EPISODE 129

Understanding Anterior Knee Pain - Dr. John Fulkerson of the Patellofemoral Foundation and Yale University

02-18-2021

Early in his career as an orthopedic surgeon, Dr. John Fulkerson was attracted to focusing on a small part of the knee called the patellofemoral joint because he felt it was overlooked and little understood. Decades later, there is still much to be learned and he’s leading a new program at Yale to advance the understanding of anterior knee pain and how to treat it. It’s actually a common problem in the general population and is responsible for more than 30% of complaints at sports medicine clinics. Despite this, many people never get relief. Check out today’s episode to learn more about this issue, the role of technology in orthopedic surgery, and the importance of perseverance, integrity and honesty in medicine.

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SHIV GAGLANI: Hi, I'm Shiv Gaglani. Today, on Raise the Line, I'm happy to be joined by Dr. John Fulkerson, who is an orthopedic surgeon and professor at Yale University. Before joining Yale's faculty last year, he spent several decades as a Professor of Surgery at the University of Connecticut School of Medicine. Dr. Fulkerson has a special focus on patellar instability and is president of the Patellofemoral Foundation. He's been a team doctor for the U.S. Olympic Ice Hockey and the NHL Hartford Whalers. 

We're also proud to be partnering with him and the Patellofemoral Foundation through our Diffusion Studios team at Osmosis, as well as his partner at the Hospital for Special Surgery, Dr. Beth Shubin Stein. Osmosis also has a deep connection with orthopedic surgeons, including Dr. Sanjeev Suratwala and Dr. Veronica Diaz, so it's good to finally have an orthopedic surgeon on Raise the Line. Dr. Fulkerson, thanks so much for taking the time to be with us today.

DR. JOHN FULKERSON: My pleasure.

SHIV GAGLANI: We always ask the guests the same question, which is how did you get interested in a career in medicine and then in your case, specifically, sports medicine and orthopedics?

DR. JOHN FULKERSON: My background is probably pretty boring. My father was a doctor. My grandfather was a doctor, and my great grandfather was a doctor. I sort of grew up thinking I was going to be a doctor so I kind of made sure that I did everything I had to do and studied hard and got the grades I needed to. Dropped calculus when I found out that I wasn't going to do very well in calculus in college, and got out of there as fast as I could and then managed to get into med school. Then when I was in med school and surgical training, which is the direction I chose, I met some really great people in orthopedic surgery, so that's how I knew what I wanted to do.

SHIV GAGLANI: That is often how people choose their specialty. I was at Hopkins Med School, and all my roommates and friends wound up choosing different specialties. It's very rare that people came in knowing exactly what they wanted to do and then became that. Most of the time, they had influential rotation and adviser who kind of changed the course of their own career. Can you tell us a bit more about after you finished your orthopedic training and what got you into academia versus private practice? And then also the origins of the patellofemoral focus and Patellofemoral Foundation?

DR. JOHN FULKERSON: It's funny. Nobody has ever asked me that before, oddly enough, but I just knew I wanted to go into academics. I was always fascinated by academic questions, I guess. In medical school, I did some research. I was fascinated by the research, and I was impressed by the people, Dr. Handschumacher in the Pharmacology Department at Yale, he was one of my mentors in research guidance. Same in college, I did some research, and I just thought it was fun, honestly. I enjoyed the research, and I had to be in academics to do research and just seemed like a wonderful place to be. To me, it always seemed like a no brainer.

I just wanted to be an academic, especially in the residency I did, it was full of some really creative people, Dr. Peter Jokl, Dr. Wayne Southwick in particular, who was a great mentor, a great role model. Just to give you an idea about him, when he retired from orthopedics probably in his 60s or so, he took up sculpture and literally became a world class sculptor. I guess one of the points I would share with the students and people who might be listening to this and are aspiring to go into medicine, I think perseverance is really important in choosing a direction and then staying with it, which is what Dr. Southwick taught me and many of us, just to work hard and stay focused. 

SHIV GAGLANI: That's great. We've been fortunate to come across a number of physicians who are multitalented, and obviously, there's a famous one like Dr. Atul Gawande who, apart from being a surgeon, is a very talented writer. I think medicine tends to attract people who are pretty focused and if they apply themselves, like doctor Southwick did to sculpting, maybe they become world-renowned there, too. 

Yale just announced this fall that they're creating a patellofemoral program under your leadership. Can you tell us a bit more about the program and then also for our audience, who hasn't yet seen the video that we created with your team, what is patellofemoral instability? What how common is it, and what should people know about it?

