend a few months helping you recover from something, why not train your entire body, your core, your your cardiovascular program, all the rest of your physiques, you come back to whatever [00:37:00] support better than you've been in a long time.

So I think if the patient can adopt that mentality, then all of the things that we can bring to the table to help them get better. Just work better and it's more fun and it's more satisfying for them and for us. So it's a, it's a partnership between us and the patients. And the better we do with that, the better they do.

Kush: That sounds so comprehensive. Yeah. I mean, if you're starting right with understanding their. Movement history, their interview history, their gait analysis, and their future goals. I guess all of those will likely yield to,a, a more long-term outcome. Tangentially talking of gait analysis and talking of just, just body alignment, many people are often born with, let's say.

Undiagnosed, alignment issues. You know, it could be things like, uh, flat feet to, knock knees or four-legged to maybe even hip [00:38:00] dysplasia. So the interventions that you are, you are executing in the also help Correct for some of these issues. The reason I ask is one can go in and make that one time,joint, partially joint, like one time intervention to the injured, joint.

But if one is not able to, let's say, correct some of the root cause with misalignment, perhaps there's a higher possibility that those injuries will come back. So do you. Do you help correct some of those foundational issues that people might have with their alignment? 

Dr Stone: Sure. So the way we say it is that bad biomechanics will destroy good biology any day of the week.

sure you put new, new tires on your car, but if the car's outta line, the tires are gonna [00:39:00] wear out too fast, right? Yep. So a big part of what we do and uh, our rehab team focuses on is trying to help people optimize their mechanics. So if you've been walking with a painful knee for a few years, you most likely you're walking badly, your hips are affected, your back's affected, your ankle's affected, We do see the person as an entire person and an entire athlete. So we wanna focus on all of it. 

Kush: Yeah. Poor biomechanics

will, will linger. Whatever intervention you put forward, if those are not, improved upon still. Okay, so what we are saying is that, these treatments can be done, will be done together, will be done, as a combination, based again on the individual in practice Now.

I'm not sure how long have some of these interventions been, executed by you, your team, and [00:40:00] others, but can you also give us a sense of what has been the experience longer term? So again, this is somewhat new, but you have been practicing this for some time now, so could you. maybe either use some real world examples or just, overall data on where are those patients who have had these interventions over the last several years and how is their health and their lifestyle today?

Dr Stone: Sure. So we published a two to 25 year outcome study on biologic knee replacement. and, and looked at patients who had severe. Cartilage damage and loss of meniscus. And what happens to those patients after you replace the cartilage or replace the meniscus or redrow the cartilage and replace the meniscus?

And we know that about 80% of them had a 17 year follow up. On average. Were happy with their outcome playing sports and were improved. [00:41:00] And so we know it's not perfect that the knees aren't perfect, but that we can get good enough car repair to keep people being added. And that's our goal. And that was before we were adding all these additives to, uh, stimulate healing.

So we think today the data will be better. 



Kush: sure. And maybe we should also just provide listeners a sense of what might be some of the financial outlay of, seeking this kind of treatment. So are in the US at least. Are insurance plans covering these, let's say your, your general insurance plan, are they covering this type of treatment?

Dr Stone: I can't really speak to it specifically 'cause every plan is totally different and it really depends. They'll cover parts of one thing and not parts of another. There's just so much vari variation that I stay out of it. 

Kush: Okay. fair enough. And maybe just one last question on this, Just the research and what's [00:42:00] going on.

So we spoke about what is happening today with what's available. what is in your mind, the next wave or the most exciting research or breakthrough that gets you, uh, excited and, and up at night with what is yet to come? 

Dr Stone: There are two major spaces. One is that I think we'll have better injections.

We'll figure out how to use birth tissues better than we're using them today. You know, there's nothing growing faster than the fetus. and the fetus is only half the mom, and yet it's not rejected by the mom. So there are potent growth factors, immunomodulatory, antifibrotic, anabolic, stimulating factors that are in birth tissues.

