Kim Vopni (00:01.432)
Hi, Dr. Whitstein. Thank you so much for joining me. I know you have just finished your clinic day. You have had a busy day. So we'll, we'll make this short and sweet so you can get on with your, the rest of your day. But thank you so much for taking the time, especially after you've been in clinic all day long. I would love to have you tell the listeners a little bit about you, who you are, what brought you to the world of orthopedics and sports medicine and specifically bone health.
Jocelyn Wittstein (00:26.326)
Yeah, yeah, thank you for having me. I started out in orthopedic surgery probably through what I often consider the gateway drug to orthopedics, which is being an athlete. It's super common for people who go into orthopedic surgery to be an athlete, maybe sustain an injury, interact with an orthopedic surgeon and kind of think, I would like to do that. you know, I...
I love what I do. I don't treat just athletes. I take care of, I think I call them athletes of all ages. So certainly I have my, you know, preadolescent and adolescent athletes, my collegiate and post collegiate. And then, you know, as we age, we become sometimes weekend warriors, unfortunately, but also our masters athletes. And I especially love taking care of what I would describe, you know, kind of the female athlete throughout their lifespan. In my role as an orthopedic surgeon, also, I'm not just a clinical
and the surgeon. also teach residents and fellows, but I'm also a clinician researcher, so I collaborate directly with PhDs, people who are basic scientists who have their own labs, but we collaborate putting together clinical questions that we can answer with basic science. So we also study things that affect athletes like joint health, post-traumatic arthritis, propensity for certain injuries to occur in women, and how potentially hormone levels might affect
those things. yeah, putting it all together, that's what I do. If that answers your question.
Kim Vopni (01:56.878)
That sounds awesome. Yeah. I, I think yesterday when I was on Instagram, if correct me if I'm wrong, but I thought I saw you were collaborating with Dr. Vonda, right in, in a research, in some research. And I think you need 50,000 participants and it's bone health. that accurate?
Jocelyn Wittstein (02:08.536)
Mm-hmm. Yeah.
Jocelyn Wittstein (02:15.138)
Well, we would love 50,000. mean, big data is helpful. So yeah, backstory on that. I collaborate quite a bit with Women's Health at Duke and we have, are multiple research efforts we've done collaboratively. Like some work on...
Kim Vopni (02:20.674)
Hahaha
Jocelyn Wittstein (02:34.03)
You know, how do you manage DVT prophylaxis around the time of orthopedic surgery if you're on oral contraception or menopausal hormone therapy? How does menopausal hormone therapy affect, you know, risk of frozen shoulder? How might your hormones and being a woman affect your cartilage health as you age? You know, things like that. I established with our Duke Women's Health Department.
with some of the providers in that department, musculoskeletal symptoms of menopause registry. So we follow some of our women's health patients longitudinally, whether or not they take menopausal hormone therapy. We're monitoring what types of joint pain they get, how severe is it, how many joints are affected, and then how does that interact with timing of onset of the menopausal hormone therapy and what's ameliorated. Do people get frozen shoulder less or more? And so,
As another sort of limb to that study, we wanted to do a bigger data grab, I would call it. You know, you can do an anonymous cross-sectional survey asking all the same questions. You don't get all of that medical history necessarily and longitudinal follow-up, but it's nice to get a big cross-sectional data set. So we took that work that I was doing with Duke Women's Health and I partnered with Vonda because we have a lot of overlapping interests. We're in some organizations together, including the Forum, which is a...
Organization of Female Sports Medicine Orthopedic Surgeons. And yeah, so we're working together to do a broad cross-sectional anonymous survey. And we just, you I think big data is huge here. That survey focuses on joint inflammation, joint symptoms primarily, which is one of the aspects of the musculoskeletal syndrome and menopause. The reason we wanted that survey to focus on that is that...
menopausal hormone therapy is currently approved for prevention of osteoporosis. It's of course approved for vasomotor symptoms and things like that. One of the things that is not an FDA indication for menopausal hormone therapy is all of the joint pain and inflammation that we see in women. There is a ton of basic science to support the relationship between these things, but that's not one of the sort of indicated symptoms, for instance.
Jocelyn Wittstein (04:48.91)
Luckily, or I shouldn't say luckily, so many people that are struck with the joint inflammation also have hot flashes, night sweats, the worsening lipid panels, maybe a worsening hemoglobin A1C and other things, and they want to prevent osteoporosis. But it would be nice for us to add to the pool of data that sort of looks at the association with joint pain.
Kim Vopni (05:08.876)
Yeah. Okay. I'll have a link to that study or to that research in the show notes. Get more recruits. Get more recruits. Let's start with joint pain. So why is it so common in sort of the perimenopause menopause phase and what are the contributing factors to it?
Jocelyn Wittstein (05:11.81)
That would be wonderful. Yeah. We would love big data. Exactly. Yeah. Yeah.
