Great article. As the owner of TWO total knees, I agree with what Dr. Luks says. We need to focus on the ability to generate more cartilage which is tricky. My husband, a general surgeon, has had two rounds of stem cell injections which have made a tremendous impact on pain and movement. We need to change the insurance industry's coverage of these procedures and focus on providing the patients with the building blocks to repair. It is possible. There's nutraceuticals out there that show much promise. Thanks for writing!
Thank you. This reflected my personal experience with my hips. I stopped running which gave me tremendous joy and stress relief. Fortunately, I was able to fall back to swimming and biking to avoid weight gain. Nevertheless, in hindsight I was depressed for over a year.
As a cardiologist I always cringe when a patient tells me they received a stent for a “widow maker”.
As I learned over the years how you present information can have significant positive or negative placebo effect.
As a runner, thank you. And along similar lines, can we please also stop telling patients with metabolic syndrome that "drinking plenty of water" is somehow key to forestalling progression of their kidney disease?
I play a lot of sports, so everyone I know has some type of injury. Which inevitably lead to quitting or surgery. This article completely skips what metabolic health looks like, or should be. Is it something that healthy active people are not doing? (The very people who really try to be healthy.) What about Professional athletes? Would “bad” metabolic health show up in yearly blood work panel? How does “metabolic health” regrow cartilage that isn’t there any longer due to repetitive use? Let’s not forget, getting older means your recovery process takes months or years, not a few days as it used to. Article hasn’t convinced me.
As any "seasoned" orthopedist knows, emotionally well-adjusted people respond to treatment; sad, unhappy people do not. We learn who benefits from surgery and who will not. The real message, as discussed by Dr Luks, is the importance of a patient's mind-set. The challenge of osteorthritis, as well as other painful conditions, is that it is a biopsychosocial issue. The "nocebo" effect ie "harmful words" has been a subject in medical literature for a long time. (JAMA Feb 7, 1996 Vol 275, No 5; Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017 Dec 26;318(24):2425-2426. doi: 10.1001/jama.2017.16216. Erratum in: JAMA. 2018 Feb 27;319(8):833. PMID: 29090307.)
Rachel Zoffness, PhD is a psychologist who specializes in cognitive behavioral therappy for chronic pain patients. She reminds us pain is a problem originating in the brain which can be modulated by
stress, emotion and cognition. Her discussions can be reviewed on YouTube and she was interviewed by Ezra Klein on a podcast.
Words can harm patients. As physicians and surgeons we need to remain mindful.
Dr Luks, well done sir for calling this to our attention.
I think this article is designed to be against the grain at the expense of better explanations of pathophysiology to please the sensible medicine crowd, who by definition enjoy a good contrarian cheap shot at all the presumably “senseless” doctors.
This article showed up on Doximity, and I’ll quote a few orthopedic doctors who responded there:
“Orthopedic surgeon here... Advice on maintaining activity is key. Some of the other suggestions about the pathogenesis of arthritis, or about the ability of articular hyaline cartilage to heal, is inaccurate. It heals as 'fibrocartilage" which is not the same thing. ALSO when the cause of arthritis is due to 3rd body wear, or a mechanical/alignment issue -- continued excessive loading can and will make the condition worse. Swimming/biking will be much more encouraged than Running”
___________________
“This article is nothing but buzz words and nonsense. He keeps saying metabolic health and metabolic disease without ever saying what that is or how to treat it. The fact is that most osteoarthritis is primarily genetic. Your arthritic joint will not heal in the presence of good “metabolic care”. I believe all of us who are good practitioners encourage our patients to stay active. That is nothing new.
My general take from this article is that he is using a very, very old paradigm and asserting it as the current standard, and then providing a course of care that is neither definable or proveable.”
I’ve been very fortunate to see multiple orthopedic docs who suggested PT for several months before deciding on surgical intervention for first a foot injury and then a knee injury a couple of years later (not the same leg). I didn’t go under the knife in either case and deeply appreciated my surgeons’ conservative recommendations. In both cases the suggestion was supported by the reassurance that it would be the same surgery today or in 6 months. So glad I went with the PT wait and see approach.