DR. JOHN FULKERSON: Well, I'm glad you asked that question. I was there, again, taken by looking at this small joint, a part of the knee very early in my career in academics, mainly because it was an area that not many people were looking and it seemed to be poorly understood. Some work was needed and some research. I was fortunate to be surrounded by smarter people than me that could help me in various ways to do some research and give some information about the patellofemoral joint and it became a wonderful career path for me, so it takes us to where we are with regard to patellar instability. The reason for the program at Yale is that there are still a lot of questions. 

Just to give you an idea, the groove that the patella goes in -- it's called the femoral trochlea -- is actually very complex. The curvatures and the way it works as the hip internally rotates and the knee is bending…normal walking causes a very complex situation where the little kneecap needs to catch up to this groove that it's kind of rotating away from.  So, unless everything's working just right, the kneecap can pop off the edge of the joint and that's a patella dislocation. 

It's very painful, and it can be very damaging, and it occurs most often in young people so it can take them right out of sports and they’re not very happy about it. So it's so important for us to be able to stabilize the patella and do it in a way that is going to last for a lifetime and enable them to return to sports. That's why the patellofemoral joint, particularly patellar instability, is mostly in the area of sports medicine, which is the area that I've been in the majority of my career.

SHIV GAGLANI: Actually, I was going to ask you about that. You've been the team doctor for the U.S. Olympic Ice Hockey team and the Hartford Whalers in the NHL. Can you tell us a bit more about that experience? Are you still consulting with them? 

DR. JOHN FULKERSON: Well, working with hockey players fell into my lap. I was invited in the late 1980s to be the team doctor for the NHL Hartford Whalers, which at the time was the only professional sports team in Connecticut. I said, “Sure, I would love to do that.” It was a lot of fun. Being with hockey players is fun, and they have some pretty serious injuries and problems, as one might imagine. It's a great experience, and because I was taking care of them, the U.S. Olympic Hockey Team in 1993 was practicing in Cromwell, Connecticut, so the head team doctor, Bill Clancy, asked me if I would take care of the team while they were practicing. I said, “Sure!” I took care of any problems they had, and then they were going to travel around Europe, so he said, “Hey, do you want to be the team doctor and go along with them?” “Sure!” So, I was paid to travel around Europe with them and it was a great experience.   

SHIV GAGLANI: Awesome.

DR. JOHN FULKERSON: Yeah, it was really, so I was very fortunate that way,

SHIV GAGLANI: I bet. Are you still involved at all with sports teams or not?

DR. JOHN FULKERSON: Not specifically at this point.

SHIV GAGLANI: We've had the pleasure of interacting with a number of physicians and professors who have, like you, been able to work with different teams. For example, one of our partners is A.T. Still University, which has several campuses, but they're based in Arizona primarily…their President, Dr. Craig Phelps, was with the Phoenix Suns and had a lot of really funny stories about talking to Shaq on the bench about different things.

Switching gears a bit, orthopedic surgery is a very high tech field, and we've also had guests on Raise the Line who come from the medical device world, including Omar Ishrak, who ran Medtronic for a number of years. Can you tell us a bit more about how the field has changed over the past few decades and what most excites you about the field of orthopedic surgery, 3-D imaging, and printing is obviously what comes to mind. Any commentary about technology in your profession?

DR. JOHN FULKERSON: Technology is huge in orthopedic surgery because it's a huge market for companies. There are a lot of gadgets, so to speak, anchors and screws and implants, things of that nature that are needed in orthopedic surgery. So, if somebody comes up with a better mousetrap, they can make a lot of money. I don’t mean to put it that way, but that makes it a very competitive marketplace. Those who are successful can do very well. 

It's good for us as orthopedic surgeons because there are constantly new devices coming out that are helpful to us so we can do surgery better. It is interesting to go around the room where companies have their products at those big meetings every year and just take a look around. It's fascinating, the new things and new ideas that people come up with. It is kind of a fun part of what we do, and it makes our lives easier. Every year gets a little bit better in that way.

SHIV GAGLANI: I'm sure, and again, given that you're at a very prestigious institution like Yale, I'm sure that there's a lot of these devices being researched, materials are being researched, or even developed there. COVID has led to a lot of change, obviously, in the health system and at universities. How has your experience with COVID been personally or at Yale as an orthopedic surgeon? And then what are some of the lasting changes you think COVID is going to have on our healthcare system?

DR. JOHN FULKERSON: Yeah, it's a good question. It's been a big problem. We are also right now only doing telehealth, which really is suboptimal, but fortunately, I got the vaccine a couple of weeks ago, and the second shot maybe in a couple of weeks from now, so then I'll be vaccinated and I'll be able to go back to the office, which is important in orthopedics. What I have learned is it's amazing how much we can understand problems with imaging without actually examining people, which is pretty unorthodox because typically it's very hands-on field. But we are able to understand problems with telehealth pretty well. 

