The Science of Joint Health: How to Keep Your Bones Strong for Life | Dr. Jocelyn Wittstein

Summary

The Science of Joint Health: How to Keep Your Bones Strong for Life | Dr. Jocelyn Wittstein

In this enlightening episode of The Dr. Gabrielle Lyon Show, host Dr. Gabrielle Lyon engages in a comprehensive discussion with Dr. Jocelyn Wittstein, a Duke orthopedic surgeon and sports medicine expert. Together, they delve into the intricate science of joint health, emphasizing the critical steps individuals, especially women, can take to maintain strong bones and healthy joints throughout their lives.

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1. Early Bone and Joint Changes: A Call to Action

Dr. Lyon (A) opens the conversation by highlighting the significance of bone and joint health beyond the age of 30. She warns, “If you're over 30, your bones and joints are already changing. And if you don't act now, you could be setting yourself up for arthritis, osteoporosis, and chronic pain later in life” (00:00).

Dr. Wittstein (B) underscores that many overlook bone health until pain or injury occurs, which often means the damage has progressed. She emphasizes the proactive approach needed to prevent such outcomes.

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2. Gender Differences in Bone Health

A substantial portion of the discussion centers on the disparities between men and women concerning bone density loss and arthritis risk.

Dr. Wittstein (B) explains, “Women become more at risk for loss of bone density over time. Before menopause, women lose 1% of their bone density per year. After menopause, that jumps up to 2%” (07:39). She elaborates on how estrogen plays a pivotal role in maintaining bone density and controlling inflammation, factors that are less pronounced in men until much later in life.

Notable Quote:

“Women are 30% more likely than men to have arthritis. And that doesn't even up again until we reach age 80.” — Dr. Wittstein (31:57)

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3. The Role of Estrogen in Bone Density and Inflammation

Estrogen's multifaceted role in bone and joint health is a key topic. Dr. Wittstein (B) discusses how estrogen acts as a major anti-inflammatory hormone and influences bone metabolism. The decline in estrogen levels during menopause leads to increased inflammation and accelerated bone density loss.

Dr. Lyon (A) probes further, asking whether receptor density varies between genders, to which Dr. Wittstein (B) responds that while men have lower estrogen levels, testosterone plays a more significant role in their bone health.

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4. Frozen Shoulder: Prevalence and Treatment

Dr. Wittstein (B) introduces the topic of adhesive capsulitis, commonly known as frozen shoulder, which predominantly affects women aged 40 to 60. She notes, “Frozen shoulder typically occurs in women age 40 to 60” (13:07).

She explains the pathophysiology, linking estrogen deficiency to increased inflammation and tissue fibrosis in the shoulder joint. Early intervention with steroid injections can effectively reverse or mitigate the condition, especially if addressed within the initial stages of pain and stiffness.

Notable Quote:

“If you catch it early, it does... reverse really nicely.” — Dr. Wittstein (17:48)

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5. Exercise and Bone Health: Debunking Myths

A significant myth addressed is the belief that activities like running cause arthritis. Dr. Wittstein (B) debunks this, stating, “Running doesn't cause arthritis. Runners are less likely than non-runners to get arthritis” (35:44).

She emphasizes the importance of strength and impact training in maintaining bone density. Activities that load the bones, such as jumping or resistance training, stimulate bone formation and prevent density loss. Conversely, lack of activity leads to disuse osteopenia, where bone density diminishes due to insufficient loading.

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6. Supplements for Joint and Bone Health

The conversation explores various supplements that support bone and joint health:

• Collagen: Dr. Wittstein (B) discusses two types—undenatured type 2 collagen (UC2) and hydrolyzed type 2 collagen. She mentions, “There is evidence regarding collagen supplements for joint health” (44:24). UC2 works through an immunologic response to reduce cartilage breakdown, while hydrolyzed collagen helps alleviate symptoms in early knee arthritis.

• Omega-3 Fatty Acids: Omega-3s are highlighted for their role in reducing inflammation and supporting joint health.

• Vitamins and Minerals: Vitamin D (2,000 IU/day) aids in reducing joint pain, while calcium and magnesium support bone density. Vitamin K assists in calcium incorporation into bones.

• Curcumin: An anti-inflammatory agent shown to reduce joint pain in early arthritis.

Notable Quote:

“I would say, people could try taking both [types of collagen].” — Dr. Wittstein (46:22)

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7. Hormone Replacement Therapy: Benefits and Risks

The episode delves into menopausal hormone therapy (MHT) and its implications for bone and joint health.

Dr. Wittstein (B) advocates for MHT as a preventive measure for osteoporosis, stating, “Menopausal hormone therapy could be considered a life-saving thing. It reduces your risk of a hip fracture by 30%, reduces your risk of a vertebral fracture by about 40%, and reduces your all-cause mortality by about 30%” (92:36).

She contrasts oral contraceptives with transdermal estrogen, noting that the latter does not increase clotting risks and is safer for bone health.

Notable Quotes:

“If you can gain, you're winning. Because the natural history would be to lose 1% of your bone mass per year or postmenopausal women, 2% per year.” — Dr. Wittstein (75:42)

“Women are more likely, this may not surprise you, to present farther into the disease process than men.” — Dr. Wittstein (32:33)

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8. Genetic Factors and Early Bone Density Maintenance

Genetics play a role in osteoporosis risk. Dr. Wittstein (B) mentions the importance of early bone density accumulation, especially before age 30. She references a study following gymnasts into adulthood, demonstrating significantly higher bone density compared to non-athletes.

Dr. Lyon (A) adds, “If you get a DEXA scan, you're 65 and you already have osteoporosis. No one told you at 52 that menopausal hormone therapy can help prevent osteoporosis” (87:52).

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9. Future Research and Ongoing Projects

Looking ahead, Dr. Wittstein (B) shares her ongoing research endeavors:

• Menopause Arthritis: Studying cartilage health in women post-menopause and the effects of hormone therapy.
• ACL Injury in Women: Investigating why female athletes are more prone to ACL tears by examining hormone levels and ligament geometry.

She is also co-authoring a book titled The Complete Bone and Joint Health Plan, which aims to provide a comprehensive guide for individuals seeking to understand and improve their musculoskeletal health.

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10. Concluding Insights

The episode wraps up with Dr. Wittstein (B) emphasizing the critical need for awareness and proactive management of bone and joint health, especially among women approaching menopause. Early interventions, proper supplementation, strength training, and informed use of hormone therapy can significantly mitigate the risks of osteoporosis and arthritis, enhancing quality of life and reducing mortality associated with fractures.

Final Quote:

“Menopausal hormone therapy could be considered a life-saving thing. It reduces your risk of a hip fracture by 30%, reduces your risk of a vertebral fracture by about 40%, and reduces your all-cause mortality by about 30%.” — Dr. Wittstein (92:36)

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Key Takeaways:

• Proactive Bone Health: Initiate bone health strategies before the age of 30 to build a robust bone density foundation.
• Gender-Specific Risks: Women face a steeper decline in bone density post-menopause compared to men, increasing their risk for osteoporosis and arthritis.
• Role of Estrogen: Estrogen is crucial for bone density maintenance and reducing inflammation; its decline accelerates bone loss and joint pain.
• Frozen Shoulder: Primarily affects middle-aged women and can be effectively treated if addressed early.
• Exercise is Beneficial: Strength and impact training promote bone density and joint health, debunking myths that activities like running cause arthritis.
• Supplements Support Health: Collagen, omega-3s, vitamins D, K, calcium, magnesium, and curcumin play significant roles in maintaining bone and joint health.
• Hormone Replacement Therapy: MHT is beneficial for preventing osteoporosis and reducing fracture risks but must be carefully managed to mitigate risks like blood clots.
• Early Intervention: Genetic factors and early bone density maintenance are vital in preventing long-term musculoskeletal issues.
• Ongoing Research: Continued studies are essential to further understand and address gender-specific bone and joint health challenges.

For those seeking an in-depth understanding and actionable plans to protect their bone and joint health, Dr. Wittstein’s upcoming book, The Complete Bone and Joint Health Plan, is a highly recommended resource.

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This episode serves as a crucial resource for individuals aiming to safeguard their musculoskeletal health through informed choices and proactive measures. By understanding the science behind bone and joint health, listeners are empowered to take charge of their well-being and lead healthier, more active lives.

Transcript

[A]

If you're over 30, your bones and joints are already changing. And if you don't act now, you could be setting yourself up for arthritis, osteoporosis and chronic pain later in Life. My guest, Dr. Jocelyn Wittstein, is a Duke orthopedic surgeon and sports medicine expert who's worked with elite athletes and everyday patients to prevent and treat osteoporosis and joint damage.

[B]

There is evidence regarding collagen supplements for joint health. A patient would ask me about collagen, I would say, that's dumb. Don't do that. And then, you know, when I really, I went down a lot of rabbit holes. And the more I read, the more I read, I actually now recommend it to people.

[A]

Most people don't think about bone and joint health until they start feeling pain or have an injury. But by then, the damage is already done. Today we're fixing that. I just wanted to jump on here with an exciting announcement. I am hosting the second ever Forever Strong Summit April 26, 27th, in Houston, Texas, 2025. There's going to be two days, the VIP day on April 26th. You will learn from former Navy Seals, from former Secret Service, from individuals that you do not want to miss. Myself, my inner tribe will be there to support you to learn everything from muscle health to science to nutrition. You don't have to be an expert. You don't even have to have a background. All you have to have is a will to win and stay strong. I will put a link in the show notes below. Please go to my website, drgabrielleline.com we sold out last year and I would hate for you to miss this opportunity. So if you're waiting for a sign, if you're thinking you need to change something up and you need community friends, we've got you covered. Dr. Jocelyn Wittstein, thank you so much for coming on the show. I'm very excited to talk to you. You are an associate professor of orthopedic surgery at Duke University and you specialize in sports medicine. And you're an extraordinary surgeon and really a thought leader. And welcome to the show.

[B]

Thank you for having me. I was excited to meet you in the corridor on the way into the White House for the conference on women's health research. And I think it was just really perfect luck or propinquity that we intersected.

[A]

There and I picked you up. I heard what you had to say and I said, that's it. Well, you got to come on the podcast and you got to talk about it. One of the things I think is really unique and interesting, and we were chatting right before we started recording, is that you are very interested in the lifespan or the muscle span of a female athlete throughout.

