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

Dr. Gabrielle Lyon: 00:00

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.

Dr. Jocelyn Wittstein: 00:27

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.

Dr. Gabrielle Lyon: 00:39

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 26 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. Dr gabrielline.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.

Dr. Jocelyn Wittstein: 02:17

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 there,

Dr. Gabrielle Lyon: 02:30

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 life span or the muscle span of a female athlete throughout, yeah,

Dr. Jocelyn Wittstein: 02:53

I think there are very unique challenges that female athletes experience throughout their Lifetime, or health span or muscle 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 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 master's 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.

Dr. Gabrielle Lyon: 03:51

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? Yeah,

Dr. Jocelyn Wittstein: 03:59

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 than male athletes to sustain an ACL tear, even when you control for sports that you know women don't play, like if you if you just compare sports that both genders play, for instance, and 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, when

Dr. Gabrielle Lyon: 04:35

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 yeah, 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, I get that these are really complex, yeah,

Dr. Jocelyn Wittstein: 04:58

but I. Yes, I think the phase of life were differences between men and women, aside from the sheer number of girls, for instance, that tears 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 speaking about you know, incidents, but just the natural history, like 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 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 of 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. And they're declined until they're like, Hey,

Dr. Gabrielle Lyon: 06:25

why? So is that because? Is that because of estrogen, or is it probably a

Dr. Jocelyn Wittstein: 06:31

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. So 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. So osteo class which which break down bone in the absence of estrogen, basically stick around longer and do their thing for longer and break down more bone. So 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% so 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, you know, absence of estrogen. So all these things are kind of coming together, and that's just not something that that men experience. Do

Dr. Gabrielle Lyon: 08:16

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

Dr. Jocelyn Wittstein: 08:25

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

Dr. Gabrielle Lyon: 08:49

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 where? Why? Yeah,

Dr. Jocelyn Wittstein: 09:02

they're not so dependent on estrogen levels testosterone, right? Doing more for them. But then it would make

Dr. Gabrielle Lyon: 09:09

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, yeah, uniquely different between men and women. Because, why? Because men could go on an estrogen blocker, like in Astros all, 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.

Dr. Jocelyn Wittstein: 09:36

Yeah, I don't know the answer to that. Actually, it's a good question. What

Dr. Gabrielle Lyon: 09:40

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?

Dr. Jocelyn Wittstein: 09:54

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 stabilizing the levels of estrogen. And then a lot of people will stay on a, you know, combine oral contraceptive pill until they then transition into menopause and then switch over to menopausal hormone therapy. But, yes, that

Dr. Gabrielle Lyon: 10:30

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. Yeah, 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 I you know, things of that nature, or even a woman that is has the athletes triad, where she doesn't have a ton of estrogen, do we see the same kind of post menopausal symptoms?

Dr. Jocelyn Wittstein: 11:16

So oral contraceptives are used in athletes that have, you know, amenorrhea, yes. So amenorrhea is, can be part of we used to call it the female athlete triad. Now we call it reds relative energy deficiency syndrome. I did not know that, 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 a that was really right, yeah, but yeah, so yeah, the contraceptive pills can, you know, provide a level of estrogen that someone doesn't have when they're not, you know, 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, you know, 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, you know, shown when it is withdrawn to have to be associated with a rebound in joint pain.

Dr. Gabrielle Lyon: 12:42

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. A 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, what happens to women? Yeah, life injury, and you talk here about frozen shoulder, and that typically hits women between 4040,

Dr. Jocelyn Wittstein: 13:17

and 60, 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 her 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. I know we're idiots, 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 that's a different situation. And of course, diabetes is associated with high levels of inflammation. But so, you know, a low estrogen state is associated with high levels of inflammation. And there are some really, you know, interesting animal studies that show that, you know, the presence of these estrogen receptors in the synovium, you know, 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. And 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.

Dr. Gabrielle Lyon: 14:45

But I say the shoulder right, as opposed to say the Yeah,

Dr. Jocelyn Wittstein: 14:49

I have wondered about that. I don't know if the shoulder joint perhaps has like, an increased density of, you know, 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 then, you know, you're 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, 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. How

Dr. Gabrielle Lyon: 15:40

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?

