Episode 120: A Real Pain in the Knee

Neal Glaviano is an assistant professor at UConn in the Department of Kinesiology and serves as the clinical education coordinator for the master’s in athletic training program. He works with a number of areas on campus ranging from athletics to ROTC. Neal joins us in this episode and talks about treatments for knee pain for everyone from college athletes to members of the military to weekend warriors. He explained how a shoulder injury sustained as a high school football player first got him interested in athletic training. Neal also provides advice to parents on how their child can try to avoid injuries and how playing a variety of sports growing up is helpful.

Link to Episode 120 at Podbean

Transcript

Mike: Well, hello everyone, and welcome to another episode of the UConn 360 podcast. I’m Mike Enright from University Communications here along with Izzy Harris and Kelsey Hall, also from University Communications, and today we’re very happy to have with us as our guest, Dr. Neil Glaviano, who is an assistant professor in the Department of Kinesiology here at UConn.

Neil’s going to tell us a lot about himself, but a few details. He serves as a clinical education coordinator and core faculty member in the master’s athletic training program. So that’s a pretty important position. Neil’s an expert in, knee pain, rehabilitation, therapeutic exercise, and, a lot of other interesting things. He’s a Wallingford, Connecticut native, earned his undergraduate from UConn, headed to Virginia, where he earned a master’s and doctorate from the University of Virginia. He’s worked with high school students, he does a lot of interesting research, and, sometime during this podcast he’s even going to let, uh, you weekend warriors know what to do to avoid, really, uh, uh, So, Neil, thank you for joining us today here on the podcast.

Neil: Thanks for having me.

Mike: So tell us a little bit about your background, and how knee pain became an area of research and interest for you.

Neil: Yeah. So I’m an athletic trainer by trade. When I was in high school, I suffered a shoulder injury and went to a physical therapist. And the first question they asked was why I didn’t see my high school athletic trainer. And at the time I had no idea what that was. So, when I went to college here, for undergraduate, I started getting interested in the athletic training program and was fortunate enough to be accepted into the program. I graduated in 2007 and went down to the University of Virginia for my master’s.

While I was there, I was exposed to research and I spent a lot of my time looking at interventions to try to improve patient outcomes and decrease their pain. From there, I went to a private physical therapy clinic and what I saw was the way that the individuals at the clinic, interacted with patients differed.

How they talked to a child was different than how they talked to an elderly population. They changed the exercises they prescribed. They changed how they, you know, provided diagrams or pictures or videos to explain what was going on. But when it came to some of the exercises or the interventions, it was the exact same thing for every person.

There was no individualized treatment. So, that really sparked my interest for research when I went and looked for a Ph. D. program. I ended up back down at the University of Virginia because the advisor I had worked with specializes in those types of interventions. And for my first year, that’s what I was doing research on.

I was looking at using electrical stimulation to help muscles turn back on after injury. And my friend, who I lived with, encouraged me to run a half marathon. And the peer pressure gave in, and I trained in Charlottesville, a very hilly place. And I ran and started developing kneecap pain. And of course, being the giant nerd that I am, I went to the research and looked up a bunch of articles.

And what I saw was that, the theory at the time was that there’s an imbalance of which muscles are firing at certain times. And that was one of the reasons why kneecap pain can occur. Coincidentally, the type of electrical stimulation I was working with at the time their claim was that you can retrain those muscles to fire at a specific time period.

So it kind of just aligned that what I was experiencing and reading in the literature was the same exact kind of intervention I was doing research on. So I conducted a project on that and went to an international conference. small, it’s like 50 individuals. They only look at kneecap pain. And I was just a little naive PhD student.

I didn’t know anyone. And they welcomed me with open arms and they just took care of me, asked me questions, made me feel so welcome with the group. And I knew I had found my people and that’s kind of where I ended up looking at kneecap pain for the rest of my career.

Izzy: So Knee pain is obviously pretty common in runners. Not that I would ever know. I can’t run over a mile. Every case is different, but what would you say is the best course of treatment for knee 0pain?

Neil: Yeah, I think one of the first things that needs to be confirmed is what is the specific type of kneecap pain? So I focus primarily in patella femoral pain, which is a pain that’s either in front or behind the kneecap.