[B]

Yeah, I think there are very unique challenges that female athletes experience throughout their lifetime or health span or active lifespan. Yeah, muscle span, whichever term we want to use. And women are very active, you know, really throughout the lifespan, but it starts very early. Kids specialize very early in sports now, and. And we see a lot of adolescent female athletes with injuries and sometimes re injury. And then as athletes move on from high school and college, women stay very active, often in endurance sports, strength training, sometimes competitive sports. And we have masters athletes. But even if you're not a master's athlete, there are some commonalities that women experience later on in life, like increased risk of arthritis and osteoporosis and fractures. And a lot of those things have a common thread, often related to estrogen levels.

[A]

I don't think that we're hearing about that in the sports and training space, or at least we haven't. Would you say that that's fair?

[B]

Yeah, I think there have been efforts made, for instance, to understand things like why are female athletes more prone to ACL tear? Female athletes are eight times more likely than male athletes to sustain an ACL tear. Even when you control for sports that women don't play. Like if you just compare sports that both genders play, for instance, there's been some efforts to understand that, to understand how perhaps the hormonal cycle, the menstrual cycle, may impact risk of ACL injury, but it's really not well understood. Still, there's a lot of questions.

[A]

When was the first experience that you had that you recognized that? There seems to be a difference between, you know, as an orthopedic surgeon, in my mind, probably a hip is a hip, but for men and women, it sounds like the injury patterns are different. I don't know if the recovery is different, the time in which they. The age in which they injure. And I get that these are really.

[B]

Complex cases, but I think the phase of life where differences between men and women, aside from the just sheer number of girls, for instance, that tear their ACL or dislocate their patella or whatever, but the time in life that the difference in men and women is most evident to me in terms of just the natural history of diseases. I'm not talking about incidents, but just the natural history. How things progress is age 50 and over. So we know that women become more at risk for osteoporosis around the time of menopause, which on average occurs at age 52. But, but they also become more at risk for joint pain and progression of arthritis. So there's a very different trajectory for men and women. Women hit this age around 50 where there's a big increase in rates and progression of arthritis, more bone loss, more progression towards osteoporosis. Men don't see that dramatic decline and things don't really even out for men and women until we're like 80 years old. So by the time we're 80, you know, an 80 year old man is finally at the same risk for osteoporosis and fracture as a 65 year old woman was. And rates of arthritis don't become the same in men and women until we reach about age 80. So there's kind of a more rapid decline for women and then we don't, the men don't really, I don't want to say catch up, catch up in their decline until they're like 80.

[A]

Why is that? Because, is that because of estrogen or.

[B]

Is it just probably a lot of it? So estrogen is a major anti inflammatory hormone and there are estrogen receptors all over the human body. Skeletal muscle, bones, synovium of joints, your tendons and ligaments. So when we get estrogen decline, we get higher levels of inflammation. Inflammation is associated with synovitis and joint pain. We see increased rates of things like frozen shoulder, we see faster loss of cartilage over the age of 50 in women than men. And then we think about bone density. Estrogen has a different effect on bones. It's not an inflammatory pathway, it's more of a, it's a pathway where it basically leads to apoptosis or death of the cells which absorb bone. Osteoclasts which break down bone in the absence of estrogen, basically stick around longer and do their thing for longer and break down more bone in that way. Women become more at risk for loss of bone density over time. Before menopause, women lose 1% of their bone density per year. After menopause, that jumps up to 2%. You've got these two things going on. Women are losing bone density, they have increased levels of inflammation. And then there's also more difficulty with maintaining muscle mass. As we talked about, estrogen receptors are on skeletal muscle. It's more difficult to repair, maintain and build muscle mass with absence of estrogen. So all these things are coming together and that's just not something that men experience.

[A]

Do they have different receptors? Men obviously also have estrogen. Is the receptor density different for men and women?

[B]

That's a good question. I actually don't know about the rates of receptors for estrogen. Obviously, men have much lower levels of levels of estrogen, and women also have testosterone. Much lower levels of testosterone. Now, we do know in men who have hypogonadism or low testosterone, they are also at risk for osteoporosis. So. But I don't know the answer to that about density of estrogen receptors.

[A]

And the reason I ask that is because if both men and women have estrogen and men have lower levels of estrogen, but they seem to decline much later in life, then why.

[B]

Yeah, they're not so dependent on estrogen levels. Testosterone is doing more for them.

[A]

But then it would make me think that the. Perhaps the joints and the muscles and the fluid isn't different, but the sensitivity to various hormones seem to be uniquely different. And again, I don't know if that's correct. Uniquely different between men and women, because why? Because men could go on an estrogen blocker like anastrozole, and then you would lower their estrogen. I'm curious, as if they would have that same outcome that would be similar to a woman.

[B]

Yeah, I don't know the answer to that, actually. It's a good question.

[A]

What about so 50 is when women see this decline in bone mass, increase in joint pain, increase in arthritis. What about when an individual is on, say, the pill?

[B]

Yeah. So a lot of times women in perimenopause are put on, like, a combined oral contraceptive pill. And that's because in perimenopause, hormone levels are fluctuating. And that is basically like an early form of menopausal hormone therapy. I mean, we don't call it that, but it's. You're. You're stabilizing the levels of estrogen. And then a lot of people will stay on a, you know, combined oral contraceptive pill until they then transition into menopause and then switch over to menopausal hormone therapy.

[A]

But does it accelerate the pain? Right. So if estrogen, if oral estrogen, maybe it's at a pretty low dose. Maybe it's at a lower dose than an individual would typically make. Do we know how the levels correlate to changes in not performance, but quality of life? So I guess what I'm getting at is there's that natural progression of aging. They lose. I don't know. Women go through menopause, then they feel like crap. But it seems like if individuals use oral Contraceptives or, you know, things of that nature. Or even a woman that is has the athlete's triad where she doesn't have a ton of estrogen, do we see the same kind of postmenopausal symptoms?

[B]

So con. Oral contraceptives are used in athletes that have, you know, amenorrhea.

[A]

Yes.

[B]

So amenorrhea is. Can be part of. We used to call it the female athletic triad. Now we call it reds relative energy deficiency syndrome.

[A]

I did not know that.

[B]

Yeah, because that does encompass male athletes too. So male athletes can also get a relative energy deficiency syndrome, but obviously they don't develop amenorrhea.

[A]

That would be really weird.

[B]

Yeah, but yeah, so for. Yeah, the contraceptive pills can, you know, provide a level of estrogen that someone doesn't have when they're not ovulating because they are in that energy deficient state. And that is the indication for that. Oral contraceptive pills do typically have a higher dose of estrogen than is in menopausal hormone therapy, actually. But at some point, the amount of estrogen that is needed in menopause isn't necessarily what was needed when you were prior to menopause. But the level that's delivered through menopausal hormone therapy does combat loss of bone loss. And in many studies has been shown to reduce joint pain. And also in many studies shown when it is withdrawn to have to be associated with a rebound and joint pain.

[A]

I mean, you have a great. So there's a great paper here. So this is, this is titled Is hormone. Is hormone replacing therapy associated with reduced risk of adhesive capsulitis in menopausal women? Single center analysis. This came out 2023. And I just think it's so fascinating that, you know, there's this domain of sports injury and then there's this domain of life.

[B]

What happens to women?

[A]

What happens to women? Life injury. And you talk here about frozen shoulder and that typically hits women between 40, 40 and 60.

[B]

Yeah. So I love the topic of frozen shoulder. It is definitely not sexy. In the world of orthopedics. People, like have a woman come in with frozen shoulder. Like, I'm gonna see this person forever. They're gonna be in pain, they're not gonna need surgery. But I love helping people with this problem. You really can help people a lot. And actually just validating what's going on with them is helpful. But so, yeah, typically occurs in women age 40 to 60. It was labeled as idiopathic forever. And you know what idiopathic means? It means we just don't know what causes.

[A]

We don't know. We're idiots.

[B]

But how can it be idiopathic if this happens mostly in women and not in men? And, in fact, if it happens in men, it's almost always in someone with really poorly controlled diabetes. So that's a different situation. And, of course, diabetes is associated with high levels of inflammation, but so a low estrogen state is associated with high levels of inflammation. There are some really interesting animal studies that show that the presence of these estrogen receptors in the synovium, say, of the shoulder and that applying estrogen to the tissue of the lining of the shoulder can reduce levels of inflammation and reduce the fibrosis. There's an actual pathway in a recent study looking at mice showing how basically fibroblasts are activated without estrogen. And this is kind of probably what contributes to the thickening and the scarring of the tissue around the shoulder joint.

[A]

But why is it the shoulder, right, as opposed to, say, the head or the wrist?

[B]

I have wondered about that. I don't know if the shoulder joint perhaps has an increased density of estrogen receptors or something, and it's not always bilateral. But I will tell you, I have many patients that it hits one side and a year later they're back with the other. But the good thing is, when it comes on the second side, they know right away. And if you're developing a frozen shoulder, what happens is, first it's really painful and not stiff, and then it gets stiff and painful, and then it just gets stiff. And a lot of times what happens is people wait to come see you until it's just super stiff, and they've kind of suffered through the painful phase. And at that point, it's a little bit hard to get rid of. You know, it kind of thaws out over a year. But if we catch you when you're still painful and not stiff or painful and stiffening, it'll respond really well to a steroid injection and kind of try to, you know, reverse or shorten the process. And usually when women have it on one side, they know right away when it's happening on the other side.

[A]

How so? Someone listening to this and they just hit 40 and they're thinking, oh, my gosh, I do not want to get frozen. Shoulder. What are they? What are the signs?

[B]

Starts with usually no trauma. Sometimes people will recall. This is, I would say, one of the more common things. I was walking my dog. My dog really pulls on my arm. But it's not anything you would think would like, you know, Cause a trauma, and they often wake up just with pain. The pain is usually okay when you're sitting, but it's painful at the end. Range of motion.

[A]

Everyone sitting in your chair, go ahead.

[B]

Yeah. And, you know, look down, move side to side. You have the same motion on each side. So the pain isn't usually mid arc, but it's kind of at the end of the arc. And like a classic sign of adhesive capsulitis or frozen shoulder is pain and range of external rotation at the side. There's really almost nothing else that causes that specific pain with that very minor motion. Um, so then the other motion people will start to lose is they'll say, well, it's hard to reach across my body, like shaving under your opposite armpit or fastening a bra or tucking in a shirt. Those are the functional things people start to notice. But I'm always amazed that people don't notice. I would lose notice if I lost, like, five degrees of motion.

[A]

But let's be fair. What people don't know is you're a Division 1, former Division 1 athlete and married to an orthopedic surgeon with five children.

[B]

And I'm an orthopedic surgeon. So they don't notice. But by the time they come in, they've usually lost emotion in their painful. The other weird symptom people will say is, oh, my fingers feel tingly. Not like cervical radiculopathy, pinched nerve down into my hand. But they'll just have the vague sense that there's this tingling sensation in their hand. And then some people will have also lateral epicondylitis, because basically what they're doing is now they're just using their arm like T. Rex arms, using everything from the arm down. So there's probably some positioning. There's probably some inflammation of the capsule around the shoulder, and maybe that spills over a little bit to the plexus of nerves that go down your arm.