Dr. Jocelyn Wittstein: 15:49

Starts with, usually, no trauma. Sometimes people will call 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. Everyone's sitting in your chair. Go ahead, yeah, and I 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. 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, tucking in a shirt. Those are the functional things people start to notice. But I'm always amazed that people don't notice them. I would lose notice if I lost like five degrees, but let's be

Dr. Gabrielle Lyon: 16:48

fair, but people don't know, is your division one? Former division one athlete and married to an orthopedic surgeon and children, and I'm

Dr. Jocelyn Wittstein: 16:54

an orthopedic surgeon. Yeah. So, so they don't, 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. Pinch nerve down into my hand. But they'll just have the vague sense that some there's this tingling sensation in their hand. And then some people will have, like, also, like lateral epicondylitis, because they're basically what's what they're doing is now they're just using their arm, like, T Rex arms, like 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. Wow. 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 the range of motion goes back. And occasionally you have to, like, inject them one other time, but it is a full resolution, 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 steroid injection. I know people are afraid of steroids, but it can really save you, not this crowd. Well, yeah, it could save you. It can save you a couple of years of, you know, thawing out.

Dr. Gabrielle Lyon: 18:13

So, no, 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 well, but yeah,

Dr. Jocelyn Wittstein: 18:27

I would, I would love to do a study of, oh, let me see that 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. You will hear

Dr. Gabrielle Lyon: 18:51

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Dr. Jocelyn Wittstein: 20:45

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, you know, poly arthralgia, even though there's mounting evidence that there's so much inflammation associated with menopause joint pain. Do

Dr. Gabrielle Lyon: 21:02

you know anyone that's doing it? Well, I enter articular.

Dr. Jocelyn Wittstein: 21:06

Well, not enter articular, but I will tell you, I have a very close working relationship with my colleague, Dr Anne Ford at Duke women's health. We are literally across the hall from each other. And did you inject her shoulder with estrogen? I didn't inject her. We've definitely helped each other. She's had an early round of frozen shoulder, and I, 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, 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, but we know the basic science of estrogen receptors in synovium. We know it's a fascinating conversation. 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 was, you know, some some, there's some increase in the pain. So, you know, 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.

Dr. Gabrielle Lyon: 23:42

You got to operate. But so sometimes

Dr. Jocelyn Wittstein: 23:46

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 Anne, 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, yes,

Dr. Gabrielle Lyon: 24:18

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, right? Yeah, doesn't seem to happen to men, if nearly at all, unless they

Dr. Jocelyn Wittstein: 24:39

have poorly controlled diabetes, which is

Dr. Gabrielle Lyon: 24:43

a good portion of the population, we have to say, Yeah, say that. But is there a level someone comes in and they don't know that there are 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 Contra. Receptive, or have a Mirena or something they're not aware. 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, oh,

Dr. Jocelyn Wittstein: 25:23

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,

Dr. Gabrielle Lyon: 25:48

yeah, yeah, which is interesting, because for men, there's a total testosterone, a free testosterone, right? Every guy, yeah, every guy, where's my testosterone? Is it 900

Dr. Jocelyn Wittstein: 26:00

what's my free test? And the range is so broad. And yeah, I know, yeah. So yeah, you know, as

Dr. Gabrielle Lyon: 26:05

we try to draw correlations to set up a paradigm of thinking, right, this framework of thinking about musculo skeletal 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, 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, yeah, and that they're having joint pain, and they're having all of these other symptoms, right? Increased visceral fat, exactly. 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? Yes, for people, obviously, we're not there yet. Yeah,

Dr. Jocelyn Wittstein: 27:19

yeah, it's really fat, and we're learning more and more about fat body fat as being inflammatory, yeah, like, you know, fat has lipokins, which are basically, you know, a something that stimulates inflammation and elevates inflammatory markers. And in obese patients, we know that they're, you know, more likely to have arthritis, but not just in weight bearing joints. So, so, so patients who have obesity, you would think, Oh, this is just mechanical overload of the cartilage. That's why they're getting more arthritis. And we know that's certainly what we would think, yeah, but they also have more arthritis and non weight bearing joints

Dr. Gabrielle Lyon: 28:06

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? Oh, yeah, you talked about or is that a myth? Yeah.

