83 Comments

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.

Expand full comment

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.

Expand full comment

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.”

Expand full comment

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.

Expand full comment

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..

Expand full comment

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?

Expand full comment

Thank you.

Expand full comment

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.

Expand full comment

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.

Expand full comment

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.

Expand full comment

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.

Expand full comment

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.

Expand full comment

In psychiatry we call it hermeneutics

Expand full comment

Strontium, a mineral similar to calcium, in my opinion, may be a very beneficial but overlooked nutritional option for osteoporosis and osteoarthritis.

In 1953 through 1957, the Mayo Clinic did an clinical trial on using strontium to treat osteoporosis. Here are 2 of their cases.

"Case 1

A 34-year old woman had experienced aching in the lower part of the back since delivery of a child 5 years earlier. The diagnosis of osteoporosis had been made, and for 3 years prior to admission she had been treated with hormones and worn a back brace, but without improvement. Examination proved stiffness of the spinal column with limitation of movement, grade 4; and roentgenograms revealed generalized osteoporosis with compression of the second lumbar vertebra. After the beginning of therapy with strontium lactate, the patient showed steady improvement, and 3 years later she was free of pain. ...

Case 6

A 62-year-old woman gave a history of having had aching in the lower part of the back through 10 years. Motion of the spinal column showed limitation, grade 2. Roentgenograms indicated osteoporosis with ballooning of the intervertebral disks. After 3 years of treatment with strontium lactate there was marked improvement in symptoms."

E. Shorr and A. C. Carter, The usefulness of strontium as an adjuvant to calcium in the

remineralization of the skeleton in man. Bull. Hosp. Joint Dis. 13, 59-66 (1952). (Unfortunately, no free version of this exist online.)

I choose these 2 cases as my example because hormones were not used. The other cases has similar results, and other human trials have also produced similar results. (But including the used of the highly toxic pharmaceutical form of strontium called Strontium Ranelate.)

Strontium seems to significantly increase bone mineralization, but since it fools x-rays, the exact amount of improvement is hard to measure. It also reverses cachexia, which is a contributing problem.

Numerous studies show that strontium has the same effect on cartilage. A recent phase II trial for using strontium to treat osteoarthritis pain showed significant improvements in both pain and physical function from a topical strontium-based formula. However, the pharmaceutical company abandoned the project for an unstated reason and never officially reported the results.

Strontium can also significantly reduce chronic pain and neuroinflammation. The mode of action is this: Strontium replaces calcium and reduces calcium signaling in numerous steps in nerve synapses, nerve cross talk, and nerve cytokine production. In 1924, a very well-respected German doctor, Dr Walter Alwens, reported that he was able to get most of his chronic pain patients off of morphine by using strontium.

(The references are listed on my Substack blog.)

I have been researching strontium for many years and unfortunately, I seem to be the only one in the world doing so that isn't bound by a NDA (Non Disclosure Agreement) or who freely shares their research. You can read my Substack blog here: https://joeanstett.substack.com/

Expand full comment

I found this post overly simplistic. Maybe I need to read the book. Even if I buy into the concepts of active recovery (which I do) and metabolic/inflammatory causes of joint pain, in my experience, the vast majority of runners would love to keep running but can’t because the pain is limiting. The real problem seems to be that we don’t have effective non-surgical treatments for joint pain in many cases. PT doesn’t work for everybody or is often insufficient. NSAIDs and cortisone offer only temporary relief.

Expand full comment

Both patients and physicians who don't do rheumatology and orthopedics stand to gain from being educated on how running doesn't worsen OA and metabolic issues are more deleterious for it than physical activity. But may I play the skeptic?

Let's say the patient didn't hear "bone-on-bone arthritis" and instead looked at their visit summary, found the term osteoarthritis, done their own Googling. They would also find all those websites talking about knee replacements. They would also be vulnerable, without education, to concluding they've overworked their knee. Wouldn't they still have been in danger of stopping running without having heard "bone-on-bone arthritis"?

On the other hand, let's say the patient did hear "bone-on-bone" but got the extensive education that you convincingly established they would benefit from. They'd know that the X-rays show bone against bone, but they would have learned that it's not the running that did it. Wouldn't they have been encouraged to maintain their physical activity despite hearing "bone-on-bone arthritis"?

Your piece is a powerful call to educate patients. I'm just a little less convinced that it all hinges on whether we describe the arthritis as bone-on-bone or not?

Expand full comment