[A]

Wow.

[B]

But if you inject their shoulder, usually within three months of symptoms, the things reverse really nicely. I can't take credit for it, but the tingling feeling in the hand will go away. Usually their range of motion goes back, and occasionally you have to, like, inject them one other time.

[A]

But it's a full resolution.

[B]

Yeah, pretty much. If you catch it early, it is, I would say, in all things orthopedic for use of a steroid injection. A glenohumeral joint injection with steroid is the best indication for a steroid injection. I know people are afraid of steroids, but it can really Save you, not this crowd. Yeah, it could save you. It can save you a couple of years of, you know, thawing out.

[A]

So I have, I have a question. You said that one of the reasons is because there's a decrease in estrogen and you treat it not with injectable estrogen. Right?

[B]

Well, but yeah, I would, I would love to do a study of.

[A]

Oh, let me see that.

[B]

The study I would love to do is apply an estrogen patch right here. But that is very off label use of transdermal estrogen. So estrogen, you know, menopausal hormone therapy, including transdermal estrogen, is FDA approved for symptoms, you know, vasomotor symptoms of menopause and for prevention of osteoporosis.

[A]

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[B]

Body as you age, luckily. I'm so glad it's approved for that because it's very helpful with that. But it's not approved for myalgias, joint inflammation, polyarthralgia. Even though there's mounting evidence that there's so much inflammation associated with menopause joint pain.

[A]

Do you know anyone that's doing it interarticular?

[B]

Well, not interarticular, but I will tell you I have a very close working relationship with my colleague Dr. Ann Ford at Duke Women's Health. We were literally across the hall from each other.

[A]

Did you inject her shoulder with estrogen?

[B]

No, I didn't inject her. We've definitely helped each other. She's had an early round of frozen shoulder and she came right over and I injected her shoulder and I. This is unbelievable. As someone who studies adhesive capsulitis, I mean, I'm an almost 47 year old female orthopedic surgeon, but I, a few weeks ago I had adhesive capsulitis. Of course, you know, I diagnosed myself, but it was classic pain and range of motion. Then I couldn't reach across my back. It was front to back, deep in my joint. And you know, I called her right away and I was like, well, number one, I had my glenohumeral joint injected. Number two, I was like, it's time for me to go on transdermal estrogen because I'm perimenopausal and I don't want to bottom out. So I'm. Yeah, so we joke around. It's definitely an off label use. And I'm not saying that every single person that gets frozen shoulder should go ask for an estrogen patch. But we know the basic science of estrogen receptors in Synovium.

[A]

We know it's a fascinating conversation.

[B]

Yeah, I mean, even like the Women's Health Initiative studies, they showed that estrogen. So they had a study where 77% of menopausal women in their study had joint pain. And when treated with menopausal hormone therapy with estrogen, there was significant decrease in joint pain, number of joints that were painful and severity of joint pain. And when the therapy was stopped, there.

[A]

Was.

[B]

Some increase in the pain. So there are studies that are not new that show this, you know, ameliorating effect of estrogen on joint pain. And we know that women are disproportionately again affected by arthritis. It's kind of like a geometric proof. It's a matter of putting all these things together. But it's definitely not an FDA approved indication. But there's a, you know, a lot of menopausal women will present with, with joint pain. So, yeah, I'm. Now I have my transdermal estrogen patch and I'm hoping to stay on that. I'm on the moderate dose. And then you go into menopause and then you, you know, go up on your dose. But I just, I don't want to get osteoporosis and I don't want to get frozen shoulder.

[A]

Come on, you gotta, you gotta operate.

[B]

But so sometimes I'll have a patient. Let me tell you, sometimes I have a patient who's recalcitrant to things like they've had a steroid injection and it's still hurting. And they're also telling me I have night sweats and I'm depressed and I can't sleep and so they need to go see a women's health doctor. Anyway. But one of their other symptoms is they have a frozen shoulder and I send them to Ann and then she, you know, treats them. But so, yeah, I'm not, and I caveat, I'm not a women's health doctor. I'm an orthopedic surgeon.

[A]

Yes, yes, but you're a very progressive, forward thinking orthopedic surgeon. The estrogen and arthritis. So we talked about adhesive capsulitis, which is kind of this inflammation. This shoulder.

[B]

Right.

[A]

Doesn't seem to happen to men, if nearly at all, unless they have poorly controlled diabetes, typically, which is a good portion of the population. Does we have to say that? But is there a level. Someone comes in and they don't know that they're in menopause. Maybe they're not up to date with their blood work or they're not tracking their periods or maybe they are on an oral contraceptive or have a Mirena or something. So they're not aware. Yeah, they present with frozen shoulder. The individual figures out that they need hormone replacement. Is there a particular. Okay, so I understand that you're a surgeon, but I'm just curious if someone were like, okay, well, what would be the number that we shoot for in the blood? Or is it just.

[B]

Oh, blood work? Yeah, blood work is again, for my work with my women's health partners, as I understand, is not a great tool because it's. So the, the issue with hormone levels and perimenopause is that they're actually kind of changing and irregular and, you know, they're chaotic and so really they, they rely heavily on symptoms. Not, not blood levels. Yeah, yeah.

[A]

Which is interesting because for men there's a total testosterone and free testosterone, right?

[B]

And it's all about.

[A]

Yeah, every guy knows, you know, my husband's like, where's my Testosterone? Is it 900? What's my free testosterone?

[B]

And the range is so broad and. Yeah, I know.

[A]

Yeah. So, you know, as we try to draw correlations to set up a paradigm of thinking, right. This framework of thinking about musculoskeletal issues with menopause, metabolic issues with menopause, and, you know, really begs the question. What I find fascinating is that, you know, I worked on some of the early studies of postmenopausal women and body composition changes and we corrected for diet and exercise and we saw amazing resolution of body fat. And when I say resolution, they lost weight, they were able to maintain lean muscle mass. And I think within the traditional nutritional science world, people, when diet and exercise are corrected for, we see that body composition can be managed. However, when we really begin to think outside the box, the influence of these hormones, because women are saying over and over again that they go through menopause and their body composition changes and that they're having joint pain and they're having all of these other symptoms.

[B]

Increased visceral fat. Exactly.

[A]

And so it just, it just begs the question, do we, you know, what is it that we know and how can we redefine our treatment protocols for people? You know, obviously we're not there yet.

[B]

Yeah, yeah, it's really fascinating. And we're learning more and more about fat, body fat as being inflammatory. Like, you know, fat has lipokines, which are basically, you know, something that stimulates inflammation and elevates inflammatory markers. And in obese patients, we know that they're more likely to have arthritis, but not just in weight bearing joints. So patients who have obesity, you would think, oh, it's just mechanical overload of the cartilage. That's why they're getting more arthritis. And we know that's true.

[A]

That's definitely what we would think.

[B]

Yeah. But they also have more arthritis in non weight bearing joints.

[A]

Tell us what arthritis is. And the number one question we get is not that we get, but one of the questions that we get is, does running really cause arthritis, which we talked about, or is that a myth?

[B]

Yeah. So what is arthritis? And I actually explained this in my book because I think people just don't understand what arthritis is.

[A]

What's the name of your book? Will you share it for us?

[B]

Yeah, the Complete Bone and Joint Health Plan.

[A]

And when does that book come out?

[B]

May 6th.

[A]

And where's my copy oh, yeah, they.

[B]

Should send you one. I'll get you. Yeah, I'm gonna get you.

[A]

Signed copy, please. Okay.

[B]

All right, so. And also I want to add, co authored with my lifelong friend and colleague Sydney Niskorski, who is a dietitian.

[A]

But so, so we gotta have her on.

[B]

Yeah, I know we're gonna have to come back with her. You would love her. But. But yeah. So what arthritis is, is basically gradual loss of the cartilage, which is the smooth gliding surface of joints. And over time, the cartilage gets thinner. The body forms bone spurs called osteophytes along the edges of the joint. You get inflammation and thickening of the lining of the joint called the synovium. Then you get some stiffness, lots of range of motion.

[A]

Usually the cartilage changes because it doesn't glide as well.

[B]

Well, no, it's probably. So this is very confusing. It's multifactorial. And also there's different types of arthritis. So osteoarthritis we think of as wear and tear arthritis that you just develop over time as you age and that even has multiple components. Some of it is loading, like biomechanical. And some people are just built badly. Like if you're really bow legged or knock kneed or whatever, you're going to overload parts of your joint and they're going to wear out sooner.

[A]

Or if you have hip dysplasia or.

[B]

You could have a badly shaped hip joint.

[A]

Thanks, dad.

[B]

Yeah, but. And there's a little bit of a biochemical factor. So even in osteoarthritis, which is, you know, considered wear and tear, we see these elevated inflammatory cytokines in joints, like interleukin 16 tumor necrosis factor alpha.

[A]

Within the joints?

[B]

Yeah, like. Well, systemically and in the joints. And there are different cell types that are activated and there's like a kind of a cascade of reactions that leads to breakdown of the cartilage and also cell death of the chondrocytes, which are the cells in cartilage. But so in osteoarthritis is probably a combination of biomechanical and a little bit inflammatory. But then on the other extreme, you have entirely inflammatory arthritis, like rheumatoid arthritis or psoriatic arthritis, where these, these people have very high levels of inflammation. It's autoimmune. The same bad acting cytokines are in their joints and affecting their cartilage, but they're at much higher levels. Like the same IL1 and 6 and TNF alpha. And then Somewhere in between you've got probably like what menopause arthritis is where you have.

[A]

Is that a thing?

[B]

Well, I think it's a thing, but maybe not. Everybody thinks it's a thing, but it's basically where now you have a combination of, yes, you're over 50, but there's an acceleration of the inflammation, higher inflammatory markers and more signaling of that pathway that leads to cartilage breakdown. Faster loss of the thickness of the cartilage over time, differences between men and women. So there's probably an interplay between inflammation and then the biomechanics of aging in women that's different than in men.

[A]

So men get arthritis what percent less than women?

[B]

Women are 30% more likely than men to have arthritis. And that doesn't even up again until we reach age 80. Women are more likely to need a knee replacement than men. Also, women are more likely, this may not surprise you, to present farther into the disease process than men. So we're probably actually underestimating the sex based difference. So women don't come in for their knee arthritis until it's like much worse. You know, the X ray looks worse, they have more symptoms. So they've been like kind of delaying treatment. So we're probably underestimating the difference.