And it does occur during a variety of different tasks, running, walking, stair ablation, squatting. But there are other types of kneecap pain or knee pain that an individual can experience. So you could have a tendinopathy or tendinitis. You could have inflammation of the bursa. So having an accurate diagnosis first would go a long way of being able to identify the individual’s intervention that’s appropriate for that person.

For a lot of these individuals, it’s making sure that the muscles are strong enough to be able to deal with the load during running. Making sure they have good range of motion, flexibility and then I think being specific in, like mileage. So a lot of times, you know, I look at myself as I’ve aged over the years.

Mentally, I think I can do a lot of things that I could when I was 20. But my body cannot. It’s just, it’s given up on me. So being realistic and making sure that you slowly integrate, you know, either mileage or intensity slowly as an individual gets into running, listening to your body. If you start having some discomfort or pain, maybe tailoring her back a little bit or giving yourself an extra rest day, as you go through.

Kelsie: What kind of research are you doing now that may change care for knee pain in the future?

Neil: Yeah, so right now, I’m fortunate enough to have funding from the Department of Defense, and we are conducting a multisite clinical trial. So, it’s a collaboration between the University of Connecticut, University of Central Florida, and the University of Toledo. And essentially what we’re doing is taking individuals who have kneecap pain, and we’re allocating them into one of two treatment groups. Currently the gold standard for treating these individuals is to give them rehab exercises to target their quad muscles, their hip muscles, their core.

But for the most part, there are three sets of ten. You know, it’s this very cookie cutter approach where everyone’s given the same sets and reps. So what our study is looking at is trying to modify those. So half the individuals will have that traditional three sets of ten, and then the other half are performing power based exercises.

So they’re gonna go through the range of motion for that exercise a little bit faster, and then a nice, slow contraction. We’re, manipulating, how much time rest they have so that way they can give a maximal effort. And we’re looking to see does just changing those exercises have better outcomes for this individual.

So do they have less pain? Can they engage in more physical activity? How do they move? What does their muscle function look like? And then we’re tracking them for two years to see do they have recurrent bouts of, of patellofemoral pain? Does it come back? And the hope is that if one of those interventions is more optimal, then that might be the way that, clinicians can actually provide, you know, more optimal care for these patients.

Mike: You mentioned you work with the military. You’re a member of the Army National Guard. What special challenges and needs do military members have in knee pain and, and why is that a special area for you?

Neil: Yeah. So as of next month, there’ll be 22 years that I’ve been in. I joined right out of high school. I actually still had military training this past weekend, which is why I’ve got my nice haircut. Although for those listening to the podcast, you can’t see it, but it looks like a military haircut. Kneecap pain is one of the main reasons why individuals can’t finish basic training. So you know, it’s a hindrance to individuals who are volunteering to serve.

And for a long time, not even just for the military, but for anyone that experiences this type of knee pain, it’s been viewed as self limiting. So the thought is, okay, they had kneecap pain, just stop that activity for a little bit and everything will be fine. But what we see is that doesn’t matter how much of a break they take or how much rest they take.

As soon as they go back into that normal activity, the pain’s going to come back. So, for me, trying to figure out what are ways that we can try to improve you know, military readiness for these individuals so that if they do want to serve, they have the ability to. We’ve been working with Army ROTC right now performing injury screening assessments for them as a way to try to connect, and that’s mostly through the UConn Institute for Sports Medicine.

So, what we’ve been doing is, uh, going to one of their PT sessions traditionally like a five o’clock in the morning and they all show up and we perform a variety of tasks and screen them and try to identify who might be at a greater risk for injury. And then one of the PhD students within our department, Lauren Sheldon, has been you know, administering interventions trying to help those individuals who are at high risk, hopefully not sustain an injury as they’re going through their training.

Mike: You mentioned the Institute for Sports Medicine. We know that’s something pretty exciting. A collaboration between UConn and UConn Health, bringing some professionals together that might operate, if you put it in silos. Tell us a little bit more about that.

Neil: Yeah, so, it’s this great initiative that started pretty much, Right as COVID was wrapping up, where, you know, we’ve got at UConn, so many world class experts in medicine and physical therapy, athletic training, biomedical engineering, and they’re all providing patient care for a variety of conditions, but they’re all working in silos.

