Ep 47: Arthritis does not mean you have to have surgery

Michael Dermansky Hi everyone and welcome to the show that helps you become more confident in your body so you can keep doing the things that you love. My name is Michael Dermansky, I’m the senior physiotherapist at MD Health and I’m joined by another senior physiotherapist at MD Health, Will Ryan, he’s been on the show before and welcome back. great to have a good conversation with you about some really important issues that we see here on a daily basis at the clinic.

Will Ryan Yeah, it’s great to be back and I think it’s a really important topic to let all the listeners know a bit more about and in a bit more depth too.

Michael Dermansky Well, let’s talk about this one. Arthritis doesn’t mean you have to have surgery. We see people with knee, back arthritis on a daily basis as well. I want to go back to a fundamental question today. We’re going to talk about a bit more about arthritis and what the options are with that too, because it’s not a dead end as well. So let’s start talking about that as a definition. From what you understand, we’ll talk about specifically about osteoarthritis. There are many different types as well. There’s inflammatory ones like rheumatoid arthritis and so forth. We’re more specifically talking about osteoarthritis, which is that change in the cartilage. That’s the most common type that we see. From your perspective, Will, what is osteoarthritis or arthritis? And how is it both a mechanical problem and inflammatory problem? Because it’s not just wear and tear, is it?

Will Ryan No, not at all. So I think where a lot of people… what a lot of people’s understanding of osteoarthritis is, is that it’s really just a wear and tear down of the articular cartilage in a joint. So the cartilage wears down, thins out, and then the bones start, I guess, rubbing against each other. That’s not necessarily the case. It can be the case in some people. But the way we should look at osteoarthritis is as a whole joint issue. So quite often with osteoarthritis, if we talk about the knee, for example, not just the articular cartilage being involved, it’s the synovial fluid, so the fluid that helps lubricate our joints that gets involved. The meniscus can often be involved as well in the knees in particular.

Michael Dermansky Yeah.

Will Ryan you know, lot of other things like bone spurs and things like that are really common in an osteoarthritic joint as well. So quite often it’s not just the cartilage being affected, it’s the whole joint itself and all those little structures within the joint. I guess the articular cartilage decay is part of the mechanical problem within the joint, but the inflammatory processes… that happen with osteoarthritis are the primary drivers of pain. So… Osteo, look, articular cartilage doesn’t actually have a great nerve supply. So just the, you know, the lack of presence of articular cartilage won’t equal pain. The biggest driver of pain in most osteoarthritic joints is swelling and inflammation within the synovial fluid itself. So that’s called synovitis. And that’s probably the biggest thing in terms of pain that us as physios help people with in terms of controlling that.

Michael Dermansky Alright, let’s go back a step because not everyone knows what articular cartilage is, not everyone knows what synovial fluid or synovium is and how are those related? What are those things as well?

Will Ryan So the arcticular cartilage is a bunch of cells called chondrocytes and there’s other things involved with those cells as well that cover the ends of our bone. They allow for good gliding movements of our bones on one another. The synovial fluid sits in between those two ends of the bone within every joint of our body. And like I said, that kind of acts more as a lubrication, helps reduce friction within the joint, helps the joints move nicely. they coexist, but they do play off each other quite a bit when it comes to osteoarthritis.

Michael Dermansky Thanks So with the Articular Carlage as well, it’s this white stuff. So it looks white, that’s the normal color of it too. It’s a spongy, so some degree it compresses. And so it can take loads, made to take load then, as Will says, well, it doesn’t have a nerve supply, so you can’t actually feel it. And so it’s made to compress and take load, and you don’t feel that part as well. And that’s the way our joints are normally designed. So as it thins, it becomes weaker. You won’t necessarily feel that process, but what happens is that around the sides of the joint, the one cell layer thin tissue called synovium and it’s there to nourish the joint. So in between each of the joints is the synovial fluid. So our joints don’t have a direct blood supply. It doesn’t get nutrients from blood coming in and out. It gets it from the bits around it. So the synovium has a blood supply to it too. That fluid goes from the blood supply in the synovium into the joint and back and forward. And as we move around, that stuff moves around and provides nutrients to this cartilage layer. to normal part of it too. Now, as opposed to the cartilage, the synovium has a very rich nerve supply and a very rich blood supply. And so that can get, you can feel that. And so when you get wear and tear, bits of cartilage, bits of break off and they float around in the joint as well. And your body will break it down to some degree and so forth. But as that stuff happens, it starts to lodge in the synovial area and it causes an inflammatory response. And that’s where lot of the pain comes from. It’s not the cartilage itself, it’s the bits of cartilage that break off over time, know, cause debris, they cause an inflammatory response in the bits around it, that’s a lot of the pain comes from, the arthritis.

Will Ryan Yep, spot on.

Michael Dermansky Yeah. And so this, this is why it’s both a mechanical problem and an inflammatory problem. It’s not just the wear and tear that will happen. but in itself, that doesn’t always people can have awful, awful, awful arthritis in the knees and not feel a thing. And people have very mild arthritis in the knees and a lot of pain. depends on the degree, the inflammation, irritation of the lining of the joint that actually gives people most of the symptoms.

Will Ryan Yeah, that’s exactly right.