We will use more effectively than we're using today. If there is a fountain of youth, it's the birth tissues that we should be able to apply the second major area that we are involved in research on, and that I think will affect people. [00:43:00] Is we need to be better at bioidentical hormone replacement for both men and women.

I, there's no such thing as the field of male hormone replacement therapy right now. Although there has been the field of female hormone replacement therapy mostly with estrogen and progesterone. But the reality is that there are millions, no, there are a wide range of hormones and peptides that. Will affect you as your age.

And so as you know, all men and women are losing muscle mass and bone mass with aging and all. And we should be better at being able to restore a number of the hormonal factors that affect their aging tissues. And we're very poor at right now. you know, you've heard about testosterone, but you think it's involved only in weightlifters, 

data from 20, 30 years ago.

The reality is that probably most men and women should have some type of testosterone replacement as they age. 'cause they need [00:44:00] the testosterone, their muscles and bones need it. But we just haven't had the right kind of guidance and protocols to figure out how to use it properly. Uh, women fortunately have figured out how to use estrogen, progesterone, to diminish the effects of aging in menopause, but men have not figured it out at all.

So I think that there will be tremendous progress in this space. I think it's a very exciting space. It includes the whole space of peptides, as we've seen with peptides for weight loss. there's just so much more potential in that space, and it'll be very exciting. 

Kush: Super exciting. Dr. Stone, initially, you know, when we were talking, you spoke about.

How upper body, maybe specifically the shoulders, 

Speaker 3: we 

Kush: are not quite as far along yet with being able to, implement or at least evaluate the same type of treatments that you have now described for us for the ankles in your knees. So [00:45:00] what is your, perspective on when can healing methods for the shoulders catch up?

Because a lot of overhead athletes start getting bogged down by shoulder issues. They were actually, they hit a certain point, 

Dr Stone: we're actually gotten pretty good at shoulder soft tissue repair, which is not, not very good at shoulder cartilage repair yet. So, you know, shoulders that are getting arthritis have.

Limited options. We're pretty good with injections. We're pretty good with tendon tissue repair, which is not very good at cartilage restoration procedures. I think they're quite far behind, same in the hip. so we do things to help buy time. We help patients restore their musculature and their tendons and their rehab and their injections, but we don't really have good techniques to delay their arthritis yet or treat their arthritis properly.

It'll come. It's just, uh, it's behind. 

Kush: What about these, other options to help either restore some [00:46:00] functioning or maybe just, degrade the growth of the arthritis by using again, PRP and stem cell? Are they, are these procedures as effective? 

Dr Stone: For shoulders. There are still, in fact, they're really the only tools we have, once we repair the soft tissues.

So we're using them extensively in the shoulder and hip, even though we don't have the surgical techniques that we wish we had to regrow those tissues. So it is the technique we have. So when we see arthritic shoulders, we're injecting them and rehabbing them quite a bit. We repair the rotator cuffs and torn labrums of course, but The cartilage side of it, we're mostly doing injections. 



Kush: and how many years away do you think, are we before we can walk into your clinic and ask for the same kind of, uh, cartilage regrowth that we have? Fair enough, fair enough. okay, great. so moving beyond surgery, I [00:47:00] love the fact that you speak about rehab and return to the sport.

Extensively. So yeah, once, 

Speaker 3: yeah, 

Kush: the surgery is done, you know, then the real work begins. And, uh, so from everything you've seen, what sets the people who come back stronger then from people who plateau and may and don't have the same, same successful outcome? 

Dr Stone: Good biology. Good head, good motivation, great physical therapy, great attention to detail, giving themselves the time to spend in rehab and fitness training, setting real goals and achieving them.

just being determined to not let anything get in their way if they have a problem from the surgery, meaning they form scar tissue or a painful spot undergoing a second procedure if they needed to tune it up. Uh, getting access to good injections in the post-op [00:48:00] period to augment the healing. All of these things play a huge role in how fast and how well people feel.



