How did Bill Hensler influence Eric Chehab's life and career?

Bill Hensler was a neighbor and father figure to Eric Chehab, who didn't grow up with his biological father. Bill's recovery from alcoholism and his unwavering support significantly shaped Eric's path, inspiring his residency essay and influencing his decision to train in New York to be closer to him.

What makes the Hospital for Special Surgery (HSS) unique in orthopedic training?

HSS is an all-orthopedic hospital known as an apex facility and a think-tank in the field. It played a significant role in the development of joint replacements and has leading specialists across all orthopedic subspecialties, offering immense volume and dedicated resident education.

What was Eric Chehab's experience like during his fellowship with the New York Giants?

His fellowship with the Giants highlighted the extreme giftedness of professional athletes and the razor-thin margin between superstars and those out of the league. He observed the intense physical violence of the game and the tremendous stress players face due to non-guaranteed contracts and competitive pressure.

What are the common missteps in exercise that lead to orthopedic injuries?

Eric Chehab identifies excessive squats and lunges with poor form (over-relying on quadriceps instead of glutes) as a major cause of knee pain. Similarly, shoulder injuries often result from overhead resistance training, where joint load is excessively high.

What is the relationship between body weight and knee pain?

The relationship is amplified due to the mechanics of the knee; every pound of weight lost from the upper body translates to four pounds less pressure on the knee when walking, six pounds less with stairs, and eight pounds less with running. Reducing weight significantly benefits painful extremity joints.

What are PRP and stem cells, and how effective are they in orthopedic treatment?

Platelet-Rich Plasma (PRP) is a concentrated blood portion with healing factors, while stem cells are used for regenerative purposes. While promising in animal studies, human trials for both are inconsistent due to preparation heterogeneity, showing only marginal clinical benefit, often without evidence of new cartilage growth, and sometimes influenced by placebo effects.

What insights did Eric Chehab gain regarding the ethics of 'sham surgery' and the placebo effect?

A study on subacromial decompression showed no difference between actual surgery and sham surgery, as both groups improved. This raises ethical questions about offering sham surgery, which could harness the placebo effect but involves deception or losing the benefit if disclosed. The forced rest and physical therapy are likely major factors in recovery.

How do lower back injuries compare to joint injuries in terms of surgical outcomes and risk?

Lower back pain is widespread, and while some spine surgeries (e.g., for massive disc herniation with cord compression) are life-altering, interventions for less dramatic issues carry significant 'asymmetric risk.' A spine operation can dramatically worsen function, unlike typical extremity joint surgeries, making conservative approaches often preferred.

What advice does Eric Chehab offer for choosing an orthopedic surgeon?

He recommends prioritizing surgeons with high patient volumes, as this indicates experience. It's crucial to select a surgeon known for responsibly managing complications and one who welcomes second opinions, indicating a patient-centric approach over self-interest.

How can patients cope with orthopedic limitations and 'knee purgatory'?

Coping involves managing expectations by focusing on what one is still capable of doing rather than what has been lost. Patients can modulate their 'activity threshold' through strengthening, weight management, and education. Adapting to new activities like swimming or biking instead of running, while slowing decline, fosters a positive mindset.

What is the philosophical difference between traumatic and intra-articular injuries?

While long bone fractures often heal with full recovery, intra-articular injuries (those within the joint) tend to put patients on a different, more challenging trajectory. These injuries often linger for a lifetime, underscoring the importance of long-term management and adaptation.

Key Moments

#36 – Eric Chehab, M.D.: Extending healthspan and preserving quality of life

Peter Attia MD

People & Blogs7 min read159 min video

Jan 7, 2020|3,193 views|50|2

Save to Pod

Key Moments

On this page

TL;DR

Dr. Eric Chehab discusses orthopedic health, injury prevention, treatment options, and coping with physical limitations.

Key Insights

Maintaining physical health is crucial for a high quality of life, especially as we age, with orthopedics playing a key role in preventing and treating injuries that lead to healthspan deterioration.