[A]

How does someone. So running doesn't actually cause.

[B]

Oh, right back to running. Yeah, so. Yeah.

[A]

Lifting or.

[B]

Yeah, so people. So one of my favorite scrub techs used to always say, this is why I'm a couch potato. People never get hurt being a couch potato. And well, that's not true because, hey.

[A]

Girl, you're gonna get frozen. Shoulder.

[B]

Yeah, well, like, you know, you're probably your lifespan some. So if you're a couch potato, you're not, you know, building muscle, you're not building bone density. You're. You're losing it, man.

[A]

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[B]

Know, 1% per year after the age of 30. But yeah, so does, does running cause arthritis? No, that's common misperception. And if you look at studies that compare runners to non runners, runners are less likely to have arthritis than age and sex matched groups.

[A]

So you have to say that again because it's really important.

[B]

Yeah. So yeah, runners are less likely than non runners to get arthritis.

[A]

Totally counterintuitive because people will say it's wear and tear. But is it actually wear and tear? I mean, I understand that again you specialize in shoulders. There can be a repetitive motion, but there is an inflammatory process. And then a.

[B]

This has been studied. There's a study where they had people run, they MRI'd their knees and you just look and see like how much did the cartilage compress, like what percentage? And it became compressed by like 3%. But then you know that that goes away. So like the next day if you did an mri, your cartilage is back to its normal thickness. It's just normal. So the thing about cartilage is it does get compressed when you're, when you're active. And then when you get off of your feet or you're not doing the activity of reloading it, it returns to its thickness. So actually that's part of how cartilage gets nutrients as it gets, you know, you Move your joint, it's like a little sponge. There's no blood supply to cartilage. It gets it, you know, through the joint fluid nutrients. So motion is good for joints. Do you have to be a runner for joint health? No, I don't want to say you need to run for your knee health, but it doesn't worsen your knee health. Now if you're obese and running, you're going to, with each load, you're going to load the cartilage more. So one of my basic science partners that I work with a lot at Duke, Dr. Lou de Freit, who's in biomechanics there, has done really interesting work on obese people looking at cartilage health. And so, yeah, they're patella, femoral and their femur and their tibia. Their cartilage does show more compression with activity. And it's also seems to be of less quality than nano boost. People like, think of cartilage that's softer, but also with weight loss, some of that corrects. So I don't, I for. My patients are really overweight. I don't usually tell them to use running as their mainstay of cardiovascular exercise. I like them to try to increase their, their muscle mass and do like lesser impact cardio at first, you know, and maybe work their way towards those other activities. But yeah. So running doesn't cause arthritis.

[A]

That's a big deal.

[B]

Yeah.

[A]

I'm sure that you hear that it does. And that activity doesn't necessarily cause arthritis.

[B]

No.

[A]

That there seems to be this progression.

[B]

Yeah. With ej, if you already have arthritis and it's like unrecognized or you just didn't know it and you start running, you're probably gonna get some knee swelling. So if you have arthritis, running might exacerbate it or make it symptomatic for you when it previously wasn't. But it doesn't cause arthritis.

[A]

You know, you said something really interesting. We've said many things. Very interesting. But this idea that cartilage is something that must be utilized, meaning that you're moving through joints, through range of motion.

[B]

Joints like to move. Yeah.

[A]

Right. And you're not immobilizing them. It also made me think about as individuals age, so when they're young, would it be so. I know with tendons you want kids to be very active. The more active an individual is, the better their tendon quality is. From what I've read in terms of their Achilles and, and just their overall.

[B]

Tendon quality disuse is so Disuse and overuse are both bad. But there are many forms of disuse that are bad. So maybe we'll talk about. Well, back to the joints. So, yeah, joints like to move. They do not like being immobilized. It's how, you know, motion. We say motion is lotion. That's like an expression we see.

[A]

I would think that that would be in the urology department, but it's not.

[B]

So that's kind of, you know, part of how cartilage is, you know, receives nutrition and hydration is through movement. So, yeah, joints do not like to be immobilized. Also, like, just the lining of the joint can get stiff and rigid without movement. And that's something we battle, you know, after orthopedic surgeries of the, say, shoulder, knee are really uneven.

[A]

How do you immobilize joints?

[B]

Well, we. As little as we have to. Yeah. So things that we try to avoid because the human body doesn't like, like we don't really want to immobilize joints. Sometimes you have to, to protect. Like, you know, when I do a patellar tendon repair on someone, sometimes I have to immobilize them for that.

[A]

You know, do we know that that has to be done? And the reason I asked this. Okay. Is I was looking at some data and there are some groups and I believe, you know, I want to say that they're in Denmark where they're. They're not immobilizing. They are trying to get them back to motion when they deal with a tendon repair very quickly.

[B]

Yeah. So whatever safe arc of motion. I can. I always. We always do mobilize. So an example, patellar tendon repair, when you repair it, when you're in surgery, you bend the knee and you see how far you can bend it before there's any gapping of your repair. And so like early on, I'm going to let someone move that much, but not more like I want them to move. You always want to let people do whatever they can safely to not compromise their outcome. So that applies to range of motion because we know joints don't like to be immobilized. It applies so much to weight bearing. So disuse of bones. If you don't weight bear, you actually get like, even within, you know, six weeks of non weight bearing. You might see on an X ray what we call some disuse osteopenia because bone density is actually like site specific. The loading of it is. So you can get disuse osteopenia where Just from being off of it on crutches. After surgery, for instance, you can get some loss of bone in that particular extremity. So one of my residents has a hat she wears that says wbat, which is weight bear as tolerated. Like you always want a wafer as tolerated, if you can. Yeah, I'll get you one of those hats. So again, you want to avoid not weight bearing if you can, but sometimes you have to, you know, to protect something that's going to be important. And then muscles. We get so much atrophy sometimes after surgery because someone can't actively use the limb because we're having to protect something that we've repaired or restored or whatever. And muscle atrophy happens very fast and it takes a long time to reverse. So, you know, you're. In general, you want people to do anything that they can do safely, whether it's muscle activation or weight bearing, a range of motion, to avoid the downsides of treatment.

[A]

Right. And that makes a lot of sense. What is the best way to prevent joint pain or joint injury and just keep joints healthy as you age?

[B]

Yeah, So a couple things. Definitely strength training, lifelong, very important. Your muscles are kind of like shock absorbers for your joints. Like when you land, they contract, they sort of slow or dull the impact on your joints. Probably the one of the number one reasons people have knee pain even before they have arthritis is they have weakness of their hip and thigh muscles. So physical therapy is often something we use to kind of help combat that, just I think paying attention to your joints as you age. So, like, if you have never had joint pain, but you love pickleball, and you start to play pickleball twice a day, three days a week, and now you have a joint effusion, you are exceeding the physiological envelope of your knee. And maybe when you were young, you could play two hours multiple days a week. But now your joint swells. You know why it's swelling? It's because your cartilage has compressed and it needs some time to rebound. And so like, you know, maybe your knee will tolerate an hour, but not two.

[A]

And then can you build up tolerance? Are there supplements? Could you use collagen? Could you use glucosamine, chondroitin? Could you use topical transdermal estrogen match?

[B]

Yeah. So I think other keys for long term joint health aside from, you know, maintaining strength and paying attention to signs of, like, what I call overloading the physiologic envelope of your knee. Yes, for people. There are a lot of things that people can do for Minimizing symptoms, maybe reducing progression. It's harder to find things that reduce progression of wear and tear on your knee. But there are. There is evidence regarding collagen supplements for joint health.

[A]

How good is the evidence?

[B]

It's pretty good. I mean, I. Honestly, before I wrote this book, a patient would ask me about collagen. I would say, that's dumb. Don't do that. And then, you know, when I really. I went down a lot of rabbit holes. And the more I read, the more I read, I actually now recommend it to people after re. Enlightening myself. There's a lot of data. There's two types of collagen supplements for joints, and they both are related to type 2 collagen, which is the main type of collagen within articular cartilage. So one of them is called. You'll see it on the shelves. It'll be listed as UC2 collagen, which is undenatured type 2 collagen. And that comes in like a 40 milligram capsule. Very interestingly, this works through almost an immunologic response or through a system called GI tolerance. You expose your GI tract to this, and it seems to reduce the levels of the enzymes which participate in breaking down cartilage. And then there are studies that show lower levels of basically cartilage breakdown products. Now, the other type of collagen for joints is hydrolyzed type 2 collagen. This is broken down into smaller peptides so you can actually absorb it. And there is evidence that this can reduce symptoms in people with early knee arthritis, but not slow progression of arthritis.

[A]

Oh, fascinating.

[B]

So they work in different ways. I always tell patients, you could try taking both. I mean, the type 2 collagen that's hydrolyzed is 500 milligrams. You're going to have to mix it into something and drink it. Whereas the UC2 is just a capsule. Interestingly, the. The undenatured version, the UC2, kind of makes a little bit more sense to me because maybe that's. And again, this is not proven. If something were going to slow progression of something, I would think something that has less breakdown products would be better than something that maybe makes symptoms less but doesn't slow progression. But, you know, they probably both work in different ways.

[A]

I mean, we use. We use and recommend collagen all the time, especially the. You know, I didn't realize that there were those two variations. We typically recommend hydrolyzed collagen, but not necessarily for joints.

[B]

So this is great. So a lot of the collagen supplements will say, like bone, joint, hair, nail, skin. I mean, they're probably incorporating different types of. Theoretically, one that's designed for joints should include hydrolyzed type 2 collagen. And then hydrolyzed type 1 collagen would be more for assisting with bone density. And there's one brand that is studied, which is called Forta bone. And they did. Basically took hydrolyzed type 1 collagen. Again, type 1 collagen is the main type of collagen in bone and did a randomized study and found actually that there was improvement in bone density in menopausal women with low bone density, which is amazing.

[A]

With collagen use.

[B]

With hydrolyzed type 1 collagen. Yeah. And then they did a small subset of them, like several years later and showed an actual continued increase. So I think that is. I think that is actually fascinating. I mean, that's such an easy thing to do. You can do 500 milligrams of hydrolyzed type 1 collagen. You get a little more protein intake.

[A]

You're probably protein score of zero, by the way.

[B]

Oh, well.

[A]

So no, no, use it for that. But definitely use it for.

[B]

So, but the effect on. So, yeah, hydrolyzed type 1 collagen has the effect on bone density. And that's the only brand I'm aware of that's been studied like that. So there are a lot of different brands of hydrolyzed type 1 or collagen supplements that include that. But that particular brand has been studied and shown to have some significant effect. And I mean, the percentage increases that were reported are in line with some of the size of effects of. We see with, you know, strength training and impact interventions.