Jocelyn Wittstein (05:28.866)
Yes, so I mean, just think about inflammation. We know that there is more inflammation as estrogen levels decline. know, menopause is an inflammatory state. There are receptors for estrogen all over the body, including the synovium or the lining of the joints. And, you know, if we have a decline in the level of estrogen, we're probably going to see more inflammation in joints. But if you just kind of
look at what else happens in joints. Like we see in women as compared to men, more rapid thinning of the articular cartilage in the joints. We know that bone density is affected by levels of estrogen and there is bone of course, behind the cartilage that supports it, we call it the subchondral bone. So we're seeing probably increased inflammation in the lining of joints, potentially weakening of the bone underneath the cartilage that supports it, more rapid thinning of the cartilage in women. So it's not uncommon at all for women to come into an orthopedic surgeon and just
feel like they have more common or worsening joint pain with no change in their activity level, their x-rays will typically look normal. And it's frustrating for people to hear, like, your studies are normal. You know, don't have a meniscus tear, you don't have bone spurs, like, what's going on? And it's not, there is something going on, it's just not yet visible sometimes. So.
Kim Vopni (06:47.63)
Right. What if somebody had, let's say, osteopenia, so signs of bone loss or maybe even osteoporosis, would that exacerbate the pain that they could experience at a joint?
Jocelyn Wittstein (07:04.846)
I think so. We sometimes see on an MRI like what we call bone marrow edema, like almost like bruising of the bone. And that's kind of like, yeah, if your bone density isn't as good, you can almost get like a little stress reaction in the bone there. And that combined with the fact that maybe the cartilage is a little thinner certainly could contribute to pain.
Interestingly, we see that if you look at studies of something like vitamin D, which of course supports bone health, like studies that look at using more than at least 2000 international units a day as a regular supplement, that's been shown to reduce joint pain. it because you're providing support to the underlying structure, the bone right underneath the cartilage, or vitamin D in and of itself does seem to be having an anti-inflammatory effect as well, but.
You cannot separate, I think, bone health and joint health necessarily. I think they're like always intimately connected for sure.
Kim Vopni (07:56.878)
When you think of bone, when general lay people think of bone, or joints, is usually arthritis or osteoarthritis, rheumatoid arthritis. What can you differentiate between those terms?
Jocelyn Wittstein (08:09.261)
Okay.
Jocelyn Wittstein (08:13.622)
Yes. So osteoarthritis is typically what we, what you consider your more, you know, wear and tear arthritis. could be biomechanical, like just overload of the joint. You know, like I have a knee model here, right? Like we're loading the joint. If someone is a little bit malaligned, like let's say you're a little like bow-legged, I'm going to, you know, overload this side of my joint. That's a mechanical thing.
that can contribute to wear and tear. That's not necessarily like an autoimmune entirely inflammatory thing. We're learning over time that there is a little bit of an inflammatory component though to regular wear and tear arthritis. Like we see levels of inflammatory, what we call cytokines in joints that have wear and tear arthritis at much lower levels than we do say in a knee that has rheumatoid arthritis. Joints that have rheumatoid arthritis are literally, you know, the...
your own body is attacking the lining of and the surface of your joint. This is an autoimmune problem with extreme levels of inflammation, higher levels of inflammatory markers like interleukin 1, 6, tumor necrosis factor alpha, like things that we know contribute to the cascade of your body destroying or breaking down the cartilage surface. So you got the extreme of rheumatoid arthritis. You have the...
other extreme, is wear and tear arthritis. In between there are other forms of arthritis. One of them is something called post-traumatic arthritis. Like if you tore your ACL, that knee is never going to be normal again. There's a level of mechanical wear and tear, injury from the trauma, but also a cascade of inflammatory proteins in the knee that always stay a little high. I also think that arthritis associated with menopause is in that in-between category. Yes, you're, you're aging. Yes, you see the
cumulative load on your knee over the course of your lifetime, but there are also increased levels of inflammation and more inflammatory processes going on in the knee, which that is why partly women are 30 % more likely than men to have, for instance, like knee arthritis. And the rate of arthritis in knees in men when they're 80 is like kind of where women were when they were like closer to 50. So it's just...
Kim Vopni (10:31.192)
Wow.
Jocelyn Wittstein (10:32.845)
There's a sharp decline in the health of joints in women that occurs with menopause that men don't see. So that's not purely biomechanical. There's always the aging process. We can't eliminate that. We all age over time. Most people get some arthritis at some point in their lifetime. But there's a different, you know, aspect where it accelerates for women. And we don't have
exactly like proof that like using menopausal hormone therapy, for instance, makes you less likely to need a knee replacement. We saw in the early studies, you know, by the by the women's health initiative that were of course a little flawed in some way, but gave us so much valuable data that like 77 % of women were presenting with menopausal women had joint pain. And there was an ameliorating effect of menopausal hormone therapy, it reduced joint pain. And when women went off of it, they had rebound, they had more joint pain.