Kush: so much of your, uh, philosophy, Dr. Stone with medicine seems to be about just holistic care and about being able to maintain, once faculties as I think as athletes. Or lifelong athletes. So do you find that when people come to you for treatment, do you think many of them walk away with that mindset of being able to use their body and being able to continue that rehab for as long as.

It's just needed. 

Dr Stone: It's the criteria by which we use to treat them. So it's a partnership between me and the patient. I give you my best surgery and best care and best injections and best research information you have to gimme your best effort at at all the rehab and your side of the deal. And if we [00:49:00] have that contract together, we're likely to succeed.

And if we don't, then it's probably better that, you know, we may not be the right fit together. 

Speaker 3: Okay. 

Kush: Yeah. that makes a lot of sense. And I, and I, I certainly appreciate that you, you put forward that expectation to and center that it doesn't end when somebody walks home post surgery.

They have to shoulder that, uh, work ahead of them. In order to get the best. It's more than that. 

Dr Stone: We prefer to, we see our patients as friends for life, who are, we want to see them back at the clinic for regular fitness checkups and how can we help them at every stage as they get older and as the years go by.

And so we do fitness tests and sport tests and research outcomes and so we try to never lose track of the patient. 

Kush: Excellent. Yes. Yes. Uh. On that note, I thought I would also ask you, we talked about, these interventions which come with surgery. What are some things that people [00:50:00] listening can start doing once they start experiencing the, let's just say, early onset of pain in their joints?

Maybe just, it could be pain, it could be just lack of mobility. It could be something else, which is. Not quite serious enough to warrant something like surgery, but something they can start doing today to restore vitality, restore movement, maybe Delay coming to you for getting things, fixed.



Dr Stone: I think the the earlier you make an accurate diagnosis and the earlier you get started on your rehab and treatment plan, the more likely you're to do well. 

Kush: Fair enough. 

so you have treated elite athletes and everyday people who, who try.

Continue this. Could you maybe share a quick story at our stone on, that captures what's possible? Maybe someone who came in who was, who was broken and [00:51:00] ended up surprising 

Dr Stone: with the outcome? Sure. I mean, the most, most dramatic patient is somebody who came in and said, listen, I wanna run, you know, across the United States and I've got bone on bone changes in both of my knees.

And, uh, so we did partial replacements for him. I think about seven months later he did his run across the United States, so Wow. Except for both knees being surgically repaired. So I think that partial knee replacements were a superb option for that patient. And getting rid of the mindset that you are limited is, is an important aspect of it.

Kush: Wonderful. I'll ask you one last question So you're not just helping other athletes, you are one athlete yourself. So what is your own formula these days for staying active and and injury free? 

Dr Stone: It's the same thing I tell all my patients it. It's really important to exercise every day, that every day, because then you become addicted to it.

And once you're addicted, [00:52:00] then you feel badly when you've missed a day. And so that addiction, that addiction to the endorphins and the hormones. Adrenaline and the pheromones and all the good things that happen from exercise. And by the way, all of the research on longevity, every single possible longevity treatment that you might seek out, none of the data is as effective as daily exercise.

Daily exercise, lengthens, telomeres, improves the tissues, improves your mental outlook, optimizes your body weight, improves your appetite. Does everything that any longevity therapy does. And so if you wanna live longer, exercise every day and then treat your tissues in a good way. Don't let yourself degrade.

If you have an injury, treat it, and try to get the best care you possibly can. 

Kush: Wonderful. Dr. Stone, brilliant parting words. Thank you so much for giving us your time today. 

Dr Stone: My pleasure. One last [00:53:00] comment. Yes. For those of you who like to read books, so I wrote a book called Play Forever and it's on Amazon and it summarizes a lot of the things we talked about today and goes into a lot of other subjects as well around staying healthy, living longer, and playing forever, which is my goal to help every patient too.

Kush: Wonderful. Dr. Stone, thank you for reminding us about your book. We will put links in the show notes of where people can find your book. Thanks again. 

Dr Stone: Good talk with you.