Weight management is a critical modifiable factor in preventing knee, hip, and back pain, as every pound of weight is amplified by a factor of 4-8x in stress on these joints during daily activities.

Repetitive exercises with poor form, particularly squats, lunges, and overhead weight training, are common causes of joint injuries (knees, shoulders) that necessitate orthopedic intervention.

Walking is an excellent low-impact exercise for cardiovascular benefits and musculoskeletal health, incurring minimal injury risk compared to high-intensity or repetitive, poorly executed exercises.

The decision for surgery versus conservative management (physical therapy, time) for conditions like meniscus tears or labral tears often depends on the severity of symptoms and patient response to initial non-operative approaches, with surgery typically being a last resort for severe cases or neurological compromise.

Current biological treatments like PRP and stem cells show marginal, subjective benefits for tendinopathies but lack robust evidence for cartilage regeneration, making them controversial and often an expensive option with uncertain long-term efficacy.

Coping with physical limitations and focusing on what one can still do, rather than what has been lost, is essential for maintaining a positive quality of life and adapting to the realities of aging and injury.

THE INTERSECTION OF LONGEVITY AND ORTHOPEDICS

Dr. Peter Attia introduces Dr. Eric Chehab, an orthopedic surgeon specializing in sports medicine, highlighting the critical role orthopedics plays in extending not just lifespan but, more importantly, healthspan. Many individuals prioritize freedom from pain, strength, and mobility over merely living longer, as the deterioration of the musculoskeletal system significantly impacts the quality of daily living. Understanding common injuries and their mitigation is key to a fulfilling later life. The conversation delves into personal stories, including Dr. Chehab's upbringing, his path to medicine, and his experiences at the prestigious Hospital for Special Surgery (HSS).

A MEDICAL JOURNEY: FROM TEACHING TO TOP ORTHOPEDICS

Dr. Chehab shares his unique journey, starting with teaching chemistry and physics overseas before pursuing medicine, a path influenced by his mother (a nurse) and biological father (a physician). His decision to specialize in orthopedics, particularly sports medicine, was almost a toss-up with internal medicine, but the surgical aspect and immediate impact on patients' quality of life appealed more. He describes his transformative residency at HSS in New York, renowned for its orthopedic breakthroughs and giants in the field, and the invaluable mentorship he received during this period.

MENTORSHIP AND THE LESSONS OF PROFESSIONAL SPORTS

A significant influence on Dr. Chehab was Dr. Russ Warren, a "godfather of sports medicine" known for his pioneering work in ACL reconstruction and arthroscopy. Dr. Warren's relentless dedication—constantly working, researching, and caring for patients—left a lasting impression, emphasizing that "all I got is time, and I'm not wasting it for anybody." Dr. Chehab's year-long sports fellowship with the New York Giants provided a stark education on the physical demands placed on elite athletes. He observed that professional players are exceptional, "freak athletes" whose careers are often shortened by the sheer violence of repeated collisions and the razor-thin margin separating stardom from being out of the league due to injury.

COMMON ORTHOPEDIC INJURIES: KNEES AND WEIGHT REDUCTION

The knee is a complex, weight-bearing joint, highly susceptible to injury. Dr. Chehab explains that while ligaments (MCL, LCL, ACL, PCL) provide stability, the cartilage is the weakest link, destined to wear down over time. Injury, genetics, and modifiable factors like weight significantly accelerate this wear. Weight loss is profoundly beneficial for knee health, with every pound lost reducing knee pressure by 4-8 pounds. Exercise, particularly weight-bearing activity before age 30, builds bone density, but continuous movement throughout the day is more beneficial than intense, sporadic workouts for long-term musculoskeletal health. Repetitive, high-volume exercises with poor form, such as squats and lunges, are frequent culprits in causing significant knee and shoulder pain.