Kim Vopni (11:10.604)
yet.
Jocelyn Wittstein (11:32.398)
But we don't know that starting on it and staying on it maybe would change that differential that we see between men and women in terms of how many men versus women need replacements over time. It makes sense to me that it would. It's just not been established and that's kind of an area that really needs to be explored more.
Kim Vopni (11:52.568)
Yeah. Do you see more hip or knee issues from a degeneration perspective or like, I know there's more hip fractures than there would be sort of fractures around the knee, but if you were to compare in women specifically, hip versus knee, what do you see more of?
Jocelyn Wittstein (12:03.047)
Mm-hmm. Yes.
Jocelyn Wittstein (12:11.414)
Yeah, more knee than, I mean, in general, knee arthritis is more common than hip arthritis. Fractures, certainly osteoporotic fractures are most common around the hip. We don't really see them around the knee so much unless some, we see them in people with osteoporosis actually around the knee. Sometimes if they've had a joint replacement and people may fracture around their replacement, because it kind of creates like a, you know, a stress riser there sometimes.
Kim Vopni (12:37.742)
Mm hmm. I, if, if somebody has had a, like, I forget the, it's osteo, it's, basically where a ligament pulls a portion of the bone away in a, in like a catastrophic, a bulging fracture. Is that what that's called? Okay.
Jocelyn Wittstein (12:51.244)
an avulsion fracture where it plucks, the ligament plucks the bone a piece, it's attachment site away from the rest of the bone.
Kim Vopni (12:58.646)
Okay. And is that something that could be associated? Like, is it more likely if you were osteopenic or osteoporotic?
Jocelyn Wittstein (13:05.23)
I, know, interestingly, the most common population we see avulsion fractures in are children because their ligaments are stronger than the attachment to the bone and it's a growth center so they can pull off. you know, you would, you would think that you would see a lot more avulsion fractures in people with osteoporosis. but I do think we see some weakening of the interface of the tendon with the bone. don't typically like necessarily see a piece of bone like pluck off.
Kim Vopni (13:12.638)
really?
Kim Vopni (13:34.21)
Mm-hmm.
Jocelyn Wittstein (13:34.668)
Now, when you see fractures, for instance, around the proximal humerus, you will see, luckily I have these models here. So you'll see, so we have a shoulder here with a rotator cuff. The tendons come over and attach. Sometimes if you break your proximal humerus, it'll break in multiple pieces and the pieces that the tendons attach to will be like, you know, separate parts.
Kim Vopni (13:43.287)
You
Kim Vopni (13:56.877)
Hmm.
Jocelyn Wittstein (13:58.126)
In the hip, sometimes you will see the hip will break into multiple pieces. And so there may be the piece that like say the abductor tendon is attached to something like that. So you can get really complex fractures and they'll break into parts of the tendons attached to them. I think a lot of times we see failure of the tendon where it directly attaches to bone. And then when you repair tendons in various places, bone quality does matter because
Kim Vopni (14:03.608)
Mmm.
Jocelyn Wittstein (14:27.495)
The tendon is less likely to heal back to the bone if the bone is weak.
Kim Vopni (14:30.542)
Yes. Okay. What, a hip fracture perspective, why is it that the risk of, like the statistic is, I believe it's over the age of 60, if you fall and break your hip, your likelihood of dying within that first year is very, very high. Why is that?
Jocelyn Wittstein (14:51.822)
So depending on the study you read, there's different populations that are studied. It's not the same across the board, but you know, there is a, some studies say 15 % chance of dying within a year and other statistics, you know, one third may die in one to two years, you know, depending on the paper and the population you're looking at. It's kind of a chicken or the egg discussion. Obviously, many of us can fall and not break a hip.
People who are osteoporotic, poor bone density, if they fall, the hip is vulnerable, they break the hip. Why are people falling? Do they have poor balance, poor muscle tone? They've lost a lot of lean muscle mass. It's a little bit of a marker of decline, but then on top of it being a marker of decline, like just...
The reason why you fell and broke your hip is because you're already having some decline in your bone density and likely your lean muscle mass and your balance and things like that. But on top of that, there are changes in your mobility after a hip fracture. So we say all the time, you know, you're likely to drop a level of mobility. If you were not using any assistive device after a hip fracture repair, you might need a cane. If you're using a cane, you might need a walker. If you were walker dependent, you might need a wheelchair sometimes.
And so if you have decreased level of mobility, you know, kind of get further cardiovascular decline. If someone's on a lot of bed rest, they might be more prone to getting, you know, UTIs. They might have a catheter in. And so then these things kind of spiral. You could have a blood clot after surgery. You could get pneumonia. I mean, these are the reasons why we want people to be treated right away if possible, usually within 24 to 48 hours for hip fracture, because we don't want these things to happen to people. But sometimes they do. So...