Dr. Jocelyn Wittstein: 28:16

So what is arthritis? And actually explain this in my book, because I think people just don't understand what arthritis is. What's the name of your book? Will you share it for? Yeah, the complete Bone and Joint Health Plan. And when does that book come out? May 6. And where's my copy? Oh, yeah, they should send you one. I'll get you Yeah, I want to get you signed copy please. Okay, all right, so, and also, I want to add co authored with my lifelong friend and colleague, Cindy niskorski, who is a dietitian, but so we got to hang her on. 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, you know, the edges of the joint. You get inflammation and thickening of the lining of the joint called the synovium. Then you get, like, some stiffness, loss of range of motion,

Dr. Gabrielle Lyon: 29:22

Julia, cartilage changes because it doesn't glide as well. Well,

Dr. Jocelyn Wittstein: 29:26

no, it's probably so this is very confusing. It's multifactorial. So then 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. Or if you

Dr. Gabrielle Lyon: 29:53

have hip dysplasia, or

Dr. Jocelyn Wittstein: 29:54

you could have a badly shaped

Dr. Gabrielle Lyon: 29:57

Thanks Todd, yeah. But, um. And

Dr. Jocelyn Wittstein: 30:00

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 one, six, tuber necrosis factor

Dr. Gabrielle Lyon: 30:12

alpha, within the joints, yeah, like systemically

Dr. Jocelyn Wittstein: 30:15

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 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 that'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 il one and six and 10 of alpha, and then somewhere in between, you've got, probably like, what menopause, arthritis is, where you have. Is that a thing? Well, I think it's a thing, but maybe not everybody thinks it's a thing, but it's basically where you have now you have a combination of, yes, you're over 50, but there's an acceleration of the inflammation, higher inflammatory markers and and more signaling of that pathway that leads to cartilage breakdown. You know, faster loss of the thickness of the cartilage over time. You know differences between men and women. So there's probably an interplay between inflammation and then, you know, the biomechanics of aging in women that's different than in men.

Dr. Gabrielle Lyon: 31:51

So men get arthritis, what percent less than women?

Dr. Jocelyn Wittstein: 31:57

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 there we're probably underestimating the the difference.

Dr. Gabrielle Lyon: 32:32

How does someone so running doesn't actually cause Oh, right,

Dr. Jocelyn Wittstein: 32:36

back to running. Yeah. So, yeah, lifting or 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 girl, you're gonna get yes and shoulder Yeah. Well, like, you know, you're probably earning 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 losing it.

Dr. Gabrielle Lyon: 33:05

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Dr. Jocelyn Wittstein: 35:24

You 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 you know, age and sex matched groups

Dr. Gabrielle Lyon: 35:42

to say that again, because it's really important,

Dr. Jocelyn Wittstein: 35:45

yeah, so yeah, runners are less likely than non runners to to get arthritis. Totally

Dr. Gabrielle Lyon: 35:51

counterintuitive, because people will say, Yes, 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 a inflammatory process, and then a this

Dr. Jocelyn Wittstein: 36:05

has been studied. There's a study where they had people run and then they MRI 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 the joint, fluid nutrients. So, 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 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 Drude freight, who's in biomechanics there, has done really interesting work on obese people looking at cartilage health, and so yeah, their 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,

Dr. Gabrielle Lyon: 38:12

that's a big deal. Yeah, I'm sure that you hear that it does and that activity doesn't necessarily cause arthritis. No, that there seems to be this progression, with

Dr. Jocelyn Wittstein: 38:21

EJ, if you already have arthritis, and it's like, unrecognized or you just didn't know it, 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. You know, you said something

Dr. Gabrielle Lyon: 38:40

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. Joints like to move 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 tendon quality

Dr. Jocelyn Wittstein: 39:15

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. I would think

Dr. Gabrielle Lyon: 39:38

that would be in the urology department, but it's not so that's

Dr. Jocelyn Wittstein: 39:42

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

Dr. Gabrielle Lyon: 40:03

young, you immobilize joints. Well, we

Dr. Jocelyn Wittstein: 40:06

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 patella or tendon repair on someone, sometimes I have to immobilize

Dr. Gabrielle Lyon: 40:19

them. That, that, 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 tenon repair very quickly.

Dr. Jocelyn Wittstein: 40:41

Yeah. So it would ever safe arc of motion I can. I always, well, we always do mobilize. So an example, but tell our 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 gonna 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 a 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 W, B, A, T, which is weight bear as tolerated, like you always want to wait for, as tolerated if you can. Yeah, I get you in those hats. So again, you want to avoid, not weight brain, 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 or range of motion, to avoid the downsides of treatment, right?

