Ep79 [WWW12] Arthitis, Achilles Tendonitis

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Wednesdays With Will continues with a discussion about Arthritis (osteo & rheumatoid). He will share what causes it and what can be done to prevent and reverse it, if anything.

Dr. Harden then answers a listener question about Achilles tendonitis – what causes it, how it is treated and what you can do.

 

 

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Will: So we’re gonna have a discussion about arthritis. And on the surface that would seem to be a huge topic and that I might be talking about a condition of those who are elderly. And I think many people hear the name arthritis and they say “Oh my, my grandma have that. Oh, yes I’ve seen the old people with arthritis.” And what they’re thinking of when they think of arthritis that way is rheumatoid arthritis. And rheumatoid arthritis is associated with mild deformation of the hands and fingers, enlarged knuckle joints. But rheumatoid arthritis is far less common than osteoarthritis.

So rheumatoid arthritis is an auto-immune disorder in which the body’s immune system is actually attacking synovial membranes. And synovial membranes are the tissue on the boarders of joints that make and release synovial fluid. And synovial fluid is the joint fluid that helps lubricate joints but that is far less common than osteoarthritis.

Osteoarthritis is the excessive depositing of bony material in and around joints which have been either structurally aligned irregularly or mechanically compromised for a prolonged period of time and almost always as a result of some old injury or repetitive pattern in our lives. For example, NFL players retire usually somewhere around 30. And by 40 many of them have shoulder surgeries. By 45, many of them have hip and or knee replacements. And nearly all of them, develop arthritis in their… That is osteoarthritis also known as degenerative arthritis; also known as degenerative joint disease; in the case of the spine, also known as degenerative disc disease. So almost all, for example, NFL players or career athletes develop osteoarthritis or degenerative arthritis. If it’s basketball players, it’s in their knees and hip and sometimes low backs. If it’s a football player, it’s in their knees, hips, back, neck, shoulders.

But in you and I, as a result of sitting in front of computers — okay. I’m an exception to that. I’m constantly moving in my career. Furthermore, I’m not in age where I’m not tied down to a computer my entire adulthood – but in people who are subject to the postural implications of sitting in front of a computer, using a cellphone for the purposes of social networking and the playing of video games, etcetera, and therefore have had neck, shoulders, upper back, rounded, forward; I see an amazing predominance of degenerative disc and joint disease in cervical spines. These are people who never participated in athletics at all some of them. On the other hand, I see 28 year olds with osteoarthritis in an area that was injured 10 years prior. For example, someone who has a significant enough motor vehicular accident, whip plash type injury at 17, it’s not uncommon that at 28, I’ll see degenerative disc and joint disease at let’s say C4, C5, C6, which means the fourth, fifth and sixth segments of the neck down from the top.

We’ve talked in past conversations about the natural curve of the neck. That curve is there to act as a natural shock absorber and to positionally keep the head back over the shoulder. and lose of that curve which occurs as either as a result of an injury like for example one or repetitive whiplash type injuries or as a result of prolonged postural stress associated with all these tasks that I was just referring to namely sitting in front of a computer all day, Always looking forward and down. And lose of that curve is by virtue of kind of a compressional implications of that forward head and also by virtue of losing the neck shock absorption capabilities, it’s a form of stress that causes progressive laying down of more bone. And that’s what arthritis is. It’s the progressive laying down of bony material in and around joints to try to stabilize and fortify a joint that’s being interpreted as under stressed.

To really get osteoarthritis, Glenn, I wanna warn you I’m getting more detailed than I need to. But I think this is really fascinating. To understand osteoarthritis, you should understand Wolff’s law, W O L F F. I think I recently quoted Wolff’s law because you asked me how to spell it.

Glenn: Yeah, you did a couple episodes ago. I can’t remember what the topic was but yes, I do remember.

Will: Okay. Well, Wolff’s law states that any change in the form or function of a bone, in other words, its alignment or its motion, will result in certain definite changes to the internal architecture and external confirmation of that bone.

Wolff’s law is a theory developed by the German anatomist and surgeon Julius Wolff (1836–1902) in the 19th century that states that bone in a healthy person or animal will adapt to the loads under which it is placed.