We're getting the right imaging. 3-D imaging is one of those areas that we focused on at Yale. I think we do it really well, and it's a program that is getting stronger all the time.  It's something we can offer to patients to really understand their joints very well with those 3-D printers because we literally can have our hands on a model to look at their knee. In this time of COVID, it's been extremely helpful to us. We look at the geometry and the morphology of the joint, so I guess that's probably the main way it has affected as people are reluctant, rightfully so, to have elective surgery, so that has changed things. It's very hard for the people who are training, I'd say. They don't have the same exact type of experience they used to have, so there’s multiple parameters, but people are resilient, and things now seem to be getting better. 

The surgery center where I work is probably just about the safest place in New Haven right now because the staff is all vaccinated and surgeons are vaccinated, and the patients are all COVID tested before they come in. 

SHIV GAGLANI: That's a good point. As you know, Osmosis has a large audience of current and future healthcare professionals. What advice would you give to students considering a career in healthcare right now, or who are already on their journeys in healthcare, about meeting the challenges of COVID and beyond?

DR. JOHN FULKERSON: Well, in a general sense… going back to the earlier discussion, persevering and doing all the right things. I'm working with a really great medical student right now,Kristin Yu, who's very smart. So, watching her behaviors…she gets tested quite frequently. She goes by all the rules. One thing that actually was sort of touching to me, she was meeting with me, and she got a COVID test before she met with me in person because we had some in-person work to do, which I thought was really nice. But she uses that testing to protect other people and we all, I think, in our field use masks well. We're diligent about it. It’s a no joke situation, and unlike what we see in public displays, people actually understand how serious this is and if everybody adhered to the rules like people in our profession, I think the world would be a better place right now. We wouldn't have so much trouble. 

I guess my advice would be to stick to the rules. Be smart. Be honest. In general, integrity and honesty are really important in our field. We don't always see that, and what's going on around the country is disturbing. I think at this point in time, it's fair to say that we need to get back to being ethical and doing the right thing for people and being smart about that, and not listening to conspiracies and crazy stuff. Just being honest with people, being kind with people. That's so important. If you want to go into the medical field, hopefully, you have that within you, because if you don't, you probably should go on and do something else.

SHIV GAGLANI:Absolutely. Hopefully we can all together overcome the disinformation, especially on the public health side about mask-wearing, social distancing and the vaccine, et cetera. That's actually one thing that drives us at Osmosis. Since we're coming up on time, Dr. Fulkerson, is there anything else you'd like to be able to share with our audience about you, the work the Patellofemoral Foundation does, Yale, or anything else?

DR. JOHN FULKERSON: Well, you mentioned funny stories before. I had one when I was a hockey team doctor. I was called in to see one of the players who had been high-sticked across the face and he had a big laceration on his nose and his nose looked deformed. So, I'm looking at it and I say "This doesn't look so good. It looks like you have a broken nose." He looked me in the eye -- because these guys are really tough -- and he said, "What are you going to do about it?” I said, "Well, we should get you to see an ear, nose and throat doctor, somebody who can take care of this and put it back into place." He looked at me and he said, "Do you know how to do it?"

I said, "Well, I have fixed broken noses, and I've done some surgical training and spent three years in general surgery." And he said, "Can you fix it for me? I don't really want to go to the emergency room and see some other doctor. We got to get on the road." So, I thought about it a little bit and said, "This is really going to hurt." He said, "I don't care." And I knew he didn't care because I was used to taking care of professional hockey players. They don't care. They deal incredibly well with pain. He said, "Just do me a favor. Just push it back.” I go, "Okay, it's going to hurt!" I grabbed hold of his nose and just tried to get everything lined up and pushed it over, and pushed, pushed, pushed, and it wouldn't move. He just broke out laughing and said "Aw, it's been that way for years."

SHIV GAGLANI: That's awesome. That's a great story. A patient pranking you as a doctor. That's a great humorous note to end on. Dr. Fulkerson, I really want to thank you not only for taking the time to be with us on Raise the Line Today, but more importantly for the work that you do every day, helping patients and improving healthcare capacity,

DR. JOHN FULKERSON: Thank you, Shiv. It’s my privilege, really, to be here. I'm very grateful for what you do. I'm just amazed by the work that you're doing at Osmosis. The quality of these educational videos that we're using now in our Patellofemoral Foundation is incredible. It's a wonderful opportunity for us to be able to educate broadly with those. I think they have broad appeal to all kinds of people at all levels and make the information understandable, so thank you for what you do.

SHIV GAGLANI: I really appreciate that. I’m very fortunate to be working with a team of incredibly talented and passionate medical illustrators and a whole host of other people. Again, thank you so much. With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line since we're all in this together. Take care.