SHOULDER, ELBOW, WRIST, HIP, AND ANKLE INJURIES

Shoulder injuries commonly stem from overhead weight training, where movements like the overhead press place excessive load on the joint. Emphasizing "pulls" over "presses" during recovery is often recommended. Elbow and wrist pain frequently manifest as tendinopathies, such as epicondylitis often termed tennis or golfer's elbow. These, along with patellar and Achilles tendinitis, share a common biological mechanism, likely related to declining microvasculature and reparative capabilities in tendons with age. Hip joints, being ball-and-socket, also wear down, though conditions like femoral acetabular impingement can be surgically reshaped to improve long-term outcomes. Ankle issues often involve the Achilles tendon or posterior tibialis tendon deficiency, affecting arch support and foot mechanics.

THE DIAGNOSTIC DILEMMA: ACCURATE PAIN IDENTIFICATION

A recurring theme in orthopedics is the challenge of accurately linking pain to specific findings, like labral tears in the hip or meniscus tears in the knee. MRI scans frequently reveal abnormalities in asymptomatic individuals, making it difficult to determine if a visible tear is truly the source of pain. This diagnostic uncertainty often necessitates a conservative approach, utilizing physical therapy and time, before considering surgical intervention. The goal is to avoid unnecessary procedures by allowing the body's natural healing processes and corrected mechanics to alleviate symptoms.

MENISCUS SURGERY: A CASE FOR CONSERVATIVE MANAGEMENT

Meniscus surgery is a particularly controversial area. Initial beliefs held that removing meniscus tissue had no long-term consequences, but it's now clear that meniscus loss often accelerates cartilage degradation and early-onset arthritis. Recent studies, including one in the New England Journal of Medicine, suggest that for many degenerative meniscus tears, physical therapy can be as effective as surgery in the long run. Dr. Chehab advises patients to try conservative measures for 1-2 months, emphasizing that only a subset of patients who don't improve will truly benefit from surgery. This highlights the importance of judicious patient selection and avoiding procedures driven by financial incentives or a "hammer-and-nail" mentality.

THE CHALLENGES OF LOW BACK PAIN

Low back pain is the leading reason people seek medical attention, presenting a complex challenge in orthopedics. While many mechanical issues, like slipped discs, resolve with time and conservative management, severe neurological compromise or weakness often necessitates more urgent surgical intervention, especially in the cervical spine. However, spine surgery carries significant risks, with a wider margin for adverse outcomes compared to extremity surgery. Patients undergoing spine operations for functional improvement (e.g., from 70% to 90%) risk a substantial decline (e.g., to 20%), making it a last resort for many. Dr. Attia shares his personal, debilitating experience with a lumbar free fragment, which, despite its severity, taught him critical body mechanics that have prevented recurrence for decades.

BIOLOGICS: PRP AND STEM CELLS

Platelet-rich plasma (PRP) involves injecting a concentrated portion of a patient's own blood platelets, rich in growth factors, into injured areas to accelerate healing. While simple to obtain and administer, PRP efficacy is complicated by heterogeneous commercial preparations (leukocyte-rich vs. leukocyte-poor). Studies show marginal benefits for tendinopathies but no clear evidence of cartilage regeneration in joints. Stem cell injections, often derived from bone marrow or fat, are popular but even more controversial. While animal studies show promise, human trials have yet to demonstrate actual cartilage regrowth. The potential benefits might be anti-inflammatory or placebo effects, but costs are exorbitant, and the risk of exploitation is high given the public's desire for a "molecular Fountain of Youth" for arthritis, for which no cure currently exists. Dr. Chehab recommends patients seeking these treatments participate in academic trials to avoid financial exploitation and contribute to rigorous scientific understanding.

CHOOSING THE RIGHT ORTHOPEDIC SURGEON

Selecting an orthopedic surgeon is challenging due to the lack of perfect metrics. Dr. Chehab suggests several guiding principles: look for high-volume surgeons (e.g., 200+ knee replacements/year) who are generally at the top of their game. Seek surgeons with a reputation for transparently addressing and managing complications, as all surgeons experience them; a willingness to confront complications is a sign of ethical practice. Surgeons who welcome second opinions and prioritize patient best interests are also preferred. While online health ratings can be misleading, the ultimate decision often comes down to trust in the physician's expertise and commitment to patient care.