In other words, if you’re misaligned, you’re not moving properly, your brain lays down an extra bone in that area to try to fuse it. And that happens in knees in runners. It’s not a coincidence that an epidemic, if you will, of osteoarthritis began in the 70’s — 10 or 12 years after running became a craze around 1960. That’s not a coincidence at all. We know that’s directly attributable to the overuse of running on knees. We also see increased osteoarthritic or degenerative disc change in low backs in runners especially long term runners but also in people who spend a career sitting. We see these changes in the necks of people who have a career sitting. So less you be concerned that I just painted a picture that makes it feel like there’s not a darn thing you can do, you’re a victim to your circumstances as it relates to osteoarthritis; there are things you can do.

One, addressing posture. It’s so incredibly important you know our moms used to say sit up straight keep your shoulders back, all that. The truth is to a degree the other methods may not have been effective. They were right. Your posture really matters. I think I’m gonna sit up straighter. And specifically, when sitting, ideally when sitting or standing anytime you’re upright, you would have your ears over your shoulders. That is a plum line dropped from your ears should hit your shoulders. But for most people if you watch them sitting, certainly if they’re in front of a computer, on their phone; you will see that a vertical line, a plum line, dropped from their ears is usually hitting their lap, which means this 10-12 lb. head is being carried out in front of the body.

Now picture yourself for a second, resting your elbow on a counter in front of you and you’re holding a bowling ball, 10-12 pounds, the weight of a human head now bend your elbow such that the bowling ball was being held out farther, you will immediately feel the kind of the compressional strain in your elbow. And you’ll feel your biceps muscle engaged. Now imagine holding it that way all day. I don’t need to tell you. You couldn’t do it. Your biceps could not handle that kind of strain. Now picture yourself holding that bowling ball with your forearm still with elbow planted on the counter, with your forearm completely vertical pointing toward the ceiling, holding that bowling ball in that position, I assure you, you could… I bet you can hold out 15, 20, 30 minutes doing that because the bowling ball is balanced on the long axis of your forearm. Right? You don’t need a whole lot of muscle action to keep it here. And that applies to the weight of the head. If your head is forward, the muscled from the base of the skull on the back of the neck, down to your shoulder blades are constantly contracting. And that constant contraction is creating a compressive effect on the neck which stresses the disc.

So good posture is that such your head is moved back on a horizontal plain to get the ears back over the shoulders. So here’s kind of an interesting perspective. If you sit and let yourself completely slumped and slouched such that your upper back and your low back are all rounded and your head is way far forward, you cannot get your ears over your shoulders without everything else underneath straightening itself. So relative to good posture as it relates to osteoarthritis long term, all you really have to do is move your head back such that your ears are over your shoulders and everything else underneath will take care of itself. So first order of business with osteoarthritis due to prolong sitting being the primary cause of a lot of osteoarthritis I see is to improve your posture. You were about to ask me something.

Glenn: I wonder if I just miss your explanation. How does arthri– or how is bad posture affecting arthritis, is it fusing joints together?

Will: Prolonged seated position especially in a compromised posture. One, it increases the intra-discal pressure. That means the pressure from the inside-out within the disc.

Glenn: Got you.

Will: The discs are the pads of cartilage between the vertebrae that act as spacers and shock absorbers. And with prolonged sitting — and when I say prolonged, I don’t mean for a couple hours. I mean for a career — is very common to see premature advanced degenerative disc disease, i.e. a form osteoarthritis in people in their mid to late 30’s. And having proper posture, while sitting, reduces that intradiscal strain and therefore reduces the likelihood of the onset of premature osteoarthritis. So having good posture.

Two, choosing athletic endeavors that do not induced compressional strain on the spine too excess. You know I always like to support a patient in whatever it is they choose to do to alleviate their stress – gain fitness, stimulate cardiovascular health, prolong their life, etcetera. But just a little word of caution, I believe that the compressional implications of running are such that we are meant to run with great regularity especially on cement surfaces only until we are, I’m gonna, say 35 years of age because during the first 35 years of our lives, we are relatively anabolic. We’re building. We’re getting better and bigger and badder and stronger and tougher. But sadly, after 35 years, we are relatively catabolic, meaning we’re essentially breaking down. And we know that the compressive implications of running are such that it does make you more susceptible to osteoarthritic changes as I mentioned in the knees but also the spine.