Dr. Gabrielle Lyon: 42:25

Because, 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?

Dr. Jocelyn Wittstein: 42:35

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 then 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, you know, 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 what 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.

Dr. Gabrielle Lyon: 43:43

And then can you build up tolerance? Are there supplements? Could you use collagen? Could you use, yeah, glucosamine, chondroitin. Could you use topical, transferable estrogen?

Dr. Jocelyn Wittstein: 43:54

So, 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. The there, how good is the evidence? It's pretty good. I mean, I honestly, before I wrote this book, I saw 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 two 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 UC two collagen. Which is undenatured type two collagen, and that comes in like a 40 milligram capsule. Very interestingly, this works through, like a almost an immunologic response, or through a system called gi tolerance. So you expose your GI tract to this, and it seems to reduce the levels of the enzymes which participate in, you know, breaking down cartilage. And then there's studies that show lower levels of basically cartilage breakdown products. Now the other type of collagen for joints is hydrolyzed, type two collagen, so this is broken down into smaller peptides so you can actually absorb it. And these, there is evidence that this can reduce symptoms in people with early knee arthritis, but not slow progression of arthritis. Fascinating. So they're so they work in different ways. I always tell patients, you could try taking both. I mean, the type two collagen, that's hydrolyzes, 500 milligrams, you're gonna have to mix it into something and drink it. Whereas the UC two is just, you know, a capsule. The interestingly, the the undenatured version that you see to 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, be better than something that maybe makes symptoms less but doesn't slow progression. But, you know, they probably both, both work in different ways.

Dr. Gabrielle Lyon: 46:22

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

Dr. Jocelyn Wittstein: 46:35

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 two collagen, and then hydrolyzed type one collagen would be more for assisting with bone density. And there's one brand that is studied, which is called Four to bone. And they did, basically took hydrolyze type one collagen, again, type one 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, that's amazing with collagen use with hydrolyzed type one 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 one collagen, you get a little more protein intake. You're probably

Dr. Gabrielle Lyon: 47:46

protein square of zero, by the way. Oh, well. So no, no. Use it for that. But definitely use it for

Dr. Jocelyn Wittstein: 47:52

so, but the effect on So, yeah, hydrolyzed type one 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 one 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 intervention. So that's wild, yeah? So bone, not that's, that's for bone, yeah. Can we regrow cartilage? You can't regrow cartilage unless I do this all time. 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 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 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. Sign up, yeah, if it's, 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, you know, like a couple months later, and put it in the defect,

Dr. Gabrielle Lyon: 49:43

and then, does that decrease pain, improve performance? Yeah. Why would we, yeah, slow progression, right?

Dr. Jocelyn Wittstein: 49:50

So, 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, and you 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 centimeters wide where you're it's missing, again, think of like a pothole and an otherwise smooth road, probably from some old injuries, 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.

Dr. Gabrielle Lyon: 50:25

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. Bond 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 bond charge is the products allow for us to balance our highly industrialized life style, 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 bond charges red light lamp as soon as it gets dark outside, and then I use the larger panels for 10 to 20 minutes each day. Bond 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 bond charge.com/dr lion and use the code Dr lion to save 15% that's B, o, n, C, H, A, R, G, e.com, and use the code Dr Lyon to save 15% off

Dr. Jocelyn Wittstein: 52:03

and implant it into a defect. Yeah. How

Dr. Gabrielle Lyon: 52:07

often is that being used? Is Is that something that is commonly offered? Is it more and more advanced? More

Dr. Jocelyn Wittstein: 52:14

Yes, yeah, some specialists will will offer it. I mean, I offered to be able, just like not a lot of people think they're going to be a candidate for that. And turns out, what they actually have, it's just early diffuse

Dr. Gabrielle Lyon: 52:24

arthritis, and nothing else you can do. PRP, do any of these. Yeah?

Dr. Jocelyn Wittstein: 52:28

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 knees aching, and you've got this X ray that's 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 get worse quickly, but will

Dr. Gabrielle Lyon: 52:55

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

Dr. Jocelyn Wittstein: 53:05

going, I mean, yeah, arthritis does gradually progress, progress over

Dr. Gabrielle Lyon: 53:09

time, no matter what an

Dr. Jocelyn Wittstein: 53:10

individual does. 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 the a lot of the other things we use.