[A]

So that's wild.

[B]

Yeah.

[A]

So for bone, not cartilage.

[B]

That's for bone. Yeah.

[A]

Can we regrow cartilage?

[B]

You can't regrow cartilage.

[A]

People ask you this all the time.

[B]

Yeah, everyone. So these are things people ask all the time. People come in with arthritis. They say, can you do a knee scope and scrape out the arthritis? And I have to tell them, you can't scrape out arthritis because that's a double negative. Arthritis is absence of something we can't remove absence of something. So generally, you know, in arthritis, you're talking about diffuse thinning or wear and tear on the cartilage. There are cases where people have just a focal defect. Like, I always tell people, it's like. Like think of a pothole in a road that's otherwise smooth. Like, you can. You can restore cartilage in isolated areas, either by taking like a. This is probably not what you want to hear about, like a donor plug of bone and joint from somewhere else in the knee or from a donor, or you can actually culture your own chondrocytes. There's a company that does this, and I do offer this to people.

[A]

Sign me up.

[B]

Yeah. If it's a focal defect, you can do a little biopsy and you send some of their cartilage to their lab, and then they basically clone the chondrocytes on a collagen membrane and then you can come back a couple months later and put it in the defect.

[A]

And then does that decrease pain, improve performance? Why would we want to slow progression of arthritis?

[B]

So as opposed to diffuse general thinning of cartilage, which is what early arthritis is that you might develop over time as you age. There are some people, they'll come in, their knee keeps swelling, but their X ray looks fine. So you get an MRI and you see, oh, it's not like you have normal cartilage in most places, but there's this one area that's a couple of centimeters wide where you're. It's missing. Again, think of like a pothole and otherwise smooth road, probably from some old injury, sometimes from bad alignment or whatever. And. Yeah, so you can do that. You can actually. That. That is technically one way you can kind of regrow.

[A]

One thing that we didn't talk about in this episode is red light therapy for pain and inflammation. I do believe that this is going to be the next frontier in health and also balancing circadian rhythms, which are light and dark cycles. Light is one of our greatest anchors for our energy, for how we sleep. You may have seen, my family and myself, I use red light and infrared heating mat. And by the way, we've been doing this to help manage our circadian rhythms. I also believe it helps my children sleep. And I am telling you, they definitely behave better. Bon Charge is a holistic wellness brand with a huge range of products to optimize your life in every way. It's founded on science and inspired by nature. What I love about Bon Charge is the products allow for us to balance our highly industrialized lifestyle, which creates all kinds of dysfunctions, from being under bright, unnatural lights to being inside all day. It's critical for our overall health that we have products that offer solutions. I use Boncharge's red light lamp as soon as it gets dark outside, and then I use the larger panels for 10 to 20 minutes each day. Bon Charge has the lowest EMF on the market and its quality is incredible. They have a 12 month warranty on all red light devices. Go to boncharge.com drlion and use the code DRLION to save 15%. That's B O N C H A R G E and use the code DRLION to save 15% off and implant.

[B]

It into a defect. Yeah.

[A]

How often is that being used? Is that something that is commonly offered? Is it more, more advanced, more specialized?

[B]

Yeah, subspecialists will offer it. I mean I offer it to be. Which is like not a lot of people think they're going to be a candidate for that. And turns out what they actually have.

[A]

Is just early diffuse arthritis and nothing else. You can do prp, do any of the.

[B]

Yeah, so, okay, so I'll, I'll tell you my. This is what I tell patients when they come in with early arthritis. This is. I give them the whole spectrum from least to most invasive. So if you come and see me and your knee is aching and you've got this X ray that shows just a little bit of joint space narrowing, your MRI shows basically generalized cartilage thinning. But you don't have terrible arthritis. You know, these are all the things you can do to try to like kind of find your path and not.

[A]

Get worse quickly, but will eventually. Everybody needs some kind of replacement. If, I mean, how does it work? Is someone who has a hip injury, arthritis in their hip eventually going?

[B]

I mean, yeah, arthritis does gradually progress.

[A]

Progress over time, no matter what an individual does.

[B]

Well, the things that can slow the progression of. The number one thing that can slow the progression of arthritis is weight loss. If you are not of a healthy body weight, that is very difficult for people. But it does slow progression. A lot of the other things we use.

[A]

But what if they are, what if they are healthy body weight, Small, very fit.

[B]

Right. And you have some arthritis. Yeah, yeah, it does gradually progress over time. So that, that becomes a matter of like, I think being strategic about your activity choices. So you don't, you know, accelerate or worsen the symptoms because the goal is for you to stay active as long as possible. And you know, I hadn't, my, my mentor used to say if you can't run, you can walk. If you can't walk, you can crawl. You know, it's just like sometimes you gotta change things up. I mean, I have patients who want to run all the time, but they have some arthritis. And so we kind of, we have to make some compromises. I'm like, okay, how much can you Run without your knee swelling or like, can you do other, you know, exercises across training? Can you, you know, substitute in more, more strength training, you know, things like that. But so sometimes it's a matter of. And I always tell people early arthritis is like, it's not like when you're in college and you had a sports injury and you have to figure out how to work around the injury. I mean, you are figuring out how to work around the injury, but the injury isn't going away. But there are a lot of things you can do to modify symptoms. And that's where I started going earlier. So, like the easiest things are of course over the counter medications, you know, Tylenol, anti inflammatories, topical Voltaren gel injections you can use. But what kind?

[A]

The corticosteroids?

[B]

Yeah, you know, it's not good to use too many corticosteroids because while that does a really good job of getting rid of inflammation, it can actually sort of soften cartilage over time. And then in terms of biologic injections, like right now it looks to be the most effective combination is something called low white cell autologous condition plasma, which is a type of prp. PRP is where you draw off peripheral blood, spin it down, get a few cc's of this supinate that has these anti inflammatory proteins and it's called platelet rich plasma. You can then modify that by like spinning off some of the white blood cells and getting a low white cell version of that. That does help people with mild to moderate arthritis. And then there's some evidence that it's potentiated by combining it with a viscose supplementation. Like you could inject them together. And there are basic science studies that show lower levels of inflammatory cytokines after that, lesser activation of macrophages and things that contribute to progression of arthritis. But do we have evidence that these injections actually slow the progression of arthritis? No. Theoretically, might it, you know, maybe. And then we talked about the collagen.

[A]

Supplements and then about calcium, vitamin D, K2 for bone. Do you typically, because you're going in there, you're probably seeing a whole spectrum of quality of bone tissue.

[B]

Yeah. These are the supplements I tell people to take for bone and joint health. I really like curcumin. That's not true. Yeah, okay. That's not for bone health, but for, for joints, 1500 milligrams per day of curcumin has been studies shown to reduce need for anti inflammatories, reduce joint pain in people. With early arthritis. And it's usually combined with piperine. There's actual real evidence behind that. Vitamin D for people who have knee pain, I like them to take 2,000 units per day. That dose has been studied to reduce joint pain in people with arthritis. It is higher than the necessary daily value, but. And there may be various reasons why it reduces joint pain. Maybe there's a little bit of osteopenia and the subchondral bone, which is adjacent to the cartilage, I don't know. But that dose does show reduction of joint pain in people who have really arthritis. Calcium. We'd rather you get through food than. I know it seems like than supplements, but if you have a poor diet, it's probably better to supplement than than not. So the vitamin D, calcium, that's for your bone health. Magnesium. A lot of people do get enough magnesium in their diet, but if you don't, a magnesium supplement can help you with your bone health. Basically, magnesium, if you think about what it does, is it helps to. It's a. It helps with activating vitamin D, which then helps with calcium absorption. So I take magnesium, glycine, 400 milligrams at night, can help with sleep and certainly can help with your bone health. And then vitamin K is interesting. A lot of people get enough vitamin K in their diet, but what vitamin K does is its job is to. Okay, so we just talked about you need the magnesium to activate vitamin D. You need the vitamin D to get the calcium in. And then the vitamin K kind of in simple terms, helps guide it to the bone for calcium for incorporation into bone. So many vitamin D supplements have vitamin K with it. I mean, the amount you need is like 100 micrograms per day. It's pretty, pretty low dose. Yeah. But, yeah, I don't think you have to take vitamin K, but I think if you've got a bad diet, you don't eat a lot of leafy greens. Some of the other sources, you should. You might want to do that too.

[A]

You know this, I have a statistic here, and this is osteoporosis affects. So osteoporosis affected 10 million Americans in 2014, and it's projected to increase by 50% by 2025.

[B]

Which is now.

[A]

Yeah, which is now. But what is so fascinating is we have an increase use in GLP1s.

[B]

Yeah.

[A]

Like Ozempic. And I'm curious as to what your thoughts on what we're getting right versus what we're getting wrong.

[B]

Yeah. So the GLP1 agonist group of medicines is fascinating. They are currently used a lot for weight loss and people lose a lot of weight. People also lose a lot of lean body mass. And you'll see ranges in different studies as low as 15, I've seen 40 to 60%. Sometimes this is, you know, proportional to the amount of body weight lost. And, you know, so is that bad? Are we like losing a lot of muscle mass and is that going to affect our bone density? You would think it would. But so far studies looking at fracture risk in people using these medications are not showing any increased risk of fractures and some studies are showing slightly less fracture risk. So that is not showing up to be a concern. The other thing we're seeing is these are basically anti inflammatory medications. They may even end up helping people with rheumatoid arthritis and psoriatic arthritis and things like that. So you're reducing fat, you're reducing probably some of the inflammation associated with metabolic syndrome. And so people with body, you know, with a loss of weight have less stress on their joints. So people are having less joint pain. We're not seeing an increased risk of fractures, I do think, because they, you know, basically delay gastric emptying and create a sense of fullness and maybe decreased appetite. People have to be, I think, more thoughtful about what they're eating, you know, because you could easily fill yourself with things that don't give you the nutrients you need. So I think, yeah. Gotta be really thoughtful about your dietary choices if you're eating less.

[A]

Yeah, yeah, I think that that's fascinating. I've never, I've seen the data that it looks like these medications actually can improve certain pathways in skeletal muscle. It seems like there are positive benefits to it as opposed to this narrative that and I.

[B]

You would expect it would be negative. Right.

[A]

But I'm not seeing that either. And I'm really interested in what you're saying about how the use of these medications, which by the way, we've never had anything work better when it comes to weight loss. Yeah, A bariatric surgery. But those complications are challenging. And I love hearing that from the bone aspect. You're not seeing increase in fracture risk because you're hearing on TikTok. Not that I'm watching on TikTok, but all these other places that it's affecting bone density.

[B]

Yeah. Doesn't seem to be. And maybe having the opposite effect.