You know, once that fracture happens, there are other things that become more of a problem. You know, you could get a bed sore, you could get a blood clot, the UTI. If you're an elderly woman and you get a UTI, you can get bacteremia. And you know, that can become a spiral, of course. So there's some chicken and the egg. Some of it is you're at a state where you sustain the fracture, and some of it is what can happen to people after having a fracture.
Kim Vopni (17:03.118)
Yeah. And in terms of the progression that gets us to that point where, you've, mentioned that it's like, it's not just one thing. It's not just because you fell. There's usually a series of things that have happened along the way that have put you more at risk. So you mentioned balance, yeah. Loss of muscle mass, loss of bone. How can we prevent falls, especially, you know, I remember, I remember probably like six or seven years ago, I was out for a run on the trail of roots and I was trying to pass somebody and I
Jocelyn Wittstein (17:21.422)
Mm-hmm.
Kim Vopni (17:33.076)
And I tripped over the side little barrier of the trail and, and made a fool of myself. And it was quite funny at the time. But thankfully I wasn't injured. got up and I carried on, but had that been somebody who didn't have quick reaction time or who had lost some bone mineral density, what happened? could have been catastrophic. How do we keep ourselves more like, how do we build a resilient body so that we're not going to fall and we're not going to break something?
Jocelyn Wittstein (17:55.372)
Right? Yeah.
Yeah. Yeah. And the older you get, the harder you fall, I swear. You know, when you fall on your kid, you just get up. And I was trail running a few months ago and just landed, you know, completely parallel. you kind of stop and feel everything and make sure nothing is broken before you get up. And then you really feel it. So, yeah, I think there's a lot of things we can do over the course of our lives to try to like stay more agile.
Kim Vopni (18:06.051)
Yes.
Kim Vopni (18:15.288)
Yes.
Jocelyn Wittstein (18:26.946)
I think it's good for people to do a little agility work, like things where you have to move your feet quickly, even if you're not like a football player, like you can do like fast feet where you like, you know, jog in place. Like, I think it's good to try to keep up with some faster movements. I think it's good to practice balance. Yoga is a great way to do that. I mean, I, my residents make fun of me sometimes if we have nothing to do or just standing around waiting for an instrument, I'll just stand there and kind of stand in a, I'll stand in a tree pose while I'll just stand on one leg.
Kim Vopni (18:54.542)
I do that too on podcasts often.
Jocelyn Wittstein (18:56.214)
Yeah, like I love a good, I could, I love the feeling of standing in tree pose and I brush my teeth that way and I switch legs. And so I think it's good to just randomly incorporate. You can absolutely multitask and incorporate balance, you know, in your life. So balance, a little agility, trying hard and it's never too late to start, but at some point, you know, thinking about and trying to maintain your lean muscle mass, we definitely lose lean muscle mass as we age and,
Kim Vopni (19:09.836)
Yes.
Jocelyn Wittstein (19:25.164)
You have to be intentional about it because the natural history of living is to lose lean muscle mass. So really trying to incorporate two or three days a week of strength training, keeping in mind what your abilities are. Not everyone will tolerate lifting really heavy. There are some good studies that show that even menopausal women who haven't lifted before can train up to lifting heavy.
four or five exercises, small number sets, something like four or six reps, kind of at like 80 % of your max, but like not everyone can do that without getting tendonitis or then getting sidelined. And so I also think it's reasonable if you want to choose, you know, something like eight exercises that you can do three or four sets at eight repetitions where the eighth one is hard and you can still do it with good form. Like that's a reasonable thing for people to do. If you're worried about like getting injured or getting tendonitis, you know, things like that, like you can start somewhere.
And if you want to lift heavier, you can drop the numbers and you just have to see what your body tolerates. You might need to work with the strength and conditioning coach. So again, maintaining lean muscle mass that helps with honestly, just like some of your padding. If you fall, like having some muscle on you, but of course gaining and maintaining lean muscle mass, the act of doing those exercises also stimulates bone density and maintaining adequate bone density so that you don't break when you fall, of course helps you, you know, not sustain a fracture.
Kim Vopni (20:49.198)
Yeah. What, many people in my community with pelvic floor dysfunction are often told you can't lift anything over X number of pounds. You can't run, you can't jump. can't do all these things, which I feel is not, I feel that's irresponsible. Right. Which there is no published research to say that a certain weight would be detrimental to the pelvic floor. There never will be because every, like what's heavy to you is
Jocelyn Wittstein (21:06.327)
with pelvic floor dysfunction? Yeah.