Dr. Gabrielle Lyon: 53:28

But what if they are, what if they are healthy body weight, small, very fit, right?

Dr. Jocelyn Wittstein: 53:33

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 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 got to 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 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, there with counter medications, you know, Tylenol, anti inflammatories, topical voltarian Gel injections, you can use, but we don't kind the corticosteroids. Yeah, you don't. 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, you know, supinate. That's has these anti inflammatory proteins, and it's called play the 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 maybe. And then we talked about the collagen supplements, and then

Dr. Gabrielle Lyon: 55:50

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? Yeah,

Dr. Jocelyn Wittstein: 56:01

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 pipeline. There's actual, like, real evidence behind that. Vitamin D, for people who have knee pain, I like them to take 2000 units per day. That dose has been studied to reduce joint pain. And people with arthritis, it is higher than the necessary, you know, daily value. But and there may be various reasons why, by it reduces joint pain, maybe there's a little bit of, you know, osteopenia and the subchondral bone, you know, which is adjacent to the cartilage, I don't know, but that dose does show reduction of joint pain in people who have early arthritis, calcium, we'd rather you get through food then now it's, it seems like 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 glycinate, 400 milligrams at night. Can help with sleep, and certainly can help, you know, 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 to the bone, for calcium, for incorporation into bone. So you'll 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 bed, you bad diet, you don't need a lot of leafy greens some of the other sources, you know, you should. You might want to do that too.

Dr. Gabrielle Lyon: 58:30

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 which

Dr. Jocelyn Wittstein: 58:45

is now, yeah, which is now.

Dr. Gabrielle Lyon: 58:48

But what is so fascinating is we have an increased use in GLP ones like ozempic. And I'm curious as to what your thoughts on what we're getting right versus what we're getting wrong?

Dr. Jocelyn Wittstein: 59:03

Yeah, so the GLP one 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 so that is not showing up to be a concern. CERN, 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. Yeah, I

Dr. Gabrielle Lyon: 1:00:53

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 you would expect, it would be negative, right? Yeah, 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 Tiktok, not that I'm watching on Tiktok, but all these other places that it's affecting bone density,

Dr. Jocelyn Wittstein: 1:01:37

yeah, doesn't seem to be and maybe having the opposite effect. So do you think that they're so far they can't lose unless you get them taken away from you, and then people rebound right

Dr. Gabrielle Lyon: 1:01:49

and again, if they're doing the right things like strength training and eating dietary protein? Oh, yeah.

Dr. Jocelyn Wittstein: 1:01:54

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

Dr. Gabrielle Lyon: 1:01:59

Yeah, when someone is thinking about osteoporosis prevention, and I think I text you, messaged 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,

Dr. Jocelyn Wittstein: 1:02:23

I always round up by ear. I always say I'm 42nd now I just say I'm 47 Yeah. But,

Dr. Gabrielle Lyon: 1:02:28

you know, I watch my parents in the gym, and I am concerned about them jumping or doing any kind of so both themselves,

Dr. Jocelyn Wittstein: 1:02:41

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, you know, bone loss, and many of them are on menopausal women with low bone density. Many of them show gains in bone density like ranging from like 1% training, or with plyometric combined, 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, it 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 at 50% of your one time Max, or is it 80% with lower numbers, they're really variable. But in general, like I'll just sort of like Forest view, higher intensity strength training does seem to yield more benefit than capacity, in terms of bone density, than than the more moderate or low intensity. But the other forms are not without benefit. So where you're kind of seeing some gains in bone mineral density with the higher intensity strength training and the impact training, but you're still there's still benefit from the less intense lifting regimens. And to be honest, not everyone people had injuries like, I don't mean injuries like falling and breaking your hip while doing these exercises, but just like tendinitis or overuse, I mean, it happens to all of us. Like I love to do pull ups, and every time I do, every time, every time I do more than 10 sets of 10, I get biceps tendinitis, and I have to take a step back so or, you know, if I do for me, I can't do really. Overhead pressing weight, because every time I do I flew up my IC joint. So that is not one I choose to do at the high intensity. I tend to choose to do that 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 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 an increase in bone marrow density. Now, if you look at what do you get from something like a bisphosphonate over a couple years, you're going to get like, 6% increase in bone density, listening

Dr. Gabrielle Lyon: 1:05:43

of bisphosphonate is a medication, medication that

Dr. Jocelyn Wittstein: 1:05:47

would inhibits resorption of bone. Yeah?