THE ART OF ADAPTATION AND COPING

The discussion concludes with the profound importance of coping and adaptation in managing orthopedic conditions and aging. When physical limitations arise, whether from injury or disease progression, the physician's role extends to helping patients cope with their new reality. This involves shifting focus from what has been lost to what remains possible and what they are still capable of doing. Examples include a 45-year-old runner transitioning to swimming or biking to maintain activity and slow physical decline. Cultivating a mindset of focusing on current capabilities, rather than past performance or perceived losses, is crucial for preserving healthspan and preventing a precipitous drop in physical quality of life, especially as individuals face the compounded effects of aging and injury.

Mentioned in This Episode

●Products

●Software & Apps

●Companies

●Organizations

●Drugs & Medications

●Concepts

●People Referenced

Common Questions

Dr. Eric Chehab is an orthopedic surgeon specializing in sports medicine, particularly knee and shoulder injuries. He is an assistant clinical professor at the University of Chicago and completed his residency at the Hospital for Special Surgery (HSS) in New York, followed by a fellowship with the New York Giants.

Topics

Injury Prevention Bone Density Health & Longevity Human Performance Pain Management Joint Health Sports Medicine Orthopedic Surgery Medicine & Clinical Patient Education Surgical Ethics

Mentioned in this video

People

Eric Chehab

An orthopedic surgeon specializing in sports medicine, knee and shoulder. He is an assistant clinical professor at the University of Chicago and Peter Attia's medical school friend.

Bill Hensler

A longshoreman and World War II veteran who became a father figure to Eric Chehab. His story highlights recovery from alcoholism, his role as a mentor, and his eventual end-of-life care.

Eric Winer

A breast oncologist at Dana-Farber Cancer Institute, recipient of a Lifetime Achievement Award, who emphasizes physicians' role in helping patients cope with illness and injury.

Ryan Flaherty

A guru of speed training for NFL players, who shifts focus from combine performance to longevity once players are in the league.

Paul Inzana

Peter Attia's brother, who is into downhill mountain biking.

Tom Brady

NFL quarterback mentioned as an example of how traditional metrics can fail to predict elite performance, being drafted 199th.

Bruce Springsteen

A favorite singer of Eric Chehab, who saw him in concert multiple times, including an Easter Sunday show in Verona and a tribute at Wrigley Field after Clarence Clemons's death.

Nick Oregon

A friend of Eric Chehab who required urgent cervical decompression and fusion surgery due to a massive disc herniation and spinal cord injury.

Peter Attia

Host of The Drive podcast and a physician focused on longevity, performance, and critical thinking.

Eddie Vedder

The lead singer of Pearl Jam, whose emotional performances resonate with older fans.

David Betar

Incredibly talented artist and friend of Peter Attia who designed 'little school back east' t-shirts.

Tom Coughlin

Former coach of the New York Giants, known for pushing players with 'gassers' drills during training camp.

Scott Rodeo

Head team physician for the Giants and a phenomenal clinician scientist, embodying a rare combination of research and clinical excellence.

Russ Warren

A mentor to Eric Chehab at HSS, considered the 'godfather of sports medicine' and a pioneer in ACL reconstruction and arthroscopy. Known for his tireless work ethic as a Vietnam War surgeon.

Chris Snee

An All-Pro guard and Tom Coughlin's son-in-law, known for delivering massive hits in NFL games.

Muhammad Ali

Boxing legend, mentioned as a striking example of an athlete whose physical decline in later life contrasted sharply with his earlier peak performance.

Carlos Rivera

Peter Attia's chief resident at UCSF, who was distracted by Peter's Doc Buc teeth during a patient presentation.

Bon Jovi

Rock band whose member played at an honorary dinner for Paul Pellicci.

Tom Morello

Electric guitarist who played with Bruce Springsteen at Madison Square Garden in 2009, with a three-minute guitar solo in 'The Ghost of Tom Joad'.