Kim Vopni (21:18.594)
like impossible for me or what's light for you is heavy for me. so we, so my, my point being in terms of if somebody was afraid, now I encourage people to move beyond that recommendation and let's build tolerance so that you can lift heavy so that you can jump. But are there other ways that we can stimulate? So I know vibration training, there's the different, very expensive machines that you would need to go to a clinic to do, but are there other things that somebody could do?
Jocelyn Wittstein (21:20.109)
Yeah.
Jocelyn Wittstein (21:44.43)
Mm-hmm.
Kim Vopni (21:47.342)
to stimulate bone that doesn't involve impact or resistance training.
Jocelyn Wittstein (21:52.142)
Well, back to the resistance training, there are different ways you can do resistance training. Like if the issue is like lifting and Valsalva and all of that, like you could also do like some more isolated machines. Like I do prefer things that are less isolated and use your core and multiple muscles. But you know, like if you can't do like a heavy hex bar lift, cause you're like bearing down so hard, you can still do like a knee extension machine or a hamstring curl machine or like a
that you can do like one leg at a time. You can also do seated arm, you know, a chest press or an overhead press. you're, that's more, those are more isolated movements, but those would still stimulate bone density because it is resistance training. Also pool-based exercise, it's not as effective as land-based, but you still get some benefit from it. Even like pool jumping, you can jump in a pool, like you need to be able to get some of your body weight out of the pool.
It does lessen the impact. So it blunts the impact, but the increased resistance you have to get yourself out of the water kind of balances out some. So there is benefit to that too. So we think people could take a strategy of maybe like heavier strength training, but in more isolation, you know, as you're doing it. And then, you know, also like some water-based things could help. But you're right. Impact does assist with bone density.
Kim Vopni (23:11.768)
Right, okay.
Jocelyn Wittstein (23:16.098)
Whole body vibration, you know, I've never seen a study that shows like in isolation that that increases bone density. I think it can be an adjunct, but it's probably amongst all of the options, you know, impact training and the resistance training, probably the least valuable part, but it certainly could help.
Kim Vopni (23:31.032)
Yeah. Yeah. one thing that we were kind of talking about offline, but sometimes people, whether they fractured a hip or for other reasons, maybe even, arthritis in the hips may need a hip replacement. And there are various types, anterior, lateral, and posterior repairs. And there are different implications for pelvic health. Now know this is not something you do not perform hip replacements, but you do know a lot of kind of.
Jocelyn Wittstein (23:56.824)
Right. I refer them to my partners.
Kim Vopni (23:59.35)
Yeah. So you know, some of the things, but what, should somebody, if they were considering needing a hip replacement surgery, what are some of the things like, what's the pros and cons of the different approaches and what should they be looking for in a surgeon?
Jocelyn Wittstein (24:06.882)
Anyway.
Jocelyn Wittstein (24:13.326)
Yeah, first of all, if you have a good trusting relationship with your surgeon and you want to work with that surgeon, you should probably let that surgeon do the approach that they do best and most predictably. Like they may have done it a thousand times or more in this way and they have really good results. You know, I think the worst case scenario, like a lot of people are very interested in an anterior approach.
which has good results in a theoretically reduced risk of dislocations. However, there's a very steep learning curve with anterior approach hip replacements. There is a higher risk of fracture, like iatrogenic when you're doing the replacement. It's not a great approach for people that have high BMIs. Like if there's like a lot of body mass, like abdominal tissue in the way, it's just really not a good approach for obese people.
some of those gains may go away. So, you know, if you have an anterior approach to the lip, you want it to be done by someone that does a lot of those. The lateral approaches can weaken your glutes a little bit. So it changes your rehab. You have to pay attention that your rehab should be specific to the approach. And the posterior approach does, you know, we detach and reattach some of your external rotators. So again, like some of that's being protected.
And you really need to make sure you and your therapist are aware of what approach you have and respect those restrictions and progressions that your surgeon wants you to follow because they're specific to your approach.
Kim Vopni (25:50.51)
Do you ever have your patients go through, so if you had a patient who was gonna be going through some sort of a surgery, doesn't have to be a hip, it could be any type of surgery, do you ever do prehab with them? Do you feel that that would be something beneficial?
Jocelyn Wittstein (25:58.222)
Mm-hmm.
Jocelyn Wittstein (26:02.846)
yes, all the time. I love prehab. I, all the time. I can give you so many examples. People who don't know how to use crutches or a cane, or they're going to have to navigate stairs at home or getting in and out of the shower, applying their brace. Like it's frightening to me, you know, to just kind of expect people to understand these things. And even if they think they'll understand them, they might not. So, and also, yeah, if you're weak in a muscle group that,
Kim Vopni (26:09.39)
you
Jocelyn Wittstein (26:32.014)
we know you're gonna get weaker in after surgery. Yeah, it's better to kind of strengthen that going into surgery so you can at least come into surgery optimized. Because if we expect a muscle to get weaker afterwards, we don't want you to start in a weakened state if we can help it. There are times where you don't have that opportunity. Like if someone has a hip fracture, we need to fix it. But if someone needs a knee replacement and they're really weak in their quadriceps, certainly you could optimize things if their knee will tolerate it. In my operative world, if someone...
you know, has patellar instability and I want to stabilize their kneecap, but they're really weak. I might have them do some preoperative, you know, physical therapy for sure.
