← Rena Malik, MD Podcast
Rena Malik, MD Podcast
How to Build Resilient Bones and Joints for Lifelong Strength with Dr. Vonda Wright
01:29:26
In this episode, Dr. Rena Malik, MD welcomes orthopedic surgeon Dr. Vonda Wright to discuss why bone and joint health matters at every age. Together, they cover the science behind bone strength, practical strategies to prevent fractures, and the importance of exercise and hormones for lifelong mobility. Listeners will walk away with evidence-based tips to stay strong and independent.
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- [00:01]
A
5:00Am I'm up with a crisp Celsius energy drink running 12 miles today. Grab a green juice, quick change and head to work. Meetings, workshops. One more Celsius. No slowing down. Working late, but obviously still meeting the girls for a little dancing. Celsius Live Fit. Go grab a cold refreshing Celsius at your local retailer or locate now@celsius.com.
- [00:27]
B
Kids. They grow up so fast. One day they're taking their first steps and the next they don't fit into the tiny sneakers they took them in. You blink your eyes and their princess dress is two sizes too small and their dinosaur backpack isn't cool anymore. But don't cry because they're growing up.
- [00:46]
A
Smile because you can profit off of it for real.
- [00:49]
B
There are a bunch of parents on Depop looking for the stuff your kid just grew out of. Download depop to start selling why should.
- [00:57]
A
We care about bones without bones?
- [00:59]
B
Muscles Just a heaping pile of steaming metabolic tissue. Bones are structural. They're the very backbone of us.
- [01:06]
A
Is it inevitable that you will have joint pain and joint issues as you age?
- [01:12]
B
I think it's common, but not inevitable. Running does not cause arthritis.
- [01:16]
A
What about wearing a weighted vest and going for a walk?
- [01:20]
B
So you know why I love weighted vests? It is not for building bone.
- [01:25]
A
Imagine living a life where you feel strong, mobile and completely independent well into your old age. Well, what if the key to that lies in understanding and protecting something a lot of us take for granted until it's too late? Our bones and our joints. I'm Dr. Reena Malik, your biologist and pelvic surgeon and welcome back to The Rena Malik, MD, podcast, your trusted guide for leveling up your health, sex life and relationships with evidence based tools. Today we're diving into everything you need to know about the musculoskeletal system and I am so thrilled to be joined by Dr. Vonda Wright, a double board certified orthopedic surgeon, a sports medicine specialist and author of the incredible new book Unbreakable. In this episode we're going to leverage her decades of research and clinical experience to provide you with a clear evidence based roadmap to optimize your bones, muscle and your joints. You'll learn why jumping and lifting are non negotiable, the critical role hormones play and how to safeguard against debilitating fractures. If you're interested in learning more science, every week with a quick summary of the most interesting research in sexual health and get a chance to have your questions answered by me for free every single week, sign up at my newsletter@newsletter.renamelicmd.com thank you so much for being here.
- [02:48]
B
My pleasure.
- [02:49]
A
I'm so excited. I love working with fellow surgeons, especially fellow female surgeons. I think there's just something about going through that experience as a female in a subspecialty where it's largely male and surgery is very rigorous. So coming on the other side, I always feel like this kinship and sisterhood with anyone who's done that. So thank you.
- [03:07]
B
Oh, I'm so glad to be here. And I totally agree with you, especially urology and orthopedics.
- [03:13]
A
Yeah, it's all boys, definitely.
- [03:15]
B
All the time.
- [03:16]
A
Yeah. Yeah, it really is. And. And. And I will say, I think orthopedic surgeons are definitely the most similar to urologists, and vice versa. I think, compared to the other subspecialties of urology. Like, I think we have a good sense of humor, but we can work hard and have a good time. And. Yeah, so it's. It's lovely. And I'm so glad that you are sharing all your knowledge online, and I'm so glad we're all going to learn from you, because I will be honest. I didn't really ever think about bones, like, until I started following you, until I started really, like, thinking about overall health and longevity, I never really cared about bones. So let's tell the audience. Why should we care about bones?
- [03:54]
B
I don't think your experience is unusual, because if. Unless we're at Fashion Week and people are commenting on cheekbones and clavicles and. Or, oh, look at your delicate wrist. Honestly, why would we think about them? Because they're right. They're there. We think they're silent. The reality is that bones are what I call the master communicator. And if I were designing a being, why wouldn't I make a highway that goes from the top of our heads to the bottom of our feet, one of the major communication systems. So bones, although structural and as I like to say, you know, that's how we know them without. Everybody's crazy about talking about muscle right now, including me. But without bones, muscle's just a heaping pile of steaming metabolic tissue. Bones are structural. They're the very backbone of us, if you will, both figuratively and actually. But as master communicators, they are endocrine organs secreting hormones that do a variety of things, such as help your brain produce BDNF and therefore new neurons, if you're a guy, that they work in conjunction with your lytic cells to help you make testosterone. Plus, with metabolism and name 10 or 12 other things that they do. It's a miracle. But not only that, bones are the storehouse of all the minerals. Our bodies use calcium, magnesium, phosphorus. They are an incubator. It's where all of our baby blood cells are made in our pelvis and our long bones. And so the list of functions that our bones do go on and on and on, and yet nobody thinks about them, of course, until we fracture one.
- [05:45]
A
Yeah, and that's a big deal. And we're going to talk about that. But it's amazing to me that I have never thought of bones as an endocrine organ. Like literally never. Never thought about the signals they're sending and how important those signals are for things like you mentioned brain health, BDNF and hormone health. And so what makes a healthy bone?
- [06:09]
B
So, you know, from a structural standpoint, bones are made in several layers. If we think about the biggest bone in our body, the femur, which starts at our hip and ends at our knee, and you cut it in half, you would see a very thick rind almost on the outside, called the cortex. Well, that gives us a lot of structural integrity. But inside of the cortex, of the cortex, the inside is like a mesh, a delicate lace mesh. And thank God it is, because if our bones were solid all the way through, we wouldn't be able to move. They'd be too heavy. But bones are structurally very complex, you know, as. As they flare into the ends of our joints. Very complex to have a very thick cortex. Our bones are made out of a scaffolding, just like you would look at a building, a scaffolding called hydroxyapatite. And then within that scaffolding, you have variety of bone cells, your body's storehouse of the minerals. So it's living and moving and dynamically absorbing and rebuilding every minute of every day, your whole life. So that's amazing. That's a healthy bone that's capable of that remodeling your entire life. You also have healthy bones if this mineral storehouses are strong enough so that they're structurally strong, you know, and actually healthy bone, or young bone is filled with bone marrow, where we make our bone cells, but as we age, that marrow is replaced by fat. And so bones morph in what is healthy throughout their lifespan, actually.
- [07:52]
A
So what keeps a bone healthy? Like, what are we doing that keeps it healthy throughout our life and what makes it less healthy?
- [08:00]
B
So bones are. We think of them as static, but they are dynamically changing all the time. So I just alluded to the fact that they remodel once we. Our bones solidifies as babies were born with bones that are mostly cartilage, and then those calcify and solidify to bone. But we are in a constant state of reabsorbing bone via a cell called the osteoclast. And so when this osteoclast cell creates an acidic environment, it releases the minerals your body needs, creates a divot. So it's the job of the osteoblast, the bone building cell, to fill that in. That process goes on in a steady state such that every 10 years, you have a new set of bone. So healthy bone will have this constant remodeling process going on. Healthy bone also has enough calcium and phosphorus and the minerals that we need for your bones or for your body to function. Right. And so it's actually a miracle that. That these are very complex organs, and we never think about it at all.
- [09:09]
A
Yeah, it really is. And I think it's. It's so interesting to think about, like, these things our body does in the background, but being in terms of, like, things that you can do to keep your.
- [09:20]
B
To help their bones.
- [09:21]
A
Yeah.