So instead of them working in isolation, the thought is to have everyone come together and provide, you multidisciplinary collaborative care for these patients. So, it’s been a great experience. It’s been really nice merging UConn with UConn Health and, you know, just trying to provide the best care for the individualized patient.

They’ve done a lot of initiatives over the last couple years. So, again, we’ve done the ROTC screening. We’ve been working with UConn Athletics and performing injury screening for some of the athletes here at UConn. We’ve been providing care for, I think, girls on the run a couple weekends ago, having a tent there. So just a lot of really cool initiatives.

Izzy: For people that enjoy to run, play golf, tennis, volleyball, pickleball, what preventative advice do you have for them?

Neil: I think a couple of things that the individuals can keep in mind, one, having a nice proper warm up would be, you know, a very beneficial thing, making sure that they’re not just jumping into an activity and providing maximal exertion, you know, going through flexibility motions, making sure all the muscles are, you know, warmed up and loose before they start engaging the activity.

I think also listening to their body is an important thing. So, you know, if you started to have discomfort or pain or something doesn’t feel right, you know, just tailing back a little bit and, you know, staying within your limits as for anyone who’s engaging in any kind of physical activity, the more frequently they do it, you know, the more the endurance builds up, the stronger they become.

So, you know, walking before running. Kind of mentality is I think I think appropriate. And I think that goes holds true for a lot of individuals because I think as you get older you spend more time, you know in a seated position You’re not engaged in the activity. So You know, there’s a lot of people who say sitting is the new smoking because it is having a very negative influence on individuals life So, you know, you can’t counteract that by just going and playing basketball for one week in a month But, you know, getting back into it slowly and being smart with those decisions.

Izzy: Kind of going off of that. What guidance can you give parents whose children are playing youth sports? And what’s the best way to prevent those injuries in general?

Neil: So I think sports specialization has become a really big topic nowadays where there’s this mentality that if an individual shows promise in their sport that they should be fully committed to it, you know, 12 months a year and spending hours and hours, you know, engaging in that sport. And what a lot of the research is showing is that’s not actually true, that individuals should have a multi sport, you know, background. If you go and you look at, individuals who are into professional sports, they didn’t play, you know, football 12 months a year because it’s not feasible.

They didn’t play baseball 12 months a year and there’s a large number of pretty serious injuries that are occurring at a younger, younger age. I’ll use baseball as an example. Individuals, rupturing their UCL and having Tommy John surgery. That was not a thing, you know, 30 years ago when an adolescent population and now it’s become this kind of rite of passage of, oh, they’re a pitcher, they’ve had Tommy John and, and that’s not the mentality that we want. The other piece of this is too, is, is as you, perform different sports, you acquire different skills. So if you’re playing baseball, having hand eye coordination to be able to catch is going to be very different than if you’re engaging in something like cross country running or swimming.

And all those skills are going to have a positive influence on an individual’s physical literacy and being able to perform certain skills. I think that’s a very important thing. The other, you know, negative consequence of the way life and education systems are right now is gym classes aren’t the same as what they used to be.

I’m going to sound old when I say this, but like when I was a kid, where, you know, I You know, they’re not learning these motor skills and these tasks, and there’s not so much free play, from a safety standpoint, you know, kids in the neighborhood going and playing baseball in the street kind of mentality, that’s going to have a negative influence.

So if they’re not engaging in normal activity and free play, and they’re only playing one sport, that repetitive motion is just going to cause the potential for some kind of chronic condition, or negative consequence.

Mike: How do psychological factors like stress and anxiety influence people’s experience or perception of pain? And where does the whole psychological aspect fit into pain management?

Neil: Yeah, so psychological features actually has become a really hot topic in a lot of chronic pain, but also musculoskeletal injuries as a whole. What you’ll see with individuals specifically with patellofemoral pain, again, which is where my, my life lives, from a research standpoint is that individuals will change their activities, not because necessarily they have pain, but they’re fearful that a task might cause pain.

My lab’s done some qualitative research. So we do. survey interviews of individuals who have kneecap pain and try to get an idea of why they do certain things or how they’re modifying their activities. And what we see is the psychological aspect has a very significant role. I remember interviewing a college student who said she dropped out of the class because the class was three hours long and the instructor wouldn’t let them stand up and take breaks.