Kim Vopni (27:09.89)
Yeah. Yeah. Yeah. It makes sense. I'm a huge proponent of that. how can, like for somebody who is maybe not yet ready for a joint replacement, they are dealing with some sort of arthritis, some sorts of movements may be challenging. So say, let's say knee arthritis. I get comments all the time because I do, I do, encourage people to get down on the floor and back up off the floor, but there are some people who are like, I can't do that anymore. I still encourage them.
Jocelyn Wittstein (27:13.964)
I hear you.
Jocelyn Wittstein (27:33.634)
Mm-hmm. Can't do it.
Kim Vopni (27:38.924)
do what they can within their limitations or their boundaries, but how else would you advise those people to manage the situation that they're dealing with? Is it a hard no, they will never do any getting down off the floor and back up? Yeah.
Jocelyn Wittstein (27:49.666)
Well, people with knee arthritis getting down on the floor and back up. So sometimes there may just actually be functional limitation to movement. You know, this is something that yoga is not going to fix or whatever. If your knee doesn't bend more than 90 degrees, it's not ever going and you have arthritis, it's not, it's probably not ever really going to bend more than 90 degrees. And, you you made a knee need a knee replacement to get past that.
Or some people's knees, for instance, don't straighten all the way. Some people's hips have so much arthritis, they cannot actually, like you ask them to sit and, you know, what we call crisps plus applesauce. Yeah. And their knees are like up at their ears. Like they, they're just, their hips do not move. They're literally blocked by bone spurs or rigidity, lack of gliding of the surface. It's no longer smooth. And so some of those things are, they can be hard to push past. Arthritis doesn't ever revert. It doesn't get.
Kim Vopni (28:25.058)
Like the butterfly pose or, yeah.
Jocelyn Wittstein (28:45.228)
better, it gradually worsens over time. So yeah, there may be some actual limitations to motions. I don't think people should, I think it's good to try to keep moving. I think functional movements are good. You know, maybe they can find an adaptive way to do something. Maybe they need a support to get up, but like it's good to be able to get up off the floor because you might need to do that if you've fall down. I think that's a reason.
Kim Vopni (29:07.692)
Well, it's on does just challenge the world to do the sit stand test on social media. So.
Jocelyn Wittstein (29:11.328)
Yeah, yeah, yeah. I mean, there are some people because of the severity of their arthritis, may not be able to do that. Yeah.
Kim Vopni (29:16.204)
Yeah. Yeah. Yeah. Yeah. Okay. So again, thinking how we can avoid these things. what from a, we've kind of talked a little bit about movement, what from a nutrition perspective can we do to support our bone health and our muscle mass as we're aging?
Jocelyn Wittstein (29:35.182)
So obviously nutrition is the fuel for everything. Certainly very important. I try to think of things not so much in the silo. You know, we need things for joint health, we need things for bone health. Ideally our diets are fairly anti-inflammatory. I do think that helps with a lot of...
aches and pains. And so in terms of an anti-inflammatory diet, you want to choose like lean proteins. You want to avoid processed meats, avoid processed foods. Whole grains are good. There are whole groups of plants that have lots of anti-inflammatory phytochemicals. know, cruciferous vegetables are a great group. There are lots of unique things that have special things in them like beets and pomegranates.
whole group of things called alliums, there are spices that are anti-inflammatory. Fiber is an anti-inflammatory thing, provides short chain fatty acids, which have been shown like those levels are associated with decreased joint pain and inflammation. So there's a whole aspect of the anti-inflammatory diet, but in terms of bone health, there are specific needs we need for our bone. So of course we need adequate calcium intake and vitamin D, adequate magnesium,
I think that in terms of maintaining your bone density, we have to remember to maintain our muscle mass, so adequate protein intake. And I think the older we get, it's good to prioritize fiber, protein, fruits, vegetables. The good thing if you're prioritizing fiber in choosing your carbohydrate sources, you may be then be choosing these whole grain, high protein.
these options that are high fiber. I think it's good to kind of, when you think about carbohydrate choices, just choose some that are also high in fiber. You're kind of using that choice together, so to speak. But yeah, and if you're trying to build muscle mass over time, you do need a higher protein intake. You'll see different ranges. You don't want to live at the level where you're just getting enough protein in to just not lose muscle mass.
Kim Vopni (31:33.186)
Yep. Right.