In truth, I’m not nearly as worried about the development of advanced osteoarthritic changes of the knees as I am of the spine because in reality — not to sound flippant about it — but you can always get a new knee but you can’t get a new spine. There’s no such thing as a spine replacement. And when excess bone grows around the vertebra since the vertebrae tightly protect and surround the spinal cord and nerve roots, there’s not any extra room for bone deposits as bone deposits into channels where nerve roots move through on their way to and from the spinal cord that creates nerve compression, right? And that’s very serious. And yes, there are surgeries for that but no such thing as a spine replacement.

So arthritis. I’m gonna go back to the idea of what can we do to address it. I think nutritionally it is important to consider cartilage health. And we don’t suspect. We know that something called glucosamine sulfate does increase of the activity of the type of cell called chondroblast. Chondroblast are the cells that make, that produce cartilage. And if you ever broke off a chicken drum stick or a turkey drumstick, you see that at the end of that bone is kind of whitish, gray, glistening, super slippery surface. That’s cartilage. And that cartilage helps keep the ends of bones, where they rub together, nice and smooth in their articulation. And osteoarthritis is marked by wear and tear on the cartilage that roughens that surface, so anything you do that smooth that surface, that is anything that causes the production of more cartilage is good for it. And we know that glucosamine sulfate at 1500 mg a day does stimulate cartilage growth. It stimulates increase chondroblastic activity. And we know that because if you radio-isotopically tag glucosamine sulfate and watch what happens after someone swallows it, within a reasonably short period of time, we see that it’s concentrating in joints.

Some people as about what “What about chondroitin sulfate? And what about MSM? And what about glucosamine hydrochloride?” First of all, there are far or less researched that glucosamine hydrochloride is clinically effective compared to glucosamine sulfate. And I’m not even saying that it’s not. Only that almost all the research showing the benefit of glucosamine was glucosamine sulfate. And historically, I have heard many, many people say they took glucosamine, granted hydrochloride, and that they did not see much of effect. And they get it at you know Walmart and Tesco. And the truth is glucosamine hydrochloride is way more common on the store shelf than glucosamine sulfate. And I – excuse me – conjecture that that’s because glucosamine hydrochloride is easier to make; therefore, less expensive, therefore more common. Glucosamine sulfate, the therapeutic does in 1500 mg a day. And it’s critical that you read the back label of any nutritional product you take. Because it’s common to see on the front label, it will say glucosamine sulfate 1500 mg, then you turn that bottle around and read the little print and it says 3 tablets supply. And worse yet, sometimes will say 6 tablets supply 1500 mg, in which case you would take 6 of those a day. So I like either a 750 or 500 mg capsule of glucosamine sulfate, you take it all at once. The body can assimilate that much all at once. It doesn’t spill out. It does go to joints. And most people who take it in 4 to 6 weeks will feel it and if they otherwise have the tendency for joint pain. MSM–

Glenn: But the glucosamine will help resist arthritis.

Will: Yes, and even to some degree people that have existing arthritis will notice marked improvement. You might have to be patient and take for it 6 or 8 or 10 weeks; however, it is promoting the growth of cartilage and is therefore good for addressing existing symptoms if not helping to prevent progression.

Glenn: Now the disc in between the vertebrae are not cartilage, correct?

Will: They are in part cartilaginous.

Glenn: So glucosamine could help.

Will: Yes. There’s reason to believe that it could in fact help with disc degeneration as well.

Glenn: Nice. And do you know my issue, my joints rub.

Will: Very

Glenn: And as far as I know, there’s no cartilage there. Is that correct?

Will: There is cartilage there–

Glenn: There is. There’s little bit.

Will:  –diarthrodial joint. It’s encapsulated by what’s called a joint capsule. It has synovial fluid in it. And it is a cartilaginous surface, the facet.