So she’s changing the class that she can actually take for a college degree because of her knee pain. So, I mean, from a psychological standpoint, like, that could have significant implications, because if that’s the only course that is offered for that student, you’re forcing her to have pain, theoretically.

I know I’m making the topic sound heavier than what it is, but that’s a really difficult situation for that student. Other aspects of psychological components is that these individuals often will develop fear avoidance strategies. So they’ll say, okay, I know that running causes pain for me, so I’m not going to run.

And that has a big influence on comorbidities from, physical inactivity. You know, there’s going to be some individuals who will avoid tasks altogether. They’ll say, okay, squatting causes pain, so I’m not going to squat. And Or, you know, they have these changes in their social interactions and their social lives.

So, again, from some of those surveys, or interviews with, individuals, we’ve had moms who have said, I don’t take my kids to the park because it’s got that uneven, rubber. ground and that aggravates my knee pain. So they’re changing the activities of what their kids can do because of that knee pain.

It’s going to have this, you know, significant influence on, on who that individual is, from a psychological standpoint, but also from a social standpoint. You also see that there’s increased of depression for these individuals because they’re not able to go out and do activities without having pain.

Within ACL populations, you’re starting to see individuals who develop, concepts called learned helplessness or also pain catastrophization where they think Their pains to be forever because they’ve had it for a couple years, or they think it’s just going to, you know, just take over their entire life and that’s the only thing they can focus on, and they kind of just lose their identity and being able to do certain things.

So I think the psychological piece is a very interesting one that’s really starting to gain traction. I think it’s one that is definitely understudied. There are very few, studies that I’ve looked at. intervening from that psychological standpoint is traditionally, well, let’s make them stronger or, let’s modify their activity. But we don’t, we don’t know what happens if you intervene from a psychological standpoint.

Izzy: Are there any other psychological consequences for athletes post injury?

Neil: Yeah, so I think if you take anyone who sustained an injury, sometimes not even requiring, you know, a surgical intervention, there’s going to be some kind of fear of them going back and perform activities. So if it’s someone who, you know, hurt their knee or their ankle, doing a cutting based motion or a landing based motion, that task might be problematic for them.

And they might be really nervous, um, to actually perform that task. So, you know, having the individual start slow and works, through that. Um, you know, if it’s an individual who sprained their ankle, maybe a cutting motion was that problematic. Have them just do lateral motions and walking side to side. They can see that they can actually do the task and slowly work up from there. Most of it’s empirical evidence from what I’ve seen, either myself or some other athletic trainers, but build confidence. It’s going to take time. They’re going to have to, you know, break that cycle that that task was what caused the injury.

If they allow their body to heal, if they go and get their muscles stronger through rehabilitation, they should be able to come back. But it all comes down to the confidence and making sure they feel comfortable doing it.

Izzy: Looking ahead, what are some of the emerging trends or areas of focus in knee pain research? Are there any breakthroughs or developments in the future?

Neil: Yeah, I think something that I’ve been really excited, working on within my lab and with some of my PhD students is looking at the variability of the individual’s pain.

So traditionally a clinician would say, okay, rate your pain on a scale of 1 to 10. Well, if they’ve done nothing all day, they should theoretically have less pain. But if they went out and were more physically active, they might have worse pain. So one of the challenges with that is, You know, if you take a runner who has patellofemoral pain, they might have that 10 pain when they get to the 12th mile of their run.

That’s very different than someone who only sits and doesn’t do anything, having 10 pain. On paper, they look the same, but one person is not doing any activity, and one person is actively out engaging in running. They’re viewed as the same person, but that’s not an accurate representation of who they are.

So something that we’ve been looking at is trying to quantify what is their pain across multiple days. Does it fluctuate? Do they have their pain under control? If they are unable to identify, you know, specific tasks that cause that pain for them, that’s going to be something that, you know, we’ve been trying to look into.

Mike: Dr. Neil Glaviano, thank you for joining us today. Great information about knee pain and how to prevent things for, for people of all ages. So thanks a lot for joining us today.

Neil: Thanks for having me.

Mike: And we thank everybody that listened and we look forward to having you on another episode of the UConn 360 podcast.