- [09:21]
B
Well, this process I was just describing, the constant remodeling bones are also very amazing in that they translate biomechanical stress into biochemical signals. Here's what I mean. If. If we were to get up and jump up and down the staircase in your house or in the front of your house, and we would land hard, that biomechanical impact. At a cellular level, There are bone cells that are in pretty much isolation, but they're connected by these little rivers of fluid. And when you impact your bone, the pressure in those rivers change. And that signals the bone cell that, oh, she's jumping around again. That's gonna take. That's gonna need some stronger bones. So the impact, changing the fluid pressure in the little canals tells the cell to send a chemical signal to the osteoblast, the bone building cell. She's jumping around again. You better build some better bone. So isn't that fas? Jumping jacks in gym class, jumping rope, jumping off a step can actually tell our bones to become stronger. So impact is critical. Another way that we build better bones is through the pull of the muscle tendon unit against bones. So even if people say to me, oh, my God, my knees hurt so much, I cannot jump around, which we can always find a way to jump around. But by building more muscle, we'll have increased tension on the tendon. Muscle is connected to bone by A tendon pulls on the bone and it's another mechanical signal to build better bone. So that's two things. Jumping, lifting weights, number three, bones hate inflammation, Hate it. And so when we focus on what to eat again, an anti inflammatory diet full of protein, bones are 50% protein, can help support bone health. But there are a couple other things that I like to talk about when it comes to bone health, and that is believing that you can do something to change the trajectory of your health. Because if you don't believe, if you don't have a mindset that what your behaviors are matter, then sitting in a chair is going to win out all the time versus jumping up and down. So we have to pivot our mindsets that we can actually take some control of our aging and bone health back by doing those things. Something critical that I talk about pretty often is making your hormone optimization decision. We know that estrogen, and to a lesser extent, testosterone and progesterone, but estrogen in particular is critical for controlling the balance of bone remodeling. Estrogen works by controlling this crazy osteoclast, the bone eating cell. Estrogen controls it. When we have estrogen in our youth, the balance between breakdown and building is homeostatic. It's balanced. But when estrogen leaves the bone, breakdown wins over. Such that in men, we know that it's normal to lose about 1% of your bone density a year in a slow steady decline. For women, when our estrogen goes away and we have this precipitous drop, we that will ramp up to 2 and a half to 3% loss a year even before women realize they're in perimenopause. We can lose over 5 to 7 years, 15, 20% of our bone density, even before we lose our periods. Right. So estrogen plays a critical role in this balance. So these are seven or eight things that we can do to build better bone.
- [13:21]
A
On the point of hormone optimization, I will say one for women. I was shocked when I first heard that hormone therapy is FDA approved for prevention of osteoporosis. And I was like, why are we not talking about this more? And I know we talk about this a lot now, at least in our circles, but I think it is really so critical to understand how important estrogen is that is already FDA approved for that purpose. Like we can talk about all the other benefits of estrogen, but this is approved by multiple societies. There's not a single expert who would disagree with this that you can use estrogen for the prevention of osteoporosis and it is. It is huge. It is so useful and so helpful. So I think that's a big take home. The other thing I would say is for men, as you mentioned, 1% per year, that's similar to the decline in testosterone. And I think what a lot of men forget is that testosterone converts to estrogen. And a lot of times when people are trying to optimize their testosterone, they are misinformed that they need to get their estrogen as low as possible because it will prevent that conversion. But there is sort of a sweet spot for estrogen for men. And so you have to be very careful if you're taking anything to reduce estrogen, that it doesn't go too low. And low testosterone will, in men, create less estrogen, which will then again, affect your bone health.
- [14:40]
B
Absolutely. And for men, we see two tipping points for bone health. For men who have poor bone health in their 50s early, it has to do with metabolic function, and maybe they've had to take a lot of steroids or autoimmune disease, but for most men, their fracture risk is in their late 70s and 80s when they are frail anyway. And so the complications for them of breaking a major bone are often life threatening. To your point, however, about. I like to say it like this, okay. You can fight about whether estrogen's helping your brain. I don't believe there's a fight, but some people like to fight about that. You can fight about whether estrogen will prevent microvascular disease of the heart. Again, I don't think there's a. I personally don't think the literature says there's a debate, but there seems to be a debate. There is no debate, to your point, no debate about the utility of estrogen and preserving bone density, and yet nobody offers it. And on top of that, what is going on with insurance only paying for DEXA scans or any type of bone monitoring like REM scan or DEXA scans? When we're 65, what are we waiting on for someone to fall down and break a hip and die? I advocate, and in my clinic, every woman gets a DEXA scan or a REM scan, because I have found many young women in their late 20s, 30s, definitely in their 40s, who have poor bone density. And so we know from multiple studies that to truly affect fracture rates, we need to optimize our hormones for up to a decade. So we need to start much earlier than we're doing.
- [16:28]
A
And this is why we need a lot more research in this space.
- [16:30]
B
Absolutely.
- [16:31]
A
In the younger ages, we've been so focused on the postmenopausal space, which is important, don't get me wrong. But we need to prevent it from getting that bad because you've alluded to this. But I think. Let's talk about it. What happens when you get a fracture? Like what is the harm of bone fractures and how does that change people's lives?
- [16:50]
B
Let's start with the most obvious part of having a fracture. It hurts.
- [16:54]
A
Yes.
- [16:55]
B
It's excruciating. You don't even feel these bones until they break and then it's all you think about. Right. Whether it's your wrist or your proximal humerus, your arm bone. So how do women. I'm going to get to the bigger bones. But how do women break their wrist and their in their arm? Well, we fall and we put our arm out to catch ourselves and our wrist absorbs it all. Or this happens so often we have big hundred pound dogs who suddenly go see a squirrel and pull our arm like that. So. And then it takes your dominant arm out for three months. Think about how you're going to function and drive. So it's painful, it takes you away from function, but it's your arm and it is not so life threatening as the bigger bones, such as a femur fracture. So people may be used to these data by now, but 70% of all hip fractures or feet, femur fractures are in women. 70%, that's huge, right? When a woman falls and breaks her hip, the minute, just like that, the snap, the minute she breaks, that infers a 30 chance of dying in the first year because of the complications that happen with being sedentary, with getting a blood clot, with getting pneumonia, with getting bed sores, with being debilitated with a chronic uti, all the things that happen as complications. And then if you survive 50% of the time, if you're an older woman, you cannot return to the home that you came from. Maybe it was the home where you raised your children.
- [18:34]
A
50.
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B
50.
- [18:35]
A
That's a.
- [18:36]
B
You cannot go back. That's one. It's either me or you, isn't it? When we sit like this, two young vibrant people, it's either going to be me or you. And when you put it like that, you're like, oh my God, oh my God, what am I going to do to get in front of this and that? Exactly the reaction I want. The minute a woman. I'm going to just name a number. 40. I mean, it probably should happen much before then. Since we reach peak bone density around 30, we should be thinking about our bones to jump around, impact our bones, eat enough protein, make our hormone optimization decision so that we have a full decade before estrogen is fully gone from our system. Yes. To get in front of it.
- [19:15]
A
Yeah. I think, I mean, I'm really grateful for the longevity space because I think that at least it's highlighting these things that I think we've been catching up. Right. We've been just fixing people and treating people and it's important those things absolutely need to happen. But now we need to focus on making us healthier one, because we live in a society where it's hard to stay healthy now. Right. There's more processed food, there's more jobs that are sedentary. There's a variety of different reasons, but we really need to focus on those things. And you mentioned DEXA scan or a REM scan. What's a REM scan?
- [19:47]
B
A REM scan. DEXA scan is a newer technology. It's very common in the UK and Australia, but it uses ultrasound to tell us bone quality. It will also tell us bone density, which is what a DEXA scan will. How much mineralization is our bone and which is what most of the fracture risk is based off of is DEXA scans. But a REM scan will tell us the ability of the bone to absorb tensile stress. So every time you step on a bone, it ever so slightly bends and bends so you could fall. But if your bone can bend and reap and then re. Go correct itself, you won't break.
- [20:27]
A
Yeah.
- [20:28]
B
And so that's what a REM scan will tell us. And the good thing about it is there's no radiation. You get it every day if you want. I wouldn't, but you could. Right?
- [20:37]
A
Yeah. You mentioned impact. And so I've been watching you for some time and I really get a sense that like, like I need to be jumping more.
- [20:45]
B
You do.
- [20:47]
A
So let's tell our audience because I guarantee you 90 of people watching this don't think about jumping, don't jump at all. So why should we jump?
- [20:54]
B
Well, remember we were talking about the dynamic, the fluid dynamics that happen inside the physics of it, that happen inside of a bone. Well, one of the best ways to impact your bones is to jump. Now, I did a study so long ago, 2010 or something, where I looked at master's age athletes. So you have to be 50 and over to be a master's age athlete in competing in the National Senior Games. And I looked at who had the best bone density. Well, the first question I asked was, can we maintain our bone density late into our 80s. And the answer was yes. But then we had to go back and say, well, which activities? And it was all the jumping sports, volleyball, basketball, anywhere that you were jumping up and down, not so much swimming and cycling as you would expect. Right. How much jumping do we actually need to do? Because probably not many people to your point jump anymore. Not because they're incapable, it's just they haven't. Right.
- [21:52]
A
They haven't had to.
- [21:53]
B
Why would they jump?
- [21:54]
A
Jumping tracks or.