Dr. Gabrielle Lyon: 1:05:51

Is the quality different of the bone that you get on a medication like a biz Fauci Yeah,

Dr. Jocelyn Wittstein: 1:05:55

probably is Yeah. So, 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, you know, for to 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

Dr. Gabrielle Lyon: 1:06:24

was I going with that? Well, I'm curious as to how, if we know that, oh, the quality of the bone we're looking at. 20 million Americans have osteoporosis here. I'm scared.

Dr. Jocelyn Wittstein: 1:06:34

Yeah, so the quality of the bone, I think, is better when you get it from actual loading of the bones. You know, one thing we see, for instance, with bisphosphonates is you can increase the density of the bone, but is it, you know, 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 that lead to that. And you know, one example that is, it's not a common problem, but there is something that occurs where people get an atypical fracture who've been on like a bisphosphonate for many years. It's called a subtrogen Jerk fracture of the hip. So it's like, below the

Dr. Gabrielle Lyon: 1:07:11

level of the hip joint. Yeah, that when the hip breaks and then they fall, well,

Dr. Jocelyn Wittstein: 1:07:15

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 area. It's not a common problem, but just an example,

Dr. Gabrielle Lyon: 1:07:38

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Dr. Jocelyn Wittstein: 1:09:43

and a lot of the So, for instance, like impact exercise in particular. So you need to find impact exercise 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. Flight, basically. So that's

Dr. Gabrielle Lyon: 1:10:01

different. 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 stimulates taking formations boom, a more robust, right, right, right, differently? Is that? Is that true? Am I

Dr. Jocelyn Wittstein: 1:10:25

Yeah, because you're kind of 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 our crutches and getting, again, the decision 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 Oh, from from impact,

Dr. Gabrielle Lyon: 1:10:55

no, you can't weight it as much.

Dr. Jocelyn Wittstein: 1:11:00

Yeah, 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 near 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

Dr. Gabrielle Lyon: 1:11:19

days. Yeah. What else could they do? So they could do a small you could

Dr. Jocelyn Wittstein: 1:11:23

just hold onto 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.

Dr. Gabrielle Lyon: 1:11:53

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.

Dr. Jocelyn Wittstein: 1:12:05

Throw that out there. I was thinking about that. I hear you,

Dr. Gabrielle Lyon: 1:12:10

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, yeah, not all in one place. That's, I mean, I think it's going to be tremendous, yeah, 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 me from calling you from with these questions that I have. So we're all good, yeah. 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

Dr. Jocelyn Wittstein: 1:13:01

like? 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, 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, female, charitable one, another achiever, total achiever. 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 all the bones, including upper extremity, lower extremity back and compared them to kids not participating in organized sports, and she followed them into adulthood with DEXA scans and other studies of the geometry of bone. And what she found was that these gymnasts ended up depending on what part of the body with 15 to 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 your you know, adolescent and early adulthood years are when you build up your base and then, 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. Can we build after 30 and 40? So some of these, you know, you're kind of trying to slow the loss, right? Because you typically will lose 1% per year no matter what typically Well, these, these resistance strength training programs, impact programs, do show that we can gain bone mass back. You're probably not ever gonna get, you're never gonna get above where you were when you were, really age 30. I

Dr. Gabrielle Lyon: 1:14:46

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?

Dr. Jocelyn Wittstein: 1:14:52

I think you would gain muscle mass. I don't. 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 already osteopenic or osteoporotic, and trying to reverse some of that, you know, with the interventions and 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 your winning because of the not like that, yeah, because not losing your winning, yeah, because the natural history would be to lose 1% of your bone mass per year, or if your post, if your menopausal woman, 2% per year,

Dr. Gabrielle Lyon: 1:15:48

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

Dr. Jocelyn Wittstein: 1:15:55

about? 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 gluts? 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 a nouveau ring, because that's, you know, 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, that's still a risk. So basically, exogenous estrogen, that's, you know, part of contraceptive delivery is, is a risk for perioperative blood clots. So sometimes that may affect our post op plan in terms of blood clot prevention, or just kind of raise our antenna in terms of concern for screening for a blood clot of someone that's calf pain or swelling. But there are a lot of contraceptives that don't have a risk, like possession 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 by a shot, right? 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