[A]

Do you think that there's.

[B]

So far they can't lose unless you get them taken away from you and then people rebound.

[A]

Right. And again, if they're doing the right things like strength training and eating dietary protein.

[B]

Oh, yeah. I definitely think people need to strength train while they're going through the weight loss process. Yeah.

[A]

When someone is thinking about osteoporosis prevention and I think I text you, messages you, what do we have to do? Do we have to do plyometrics? Do. Are there certain movements that we should think as women that we should all be doing to prevent? I think about my mom. So my mom is in her 70s. She would cringe. She's like, you can tell everybody because I look so young. This is what my mom.

[B]

I always round up by a year. I always say I'm 46. And how. I just say I'm 47. Yeah.

[A]

But I watch my parents in the gym and I am concerned about them jumping or doing any kind of.

[B]

Both.

[A]

Themselves and jumping in the gym.

[B]

Yes. Right. So that's been studied. Yeah, the high impact activity. And in almost every study, there aren't injuries reported. Now these are, of course, supervised programs and there are people who have bad balance or maybe more of a fall risk. And I think all that has to be taken into account. But there's huge heterogeneity in the studies on exercise programs for addressing bone loss. And many of them are on menopausal women with low bone density. Many of them show gains in bone density ranging from 1% with strength training.

[A]

Or with plyometric training.

[B]

Generally combined strength training and some impact training. It doesn't have to be a ton of impact training. Like one of the studies showed improvement in bone density and using like 50 jumps per session, a few days a week added to the, you know, made made a difference. So. But the most effective program seemed to combine some impact and some strength training. And a few days a week, they're all over the map in terms of numbers of exercises, numbers of reps. The intensity, is it 50% of your, you know, one time max, or is it 80% with lower numbers? They're really variable. But in general, I'll just sort of forest view. Higher intensity strength training does seem to yield more benefit, more capacity in terms of bone density than the more moderate or low intensity. But the other forms are not without benefit. So you're kind of seeing some gains in bone mineral density with the higher intensity, the strength training and the impact training. But you're still, there's still benefit from the less intense, you know, lifting regimens. And, and to be honest, not everyone people get injuries like, I don't mean injuries like falling and breaking your hip while doing These exercises. But just like tendonitis or overuse, I mean, it happens to all of us. Like, I love to do pull ups.

[A]

And every time I, every time, every.

[B]

Time I do more than 10 sets of 10, I get biceps tendonitis and I have to take a step back.

[A]

So.

[B]

Or, you know, if I do, for me, I can't do really high overhead pressing weight because every time I do I flirt my AC joint. So that is not one I choose to do at the high intensity. I tend, I choose to do that one at a lower intensity. But, but my point is, yeah, these programs, strengthening some impact training and balance training combined are things that help with increasing bone density and reducing risk of falls and fractures. But you know, honestly, they're, they're quite effective. A lot of the studies range from six to eight months and follow up will show a few, you know, I would say on average, a few percentage points and increase in bone marrow density. Now, if you look at what do you get from something like a bisphosphonate, over a couple of years, you're going to get like 6% increase in bone density.

[A]

For someone who's listening, a bisphosphonate is, is a medication.

[B]

Medication that would inhibits resorption of bone. Yeah.

[A]

Is the quality different of the bone that you get on a medication like a bisphosphate?

[B]

Yeah, probably, yeah. So the natural, like loading of your bone, you've got the pulling and the pushing, all the tension of the skeletal muscle on your bones that stimulates the bone to grow and have more density. Axial loading or impact stimulates new bone formation. Our bones respond. Again, we talked about disuse, osteopenia. That's the opposite of use. You know, use increases density. So where was I going with that?

[A]

Well, I'm curious as to how, if we know that, oh, the quality of the bone. We're looking at 20 million Americans who are going to have osteoporosis this year. I'm scared.

[B]

Yeah. So the quality of the bone, I think is better when you get it from actual loading of the bones. One thing we see, for instance, with bisphosphonates is you can increase the density of the bone. But is it as normally organized and is it actually laid down in the areas where the stress occurs? Probably not as well as we get with our own efforts that lead to that. One example of that is it's not a common problem, but there is something that occurs where people get an atypical fracture who've been on a bisphosphonate for many years. It's called a subtrochenteric fracture of the hip. So it's like below the level of the hip joint.

[A]

Is that when the hip breaks and then they fall?

[B]

Well, it, yeah, it's like a break below the level of the hip. And so that's probably, you know, over time there's probably micro damage to the bone because it's been, you know, normally bone is dynamic. It kind of resorbs and forms in relation to the stress that's applied to it. But if you're on this medication that's, you know, just preventing resorption, it can become maybe abnormal. In arena, it's not a common problem, but just an example me, man.

[A]

If all this talk about joint pain and bone loss isn't depressing enough, let's talk about hair loss which affects over 80 million Americans and almost all of my patients. I personally have struggled on and off for many years with hair loss. And there have been many times in my life that I thought I was going to go bald and lose all my hair. I swear to you. And I've tried just about everything. A million different topical and oral formulations and Divi is one that I love. I have seen tremendous results using it alongside combination with prp. Now Divi's first product is a clinically tested scalp serum that improves the appearance of breakage, nourishes hair follicles and removes products and oil buildup. Some key ingredients, you're wondering. Copper, tripeptide, caffeine, tea tree oil. And in an independent study of 31 subjects participants over 6 weeks use of daily Divi serum saw improvements. Divi also finally released their dry shampoo with clean safe ingredients that will allow you to not wash your hair every day. And it makes it thicker, extends the time between washes even better. All of Divi's products come together to create a daily solution that helps both men and women. Divi is not just for those experiencing hair loss, but it can be used by everybody. Men, women of all ages who want to start their scalp care journey. Do you want to take back control of your hair and your scalp health and do it with clean science backed ingredients? Well, we have a special offer for you and that is go to diviofficial.com and use the code DrLion at checkout or go to diviofficial.Com DrLion and enter DoctorLion for 20 off your first order. That's D I V I official.com Dr. Lion for 20% off your first order.

[B]

And a lot of the so for instance like Impact exercise.

[A]

In particular, when you define impact exercise.

[B]

Like a jump, like it could be jumping rope or a box jump, jumping jacks, running, something where there's like some takeoff and landing, there's a little flight basically that's different.

[A]

And you know, when we think about that, that's different than doing say a leg press. Because I would think that a leg press would build more muscle. But what I'm hearing you say is that the takeoff and landing actually that, that targeted activity, if I'm stimulating bone a more robust.

[B]

Right, right, right.

[A]

Differently. Is that, is that true? Am I?

[B]

Yeah, because you're kind of like, like it's more like twice the ground reaction force that you would have with just like standing or walking, for instance. So what, like a leg press is a load bearing exercise? Load bearing exercise is good for bone density. Like in the opposite. That would be not load weight, but like being on crutches and getting. Again, being an astronaut is the extreme example of disuse osteoporosis. So yeah, load bearing, muscle pulling on bones, those things do stimulate bone formation, but you get an extra oomph from.

[A]

And from impact, even though you can't weight it as much.

[B]

Yeah, there's. It create it. There's a response in the bone that increases bone density. So now not everybody can jump because they've got. Some people have some knee arthritis. So I don't want people to think they need to go like jump rope for 30 minutes. You could just do, add a little impact, you know, to your routine a few days.

[A]

Yeah, what else could they do? So they could do a small jump.

[B]

You could just hold on to the back of a chair and jump, you know, 30 times. You could do some jumping jacks. There's some evidence that actually pool based jumping can increase bone density. So like you'd be in a pool and you would jump out of the water, but then still land. And that's probably a combination of the resistance exercise it takes to overcome the water, to jump out of the water, but then land into it. So obviously you're in a place where you're not completely submerged to do that. But that may be an option for people who can't, you know, do a lot of land based jumping.

[A]

And if you were to think about how you would design or what you would tell everyone to do, would you say have them jump? And this might be in your book because I haven't gotten a copy of it yet. Throw that out there.

[B]

I was thinking about that.

[A]

But you know, in all fairness, I've looked at multiple research papers that you've put together. So I'm just, I'm so excited for your book. I think it is going to be tremendous because there's a lot of information out there about building muscle and body composition, but really when it comes to bones and joints.

[B]

Yeah. Not all in one place.

[A]

That's. I mean, I think it's going to be tremendous.

[B]

I tried to put everything all in one place that all of my patients asked me all the time and just, I just wanted it so badly to be in one place for people. That was what's not going to stop.

[A]

Me from calling you from, with these questions that I have. So we're all good.

[B]

Yeah.

[A]

What would you have someone do if they were to prioritize? Because it's tricky, right. You have to prioritize muscle for metabolic, metabolic health. But you also need strong bones. So I'm curious as to how often someone would need to do some kind of activity. What is the volume look like?

[B]

Yeah. So first of all, bone health starts very early. So I think we need to like backtrack a little bit when you're like a child.

[A]

So my kids.

[B]

Yes. One of my very close friends who's a brilliant woman, Tammy Scarpella, who's chief of orthopedics and sports medicine at University of Wisconsin, which is very unusual, have a female chair of orthopedics.

[A]

What an underachiever.

[B]

I'm not sure how she lives still underachiever. But she has this amazing body of literature. It's like a 25 year project where she took kids as young as seven up into their teenage years and followed them for like 25 years. And they were gymnasts. So this is loading of the bones, including upper extremity, lower extremity back and compared them to kids not participating in organized sports. She followed them into adulthood with DEXA scans and other studies of the geometry of bone. What she found was that these gymnasts ended up depending on what part of the body with 15, 40% more bone density than their comparison group maintained even into adulthood. Now at around age 30, we typically say that's when bone density starts to decline. So you're, you know, adolescent and early adulthood years are when you build up your base and if you don't build up your bone density before the age of 30, like that's where you start from. So now we can maintain from there with interventions and try to not fall into the 1% loss per year.

[A]

Can we build after 30 and 40?

[B]

So some of these, you know, you're kind of Trying to slow the loss. Right. Because you typically will lose 1% per.

[A]

Year no matter what.

[B]

Typical, these, these resistance strength training programs, impact programs do show that we can gain bone mass back. You're probably not ever going to get, you're never going to get above where you were when you were really age 30.

[A]

I mean, because from, for muscle mass, you can get above where you were when you were age 30. Do you think that it's possible?