Jerry Rice

Legendary wide receiver whose poster symbolized physical giftedness for Peter Attia.

Clarence Clemons

The 'Big Man' saxophonist for Bruce Springsteen's E Street Band, whose passing was marked by a moving tribute during live concerts.

Lawrence Taylor

Considered the greatest linebacker of all time and one of the greatest people by Eric Chehab.

Todd Henderson

A law professor at the University of Chicago who discussed the ethics of sham surgery in orthopedics.

Matthias Bostrom

A 'great guy' and surgeon at Special Surgery who performed hip surgery on Bill Hensler.

Paul Pellicci

An exceptionally gifted joint replacement surgeon at HSS, known for performing total hip replacements in 45-60 minutes.

Tom Wickiewicz

Director of Eric Chehab's fellowship, described as a 'super good guy'.

Organizations

St. Albans School

An all-boys preparatory school in D.C. where Eric Chehab taught chemistry and physics.

Roosevelt Hospital

Where Eric Chehab's parents met while his father was training and his mother was working as a medical assistant.

University of Chicago

Where Eric Chehab serves as an assistant clinical professor.

The band Pearl Jam opened for on the Zooropa tour in Verona in 1992.

Harvard University

The 'little school back east' that Eric Chehab and Peter Attia both attended, often joked about for its reputation.

Stanford University

Where Peter Attia and Eric Chehab met in medical school. Also where Eric Chehab interviewed for medical school and met with engineers for bracing during his fellowship.

Carrier Clinic

A facility in New Jersey where Bill Hensler sobered up from alcoholism.

Harvard T.H. Chan School of Public Health

Mentioned in the context of studies on walking and cardiovascular risk reduction, though Peter Attia expresses bias concerns.

Hospital for Special Surgery

Generally regarded as the best orthopedic facility, where Eric Chehab did his residency in orthopedic surgery. Described as an apex facility and a think-tank for orthopedics.

Books

Born to Run

Album cover featuring Clarence Clemons's silhouette during a tribute at a Bruce Springsteen concert.

Drugs & Medications

Cortisone

An anti-inflammatory drug, mentioned as a cheaper alternative for anti-inflammatory effects compared to stem cell injections.

Boniva

A bisphosphonate drug mentioned alongside Fosamax for its role in inhibiting osteoclast function.

Fosamax

A bisphosphonate drug mentioned for its role in inhibiting osteoclast function to slow down bone resorption, but with concerns about 'fault lines' in bone.

Software & Apps

Healthgrades

A platform for rating doctors, criticized for its inability to accurately reflect surgeon quality due to selection bias.

Media

The Ghost of Tom Joad

An eight-minute song played by Bruce Springsteen and Tom Morello, featuring Morello's extended guitar solo.

South Park

Animated TV show mentioned in reference to the 'Al Gore special episode' as an analogy for extreme selection bias.

Products

Honda Civic

Peter Attia describes Eric Chehab's old 1983 Honda Civic station wagon with worn-through floorboards and no radio or air conditioning.

Platelet-Rich Plasma

A concentrated portion of blood rich in healing factors, injected to stimulate and accelerate healing in joints and tendons. Studies show marginal benefit, but lack standardization and rigor.

Doc Buc

Fake buck teeth, used by Peter Attia and Eric Chehab for pranks and social experiments during medical school and residency. Peter describes being obsessed, having multiple pairs, and wearing them during surgery.

Companies

New York Giants

The NFL team Eric Chehab did his fellowship with as a team physician, fostering childhood fandom and providing insights into the challenges of pro sports medicine.

The Dan Band

The band at Peter Attia's wedding with whom Eric Chehab sang 'Fire,' creating a memorable and humorous moment.

Pearl Jam

A band Peter Attia has seen multiple times, appreciating the intergenerational joy in their concerts. Eric Chehab saw them open for U2 in 1992.

Concepts

Wolf's Law

A principle where the body reacts to stress by laying down more bone, explaining how weight-bearing exercise increases bone density.