Enjoyed your sentiment. If only we have evidence that reversal of metabolic syndrome translates to a decrease in pain, joint operations, or improvement in the radiographic appearance of the “bone on bone”. I will see myself out now..
This is great. After years of running (and cycling and swimming and strength training) I developed left hip pain on long runs. Running is meditative for me. Perhaps I can get back to it yet. Besides further reducing sugar, do you have other suggestions?
So what is a good diet for OA? I also was an avid runner (and rugby player) but was told all that running and rugby ruined my knees and my only remedy would be a total knee replacement in both knees (since I am in my forties I decided against a knee replacement). I would love to learn if there is a suggested diet to improve cartilage in my knees.
The 80s salt restriction propaganda has demonised necessary nutrients Na Cl.
Look at where they are placed on a std blood test. Na has first place.
With intentional salt restriction, hyponatremia or dehydration results and the adrenals must come to the rescue with aldosterone and the rest of the adrenal cortical hormones to scavenge from all salt reserves.
Salt reserves include: muscle, joint capsules, mucosa, bone.
This is why the elderly shrink.
Their joints are robbed of salt and the water leaves too.
Salt restriction has bought a bonanza of chronic conditions to treat.
The most cruel is dementia and alzheimers. This is the result of a chronically dehydrated brain. The tide has gone out, leaving plague visible on the shores.
The kidneys ease is to remove excess salt. Think before refrigeration a lot of foods were preserved in salt.
Aldosterone reverses the kidneys role and they become salt savers. Which is fine for the occasional emergency. But in chronic low salt conditions the adrenals remain online and the kidneys become dis-eased.
Aldosterone - salt saving and salt scavenging from all salt stores.
Cortisol - blood sugar T2 diabetes
Adrenaline - anxiety & panic attacks
And the adrenals suppress production of sex hormones - fertility problems.
With low salt: the adrenals have two choices: exhaustion or hyperplasia.
With hyperplasia: hypertension arises because the adrenal response is amplified.
The body’s power to heal begins with hydration.
Salt plus water equals hydration
My Substack article is called we breathe air not oxygen
Kind of a peculiar article on a website devoted to discussing the validity of medical studies. No objective scientific evidence is given. As a cardiologist I don't claim to have much knowledge about cartilage and joints. But it is difficult to believe that a biological tissue with no blood supply can regenerate itself. An admittedly brief look into the current research shows that regeneration is being attempted with stem cell injections. All seem quite definite in stating that cartilage cannot regenerate in adults. I assume there is some scientific evidence to the contrary that backs up his claim that metabolic therapy can accomplish this. Let us see it and it should be the mission of this site to critique it.
Dr. Luks, I'm new to your stack. So glad I found it. Thank you for your knowledge, integrity, convictions.
You wrote, "Since orthopedics and cardiology so often share patients...." Interesting as I didn't realize those two branches of medicine are so connected.
How so? (Forgive me for asking what might be obvious to other readers.)
Yes, I think there are words which should be specific and less general. Just like you're suggesting. However, I'm not sure that it's the words themselves who are causing the problems. It's people's perceptions of them.
I like the advice but not sure about the relationship between changing overall metabolic and its effect on joint disease. It’s a nice narrative but not sure about the evidence. I’d love to see a reference or two about these outcomes, although I’m not willing to go as far as VP might and call for randomized trials of it. Well, maybe we should all demand it before Dr. Luks confidently uses it to explain how osteoarthritis works.
Great article. As the owner of TWO total knees, I agree with what Dr. Luks says. We need to focus on the ability to generate more cartilage which is tricky. My husband, a general surgeon, has had two rounds of stem cell injections which have made a tremendous impact on pain and movement. We need to change the insurance industry's coverage of these procedures and focus on providing the patients with the building blocks to repair. It is possible. There's nutraceuticals out there that show much promise. Thanks for writing!