[B]

I think you could gain muscle mass. I don't, I, I haven't seen any literature to suggest that you would gain, that you would ever be higher than you were at age 30 with, with bone density. But, and again, these studies, but however, these studies on, now Tammy's work is unusual because there aren't many studies looking at the younger population like, like that. But if you look at, you know, most of the studies on these interventions were already, we're taking people who are already osteopenic or osteoporotic and trying to reverse some of that, you know, with the interventions. And the gains aren't huge, but they're enough that like, if you gain a few percentage points, you might tip yourself from osteoporotic back into osteopenia. You know, take your T score from negative 2.6 to 2.5. But you're, if you're not losing, you're winning. Because the natural.

[A]

Yeah, because not losing, you're winning.

[B]

Yeah, because the natural history would be to lose 1% of your bone mass per year or if you're post, if you're a menopausal woman, 2% per year.

[A]

You do a lot of surgery. And what are some of the perioperative risks associated with oral contraceptive use? What should we be thinking about?

[B]

Yeah, well, number one, a lot of your patients or my patients, if I ask them if they're taking any medications and they're a teenager, college age girl, they will say no because they don't think an oral contraceptive pill is a medication. So you have to specifically ask, and I always ask my patients this when I'm thinking about surgery or scheduling surgery. Do you have any personal or family history of blood clots? Do you smoke? And do you take any contraception? And then if they say yes, I ask them what type of contraception. If it's a combined oral contraceptive pill, meaning an oral pill that has estrogen in it. There is some increased risk of blood clots from even an outpatient sports medicine surgery, like an ACL surgery, for instance. It's been shown to Double the risk of a blood clot. And if you're also obese or a smoker and using an oral contraceptive, it quadruples the risk. So that's not good. So we need to do some risk assessment. You also do have to pay attention to things like anuvaring because that's an estrogen delivery that's exogenous. We don't know the clotting risk is as high as it is with an oral contraceptive, but that's still a risk. So basically, exogenous estrogen that's part of contraceptive delivery is a risk for perioperative blood clots. So sometimes that may affect our post op plan in terms of blood clot prevention or just raise our antenna in terms of concern for screening for a blood clot if someone has calf pain or swelling. But there are a lot of contraceptives that don't have a risk, like progesterone. Only pills don't have that risk. Marine IUD doesn't have that risk. One that I hate the most to see young women on is Depo Provera. It does increase risk of blood clots.

[A]

But it's a shot, right?

[B]

Yeah, yeah. It increases risk of blood clots, but it also has a supposedly reversible effect on bone density. It reduces bone density. So I had a patient recently who, you know, had a knee injury and I was trying to fix a fragment of bone on her tibia. And this is someone who has some nicotine exposure and is on Depo Provera and the bone was just crumbling, just really poor quality. And, you know, while the bone loss may be reversible when someone goes off of Depo Provera, you never know when someone's going to injure themselves and need a surgery. So they have the bone loss while they're injured. That's. That's not good.

[A]

So you said something there that I wasn't anticipating. And I'm looking at my producer over here smiling. A lot of individuals use nicotine, nicotine gum, nicotine mints. Do we know is it the nicotine or is it the smoking that the nicotine. Oh, gosh. Everyone is crying right now, including my husband.

[B]

He loves nicotine use is bad for all things orthopedic surgery, wound healing, infection, your bone fracture healing, tendon healing, rotator cuff tear healing.

[A]

You just hurt a lot of people's heart, right? Yeah, because it's a thing. So I did my fellowship in geriatrics and one of the things actually I did at Washu, it was really hard. I don't recommend anyone doing. Just kidding. They're always looking for fellows, please. But one of the things is they were talking about nicotine use and the impact on brain, brain function. Positive impacts for Parkinson's and other type of memory challenges. And now we're hearing from you, from your mouth to God's ears. Nicotine exposure is not good for bone, tendons and anything orthopedic. That's great to know.

[B]

Yeah. Unfortunately we're all crying now.

[A]

You said something else. You said oral contraceptive or exogenous estrogen use. What about individuals that are using the patch?

[B]

Transdermal estrogen used at the level in menopausal hormone therapy has no increased risk of clotting as opposed to the oral versions which do. And that's because the transdermal delivery basically bypasses that first pass through the liver that can affect the clotting cascades. So transdermal estrogen is quite safe. Now, one question mark is if you were having a major orthopedic surgery where you have another risk factor, does transdermal estrogen add to that? I mean, in the non injured population, there's just really almost no risk for transdermal delivery. So transdermal delivery is very safe.

[A]

I don't want to open up a can of worms here, but we talked about estrogen. When you are discussing menopause hormone replacement therapy, are you thinking about estrogen? Are you thinking also about progesterone and testosterone?

[B]

Oh, right. So if you have a uterus you can't use, again, I'm not a women's health doctor, but I do know this. You can't use unopposed estrogen. You have to have some form of progesterone to protect your uterus from uterine cancer. So that could be in the form of a Mirena IUD combined with, you know, a transdermal patch. Or you could have oral progestin, you know, something which has other benefits like sleep and things like that.

[A]

Are you thinking in terms of bone health? Is it something that you are thinking about for bone health?

[B]

Testosterone. So testosterone therapy is of course not FDA approved approved for women unless it's for low libido, which it is approved for. And I think probably many of your listeners know that yes, women have testosterone. It's just at a much lower level than men, about like 10%. So there's a lot of research going on in terms of, yeah, like should testosterone be used for bone density and maintenance of muscle mass? And I think currently that's certainly not a common use for it. And I Think we're still gathering data on that, but it would make sense that for at least women who have lower testosterone levels than they should, that the testosterone would contribute to certainly muscle mass. And we know muscle mass contributes to bone density, so. But yeah, right now, that's not sort of a typical part of a regimen in terms of menopausal hormone therapy.

[A]

Not yet.

[B]

Not yet. Yeah.

[A]

If you are young, you suggest you have five kids. Did you have them start your kids? Yeah. Early.

[B]

Yeah. Yeah. They all have participate in sports, and we have a couple that didn't love sports, but we sometimes we would go on walks and they would call them forced marches. But, you know, like, most of our kids enjoy sports.

[A]

I mean, you know.

[B]

But yeah, I think sports participation, athletics is really important in adolescence and very important in girls.

[A]

Yeah.

[B]

Because, you know, if girls aren't participating in, like, high school sports, they're probably not gonna go off into college and then, like, go do a regular workout. Like, I can't imagine not exercising every day. But I grew up always being active, and I also think it's really important to model activity for your kids, like work out with them or them seeing you work out. Like, my husband and I, we very much prioritize exercise and strength training. And our kids know we have to get a workout in every day, and they've over the years been, you know, we always have a workout room in whatever house we live in, and they've always spent time in those rooms or use the equipment or whatever. So I think you need to model for your kids, but also you got to get them involved in activity. So they're active through those years.

[A]

And that's from bone density, cartilage, tendons, muscles.

[B]

I think. Yeah. Now, you don't want to over develop muscle too quickly and pull on tendons too hard before you're done growing, because that's when you get things like apophysitis. Like, you've probably heard of Osgood Schlatter's disease or of the knee, where people get that bump on their shin bone. They're aggravating the attachment of the tendon to bone, because when you're not done growing, your tendons are a little stronger than the attachments.

[A]

In some ways, your tendons are stronger than where they attach to the bone.

[B]

So you can get apophysitis, which is just irritation of the attachment of the tendon to the growth center on the bone that it attaches to because it's an area of growth. So, you know, that's when and Your child won't know if they're doing too much because it'll hurt and they'll tell you and it's not, it's just a thing that, where you kind of rest as needed. There's no intervention other than rest as needed. But you know, so sometimes too much activity can lead to apophysitis in kids. But it, physical activity is very good for children. There's a, you know, we have a huge obesity problem in America in general. Yes. Being active is good, not being, you know. Yeah. You don't want them to be sedentary. No.

[A]

When girls go through, let's say the no longer term for the athletes triad, women that are over exercising, under eating and they lose bone.

[B]

Yes. This is part of accruing bone before the age of 30. So that is a huge risk factor. Like let's say you had what used to be called the female athlete triad. Like when you were in high school or college, you had an energy deficiency. Whether it was from inadequate energy intake or just not matching your output with your intake. That's actually a lot of. So the reason the term is now relative energy deficiencies. It's not always with disordered eating there can just actually be. You're under fueled chronically. And this will be the kid that presents with a stress fracture, the cross country runner that they don't have.

[A]

And what she means by that is that say for example, an individual is really active and they're just not thinking.

[B]

About eating and they're, they just cannot keep up with the demands.

[A]

Eating a lot of food, but they're, they're still underfueled. Yeah, they're under fueled.

[B]

Uh, so. Yeah. And so if you, if you tip into a state of, you know, amenorrhea where you're not having cycles, you're now in like an estrogen deficient. Estrogen deficiency, very low body weight. You're. You're losing bone mineral density when you're supposed to be building up your base.

[A]

Right.

[B]

And so people can get to. So they'll arrive at 30 with diminished bone density. And so you don't want that to happen. Now let's say you're.

[A]

And what's done about that? Do they give them the pill?

[B]

Well, they're. Yeah. I mean nutritional consultation and consultation. You can use contraceptive pill, but they won't catch up.

[A]

And again, I don't want to be negative, will they?

[B]

You, you can, but you're, it's. It. There's some downstream effect that is not probably entirely irreversible. And depends on how long it goes on for and how many bouts of this happen to a person.

[A]

How genetic is osteoporosis?

[B]

You know, I don't know if we know the exact genetic propensity, but if that is a question when we're assessing risk, like if you have a family history of osteoporosis, you know, that makes me more likely to send someone for a DEXA scan now. So what I was getting at is if you arrive at, let's say, arrive at menopause, and so risk. So menopause in and of itself is a risk for osteoporosis, as is being Caucasian, being thin or underweight. But if you also tell me, oh, I have a history of, you know, amenorrhea or an eating disorder or we didn't call it back then when this person was young, red, center, whatever, like where you. Where you had an added risk to not have as much bone density as you should, those are all adding up for you at that point. You know, these are risk factors that might mean you need to have a DEXA scan to check for osteopenia, osteoporosis sooner than is typically indicated, which is 65, which is probably way too late.

[A]

Well, our patient, we have a medical practice, and we always have. For baseline, we have our patients, I mean, they could be 40, and we want to see a DEXA.