- [21:55]
B
Right. Why would we? So you know, if we're walking, that exerts about 1.5 times body weight. If we're running, jogging, it's about 1.2.5. The science tells us that we need three and a half, four times body weight to cause the impact that will cause the osteoblast to build better bone. Right. We can get that by jumping. So the recommendations are anywhere, depending on who you read, and there's several guidelines, but either 10 minutes of multi directional jumping three times a week or every single day jumping broken up in a couple sets 50 times a day. So 20 here, 20 there. It's better to do it multi directionally because if you do 50 in a row, the fluid dynamics will equalize and they won't stimulate the osteoblasts. But if you're jumping ahead and back and like hopscotch. I did a post recently where I was reintroducing hopscotch to the world. Because think about it, you jump in a line and then you jump side to side and, and so it doesn't have to be arduous, it can be fun. But there's a difference between jumping up and down the way I'm talking about now and jumping on a plyo box for type 2 muscle fibers. Because when I also demonstrate that online on online, I often get comments of, oh, I could never do a 24 inch box. Well, I'm actually not asking you to. Jumping up and down on the ground can take you a long way. And then even 8 inches, which is the height of an average stage step, will give you four times body weight.
- [23:33]
A
What about wearing a weighted vest and going for a walk?
- [23:36]
B
So you know why I love weighted vests? It is not for building bone. I love weighted vests because it will increase your workload about 10%. And, and I give it that number based on my own experience. When I wear a weighted vest to do my zone 2 or my baseline training on a treadmill, it increases my heart rate about 10% with the same incline and speed yeah. So I think weighted vests are a great way to add workload to your walk or something, but it's not enough weight to really add impact to your bones. Now, there are some very small studies as they tend to be. Weighted vest with weight lifting can have an impact on bone, but then we know weightlifting alone will have an impact on bone.
- [24:24]
A
So is weightlifting enough? Do you have to jump or is weightlifting enough to get that 4x weightlifting.
- [24:31]
B
De novo has been found to be able to have a positive impact on bone density. But listen, why are we doing one or the other? Let's just do all eight things or seven or eight things.
- [24:43]
A
Yeah.
- [24:44]
B
And optimize our chances. You know, sometimes I get. I keep referring to social media, but I am on. We are both very big and very frequent active on social media. So I get. I get all kinds of comments and I get a lot of comments about. Well, there is no randomized control trial that a vest plus jumping, plus weights plus. Okay, so there is not a randomized study that tests all four things on bone density. It doesn't mean that we don't know individually these things can help and that perhaps by stacking them, we can save people from the ravages of fracture. Because unless you have been at the bedside of a woman who is curled up in a ball writhing in pain has a 30% chance of dying, do not talk to me about your experience with a woman with a fracture because you don't know.
- [25:39]
A
Yeah. And there's no re. It's not like we're harming anybody.
- [25:42]
B
We are not harming people.
- [25:44]
A
Jumping is not very. Not bad for you. Now, I will say a lot of women don't want to jump because of stress, incontinence.
- [25:50]
B
There is that. Let's fix that for them. Let's do something for that.
- [25:54]
A
So please, you know, see your urologist, your urogynecologist, go to pelvic floor physical therapy. Do Kegels do, you know, figure out. There are so many things available. There are minimally invasive procedures. There are surgeries, but they're, you know, really minimal surgeries. So talk to your doctor. Don't suffer in silence. Don't use that as an excuse.
- [26:12]
B
Well, and I love that you're bringing that out. And it's so apropos because even I just don't want women to feel like they're alone or have to be ashamed when that happens because I don't know. Tell me if these data are right, but I have in my mind 80% of women have some form of incontinence and even the strongest women in the world, if you watch the Reebok CrossFit games, these are the strongest women in the world. And when they're box jumping with heavy weights, sometimes they're incontinent. So it's not because you are a failure. It's a physical manifestation of a skeletal muscle not doing its job in the pelvis.
- [26:51]
A
Right. And it's a skeletal muscle that we are often utilizing for walking, for standing on your feet all day, for coughing, for childbirth, for everything. And so it can get weak. Right. And just like any other muscle. And we are not really taught about the pelvic floor early on, and we're not taught to give it the attention it deserves. And so don't feel bad about it.
- [27:10]
B
That's right.
- [27:11]
A
Should not. This is the thing I will say for my female listeners is we suffer in silence too long. We're too busy taking care of our kids, taking care of our aging parents, taking care of our spouse, taking care of everybody else before we take care of ourselves. And I see it every day in my clinic where women have dealt with it for 20 years, 30 years. And so I would say if you're bothered, absolutely, do something about it. If you're not bothered, it's not dangerous. But we're off the topic.
- [27:37]
B
But you know, it changes whole lifestyle, so let's address it.
- [27:42]
A
Yeah, absolutely. So we talked about impact.
- [27:44]
B
Yes.
- [27:45]
A
Now pulling muscle tendons. So resistance training.
- [27:47]
B
Yes.
- [27:48]
A
Tell me about training mistakes that people make that can actually hurt their bone. Because I think everyone hopefully knows, if they listen to my podcast, listen to you, that resistance training is important. But when are they hurting themselves?
- [28:00]
B
I think it is very common to hear a recommendation and think that everybody is going to start at the same place. I think you have to do an honest assessment of where you're starting. If you are literally an adult onset exerciser, meaning you never have done anything but you've gotten the message. Now it takes a ramp up, sometimes a year to learn how your body moves, to build some reps so that your bones and tendons can bear the load, to learn the technique to lift in a proper way so that you're not going to hurt yourself, to not overdo it too much too soon, too often you can get a stress fracture from going from zero to hyperintensity over a short amount of time. So if you're an adult onset exerciser, give yourself a Runway. If you are a once upon a timer, which is those people who remember the athlete they were in high school or college 20 or 30 years ago and think we're just going to go back and start where we left again. Give yourself the ramp up. Nobody says that you have to arrive tomorrow at a place where you're lifting heavy, jumping up and down, doing plyo boxes, doing a lot of reps. That is a slow, steady progression. It is not a six week program because I want people to pivot their mindsets to this is how I live for the rest of my life. Not a six week program. And I'll be done with it. That's not how our body works.
- [29:35]
A
Yeah.
- [29:36]
B
So just give yourself the grace to be progressive. You will get there with consistency.
- [29:43]
A
And if you build that consistency, it will continue.
- [29:45]
B
It will continue.
- [29:46]
A
If you try to go hard and heavy, you'll likely burn out.
- [29:49]
B
Well, what happens is I see this, my, my office, but purposefully, I put my office in this gorgeous performance center. And my office has floor to ceiling windows that overlook a football field, an indoor football field. And what I see happening day after day, because it's the same people, bless their hearts, they're trying so hard, they're doing so many reps at moderate intensity, they're not getting enough recovery. It's not periodized. Light workout one day, really intense the next day. They're hurt all the time in my office every three weeks with another overuse injury because our body needs recovery days, our body needs light days and really heavy days. And so those are all the ways we can get hurt while we're just trying to do the right thing.
- [30:40]
A
Yeah, yeah, I was, I've been talking to my husband about it. And we lift and we've come to a point where we're like, we're not always going to failure. We're not always trying to push ourselves because we don't want to injure ourselves. Like the longevity of being able to continue going to the gym and lifting is so much more important to us than just making that day hit a pr.
- [31:00]
B
The pr.
- [31:01]
A
So how can people know? Because I think this is the other thing people think. No pain, no gain. Right. So how can people know the difference between pain that's, you know, just physiologic adaptation versus pain that, hey, I need to slow down.
- [31:14]
B
Adults, midlife people have delayed onset soreness. So it's the day after your workout, you might not be that sore, but two days later you're very sore and then it should go away. By the time you cycle back to that, if it's a leg day and you get sore three or four days later, that soreness should be gone and you could, you know, you're pretty well recovered. If you're not well, then give yourself the grace to do another body part that day if you're still so sore and inflamed. So that's one way to know. Also there, there is a character difference between sharp, stabbing ripping pain and fatigue and soreness. In all likelihood, intermittent sharp stabbing ripping pain is actual damage. It will be accompanied by swelling and redness and heat. That is an injury and should be treated as such. Versus I'm sore a few days after my workout. You know, I, I lifted really hard. Well, maybe that's a sign that we need more recovery.
- [32:16]
A
Yeah, absolutely. How can someone sort of pick up on the fact that they're over training? I mean, I see people all the time who say, I work out seven days a week, I work out six days a week. And some of them are doing it period with periodization. So they're having light days. But other times they are just like CrossFit every day or they're, you know, they're really intensely working out. So how can someone identify like they're headed in that way?