Glenn: I’ve never seen it on any of the models I’ve played with.

Will: Uhuh, yes. It indeed is.

Glenn: Okay. Good.

Will: So MSM is methyl sulfanol methane. And basically MSM is used for people with fibromyalgia, arthritis, chronic pain, ‘rheumatism.’ And it’s basically a form of organic sulfur. And many people do swear that it helps. And I would conjecture, it’s because it’s a form… it’s a source of sulfur. And sulfur is an important component of cartilage. And therefore if you had a deficiency of sulfur in your system and you took MSM, chances are you’ll see improvement in chronic joint pain. Is it actually promoting cartilage growth? I can’t answer that for certainty. I can only tell you that it does seem to help many people with arthritis. I believe that glucosamine sulfate is more directly effective at addressing degenerative joint disease than MSM, which I think of as more as a way to ameliorate pain, a way to address pain.

The third thing nutritionally used for arthritis is chondroitin sulfate. And often, you’ll see a combination of either glucosamine and chondroitin or glucosamine, chondroitin and MSM. And whereas I am not opposed to taking glucosamine sulfate… It’s kind of like this. When you take any nutrient, it goes from the stomach, absorbs through the intestinal wall, goes in to the bloodstream, circulates through the system and ideally is taken up and used by the tissues that need it. And it’s first got to get out of capillaries into the tissue. It is believed — I’m gonna give you an analogy — that the size of the pores of your capillaries are about that of a golf ball. Glucosamine sulfate is a size of marble so it easily gets out of the pores. But chondroitin sulfate is the size of a baseball. Therefore, I believe without question it is highly debatable whether chondroitin sulfate can even get into the joints. And yet, I have observed that whereas many, if not most people, say “I tried that, it didn’t do much.” Sometimes I have patients “I swear if it doesn’t have chondroitin sulfate, I won’t respond as well.” In other words, I’ve taken it before, it totally works for me. I proposed to you that those are people that have baseball sized or bigger capillary pores and that’s how they respond to it. That or it’s pure placebo because someone they know swore that it changed their life so they took it with the firm belief that it would and it did. In either case, I’d say more power to him; take it.

Glenn: I totally understand what you’re saying on a physiological level. And I totally agree. And understand how that how that chondroitin wouldn’t be absorbed in to the tissue that needs it. But many, many years ago when I was trying to run on a daily basis, my knees would hurt. and I started taking chondroitin because I heard it was supposed to be good for your joints. And it really did work.

Will: Was it pure chondroitin?

Glenn: It may have been mix with MSM. I don’t recall—

Will: I asked ‘coz if it was pure chondroitin and you did well with that, I would postulate you do in fact have fairly puros capillaries. And that you are one of those people that does in fact absorb it and get it in to tissues, joint tissues, and use it.

Glenn: But now I don’t run so much and even when I do, I have a different gait so I don’t put as much pressure in my knees.

Will: Alright.

Glenn: And so I haven’t really needed it. Hence, I haven’t really tried it but I have some glucosamine sulfide at home so I will keep taking that.

Will: Wonderful. Of all the things you said, what I love the most is you changed your gait for–

Glenn: Yeah.

Will: –for a therapeutic manner. That’s great.

Glenn: Yeah, it really made a big difference.

Will: So that being true, you’re defying that idea that – well, you’re gonna be 35 soon so never mind, you’re still okay. (Laughter)

Glenn: Yeah, I just had my… Was it 33 birthday?

Will: Oh, that was yesterday. That’s right.

Glen: Yeah.

Will: Happy birthday.

Glenn: Happy birthday to me. I’m still 33.

Will: Congratulations, you’re getting there.

Glenn: I’m still 33. Someday I’ll reach your age.

Will: You’re gonna reach your prime soon.

So arthritis, I think it’s also really important not to miss the simple aspects of self-care as it relates to arthritis as for example, maintain a good hydration. Maintaining a good hydration and therefore blood volume and therefore plasma volume is really important for promoting the movement of blood and therefore oxygen to all tissues including joint tissue; and the movement of fluids and or inflammation, fluids in the form of hydration into joints including disc; movement of fluids in the way inflammatory fluids out of joints that are inflamed; another consideration, management of inflammation. And we talked I think about inflammation with everything from proteolytic enzymes to turmeric. And that can be extremely beneficial for people with arthritis, the use of turmeric. I’m seeing more and more frequent positive responses to that in patients.