[B]

Yeah. Now, for patients under 50, of course, you're not necessarily looking at the T score. You can look at their Z score because the T score is comparing older people to younger people. And if you're under 50, you're kind of still younger people. But, yeah, there's value in that, especially with any risk factors. And, you know, I think the frustrating thing about the typical recommendation being to get a DEXA scan when you're 65 is that if you get a DEXA scan, you're 65 and you already have osteoporosis. And no one told you when you were 52 that menopausal hormone therapy can help prevent osteoporosis and prevents fractures in many people. You know, now you're 65, and you're kind of. You're kind of out of the window of time where it's recommended to initiate menopausal hormone therapy, which is within 10 years of menopause. So a lot of people are missing the boat. There are a lot of people who are seeing doctors who got their medical training when there was a lot of misinformation about menopausal hormone therapy and don't provide it and it truly is indicated for prevention of osteoporosis. So, you know, unfortunately, I think some of the most long term consequences of menopause are musculoskeletal and bone density is. Osteoporosis is one of the biggest ones and there's more and more of a shift in this understanding. But again, if you just think back that initially menopausal hormone therapy or formerly called HRT was indicated for vasomotor symptoms. And that's not even the tip of the iceberg. The long term effect, probably the one that's most life changing is the effect on bone density. I mean, joint pain, inflammation, arthritis, frozen shoulder, yes, those aren't good things. But the, the very long term consequences, like it's life altering, mobility altering. If you get osteoporosis and you get a hip fracture, it's, you know, there's mortality and morbidity associated with that.

[A]

And why is that that? Do you. What are some of the rates for morbidity and mortality of falls? And you know, we were talking about impact training and it seems that, because I was asking these questions before, that it really is about the joints or the, the location that you're loading. It's not full body, which I think is fascinating.

[B]

Yeah, yeah. No. And so if you look at what's in these resistance exercise programs, you'll see, yes, it does include overhead press. And I mean, again, they're all different, but a lot of them have like an upper extremity pressing maneuver, maybe a deadlift, a squat, some impact. You're trying to get like large muscle groups, but you're also trying to load, you know, the upper extremities, the lower extremities, the spine and then the impact. Yeah, probably why it's more likely to improve, you know, femoral neck bone density and cortical thickness is because that's what you're loading. You're loading the lower extremity with that, with that impact, you're not loading so much your spine or your arms unless you're a gymnast. And then you have good upper extremity.

[A]

And it's a side. They call osteoporosis a silent disease.

[B]

Silent disease. Yeah.

[A]

Someone isn't going to know that they.

[B]

Have osteoporosis until they break something.

[A]

Until they break something which is terrible.

[B]

Or have a stress fracture. Like you could be like a master's athlete.

[A]

What about. And if they're younger and have a stress fracture, is that an indication that someone.

[B]

Well, sometimes stress fractures are part of energy deficiency syndrome.

[A]

Okay.

[B]

Sometimes they're just part of bad alignment. Like you got a high arch and your foot rolls over the side. So you're going to get a stress fraction. Your fifth metatarsal. That's different. You know, that's an alignment issue.

[A]

What about tendons? Have you thought much about tendons, tendon health with hormone replacement loading them, or is that still.

[B]

Yeah, so tendons also have estrogen receptors and yeah, definitely, we see a lot more tendonitis periarticular pain around the same time that was the increase in joint pain.

[A]

Do, does hormone replacement, menopause replacement therapy help that?

[B]

I think the data is not specific enough. And that's. So, you know, again, looking back at these studies, a lot of them are just like, did you have joint pain? Or how severe was it? Did it get better? It's. The data isn't as granular as it could be, which is really why orthopedic surgeons or researchers need to work with women's health doctors to get more specific information. I started a registry with our women's health department at Duke looking at, trying to sort of correlate vasomotor symptoms with musculoskeletal symptoms.

[A]

So you're, you know, in this study, this is. So far, you're looking at 1,000 participants. Is that.

[B]

Well, right now, we, we just opened it. We have a couple hundred people enrolled. We're going to continue to enroll, but we're. We're trying to look very granularly at joint pain. Like which joints are painful? How, you know, is it bilateral? How bad is each joint? Did it get worse or better when you started hormone therapy? You know, what do your vasomotor symptoms mimic the severity of your joint symptoms?

[A]

That's interesting.

[B]

Yeah, well, we don't know that. I don't think. And so we're trying to be more detailed and granular in our inner information in that way. But so I think, like the. You do see this acute exacerbation of joint pain and arthritis and inflammation early on in menopause. That's less silent. Your joints are talking to you as opposed to the osteoporosis is kind of insidiously happening in the background. And you don't know you have it until you get a DEXA scan or, you know, break a hip or your wrist or, you know, a lot of times people be out being active and fall playing pickleball or tennis and, you know, get a distal radius fracture. You know, we tend to see some of those when people are active. We Might see distal radius, proximal humerus. My neighbor just broke her proximal humerus skiing. You know, she loves that she's your neighbor though.

[A]

He jostled him.

[B]

But then, you know, the more what we typically think of as fragility fractures that happen as we get old with just the same level fall, you know, tend to be the hip fractures and the vertebral fractures too.

[A]

The mortality rate is. So is the mortality rate high when someone falls and breaks a hip? Is it different in men versus women?

[B]

Yeah, depending on the study you read. And they all vary based on the populations that are included. You will see a third of people die within a year or two depending on which study you're looking at. Obviously the worst statistics is a year, but some show maybe 15 or 20% a year. But by the time you get to two years, there's a third of people. Some slayshow, you know, a third within a year. So yeah. Does the hip fracture cause mortality or is it a sign of your current overall well being and state? You know, some of both. People do become less mobile after hip fracture. There's a statistic that, you know, I always, always taught when I was a resident and it wasn't probably based on data, but just years of clinical gestalt of the people who trained me. But when you look at data now, it's true. It's like if you fall and break your hip and someone fixes it for you, you know, there's a one third chance it might not heal and you might need a total hip anyway. There's one third are going to heal and one third are going to die. And that's kind of has held true. Now do you, do people resume the same level of mobility after like let's say their hip fracture heals? How do they do? If you were not using any assistive device, you're probably going to be using a cane. If you were using a cane, you may be using a walker. If you were walker dependent and broke your hip and it's fixed, you know, you may end up needing a wheelchair or more assistance. So there is a subsequent effect probably on mobility which also compounds the state of the person that fell on their hip.

[A]

If you were to define mobility, is that just moving a joint through a full range of motion or just you.

[B]

Being able to get up and move, you know, use your muscles, do things for yourself, future fall risk. So yeah, so there's maybe a little bit of a chicken and egg thing, but it's there, there is, there is high risk of mortality after hip fractures. And then for men, interestingly, or like somewhat paradoxically, because, you know, we know like 75% of osteoporotic hip fractures happen to women and only 25% happen to men. But the men who get a hip fracture are probably not, they're probably of atypical health as compared to those who don't. Like they have other metabolic syndromes, maybe like renal disease or you know, other things that have made their bone not healthy in addition to just osteoporosis, perhaps. So men actually, if they have a fragility fracture of the hip or they don't do as well, they have a higher mortality rate than women. So. So a little bit, A little bit flipped there. Yeah, but so anyway, I actually think it sounds dramatic, but I don't think it is. I think that menopausal hormone therapy could be considered a life saving thing. It reduces your risk of a hip fracture by 30%, reduces your risk of a vertebral fracture by about 40% and reduces your all cause mortality by about 30%. We know if you get a hip fracture, you have the subsequent risk of mortality possibly one third within one or two years of that injury. So it's a really big deal for people to now be going through training doctors, not being misinformed about some of the benefits and safety of menopausal hormone therapy and what the downstream consequences are. I think there's going to be more providers coming out that are willing to use menopausal hormone therapy for prevention of osteoporosis or just, you know, respond to women's needs and actually use these medications. And there's probably going to be a big population benefit to that over time.

[A]

Well, I think that the work that you're doing is amazing and I would love to hear about any of your current or future research projects. I definitely want you to mention where we can find your book.

[B]

Again, we're sharing. So I have a big theme in many of my research interests which is identifying things that disparately affect women and trying to solve them. One of the studies we have coming up is we're taking some of the information that I've learned from my work on post traumatic arthritis, which is the type of arthritis that people get after they tear their ACL or tear their meniscus. They kind of get early arthritis than people who never had these injuries, typically about 15 years after those injuries. So we did some work in that area where we looked at how cartilage basically responds to this trauma for biomechanical reasons and biochemical reasons. And we have a way of studying how load bearing, how much it compresses cartilage and how long it takes cartilage to kind of get back to its normal thickness after load brewing. So we're taking that same kind of work that we used on post traumatic arthritis and we're going to apply it to menopause arthritis. So we're going to be studying cartilage health in women different numbers of years after menopause and considering the effects of hormone therapy. So that's going to be exciting. And then in our younger population, because we know that ACL tears are more likely in women than men, but we don't know why. There have been a lot of theories, none of them have totally panned out. But we're going to be doing some studies where we look at how much the ACL is strained with activities and we're going to use hormone levels to assess that. And also we're looking at different geometries of the ACL in men and women and looking how fatigue in men and women may affect strain on the acl. So these are kind of, you know, again, I think the themes of my, of my interest, they're, they're kind of always going back to that same sort of thread.

[A]

And why was that?

[B]

Just because it needs to be solved.

[A]

And you, I think you also did your undergraduate at Columbia, right?

[B]

Cornell. Cornell, yeah.

[A]

Yes. So you're always just really trying to solve problems.

[B]

Yeah, yeah, yeah. I was a nutritional, I studied nutritional science there before I got into orthopedics. And you don't learn a lot of nutrition in medical school, but I'm always thinking about it and how it relates to my patients. So. And then the book is just something I just, I always wanted to do and I thought about it for years and years, but I, I feel like I cannot say enough of what I want to say in a visit to people. And I'm not going to say to my patients just by my book. I'm still going to get behind in clinic and explain everything to them but.

[A]

But in case they wanted to.

[B]

But I, yeah, I just, I wanted to have basically for non medical people a way for them to understand like what is arthritis, what is osteoporosis, you know, what you can do to help your joints, what you can do to prevent or treat osteoporosis and arthritis if you have it. And just for people to be like really well armed with a lot of information when they go to see their doctor, so they know what questions to ask and what to expect.

[A]

Well, thank you Dr. Jocelyn Wittstein. Yes, I got it. I think that you're just doing wonderful work and pioneering something that we all need to learn more about because with knowledge then we can make changes. So thank you so much for your time.

[B]

Thank you for having me.

[A]

Yes. And we will link everything for your book and we'll shout it out and can't wait for my copy.

[B]

Yes, I'll get it to you before May 6th. Yeah.

[A]

Wow. That was an incredibly eye opening conversation with Dr. Jocelyn. If this helped answer some of your biggest health questions, be sure to share this episode with someone who needs to hear it. And if you want a complete plan to protect your joints and Prevent Osteoporosis, grab Dr. Wittstein's book, the Complete Bone and Joint Health Plan. Link in the description before you go. Please hit subscribe and turn on notifications because on this channel we bring you the science backed answers no one else is talking about.