- [32:38]
B
It's important to listen to your body because there is a certain reward system to being that intense every day. The reality is pro athletes don't do the same intense workout every day. If we're all trying to emulate the best of us, right? They have light days, they have heavy days, they have very set schedules. So why do we think as mere mortal athletes doing the same high intensity, burn your brain out type thing is going to be helpful? Well, it feels good while we're doing it, but then when you start being more sore longer, if you start not being able to get your heart rate up to what you're used to, if your sleep becomes disturbed, if you're noticing that you're more susceptible to colds, then those are all signs that you're over training. Not to mention maybe you have a nagging ache and pain that's just not going away because you're doing the same thing every day, abusing the same muscle groups, Right? And that is, that is really important to realize if you're, and I'm not picking on cyclists, but if you're a cyclist and that is the only thing you do, and you're doing the same intense uphill downhill because somebody's yelling you at the other side of the screen to do it, and you're fatigued and heavy and you have pains that won't go away, your body is speaking to you. About the fact that it needs more recovery. And when you look at older professional athletes, I mean, like Lindsey Vonn just won a World Championship at 41. Dara Torres came back to the Olympics twice in her 40s. A variety of hockey players, Tom Brady. We're performing athletes into their 40s now when we never were before, but they do not train in the same way that they did when they were 20. When Dara Torres came back to the Olympics as a swimmer in her 40s, she was not swimming the same high intensity number of laps she did when she was younger. She had more recovery, she had more total body days. I mean, she's very open about talking about it. So why would we think as mere mortal midlife athletes that we could just go hard and intense every day? Yeah.
- [34:55]
A
And there's not a benefit to it. I don't think you're going to be seeing a long term benefit in terms of health by doing it every single day.
- [35:03]
B
Right. And especially those high intensity every day tend to be all aerobic exercise to the detriment of lifting weights, which we know really if cardiac is important. But for preventing frailty, it's the strength training that will get us there.
- [35:23]
A
Yeah. In your book you actually have a score, it's called the unbreakable score that helps people sort of measure their baseline fitness and use that as a marker. Tell us a little bit about that.
- [35:34]
B
There are eight or so measures of physical health and strength that have research that backs up their impact on longevity. So we took the top eight of those that had pretty solid research and using the research we weighted which were most important, like VO2 Max is at the top of the heap. BMI, although we don't love BMI, but there isn't a lot of data on percent body fat. So we use BMI, grip strength, sit to stand, gait speed and a few others that we ranked according to. Out of the eight, which was most important all the way down to eight, and then created a weighted score so that, you know, it doesn't take that long to do these tests. When we put people through it in about 45 minutes or so, we can run through all eight of these and give you a score that reflects how fit you are according to those tests. Tests that impact longevity. The priming prime one is your VO2 max, which does not have to be tested with the mask on your face. There are, there are proxy tests that give you a good estimation. And the only reason to do the unbreakable assessment is to know where you're starting. It is Not a judgment. Right. But if you don't know where you're starting, then after all this hard work, you're going to invest in yourself. You won't know the progress you've made.
- [37:04]
A
Right.
- [37:04]
B
And so that's why we use it. And so it's. The chapter is very long and unbreakable that explains how to do it. But we also have a platform called the Unbreakable app, where it teaches you how to do the. It gives you pictures of it, and it's just a good way to start.
- [37:21]
A
Yeah, no, I think it's great. I mean, I think people and. And from what I remember is it's pretty affordable to do at home. You don't.
- [37:28]
B
You need barely anything.
- [37:29]
A
Barely anything. So it's not like you have to go, as you mentioned, to a specialized lab. You can do a proxy measure of VO2 max. And so it's great. I think everyone should do it.
- [37:38]
B
Just test it out.
- [37:39]
A
Yeah, absolutely. And in the book, you also talk about the importance of mobility and flexibility, which I think, again, we don't talk about enough. Everyone knows inherently that you want to be able to move like you want to be able to sit, to stand and lift your luggage up in the overhead compartment when you're older. But how can we really focus on those areas? What are the keys to maintain.
- [38:01]
B
So when I prescribe exercise to midlife people, and, you know, midlife, according to the NIH, starts at 35. It's much younger than you think. It's not just the cardio that we talk about, the aerobic and the weightlifting. The acronym I use is called face, Face your future. And it's the four components of Total body wellness. So it's F is for flexibility and joint range of motion. It is the natural history of the collagen in our tendons and ligaments and muscle to get tighter and tighter, the covalent bonding increases. So if we don't stretch these back out, a few things happen. We're more. We're more prone to injury because they're more brittle. We lose our joint range of motion. And that's why you see little people shuffling along because they've lost their hip motion and their knee motion. So beautiful ways to get in front of flexibility is. Is to dynamically, which means stretching through motion, which I teach you in the book, or even statically after we've worked out, which is what we all learned in. In grade school PE class. Stretch your muscles, tendons and ligaments back out. But another beautiful way is Pilates and yoga and Tai Chi. And all the mobility type arts that keep your joints moving through a full range of motion. Even I've demonstrated online just squatting down. Like, I don't really know what it's called, but it's a deep squat and sometimes it's attributed to Asian people. We're squatting down. Well, my 86 year old mother can still do that because it's just culturally something she's done her whole life, right? So keeping that flexibility and joint range of motion is critical. So that's F A is aerobic, we've talked about that. C, F, A C, Carry a load. Now, I purposely didn't name it weightlifting because frankly, you can lift buckets of heavy water in your garage. You could lift a log. It doesn't have to be iron, but it has to be heavy to challenge you. But then E, F, A, C E is equilibrium and foot speed, which is another way to say we got to keep you upright because when you fall is when you get hurt. So we have to retrain our balance, which is simple. Either you can stand on one foot. Sometimes I see video of me on stage and I'm standing on one foot. I'm just so used to teaching people to do it. Or you can stand on one foot where you brush your teeth because the movement of your arm will help you regain your balance. And then foot speed, this is a surprising one for people you know, when you're about to trip. I write in the book about tripping in front of the Plaza Hotel in New York and suboptimal or tripping over my work bag, which I insist on putting on the side of my desk. If you have the foot speed to be able to hop over it, you.
- [40:50]
A
Won'T fall down, right?
- [40:51]
B
And you can totally retrain that with simple exercises to get back some of that agility that we lose when we lose our type 2 muscle fibers.
- [40:59]
A
So are there certain things that you think you mentioned, like the squat, but are there certain motions or activities that everyone should be able to do that would say like, yes, you have good mobility and flexibility, are like, are there maybe by decade, like 40s, 50s, 60s?
- [41:13]
B
Well, certainly you should maintain these throughout the lifespan. But if you can get into your 60s still being able to squat all the way down, still being able to bend over and pick something up without toppling over, being able to stand on one foot, those simple acts will go a long way for you. But. But you know, I think if people in their 30s are listening and try to reach over and get a piece of paper off the floor, with one foot, they may be unstable. But the good news is that you can retrain that at every single age. What I would want is people to start early and then maintain it, not find themselves at 50, 60 and beyond, totally behind the eight ball and have to desperately try to catch up.
- [41:59]
A
Yeah, well, unfortunately, I think there are a lot of people who are in that situation.
- [42:03]
B
There are. There are.
- [42:05]
A
So. And then I guess the other question I have in sort of similar is like, what changes are you seeing in young people? And like teenagers and young adults, are we seeing changes in their bone density and things we need to sort of look out for?
- [42:18]
B
I'm glad you asked that question, because sometimes we think of bone health as an old person disease. The reality is, is that osteoporosis manifests in your old age. But is the disease of young people meaning that we know that we will reach peak bone density at between 25 and 30, both men and women, and then from that time we will have the slow decline that we talked about. But what we don't talk about is the fact that I see a lot of young kids, 20s, with poor bone density. And why would that be? Well, maybe it's because they are currently buying into the myth that most of us were raised at that if you're a girl, you have to be teeny tiny and you can't eat, and maybe you eat so little that you don't have your periods. Right. Periods are a vital sign. You know, as we've. We're both friends with Natalie Crawford, and she would describe it like that there's something wrong if you don't have your period. So, I mean, and I didn't know that I was a ballet dancer. And frankly, not having your period for six to nine months was great. Only now to realize that I wasn't probably building bone then. So we're not having periods because we're not eating enough. Or maybe we are athletes and we're burning 10,000 calories a day out on the soccer field and we're. Our training table consists of gummy worms and Dunkin donuts. That is never going to build enough bone for you because you're expending too many calories. Right. You're never refeeding. Or maybe we're not building enough bone because everybody now is born as a digital native.
- [43:56]
A
Yeah.
- [43:56]
B
And bless their hearts, esports is a real sport and paying millions of dollars. So you have people in their basements sitting for 15 hours a day not building bone. Right. So we have a. We have a generation of young People not reaching a high peak bone marrow density. And then for women who choose to have children, it takes about 500 milligrams a day of calcium to build a baby. Now, the good news is that our body knows this is going on and is prepared to rebuild our bone, but only if we feed ourselves. Right. So in our haste to get back to our pre baby weight, if we're not eating, or we're just so tired because the baby's up all the time, we're not eating, we may not do that. And there is a real phenomenon called the osteoporosis of pregnancy that manifests as spine fractures. I know, I know. And then it goes on and on, even though our bodies know how to rebuild. For those of us who choose to breastfeed, and hear me, people do not send hate mail. I am all about breastfeeding. I breastfed for a year when I had my last child. It takes calcium out of our bones to do that. So I encourage all nursing mothers. You latch on, you drink your fluid and you replenish your calcium.