Glenn: How does that work?

Will: Well, curcumin is the extract of turmeric and there are essentially 3 pathways of inflammation. I am maybe getting way more detailed here than you care to know but essentially, there are 3 primary chemical pathways that contribute to inflammation: the prostaglandin system, the cox and the lox systems of inflammation. That’s C O X and L O X. And it’s believed that curcumin probably works on all 3 of those chemical pathways to control inflammation which is phenomenal considering other in pharmaceutical anti-inflammatories work only on one. For example, non-steroidal anti-inflammatory drugs like ibuprofen work only on the prostaglandin system. But it’s really important that there’s a certain proportionate activity within each of the 3 inflammatory pathways. And when you cut off one, you are relatively increasing the manifestations of the other two. Does that make sense?

Glenn: Uhum. Yup.

Will: We know that if you just limit, cut off the cox2 system that there are other chemical implications to the cardiovascular system. That’s why Vioxx was pulled off the market because – I don’t remember – 60  thousand something people died from it from vascular disease. Well, that was because the cox2 system was being selectively shot off. And so any anti-inflammatory that is affecting all of the systems is automatically better for you than one which only affects one system. Besides, turmeric has no side effects. And we know there are multiple negative side effects of pharmaceutical anti-inflammatories. So I think that’s a decent summary of arthritis as it relates to how I think of it.

Glenn: So in summary, a person should maintain good posture, mobility, movement, not to be stationary for too long.

Will: That’s right.

Glenn: For a period of time. If they do like to run or they have had joints injuries or even if they want to be preventative, they should take glucosamine—

Will: Sulfate.

Glenn: –sulfate.

Will: Yes.

Glenn: And drink plenty of water.

Will: And of course, I always say getting adequate sleep is important for everything.

Glenn: Yeah, that keeping your stress down is just healthy for absolutely everything.

Will: Agreed.

Glenn: Yeah.

Will: And I think that probably should not go without mentioning.

Glenn: I agree. I don’t think we mentioned it enough and it’s kind of the… it’s like we know we’re supposed to drink a lot of water but people tend to promote that more than sleep.

Will: Yeah, that’s very true.

Glenn: And is at least equally—

Will: That’s very true.

Glenn: –as important but yet, sleep is the first thing to go when push comes to shove. You have a test to study for–

Will: Right.

Glenn: –or extra work or you’re working out or you’re training really hard. And I talk to athletes all the time too because I get these young kids who want to build muscles for football or basketball or something like that and yet they’re getting like 5 hours of sleep–

Will: Right, exactly.

Glenn: –and training twice a day every single day. (Laughter)

Will: Talk about spinning your wheels.

Glenn: Oh yeah. Yeah.

Will: Right. During sleep, regeneration of new healthy cells, building of muscle tissue, on and on.

Glenn: Yeah.

Will: And especially in the face of something like trying to put on muscle weight.

Glenn: Well, I heard today this one young kid; he’s probably 19 years old. He wants to grow his muscle mass and he’s sleeping like 5 hours a night.

Will: Oh my god.

Glenn: And he said… I had this very conversation with him. And he said “but I’m taking protein powder.”

Will: (laughter) Oh boy.

Glenn: And I said, “Well, okay. Good. Nutrition wise. That’s good.”

Will: Uhum.

Glenn: But you need to sleep.

Will: He’s building a good house there but it’s got zero foundation.

Glenn: Exactly.

Will: It will not stay up.

Glenn: Exactly. So, Will…

Will: Yes.

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Listener Question

Glenn: I have a listener question. Now this comes from a friend of mine. He’s name’s Jason. I haven’t spoken with him in in about 5years. I used to work with him as a personal trainer. And then he moved down to California. And out of the blue, my phone rings and here it is. And he had a question for me about Achilles tendinitis. He said he has been suffering this for a couple of years and trying to treat it and probably not giving it ultimately enough rest but he’s had physical therapy which included Graston. He’s been giving it some rest but he’s an active guy, training for triathlon. He cycles and he runs but he’s been reducing that in order to give it rest. Do you have any recommendations on anything else he can do other than do nothing?