Dr. Gabrielle Lyon: 1:18:17

nice. 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. Oh yeah. 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. He loves nicotine. Uses

Dr. Jocelyn Wittstein: 1:18:38

bad for all things orthopedic surgery, wound healing, infection, your bone fracture healing, tendon healing, rotator cuff tear healing, just

Dr. Gabrielle Lyon: 1:18:48

hurt a lot of people's heart, right? Yeah? Because it's a thing. So yeah, I did my fellowship in geriatrics, and one of the things actually I did at Wash U it was really hard. I don't recommend anyone doing just kidding. You know, 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, oh, positive impacts for Parkinson's and other type of memory challenges. And now we're hearing from you, from from your mouth to God's ears. Nicotine exposure is not good for bone, tendons and anything orthopedic,

Dr. Jocelyn Wittstein: 1:19:27

right to know? Yeah, okay, unfortunately,

Dr. Gabrielle Lyon: 1:19:31

we're all crying now, yeah, you said something else. You said oral contraceptive or exogenous estrogen use. What about individuals that are using the patch

Dr. Jocelyn Wittstein: 1:19:42

transdermal estrogen used at the level in menopausal hormone therapy has no increased risk of 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, you know, quite safe. Now, one question mark is, if you were having, like, a major orthopedic surgery, you know, 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 transnable, dermal delivery is very safe.

Dr. Gabrielle Lyon: 1:20:22

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. Oh,

Dr. Jocelyn Wittstein: 1:20:41

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 progressed in, you know, something which has other benefits, like sleep and things like seeing

Dr. Gabrielle Lyon: 1:21:09

in terms of bone health, is it something that you are thinking about for bone health?

Dr. Jocelyn Wittstein: 1:21:14

Yeah, 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. Not yet, not yet. Yeah,

Dr. Gabrielle Lyon: 1:22:15

if you are young, you suggest you have five kids. Did you have them start your kids, yeah, early,

Dr. Jocelyn Wittstein: 1:22:21

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, but yeah, I think sports. Participation in athletics is really important in adolescents and very important girls, yeah, because you know, if girls aren't participating in, like, high school sports, that 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, right? 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 your workout like my husband, 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 and whatever house we live in, and they've always spent time in those rooms or use this the equipment, or whatever. So I think you need to model for your kids, but also you got to get them involved in activity, you know, at it, you know, so they're active through those years. And

Dr. Gabrielle Lyon: 1:23:32

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

Dr. Jocelyn Wittstein: 1:23:36

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 Oscar Slaughter'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. In some ways, your tendons are stronger than where they attach to bone, 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 beastie problem in America in general, yes, being active is good. There's not being, you know, yeah, you don't want them to be sedentary. No, when

Dr. Gabrielle Lyon: 1:24:50

girls go through, let's say the no longer term for the athletes try out women that are over actually. As in under eating and they lose bone. Yes, this

Dr. Jocelyn Wittstein: 1:25:04

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 not relative energy deficiency, term is not always with disordered eating, there can just actually be, you're not, you're under fueled chronically, and you'll this will be the kid that presents with a stress fracture, the cross country runner that they don't have. And

Dr. Gabrielle Lyon: 1:25:36

what she means by that is

Dr. Jocelyn Wittstein: 1:25:38

that, say, for example, an individual is really active, and they're just not thinking about eating. And they're, they just cannot keep up, but they demand a lot of food, but they're just still under fueled. Yeah. So yeah. And so if you, if you tip into a state of, you know, amen area, 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 marrow density when you're supposed to be building up your base, right? 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,

Dr. Gabrielle Lyon: 1:26:15

and what's done about that? Do they give them the pill? Well, they're, yeah,

Dr. Jocelyn Wittstein: 1:26:19

I mean nutritional consultation, American consultation, you can use contraceptive pill, but

Dr. Gabrielle Lyon: 1:26:25

they won't catch up. And again, I don't want

Dr. Jocelyn Wittstein: 1:26:28

to be negative, will you? 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 how long it goes on for and how many bouts of this happen to a person.

Dr. Gabrielle Lyon: 1:26:47

How genetic is osteoporosis?