- [45:17]
A
It's also a low estrogen state when you're breastfeeding completely.
- [45:20]
B
So we're not building bone like that. And so even though we're equipped to build bones, sometimes we never do the other thing.
- [45:28]
A
I think while you've been saying this, I've been thinking about this. GLP1s people are not eating enough.
- [45:34]
B
That's right.
- [45:35]
A
On GLP1s. Are you seeing a change in their bone density? Are you seeing this happen in your clinical practice?
- [45:40]
B
You know what? GLP1s have been so common, but only for the last three years or so.
- [45:46]
A
Yeah.
- [45:47]
B
So I think, give me five more years, give me 10 years. I think we're going to see, especially because there's some really conscientious clinicians who, when they prescribe GLP1s, they're also saying things like, I will not give this to you unless you lift. I will not give this to you unless you're eating enough protein so that the weight that's lost is not at the sacrifice of the muscle. But not every clinician is that way. And I know this because I have people coming into my office who are very happy with the weight loss that they've had, but they have never been told that they're losing 40% of it as their muscle. Yeah, they have never been told that. So I think we're gonna see a lot of badness in the future.
- [46:30]
A
I am worried because the thing is, they're eating less.
- [46:33]
B
Yes.
- [46:34]
A
And then if they're not eating the protein and the calcium that they need, they're gonna have bone sequelae too and fractures.
- [46:41]
B
So yeah, give us a little time and I think we'll see that. And then there is the. Also one of the hormonal influences of bone is to, is to play a role in satiety. Telling you when you're full. Well, if something else is telling you when you're full, that takes. The bone is telling you it needs something if it's not telling you you're full. With LCN2, which is the hormone it produces that says you're full. If, if the bone is not full, then you will be stimulated to continue eating to replace what the bone needs. But with this other influence that's more powerful as a GLP1 telling your brain because it's really a neuro, a neurotrophic peptide. Right. That feedback is altered. And I'm not against GLP1s at all. I'm just saying that done right, they're a miracle. Done sloppily. I think we don't know what's going to happen yet.
- [47:37]
A
Yes, I really worry about that because I feel like there's a, I mean there's a huge pressure to look a certain way.
- [47:43]
B
Yeah.
- [47:44]
A
And we're going back to the, you know, fashion cycle itself. But the, but the low rise jeans and the, the appearance of the 90s when everybody was so, so skinny is coming back in. And part of it, I think is because of GLP1s allowing people that maintain that body image. But yeah, I do worry about it. I do worry about that because I do think they're a wonderful drug when used correctly. But when used willy nilly, it can be dangerous.
- [48:11]
B
Completely.
- [48:12]
A
Yeah. So let's talk about what happens when you really break a bone. Like when you think about when you cut your skin. I tell patients like it takes a full year for that cut to really heal, although you'll see it heal much sooner. What happen happens when you break a bone.
- [48:25]
B
So a bone has a lot of difficulty healing if it is not stabilized. So that's why orthopedic surgeons either realign the bones and put a cast on so that they cannot move, or put a metal rod or metal plate on because once bones stop moving, all the work they're going to do in creating an inflammatory process which brings inflammatory cytokines to the area, which will eventually result in laying down calcium, which is called callus. When you see a bone that's healing, you'll start to see this little cotton candy Arrangement of calcium over the fracture, and that is the body bringing in the scaffolding that will then be calcified and mineralized so that the callus covering the bone becomes 360. So the interesting to think it's not that the fracture itself, the two edges seal back together. The body surrounds the two edges with new bone called a callus, which holds it together and can be incredibly strong. And then over time, in the remodeling process, the callus is remodeled into a bone with a cortex and a matrix. Isn't that interesting? It's not like the two edges seam back together, the callus surrounds it, it mineralizes, and then it remodels. In children, you can heal a bone in six weeks. Like put two bones in a room, a child will heal them. In an adult, it can take a minimum of three months. And then we don't really trust that bone for some six months because it's not just the initial callus. You can break through that callus under too much stress. You need the remodeling of the bone into a mature bone with cortex and matrix. So think about how much time that takes off. Right. You're not, you're not back to skiing for six months or what, you know, whatever.
- [50:31]
A
So the lack of activity is to allow it to heal, but also to keep it stabilized. Right.
- [50:36]
B
Well, that's interesting. You say that in orthopedics. Originally the thought was put the bones in a cast, don't let them move. So the callus doesn't move. Because what happens if the bones are moving and the body is desperately trying to build callus but the bones are moving, it forms something called a non union. And you just have this unstable mass of bone, of bone that isn't healed together. But when you put a metal rod in it and it stays still, the callus can become solidified and it can heal over the long term and then remodel. So technology in orthopedics has evolved such that once we fix the bones with metal or implants, we actually let you weight bear.
- [51:21]
A
Oh, that's great.
- [51:22]
B
Yeah, so that we get the added impulse of the impact. Now there's a fine line, right. Because the metal will break with an. It's like a metal hanger. Enough reps that's going to break. So there's a fine line between putting weight across the bone while it has metal in it and giving it time to heal. So that's the art and science of, of healing bone. But our technology has improved such we want you to move Earlier.
- [51:52]
A
I think that's great because, you know, I think there's so many things in surgery that we do out of dogma. Right. Like bed rest after surgery. I mean, it's very infrequent. So bad for us, but there's so many things that we've done with dogma, and some, some of these things still persist, like avoiding showering for a certain period of time after surgery. Like there's something that people still get.
- [52:12]
B
Prescribed out of our fear of infection or our fear of failure. Right?
- [52:16]
A
Yes. Yeah, but that's. That's really interesting. What about. So you said, you know, obviously your body is going to need so much more metabolic activity to heal. So what do you recommend people do in certain. Should they be taking additional types of nourishments, vitamins, things to help that process.
- [52:32]
B
Move along more quickly to heal a fracture, to. To keep our bones great in general?
- [52:36]
A
Well, let's start with the same. It's probably the same, but, yeah, it's the same.
- [52:39]
B
You know, when someone has an injury or whether. Even if it's an acl, it's a soft tissue injury, we always, in my clinic talk about their protein intake. Are you even eating enough that you're going to have the building blocks? And so for people who are not hurt, I like them to eat a gram of protein per ideal pound and knowing that they're not going to absorb all of that. And some people think that's unfathomable, but it's actually not that voluminous. Bones need it. Muscles need it. Let's feed with protein. I like people to get their calcium for bone healing from their food, not a calcium supplement in the forms of the Tums or whatever. So that means you're going to be eating a lot of Greek yogurt and tempeh and tofu and. And maybe some canned sardines with bones in it, because it's the bones that. That will give us the calcium we need. Or salmon in a. In a can, we can get 1200 milligrams of calcium from our food a day. If we eat high calcium foods three or four times. That's what I like people do. Magnesium is important for bones. Some micronutrients, boron, selenium, there's. There's a whole list that our bones need. And really micro. So those are all things that we encourage people to do as they're healing bones, but mainly eat protein.
- [53:58]
A
Yeah, Eat protein. Probably like a little multivitamin and a little multivitamin.
- [54:02]
B
Sure. It doesn't have to be fancy yeah.
- [54:05]
A
Okay. We haven't talked much about joints.
- [54:07]
B
Yeah.
- [54:08]
A
But joints, obviously they wear and tear over age, and that's why many orthopedic surgeons are having business. Why does this happen? And what can people do to prevent joint degeneration?