Thank you. This reflected my personal experience with my hips. I stopped running which gave me tremendous joy and stress relief. Fortunately, I was able to fall back to swimming and biking to avoid weight gain. Nevertheless, in hindsight I was depressed for over a year.
As a cardiologist I always cringe when a patient tells me they received a stent for a “widow maker”.
As I learned over the years how you present information can have significant positive or negative placebo effect.
As a runner, thank you. And along similar lines, can we please also stop telling patients with metabolic syndrome that "drinking plenty of water" is somehow key to forestalling progression of their kidney disease?
I play a lot of sports, so everyone I know has some type of injury. Which inevitably lead to quitting or surgery. This article completely skips what metabolic health looks like, or should be. Is it something that healthy active people are not doing? (The very people who really try to be healthy.) What about Professional athletes? Would “bad” metabolic health show up in yearly blood work panel? How does “metabolic health” regrow cartilage that isn’t there any longer due to repetitive use? Let’s not forget, getting older means your recovery process takes months or years, not a few days as it used to. Article hasn’t convinced me.
As any "seasoned" orthopedist knows, emotionally well-adjusted people respond to treatment; sad, unhappy people do not. We learn who benefits from surgery and who will not. The real message, as discussed by Dr Luks, is the importance of a patient's mind-set. The challenge of osteorthritis, as well as other painful conditions, is that it is a biopsychosocial issue. The "nocebo" effect ie "harmful words" has been a subject in medical literature for a long time. (JAMA Feb 7, 1996 Vol 275, No 5; Barsky AJ. The Iatrogenic Potential of the Physician's Words. JAMA. 2017 Dec 26;318(24):2425-2426. doi: 10.1001/jama.2017.16216. Erratum in: JAMA. 2018 Feb 27;319(8):833. PMID: 29090307.)
Rachel Zoffness, PhD is a psychologist who specializes in cognitive behavioral therappy for chronic pain patients. She reminds us pain is a problem originating in the brain which can be modulated by
stress, emotion and cognition. Her discussions can be reviewed on YouTube and she was interviewed by Ezra Klein on a podcast.
Words can harm patients. As physicians and surgeons we need to remain mindful.
Dr Luks, well done sir for calling this to our attention.
I think this article is designed to be against the grain at the expense of better explanations of pathophysiology to please the sensible medicine crowd, who by definition enjoy a good contrarian cheap shot at all the presumably “senseless” doctors.
This article showed up on Doximity, and I’ll quote a few orthopedic doctors who responded there:
“Orthopedic surgeon here... Advice on maintaining activity is key. Some of the other suggestions about the pathogenesis of arthritis, or about the ability of articular hyaline cartilage to heal, is inaccurate. It heals as 'fibrocartilage" which is not the same thing. ALSO when the cause of arthritis is due to 3rd body wear, or a mechanical/alignment issue -- continued excessive loading can and will make the condition worse. Swimming/biking will be much more encouraged than Running”
___________________
“This article is nothing but buzz words and nonsense. He keeps saying metabolic health and metabolic disease without ever saying what that is or how to treat it. The fact is that most osteoarthritis is primarily genetic. Your arthritic joint will not heal in the presence of good “metabolic care”. I believe all of us who are good practitioners encourage our patients to stay active. That is nothing new.
My general take from this article is that he is using a very, very old paradigm and asserting it as the current standard, and then providing a course of care that is neither definable or proveable.”
I’ve been very fortunate to see multiple orthopedic docs who suggested PT for several months before deciding on surgical intervention for first a foot injury and then a knee injury a couple of years later (not the same leg). I didn’t go under the knife in either case and deeply appreciated my surgeons’ conservative recommendations. In both cases the suggestion was supported by the reassurance that it would be the same surgery today or in 6 months. So glad I went with the PT wait and see approach.