Will: Yeah. So stage 1 of Achilles tendinitis would be to control the inflammation by icing it, elevating it, resting it. But Achilles tendinitis can become a very chronic condition. What causes Achilles tendinitis, nobody really knows but we could postulate it’s from either overuse or chronic tension within the Achilles tendon. The Achilles tendon is nothing other than the strap that attaches the calf muscles to the heel and then wraps underneath the bottom of the foot and really kind of integrates itself into the arch of the foot. So the Achilles tendon behind and just above the heel is a really strong, thick tendon because you’re calf muscles are amazingly strong. They propel you forward when you walk, run, jump but they also are essentially, if you’re standing in one place, constantly engaging to push your toes down against the floor so that you don’t fall forward.

In fact, it’s really interesting. When they do an EMG, when they put EMG sensors on the like the entire body’s muscular system and then tell someone to stand and relax as much as they can. There’s one muscle that remains more active than all others when you are completely resting when standing to the extent that you can. And that’s your calf muscles which means the Achilles tendons never get a break. So deep tissue work on the calf muscles. That’s almost certainly gonna reduce tension on the Achilles tendon. But that’s probably not gonna do much for a chronic Achilles tendinitis.

Graston technique, Graston technique is a technique that involves of the use of typically stainless steel tools that a practitioner uses to grate or grind on and adhese scarred chronically painful tissue like a tendon or a muscle. But I understand your friend’s done that. So if that hasn’t worked, the next thing to do is a hamstring tendinitis, sometimes chronic back muscle spasm, chronic knee problems, and yes, Achilles tendinitis would be a therapy called Prolotherapy. Prolotherapy has been around from a couple decades at least. And it was initially an injection of sugar water into a tendon or a muscle that has some kind of scarring or adhesion or tension. And it stimulates proliferation of healthy new tissue. However, Prolotherapy has really evolved quite a bit in the last 5-8 years. And now the most commonly used technique is called PRP, which is platelet-rich plasma. So your blood is withdrawn, small amount of it, it’s spun. The platelets are concentrated. And then they are injected, in this case, in to the Achilles tendon. And it’s believed that causes that release of stem cells into this chronically irritated or adhese or tensed tendon. And that’s stimulates the rapid regeneration of healthy new cells. And often in one treatment with this PRP, a chronic tendinitis will clear. Sometime it takes two or three and rarely even more but usually 1-2 treatment of platelet-rich plasma injection Prolotherapy will remarkably improve or resolve these.

Glenn: Hmm…

Will: In the meantime, if you can reduce chronic tension on the Achilles, it’s good for it. So light stretching of the calf, the use of heel lifts to raise the heel to kind of put some slack in to the Achilles tendon, can be symptom relieving. Proper arch supports, wearing forgiving shoes in terms of a wide-toe box and good arch support is very wise with a chronic Achilles tendinitis.

Glenn: Very nice. Very nice. Thank you. Yeah, he’s a firefighter so he can’t really rest it too much.

Will: That is for sure.

Glenn: But I imagine he does wear some boots with a heel and–

Will: That’s true.

Glenn: –the toe box is big enough.

Will: Good point.

Glenn: If he can rest on his days off, that’s…

Will: So he’s next step would be the PRP or Prolotherapy.

Glenn: Sounds good. I’ll make sure he gets the message.

Will: Wonderful.

Glenn: Thank you, Will.

Will: Indeed.

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These special Wednesdays With Will episodes are a series with Dr. Will Harden, chiropractor, creator of the Dr. Will Bar,  and health and fitness guru. He will discuss health, fitness, nutrition, and chiropractic issues that have the potential to improve your health and life. Dr. Will Harden has been a chiropractor for 26 years. He graduated first in his class from National College of Chiropractic in Chicago, IL and moved to Portland, OR in 1989 and owns a practice called the Corbett Hill Wellness Center.


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