Dr. Jocelyn Wittstein: 1:26:52

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 were 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 too late, too

Dr. Gabrielle Lyon: 1:27:43

late. Well, our pizza, 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 DEXA,

Dr. Jocelyn Wittstein: 1:27:51

yeah. Now for patients under 50, of course, you're not necessarily 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, 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 present 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, you know, osteoporosis is one of the biggest ones. So, you know, there's just, 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 very long term consequences like it's life altering, mobility altering. If you get osteoporosis and you get a. Fracture. It's, you know, there's mortality and morbidity associated with that.

Dr. Gabrielle Lyon: 1:30:04

Why is 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 is not full body, which I think is fascinating, yeah,

Dr. Jocelyn Wittstein: 1:30:24

yeah, no. 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 dead lift, 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 your arms, unless you're a gymnast, and then you have

Dr. Gabrielle Lyon: 1:31:08

good upper extremity. And it's inside. They call osteoporosis a silent, silence disease. Yeah? Someone isn't gonna know that they have osteoporosis until they break something, until they break something which is terrible,

Dr. Jocelyn Wittstein: 1:31:18

yeah? Or have a stress fracture, like you could be like a master's athlete, you know, what about

Dr. Gabrielle Lyon: 1:31:22

and if they're younger and have a stress fracture, is that an indication that? Well,

Dr. Jocelyn Wittstein: 1:31:26

sometimes stress fractures are part of energy deficiency syndrome, okay? Sometimes they're just part of, you know, bad alignment, like you got a high arch and your foot rolls over the side, so you're gonna get a stress fracture in your fifth metatarsal. That's different. You know? That's an alignment issue.

Dr. Gabrielle Lyon: 1:31:40

What about tendons? Have you thought much about tendons? Tendon health with hormone replacement loading them? Or is that still, yeah,

Dr. Jocelyn Wittstein: 1:31:48

so tendons also have estrogen receptors and, yeah, definitely, we see a lot more tendonitis, you know, Peri articular pain, you know, around the same time that was the increases in joint pain. Do

Dr. Gabrielle Lyon: 1:31:57

does hormone replacement, menopause, replacement therapy, help that

Dr. Jocelyn Wittstein: 1:32:02

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. So you're, you know study

Dr. Gabrielle Lyon: 1:32:37

this is, so far you're looking at 1000 participants, is that? Well,

Dr. Jocelyn Wittstein: 1:32:42

right now, we just opened it. We have a couple 100 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? That's interesting. Yeah, well, we don't know that, I don't think. And so we're trying to be more detailed and granular in our in our 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 humorous skiing, you know.

Dr. Gabrielle Lyon: 1:33:56

But loves that she's a neighbor, though.

Dr. Jocelyn Wittstein: 1:34:00

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

Dr. Gabrielle Lyon: 1:34:13

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

Dr. Jocelyn Wittstein: 1:34:23

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 is a year, but some show maybe 15 or 20% of the year. But the time you get to two years, a third of people. Some studies show, 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, but 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 1/3 chance it might not heal, and you might need a total hip anyway. There's 1/3 are going to heal and 1/3 are going to die. And that's it kind of has held true. Um, 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 weren't, 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, so there, there is a subsequent effect probably on mobility, which also, you know, compounds the state of the person that fell apart.

Dr. Gabrielle Lyon: 1:35:57

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

Dr. Jocelyn Wittstein: 1:36:02

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 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 little bit strong, a little bit flip 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 1/3 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. Well,

Dr. Gabrielle Lyon: 1:38:02

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 again. Yeah.

Dr. Jocelyn Wittstein: 1:38:14

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. So 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 like 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 from 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 bearing. 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 and 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. And why was that?

Dr. Gabrielle Lyon: 1:40:21

Just because

Dr. Jocelyn Wittstein: 1:40:23

it needs to be solved.

Dr. Gabrielle Lyon: 1:40:27

And you, I think you also did your undergraduate at Columbia, right? Cornell, Cornell, yeah, yeah, yes, yeah. We're always just really trying to solve problems. Yeah,

Dr. Jocelyn Wittstein: 1:40:36

yeah, yeah. I was in 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 feel like I cannot say enough of what I want to say, and 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, but in case they wanted to, 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 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. Well,

Dr. Gabrielle Lyon: 1:41:34

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. Thank you for having me Yes, and we will link everything for your book, and we'll shout it out, and can't wait for my copy.

Dr. Jocelyn Wittstein: 1:41:57

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

Dr. Gabrielle Lyon: 1:42:01

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 whitstein'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 you.