Enjoyed your sentiment. If only we have evidence that reversal of metabolic syndrome translates to a decrease in pain, joint operations, or improvement in the radiographic appearance of the “bone on bone”. I will see myself out now..
This is great. After years of running (and cycling and swimming and strength training) I developed left hip pain on long runs. Running is meditative for me. Perhaps I can get back to it yet. Besides further reducing sugar, do you have other suggestions?
Thank you.
So what is a good diet for OA? I also was an avid runner (and rugby player) but was told all that running and rugby ruined my knees and my only remedy would be a total knee replacement in both knees (since I am in my forties I decided against a knee replacement). I would love to learn if there is a suggested diet to improve cartilage in my knees.
Joint capsules are hydrated with salt plus water.
The 80s salt restriction propaganda has demonised necessary nutrients Na Cl.
Look at where they are placed on a std blood test. Na has first place.
With intentional salt restriction, hyponatremia or dehydration results and the adrenals must come to the rescue with aldosterone and the rest of the adrenal cortical hormones to scavenge from all salt reserves.
Salt reserves include: muscle, joint capsules, mucosa, bone.
This is why the elderly shrink.
Their joints are robbed of salt and the water leaves too.
Salt restriction has bought a bonanza of chronic conditions to treat.
The most cruel is dementia and alzheimers. This is the result of a chronically dehydrated brain. The tide has gone out, leaving plague visible on the shores.
The kidneys ease is to remove excess salt. Think before refrigeration a lot of foods were preserved in salt.
Aldosterone reverses the kidneys role and they become salt savers. Which is fine for the occasional emergency. But in chronic low salt conditions the adrenals remain online and the kidneys become dis-eased.
Aldosterone - salt saving and salt scavenging from all salt stores.
Cortisol - blood sugar T2 diabetes
Adrenaline - anxiety & panic attacks
And the adrenals suppress production of sex hormones - fertility problems.
With low salt: the adrenals have two choices: exhaustion or hyperplasia.
With hyperplasia: hypertension arises because the adrenal response is amplified.
The body’s power to heal begins with hydration.
Salt plus water equals hydration
My Substack article is called we breathe air not oxygen
https://open.substack.com/pub/jane333/p/we-breath-air-not-oxygen?r=ykfsh&utm_medium=ios&utm_campaign=post
Kind of a peculiar article on a website devoted to discussing the validity of medical studies. No objective scientific evidence is given. As a cardiologist I don't claim to have much knowledge about cartilage and joints. But it is difficult to believe that a biological tissue with no blood supply can regenerate itself. An admittedly brief look into the current research shows that regeneration is being attempted with stem cell injections. All seem quite definite in stating that cartilage cannot regenerate in adults. I assume there is some scientific evidence to the contrary that backs up his claim that metabolic therapy can accomplish this. Let us see it and it should be the mission of this site to critique it.
Oh there you go, being all sciency and truthy, raining on the parade, pooping in the popcorn popper.
Dr. Luks, I'm new to your stack. So glad I found it. Thank you for your knowledge, integrity, convictions.
You wrote, "Since orthopedics and cardiology so often share patients...." Interesting as I didn't realize those two branches of medicine are so connected.
How so? (Forgive me for asking what might be obvious to other readers.)
Take care.
Katherine your pic is quite remarkable.
My avatar? Lol. She's an old Cuban woman I've seen online. She seems pretty spirited.
I love her!
Thanks Zade! But not as much as I love your name. Happy Holidays.
Yes, I think there are words which should be specific and less general. Just like you're suggesting. However, I'm not sure that it's the words themselves who are causing the problems. It's people's perceptions of them.
I like the advice but not sure about the relationship between changing overall metabolic and its effect on joint disease. It’s a nice narrative but not sure about the evidence. I’d love to see a reference or two about these outcomes, although I’m not willing to go as far as VP might and call for randomized trials of it. Well, maybe we should all demand it before Dr. Luks confidently uses it to explain how osteoarthritis works.
In psychiatry we call it hermeneutics