Jocelyn Wittstein (31:49.85)
So a higher protein intake would be something like 1.6 grams per kilogram, something like
Kim Vopni (31:54.86)
Yeah. And I heard you on another podcast, I believe it was with Dr. Gabrielle Lyon and the one, I think her question was, are, what are women doing wrong? And your answer was they're not starting soon enough in terms of building their bone. Can you talk a little bit about that?
Jocelyn Wittstein (32:06.562)
I mean.
Jocelyn Wittstein (32:11.702)
Yes. So we don't want it to be like a doomsday thought process. Like if you didn't, if you were just coming to this realization, you're 50, it's definitely not too late. You can build bone after 50 or whenever. You can always start to build bone. However, it is true. We do peak in our bone density or in our bone marrow density around the age of 30. So there's so much that's going on, like even in our teens and twenties, like
fueling as an athlete, trying to avoid relative energy deficiency in sports. You don't like hurt that peak bone mass that you achieve by the age of 30. Participating in activities that include like loading and strength training, you know, beyond high school and college. If you were, you know, an athlete, sometimes people finish sports and they're done. You you got to, it's important that people continue to participate in strength training and, and some impact exercise. And so we're going to build that base. We're going to achieve it.
We kind of peak at age 30. We do start to lose typically 1 % of that bone marrow density per year. Unfortunately for women, it accelerates at menopause, which is average age of 52. So as estrogen declines, we kind of fall into a 2 % per year bone loss, which is a big deal. And that's, course, why women are more prone to osteoporotic fractures. So my...
My thought when I tell people, like one mistake people make is they don't start earlier enough is like, obviously we're speaking to women who are, you know, under the age of 30 when we say that, like you can still increase your peak bone density. If you're beyond the age of 30, it's not too late. We know that resistance programs, even those that are not super intense, still help with bone density. Higher intensity strength training does help more, but if you can't tolerate that really high intensity, it's like.
doing some of the less intense work does still help. Some impact training helps, like jumping of some sort, could be jumping jacks, box jumps, jumping rope, anything like that, that helps build bone density. And then just, you know, maintaining these efforts over time. There are studies that show even people who have osteoporosis, if they participate in these sort of structured programs and very diligently do this a few days a week, they can gain a few percentage points of their bone mineral density.
Jocelyn Wittstein (34:25.646)
so even if you're not like losing bone-roll density, that means you're technically gaining. If we know that the natural history is to lose a little bit and you're not losing, that means you're defeating that, that process or you're beating that process. So yes, I think a lot of women don't start, oops, say yes, I think a lot of women don't start soon enough, but if you happen to fall in that category and you were doing cardio your whole life, trying to drop weight or
Kim Vopni (34:32.867)
Yeah.
Jocelyn Wittstein (34:55.66)
you know, maintain a certain body weight and you weren't focusing on strength training because it was like kind of what you thought was best for your well-being at the time. And then you kind of make a shift. If that shift occurs after the age of 30, it's not too late. It's just, we can't go back in time to the age before 30.
Kim Vopni (35:09.272)
Yeah. And wrapping it up with some HRT. there was a brilliant paper put out by Dr. Vonda Wright, musculoskeletal syndrome of menopause. So applying a term to it, kind of harnessing a lot of what we've... You are, okay, amazing.
Jocelyn Wittstein (35:20.492)
Yes, I'm a co-author on that paper. Yes, we wrote that paper together.
Kim Vopni (35:25.93)
Amazing. Okay. Thank you for letting me know. didn't know that. I'm sorry. so that is kind of summarizing a lot of what we have talked about here in terms of joint pain and the increased challenges that, that women are facing as they are reaching this menopause phase. And you mentioned, osteoporosis, sorry, estrogen is indicated for the, is established for the prevention of osteoporosis.
Jocelyn Wittstein (35:34.934)
Okay.
Jocelyn Wittstein (35:38.435)
Right.
Jocelyn Wittstein (35:49.356)
Mm-hmm. Yeah, that's an FDA approved utilization of it. Mm-hmm.
Kim Vopni (35:52.598)
Right. And hoping to expand on that, but right now, so research and evidence is supporting the use of hormone therapy. What about testosterone and progesterone? Do they have a role from a bone health perspective as well?
Jocelyn Wittstein (35:59.726)
Okay.
Jocelyn Wittstein (36:05.422)
So yeah, currently the indications for prevention of osteoporosis are for estrogen therapy. Of course, hormone therapy could also include progesterone. And there are other reasons for people to use progesterone, sleep, things like that. You also can't have unopposed estrogen, you know, if you have a uterus that can lead to increased risk of uterine cancer. Testosterone, interestingly enough, there was a recent study that showed decreased risk of osteoarthritis in both
Men and women if they are sorry I should phrase it this way increased risk of osteoarthritis and men and women who had low testosterone levels of course women's testosterone levels are supposed to be about 10 % of men's they're not like as high but But yeah, so there seems to be some association with testosterone that is There's absolutely research going on in this area We're doing some research on cartilage health and resiliency including testosterone
estrogen and progesterone levels in one of the labs that I work in using some MRI, three-dimensional models of knees. So we're working on that. I would say we definitely need more data. The only current FDA approved indication for testosterone in women currently is low libido. And I always give this caveat. Remember, I'm an orthopedic surgeon and I see my patients as whole people and I totally treat them as whole people and I collaborate very regularly with women's health providers.