- [54:21]
B
Yeah. So let's define a joint. A joint is just where two bones come together. The ones we think about most are our shoulder joint, our knee, our hip, especially in midlife women and men. So when two bones come together, bones are actually pretty fragile. And so every bone is coated on the end with a layer of cartilage. Cartilage is, is white, it's glistening, it's smoother than ice. It has a coefficient of friction that's less than ice. So it's so smooth you don't even perceive it moving in your joints until it starts to break down. Cartilage itself is a matrix with some few scattered cartilage cells in it. So it's mostly scaffolding. And the thing that makes it healthy is joint fluid. Joint fluid that is not filled with inflammatory cytokines. Joints are healthy when the cartilage do not hasn't been worn down like a food grater. Why would the cartilage matrix be worn down? Well, there's so many reasons. It could be due to high steroid use. Maybe you had asthma, maybe you had cancer and have to have high steroids. That's really bad for cartilage. Maybe. Or you abuse steroids, or you abuse steroids. How about that? Anabolic steroids. Or maybe you were pre ozempic and carrying around a couple hundred extra pounds. Joints bear 7 to 10 times body weight. So imagine 100 extra pounds. It's like a thousand extra pounds of pressure across a very delicate structure. And in the laboratory, when you want to damage cartilage, you drop a marble on it. It's very sensitive to. And so maybe it was due to wear and tear of weight, maybe it's due to trauma. Athletes twist and bend and bang, and we get one sheet of cartilage on every bone for our entire life. Once it's gone, it, it can repair with a patch, but it will never be the healthy cartilage we have again. So these are all reasons why people end up with joint degradation, aka arthritis. Before 50 men have more arthritis than women, a higher incidence of arthritis. After 50 women will have can have a rapid progression in their arthritis. In fact, get this. There was a paper published in 1925, a hundred years ago by a researcher named Noble, documenting the arthritis of menopause. A hundred years ago, that's insane. Someone started asking, why do all these women in menopause have so much more arthritis? Well, it's because every musculoskeletal tissue, tendon, ligament, muscle, bone, fat, muscle derived stem cells, they all are cousins and they all have estrogen alpha and beta receptors. So if estrogen is not sitting in the receptor on the cartilage matrix, it cannot maintain its integrity as well. And therefore, lo and behold, we have a rapid progression of arthritis in women in midlife. Of course, during a time when they're putting on weight that they never wanted to have. And so we have that added pressure. Maybe they're still not eating because they're trying to diet their way to feeling better. Maybe they hurt so much because of arthralgia that they're not exercising. Because becoming strong and moving your joints is one of the cures for joint pain. But it's counterintuitive. If it hurts, don't move it. Not true. All the reasons that all of a sudden women in midlife have this rapid progression in arthritis and then it slows them down and it just one thing leads to the next.
- [58:09]
A
Is it inevitable? I mean, because we're living longer, Is it inevitable that you will have joint pain and joint issues as you age?
- [58:18]
B
I think it's common, but not inevitable. And I think it goes in degrees. I mean, I, I think having an ache and pain once in a while, maybe that's inevitable. Having pain that's so debilitating they have to sit in a chair. I don't think that's inevitable. But it cannot start when we're 60 or 70. We have to be mindful from a very younger age and do all the things that we've talked about in terms of keeping. For instance, let's talk about the knees. When people come to me with knee pain, I never just address their knee. We always. One of the steps in my plan for them is always to become strong as a bull. The muscle support above and below the knee has a critical effect on the impact that the knee sees. So they're always very surprised when I'm like, we're sending you to physical therapy and then we're getting you in a gym because we are going to get you strong as a bull and your knees will benefit. So to answer your question, I don't think debilitating joint pain is inevitable, but we have to start early on all the things we talked about. Will we have aches and pain as we age? Yeah, but not so much that they make us sit in a chair, usually Right.
- [59:37]
A
Well, also, I mean, you can damage your joints from overuse too. Right. So where is the balance then of. Obviously you want to strengthen your muscles to maintain joint health and do all the other things we've talked about, but also avoid sort of, you know, really minimizing that joint fluid and space that kind of that cushion there in the joints.
- [59:58]
B
You know what's interesting is there is clear literature that even the impact of running, long term, chronic running, does not speed up arthritis progression.
- [60:09]
A
Really?
- [60:09]
B
Running does not cause arthritis. Yes.
- [60:12]
A
That's good to know.
- [60:13]
B
Yes. Because that is a very common fallacy. Oh, you gotta stop running. Well, if you have trauma and your cartilage is damaged, then the repetitive nature of a thousand steps a mile can make you feel worse. But long term, runners, running itself doesn't cause arthritis, probably for a lot of reasons, one of which is, is there tend to be lighter people. Right.
- [60:38]
A
So generally speaking, we don't need to worry about that. If you're doing all the right things.
- [60:41]
B
If we're doing all the right things.
- [60:44]
A
You don't need to worry that you're actually like wearing out your joints.
- [60:46]
B
I would not know. I would not stop being mobile because of being afraid of wearing out your joints. Because what am I sentencing you to then? If I say, why don't you sit still and don't wear out your joints? I am sentencing you to sedentary death syndrome. We know that. It's kind of like a societal mantra. Sitting will kill you. Well, smoking, it's like smoking. Yeah, Yeah.
- [61:10]
A
I want to talk about a couple things that are sort of novel and interesting and people are talking about them. What about vibration plates?
- [61:18]
B
So power plates, Vibration plates. There is some small study data that it can stimulate impact and build bone density. Not as much as lifting, not as much as jumping. Vibratory plates are great for engaging the lymphatic system. They're great for involving your core strength in big compound lifts. Right. If your feet are firm on the ground and you're doing compound lifts, even though it's hard, it's not as hard as doing those squats, for instance, on a power plate, because then you must engage all your small muscles to stay upright. So there's great value to it. Value alone in building bone is not as strong from a research perspective.
- [62:06]
A
Okay, and what about prp?
- [62:09]
B
So PRP is platelet rich plasma. We know that platelets, when you cut your leg shaving platelets rush to the scene of the crime in your bloodstream and they plug the hole. But they're not just Bricks in a wall, they're sacks full of variety of growth factors that your body use to initiate the healing cascade. So what we've learned. I started doing research on platelet rich plasma in 2000 when I was in the lab. I know. And I would just draw my own blood, spin off my platelets because I had blood. Why not, right? Since that time, researchers have found that platelet rich plasma in a musculoskeletal system can be very effective for chronic tendon problems, for rotator cuff tears, for moderate arthritis, for tendon and ligaments, as I've said, like patellar tendonitis, tennis elbow, Achilles tendonitis. But it is dose dependent and you have to know how many platelets you're giving. So the current literature points to needing 10 billion platelets to, to mount an effective anti inflammatory and healing response. 10 billion. So that means wherever you're getting it done needs to have the ability to count, otherwise you don't know what you're getting and you don't know why it's not working. Right. And the science is evolving. But we do have enough papers to have meta analysis, meaning a lot of randomized control trials. Then you compare them all in a meta analysis. When I first started using platelets clinically, we were doing 5 billion in three injections. Well, the data evolved. Now we know one injection of 10 billion is as effective. My patients get about 80% relief for more than a year, sometimes up to two years. So when we put the platelets into the knee joint, for instance, they burst, they release their growth factors, start initiating an anti inflammatory cascade. And we believe that they call the stem cells from the synovium into the milieu to start working. Because to heal a tissue, you need cells, you need scaffold and you need growth factors. So the platelets are providing growth factors, they're calling in the stels. And the knee has its own structure. Right. Are we to the end of the road with research knowing how everything works? Precisely. No, actually not. But does it offer an amazing option if we don't want to go do surgery, which most of my patients aren't looking for surgery.
- [64:51]
A
Yeah.
- [64:52]
B
And I've had great success with it. So I offer it generative.
- [64:55]
A
Right. Like instead of an injection for pain, which is just relieving the pain or inflammatory markers, potentially it's actually creating a healing response.
- [65:04]
B
Well, let's compare that. Right. So I just told you that a dose of 10 billion platelets in my patients and in the literature has an 80% efficacy and relief of pain and can Last durably, a steroid injection, which is the go to knee jerk reaction, which I rarely give in the literature, lasts three weeks and we don't really know what.
- [65:29]
A
Three weeks.
- [65:30]
B
Three weeks. Now some people get a six months out of it, but that is the exception, not the rule.
- [65:35]
A
Yeah.
- [65:36]
B
And so the only time I use steroid injections is when people do not want platelets or their joint is so damaged it's bone on bone. We're just trying to buy some time getting them out of excruciating pain and then I'll do it because I'm not inhumane.
- [65:53]
A
Right. Yeah. And I think the interesting thing about PRP is one, there's definitely this lack of counting of platelets.
- [66:00]
B
Yeah.
- [66:01]
A
You know, and two is it's a blood product. And so there's no. Right. You don't have to go through the same regulation as like a pharmaceutical injection. And so anybody can really give it. Anybody can.
- [66:10]
B
I'm glad you brought that up. Right.
- [66:12]
A
Give it. And so I do worry and I tell my patients this too. I think first. So people do use PRP for erectile dysfunction. However, the data is mixed and because I think we don't know the right amount of platelets. We don't know that. You know, there's still some, some things that need to be figured out. And so. Yeah. Could it work for the same reasons? Right. It's bringing growth factors and things like that. Yes, it could. I'm not convinced yet that I know exactly what to do. Right. And so I'm not offering it. But I think the issue is that, yeah, anybody can do it. Like anyone can give you PRP without really even necessarily being trained on it.
- [66:45]
B
Well, that's true. And so patients need to know who's treating them. Are they board certified doctors or licensed clinicians? At the very least board certified. There's a, you know, there's all kinds of letters after names out there. Lots of letters, Lots of letters. And there are legitimate letters and there are letters that I don't really know where they came from. And I think if I don't know where they came from, that the public definitely doesn't know. So I just think people need to be careful, ask for the data, don't be sold.
- [67:19]
A
People are very good salespeople. We were just talking about this before we, before we started that we're not good at selling things.