So I don't provide, I don't prescribe these hormones. I would never claim to be like an ultimate menopause expert. What I do spend a lot of time thinking about and working on with my colleagues who are menopause experts is that intersection with musculoskeletal health and how we can make things better for women by working together. yeah, I just put in a new grant application for our study looking at cartilage health and...
testosterone, estrogen, and we're also looking at men.
Kim Vopni (38:06.894)
Amazing. There was a woman who was a yoga instructor at a retreat that I was at recently, and she said this one thing that has just stuck with me that said, the more we bend, the less we break. So from a joint health and kind of you talked a little bit about agility and mobility, I think that's something else that we would really benefit from as well. Do agree?
Jocelyn Wittstein (38:20.598)
Yeah.
Jocelyn Wittstein (38:28.078)
stretch it.
Yeah, yeah, yes, there are some papers that and studies that look at the benefits of stretching and flexibility in terms of actually the affecting things like agility, walking speed. So yeah, I certainly think I know you mentioned Instagram, I made a little post about the importance of stretching. Harkening back to my gymnastics days, it was.
doing a bridge. yeah, think that's another component of things is maintaining flexibility. And the other thing is joints like motion. They do not like immobility. You know, the way our joint surface actually gets nutrition is through range of motion of the joints and hydrates the joint. So, you know, it's just like if you sit on a, if you're on a transatlantic flight and you don't move your knees around for a long time, you stand up, your knee feel, they feel stiff. They're uncomfortable. The joints really like movement.
Kim Vopni (38:56.397)
Yeah.
Jocelyn Wittstein (39:24.076)
So yeah, think mobility is good. Also, just maintaining flexibility of your muscles makes you less likely to get tendonitis and injure your tendons.
Kim Vopni (39:33.976)
Yeah, yeah, yeah. All right, well, thank you. I'm gonna send you off on your way. You've had a long day and I so appreciate you taking the time. where can people find you? You mentioned you are on Instagram. So where can people learn more about the research and what you're doing?
Jocelyn Wittstein (39:40.044)
Yeah, no, it's no problem at all. Yeah, yeah.
Jocelyn Wittstein (39:47.022)
Yeah, my Instagram handle is just Jocelyn underscore Whitstein underscore MD. I work at Duke University. So I am in the Raleigh-Durham-Chapel Hill Triangle area. If you're interested in these topics, particularly anti-inflammatory diet, bone health diet, how you can basically feed your bones and your joints.
Um, exercises you can do. recently published this book I did with Mike. Yeah, it actually released today. It's called the complete, yeah, it's called the complete bone and joint health plan. And, I, this is, um, I just wanted to, I, I thought about doing this for a really long time and I just wanted to kind of like wrap everything up that people asked me all the time. People ask me all the time, like, what should I eat? What exercises I should do? What supplements should I take? And so I tried to address all those things in more.
Kim Vopni (40:17.998)
Amazing.
Amazing. that's perfect. Perfect timing.
Kim Vopni (40:37.675)
Thank
Jocelyn Wittstein (40:43.886)
in this, but I worked on this with one of my very good lifelong friends, my friend, Sydney Nitskorski, who is a registered dietician and also fitness instructor. And so we kind of blended together all of our knowledge. I was in nutritional science major at Cornell. And so I always love incorporating nutrition in my practice, even though that's not typically like part of an orthopedic surgery visit, but I love incorporating that. if that interests people, I hope it's a useful.
reference for people that is not textbook-like, more sort of, and you don't have to be a healthcare provider of any sort to understand it. It's really for people of all backgrounds to just be able to like kind of have a little user manual for their bone and joints.
Kim Vopni (41:27.928)
Yeah, I love it. Well, congratulations. I know how much effort it takes to get a book out and that's amazing. So I'll have links to everything in the show notes. Thank you so much for your time. I so appreciate the work that you do. I am excited for more research that you're doing and no, it does not.
Jocelyn Wittstein (41:33.772)
Yeah.
Jocelyn Wittstein (41:40.556)
Yeah, more to come. Research doesn't happen fast. If you do good research, it's actually a really slow process. have to, it's a lot of delayed gratification.
Kim Vopni (41:49.228)
Yes, yes, for sure. Well, the fact that it's even happening though is a win. So I'm happy to wait. anyway, thank you so much. I so appreciate your time.
Jocelyn Wittstein (41:57.804)
Yeah, thank you for having me.