- [67:26]
B
We're not, we're not taught in school. There's no sell anything. Well, that's not our vision, that's not our mission. Doctors are not, not all doctors, but.
- [67:37]
A
We are not certainly looking to sell anything. But, yeah, I would say, look, if I was getting something injected in my joint, I would want it from an orthopedic surgeon or a PMNR physician, someone who has primary care sports medicine. Yes, primary care sports medicine. That's who I would look for. If I had something injected in my penis, I would go to a urologist. I don't have a penis, but you know what I mean. So, you know all those things. I think it's really important to bring that up because this is. This is one of the things that's not regulated and won't be, and there's going to be more in the future. So it's really important now, especially in the time of social media, to be informed and to look at who you're. Who's talking to you on the other end really, really critically.
- [68:15]
B
I. Do you see this. I see a little bit of turn where audiences want to know what the qualifications are of the people speaking to them.
- [68:25]
A
I've always seen it, but I think now it's more so, like, okay, just because you have the qualifications, they want a little more. They want to know, like, well, what does that even mean? Which is good. I think it's important for people to. To be discerning. But also I see the other side of it where they just see someone who has a big following and is very eloquent and charming, and they just say, well, this person said this.
- [68:49]
B
And, well, what's interesting. Oh, I'm. I'm glad you were. I'm going to sound all hateful and spiteful. I'm not. But I see a real difference between the challenges that happen with female doctors and men online. Doctors are not who. Who. I don't think there's this much scrutiny, frankly. And I'm not trying to start anything on your podcast, but I observe it. I'm on there every day.
- [69:14]
A
Yeah.
- [69:14]
B
Observing who's. Who's being questioned and who isn't. So I don't think questioning is bad, frankly.
- [69:20]
A
I think questioning is good. I want to be questioned. I want people to call me. I've been wrong before, I'll be wrong again. Right. I'm certain I will. I'll misinterpret something. I'll under. I'll not be. I'll, you know, I'll mess up.
- [69:31]
B
And it's the nature of medicine to do more research into change.
- [69:35]
A
Yes. And I think the other thing is how you present information. Right. It's. I think if you guys have listened to me for a while or you listen to even this conversation. We've not said things in absolutes unless they were truly absolute and not harmful. Right. Like exercise is good for you. It's not harmful. Right. We can say that in absolutes. But there are certain things we're like, yes, there are some data on this. This is the data, this is what we know right now and this is how we're practicing because of it. I think that's where you need to think there should be nuance because people are vying for your attention in such a way where if you say a negative, I just actually just heard this. If you say a negative thing, if your title is negative. If you start with a negative, people are like almost four times more likely to. It depends on the topic or how you're doing it. But they're significantly more likely to listen. And so it makes sense that people will find that pattern and say, oh, if I say someone didn't tell you this or you're doing this wrong or you know something negative, people pay attention. It's a survival instinct. Right? We want to know the things, we.
- [70:37]
B
Should look the bad. Yeah, yeah, that makes sense.
- [70:40]
A
You actually on the prp, you did a study on this, you looked at using PRP before rotator cuff surgery and that it actually improved outcome.
- [70:50]
B
It does, it does. And so why do we think that is? Well, it was observing data, it wasn't a causation study. But what we observed is that by adding an adequate dose of platelet rich plasma to a milieu where you have put the tissue back together. So what if the rotator cuff, this is the rotator cuff, this is the bone. What if the rotator cuff was still torn, torn and I dumped platelet rich plasma in there? Well, actually there, there is an anti inflammatory pain relief effect of that, but it does nothing to the tissue. Cells don't jump. And so that paper showed that with repairing the tissue so we have the structure, right, the scaffold, we've talked about adding the growth factors in the form of platelets bursting and expressing their growth factors and helped the bone heal to the tendon better because that's the direction of healing. The bone sends out fibers to heal the tendon and that was augmented by the addition of growth factors to the milieu. And so in a repair where some data shows that up to 40% of rotator cuff tears re tear, it's a lot. And it's not due to surgical technique. It's due to the fact that rotator cuffs have no Blood supply and blood is key for bringing growth factors and cells to an area. Right. So in an event where 40 a surgical response that 40% of the time, it can retear the fact that we can simply add your own biologics back to the system and see better outcome. That's a bonus.
- [72:32]
A
That's a huge bonus. Do you. Do you foresee a future?
- [72:36]
B
Will this become standard of care in many sports practices? In elite sports practices, it is standard of care. It's not a standard of care of everywhere. But almost everybody I know does it. Just because I come from a big academic center and those are the clinicians that I practice at that level, it might not be available in some small space without a centrifuge. Not because it can't be. It's just not.
- [73:04]
A
Well, I mean, I don't know. I don't know. The orthopedic training. Is this something that everyone's trained on in orthopedic training?
- [73:11]
B
You know what I would say in the big fellowships, they see it. Absolutely.
- [73:15]
A
Yeah. But maybe a general orthopedic surgeon who's in a community taking care of everything would not necessarily see it.
- [73:20]
B
If you haven't done a fellowship in orthopedics, you can still go practice as a generalist. You might not have seen it, but if you've done a sports fellowship, you are likely to have seen it because it's a concentrated year of how to best take care of tendons, ligaments, bones, that kind of thing.
- [73:38]
A
Got it.
- [73:39]
B
Yeah.
- [73:40]
A
The one thing I also want to talk about, and we talked a little bit about this before we started the podcast, is how the pelvis and the hip bones all play a role together. Are you seeing in your patients that, like, when they have abnormalities in the pelvis, whether it's hip injuries or instability, that they're also developing pelvic floor dysfunction?
- [74:01]
B
So, you know what's interesting is when I've been doing hip arthroscopy since, I don't know, 2005, 2006. So as I explain to patients what's going on, if you have a hip, a hip is a cup in your pelvis and the femur bone, that fits in. If you have a hip that doesn't move either because it has arthritis or because the cup is too closed and you have very little native motion, that doesn't mean that your body doesn't need motion. It just means it's not going to get it from its hip. So let's just say you need 10 units of motion to walk. And if we can't get what we need from the hip, we're going to steal it from somewhere. We're going to steal it from the low back, the SI joints. For instance, people get low back pain, and it's not actually their back, it's their hip. Right. Or they might steal it from the front, their symphysis pubis, where the two sides of the pelvis come together, that could become unstable, or they could put undue pressure on the pelvic floor so that it's either too tight all the time or it can't respond to support the internal organs as it's supposed to. All because your hip doesn't move. Right. And so identifying what is the actual cause of your SI joint pain, of your incontinence, if you will, or the almost tetany of your pelvic floor when it's, it's tense all the time, is really critical when you're examining people and not to just take, oh, it's your hip that's the, it's, it's your back that's the problem. It's never one thing. It all works together. And so often when it comes to hip and SI joints or, or low back, it's. If it's the right hip that doesn't move, it will be the other side that, that's being called upon to give the motion. Yeah, it's that interesting.
- [75:49]
A
Yeah. And I think it's really important as a, as a patient, if you start having discomfort, to get a proper evaluation, because by the time they come to see us, they've already been diagnosed by somebody that they have a problem in their hip or their back or their pelvic floor. But it can take them, many doctors before they sometimes figure that out. And so I always encourage people, if you have access to a pelvic floor, physical, physical therapist, that's great. If you're having any dysfunction and then getting help for those issues. Right. I think it can be very helpful.
- [76:19]
B
I think even when people know there's something going wrong, like, tell me I, I said these data to you at lunch. I'm. It's what I say all the time. But about 80% of women have some form of, of incontinence. Very few people talk about that. So how can you possibly get help? Due to a variety of reasons. Right. It'll pass. I'm embarrassed. Nothing you can do about it anyway. Not true. It bears conversation. And if somebody, if the doctor you're with is not an expert at that and says, you say that to them and they don't even acknowledge it or something. That is a good time to seek different help. It's not a period at the end of the sentence, it's a, okay, and I need to find different help. Help.
- [77:04]
A
Yeah. And thankfully, thankfully telemedicine exists now even if you live in a place where there's not a lot of options. Oftentimes even insurance companies have telemedicine. If you don't know, you know where to go find someone. Usually you can look through your insurance company and it can be affordable or free. So absolutely can ask for and yeah, it takes time away from work, it takes time away from things, but oftentimes they're doing evening and weekend appointments. So make the time for yourself. Yeah, absolutely. You've been working with athletes and aging athletes for decades, over two decades. What's something you know now that changed that you changed your mind about?
- [77:41]
B
I think when I was a younger doctor, I expected. Although you know, maybe this is not true. I was going to say maybe. I have always expected a lot of my people. Meaning we underestimate what we're capable of. Now that I am myself older, I look back and think, you know what, I should have never assigned a 60 year old. Oh, you're just 60. I should have never said that. And maybe I didn't because I was always studying masters athletes. But I think what has changed over time for me is an even increased expectation that we can be healthy, vital, active, joyful longer. Because as I age into this decade that I hate to say out loud, I'm, I can still do anything I want to do.
- [78:28]
A
Yeah.
- [78:28]
B
Because I've been working at it a long time and you know, two years ago I was pressured into jumping into a Spartan race and I finished the Spartan race. I'm like, I didn't know how to get over an eight foot wall. I didn't know how to climb a 30 foot rope or throw a javelin and but what I did know is that I had a baseline amount of shape in me that I had figured out so many things in life that I was going to figure out these obstacles. And I think that I might not have expected that when I was 30, but now I expected of everyone aging that you're bringing with you the wisdom of being able to figure everything out. And now are we going to invest in our bodies to be able to keep up with what our minds are capable of?
- [79:18]
A
Yeah, I think it's a non negotiable. You have to invest in yourself. You have to take the time for yourself. Otherwise you'll pay for it later on.
- [79:24]
B
You will. And it's harder to catch up. You can catch up. I have lots of examples of people catching up or starting over. It's easier young people just to keep up than to catch up.
- [79:35]
A
Yeah. And I spend a lot of time with my kids. I said, we go. We work out with my older. We work out with our older son. He's older enough to use the weights at the gym. And I'm like, look. And he enjoys it. And I say, look, I. I don't. I just want you to keep it up when you leave us. Right. Like, keep going to the gym. Make time to do activities.
- [79:53]
B
It's your lifestyle.
- [79:54]
A
Yeah. Make it a normal part of life. And I hope that all this work will pay off when he leaves us.
- [80:00]
B
For college, he'll return to it.
- [80:03]
A
Yeah, I hope so. I hope so. And it makes a difference. Right. And there is muscle memory to some degree. Right. Those muscles you make when you're young, they become easier to. To remake when you're older.
- [80:12]
B
And even when you're older, there's muscle memory. I mean, you know, this is the tail end of me launching this book. And I've traveled so much in the last four months that the regularity of what I do has suffered. That being said, when I do go back and do my routine, I'm not starting at zero. Our bodies will remember. And so you just have to give it the stimulus it needs.
- [80:40]
A
Absolutely. Absolutely. When you think about musculoskeletal health, what in the future of musculoskeletal health is kind of getting you excited?
- [80:47]
B
I am really excited about everything we're learning about biologics and the fact that we will need to do fewer surgeries in the future. I'm really excited about a technique that I do now to fix knees and meniscus is. I don't even cut people anymore. I do this surgery through 14 gauge needles.
- [81:07]
A
That's crazy.
- [81:08]
B
It's called needle scoping. It's by a company called Arthrex. And I have complete. I'm an early adopter, completely adopted this, such that I can do it awake. If you want, I'll just numb up your knee. And most people don't want to be awake. They want to be sedated. But the. The reason to be excited about this is not because of the surgical technique. It's because you don't need any narcotics. You don't need general anesthesia. You recover so quickly, you walk around the very next day as if nothing happened, except you're out of pain. Right. And so we're back to activity faster, which makes us healthier. And so I see that minimal as minimal invasive. Harnessing the power of biologics as an incredible future for musculoskeletal health.
- [81:59]
A
You know, the one thing I didn't ask you about is hip surgery. So there's actually some data on people who re injure their hips after hip surgery because they start having sex.
- [82:08]
B
Oh, right.
- [82:09]
A
So what is the protocol for that? What do you tell people? For one, maintaining good hip mobility for sexual health. And then two, like, is there a restriction on that?
- [82:20]
B
You know what's interesting about that question is many women who have healthy hip, then have babies are put in that weird lithotomy position that we're all put in.
- [82:31]
A
Yeah. Meaning legs up in the air.
- [82:33]
B
Legs up in the air. Flex past 90 degrees up to our chins. And then we're pushing really hard. And the poor labrum, the soft tissue lining, it's like a suction cup on the bone, just gets twisted and we tear. And so many women come to me postpartum with sharp stabbing pain in the groin with twisting. Which is exactly what happens with some forms of intercourse. Right. So when I have a patient recovering from hip arthroscopy, depending if it's the man or the woman, but until we are totally healed four months later or more, we're not going to put our hip in a hyper flexed, internally rotated position. So I'm not saying that you can't have sexual relations. I'm just saying they have to be less creative with the positions you put your body in.
- [83:22]
A
Got it?
- [83:22]
B
Yes.
- [83:23]
A
Yeah. So sex is still fine.
- [83:25]
B
It's fine. Just be. Just be wary of hyper flexed, internally rotated, twisting in motion positions. Just be a little less creative until we're healed.
- [83:36]
A
Find other ways to induce, introduce novelty. That's right. Awesome. Where can people find out more about you about your book? I loved your book, by the way.
- [83:47]
B
Thank you.
- [83:47]
A
I really hope everyone. I think everyone should buy it. It's called Unbreak. I was like this. It's got. It's got like a. It's like a guidebook and a book all rolled into one. It literally tells you what to do. And I think it's so helpful because bones are so important. Bones and joints are so important. So where can they find out more?
- [84:05]
B
So I am every day on Instagram and a variety of social media@drvonder wright.com or Dr. Vonda Wright. It's also Dr. Vonderwright.com I have a podcast called Hot for your health. So think of every 360 media, whether it's YouTube, podcasting, social media, I am there educating people. Because you know what's funny? As I've done this now, the education part, I realize what I am in my heart and soul. I mean, I'm a really good surgeon, but I am an educator, and I think I would have been a very happy fourth grade teacher.
- [84:40]
A
Yeah.
- [84:41]
B
Just teaching people all the time.
- [84:42]
A
I agree with you.
- [84:43]
B
Yeah.
- [84:43]
A
Yeah. It's a very good skill, and it's one that not everyone has. So I think we are grateful to you. Thank you for doing it. Now we end our podcast with questions we ask everyone. They don't have to be about bones. It can be anything. What's something you know now in life? And we sort of ask something like this so you can think of something else. What's something, you know now in life that you wish you knew earlier?
- [85:02]
B
You know what? I think I came to the authenticity of being midlife pretty late in life. Right. Because at this point, I am so authentic. People always comment to this when they meet me in public now. They're like, oh, my God, you're the same person in person as you are. And that's absolutely right. What you see is what you get. And that comes from the authenticity of knowing that I have value as the way I am. I don't have to live up to any other standard, which is hard in a surgical residency. Right. You're performing all the time. And knowing that I have figured out almost every situation in life and that gives you the confidence just to be.
- [85:44]
A
Well, and knowing that you can figure.
- [85:45]
B
It out and I can figure it out. Right?
- [85:48]
A
Yeah. And that's great. What's a non negotiable something you have to do every day?
- [85:52]
B
Interestingly, you wouldn't know this from my public place, but I'm an introvert. So what is non negotiable for me every day is that I take time to say, settle, because then I can be productive and help other people. But until I take that time, for me, whether it's walking home from my office, which is 2 miles, or literally just grabbing a cup of coffee and sitting still, it's not talking that's critical for me to function at the high capacity that I function.
- [86:23]
A
Yeah, I. I can relate to that. Yeah. I think it's. It's so important. And everyone has their own routines, but I think it's. It's okay to be authentic to yourself and do what you need.
- [86:32]
B
Right.
- [86:32]
A
And ask for that space that Comes with the maturity of knowing that, you know, you're comfortable in yourself.
- [86:36]
B
Yeah.
- [86:37]
A
What's a life hack or health hack? You'd share with everybody. You shared a lot, but you could share another one.
- [86:42]
B
You know what? People always ask me, if there's one thing to do, what do I have to do? And there is not one thing you have to do. But if it. If you only have 30 minutes, you're gonna go lift some weights. And if you want to get it all in, they're like, literally, I one thing. Go row. Use a rowing machine. You're going to get cardio and you're going to build muscle at the same time.
- [87:04]
A
Rowing. All right.
- [87:05]
B
Yep.
- [87:05]
A
If you couldn't be an orthopedic surgeon, a speaker, an entrepreneur, a writer, what else would you be?
- [87:12]
B
You know what? I. There's a certain performance thing in me. I would like to have been a rock star.
- [87:18]
A
Yeah. I love that.
- [87:22]
B
Yeah, yeah, yeah. Maybe Pat Benatar, somebody like that. Really off the. Off the edge.
- [87:27]
A
Awesome. Well, thank you so much.
- [87:29]
B
Thank you.
- [87:29]
A
Pleasure to have you.
- [87:31]
B
Thanks for having me.
- [87:32]
A
Before you click away and find your next podcast, I need one favor. If you guys have been enjoying the podcast, make sure to go on the podcast app that you're on. Subscribe or follow the podcast. This signals to these platforms that, hey, this is a podcast worth listening to, and it helps them show it to new listeners. And guys, it helps me so much. And as always, I'm going to take care of yourself because you're worth it.