Michael Dermansky Yep, and so managing that process is super important. And it doesn’t, and just because you have it cleaned out, doesn’t mean those bits of cartilage aren’t gonna be there. They’ll still be there. that’s, know, we know that having a knee arthroscope to clean out the knee for arthritis just doesn’t work. It doesn’t do anything. It won’t make it better. It won’t fix it. It won’t slow the process down. So managing that inflammatory part of it too is super important. So the big one is, I know our opinion is a bit biased, but is exercise safe? Am I going to do more damage by doing exercise for arthritis, both knee, hip, back, whatever area?

Will Ryan Yeah, I guess when we talk about exercise with osteoarthritis, it’s very much what can we tolerate and what levels are safe to do. Exercise is safe to do to a certain point. So you wouldn’t go out and go past, like push through the pain quite a lot, because you can actually cause more damage doing that, but you can exercise to a degree. Look, one of the guides we tend to kind of use is an out of 10 pain scale. can exercise up to a four or a five out of 10 safely, not past that. That’s probably one of the easiest tools we use when we’re working with our clients. But exercise is really beneficial for an osteoarthritic knee. It can help the cartilage cells regenerate. It attracts water to the joint, which mitigates that inflammatory response that we were talking about, which is the pain, that main pain driver. So exercise to tolerable amounts is super super important with osteoarthritis for sure.

Michael Dermansky Yeah, and so the big deal about that, in we’re saying as well, that the cartilage is, particularly the articular cartilage that is the lining joint, needs load. It needs load to know how to do it. So chondrocytes, which are the main cells of articular cartilage, need load in order to be able to then do their job properly as well. That’s how they respond and react well. If we don’t load those joints appropriately, They’re going to die away. They’re they’re built for load. So they need that degree of nourishment and that, that degree of stress to be able to do their job properly as well. And the other big thing as well, because there’s no blood supply into the joints as well, if we don’t move the joints, that stuff sticks around. It doesn’t, it doesn’t get nourished. doesn’t allow the fluoroval fluid to move around. It doesn’t allow that to, to wash away. So. The way it actually gets nourishment and gets blood supply from the surrounding areas is by moving in the area. If we don’t move the area, that’s why after we move, if you do have arthritis or early arthritis and it feels so stiff when you’re moving, because that synovial fluid hasn’t moved and the inflammatory chemicals that have built up are in one spot and if you feel them when you move around, you move that around. So it’s a really important part of management, both for the synovial fluid and the fact that the joints need load.

Will Ryan I think that’s super important. And I think the issue with osteoarthritis that we see quite a lot is people get an osteoarthritis flare up and go into quite a high level of pain. And then they’ll completely stop doing any form of exercise whatsoever, which they think is going to make things better when in fact it actually makes things worse and accelerates the inflammatory processes. So despite pain being there, it is still quite important to do exercise to some degree to help those processes out.

Michael Dermansky Let’s go into what you just did a minute ago and I’ll go into more detail about that too. so I’m exercise what should I do? What are the most important factors and how do you know is too much, too little? What is the recommended structure that you would talk about for someone who’s got arthritis in any body part?

Will Ryan Look, the biggest thing which actually has been shown up in the research quite a lot is muscle strength around those joints. So if we talk about the knees, the most important muscle to work on around the knees would be our quadriceps muscle. If we talk about our hips, it would be those muscles in our glutes and on the sides of our hips that are really important at helping. I guess it helps disperse the load across the joint a lot better. So we’re not overloading the joint itself, the muscles take more of the load and it means we’re moving the joint in really good tolerable ways. But I think before we do any exercise program, it’s really important to get looked over thoroughly by a professional, because they should be able to tell you at that point what you can and can’t tolerate and work with you to figure that out. Like I said, when we do do exercise with osteoarthritis, needs to be done at a safe level. So we’re not getting constant flare ups. So I think it’s really important to find out what you can tolerate and work in that. And then over time that gets better and better and better.

Michael Dermansky Yeah. So what I hear from you as well is if you do, I can exercise one of the most important parts of strength training, particularly so on the major support muscles around the area too. around the knees, the quadriceps, around the hips, the glute muscles as well, because they’re the ones that should take most of the load. And so if they’re not strong, the joints take more of the load. As those support muscles get stronger, they take more of the load. They help reduce the load onto the joints as well. So that helps that balancing act. Second of all as well is that by exercising the area too, you provide the stimulus for the cells within the joint to actually be nourished and actually respond and get stronger as well. So there’s two positive sides to that too. The third part is at the level of exercise as well. the pain level is a real guide of how much is enough or too little as well. So a degree of pain is normal with not doing more damage to it too, but up to about a four or five out of 10 is the sweet spot above that. We started to injure it we increase the inflammatory process below that we’re nourishing it and a positive process as well So that finding that right balancing act is really the key for a exercising arthritis not it’s not everything It’s not nothing it’s that in between spot to know where your body can tolerate it and it’s nourishing the area and not too much That is irritating it to and that’s where the role of health professional comes into it to like the physio exercise physiologist our jobs is to make sure that you pick the right sweet spot that you’re improving the health of the area without making it worse. Is that right, Yep, okay. So next one as well is that anything else, so people decide to do strength work, they’re doing it, how often should they be doing strength work, by the way?

Will Ryan Yeah, that’s exactly right, Mike. Well, at a minimum it should be twice a week. I personally would say for people with osteoarthritis, you’d be looking at more three times a week with a day or two in between to allow for the muscles to recover and pain levels to dissipate if that’s a factor. But yeah, I would say at a minimum twice a week. I think that’s super important. And we know the reasons behind that to actually, you know, get the benefit out of exercise. We need that stimulus at least twice a week. And like I said, for osteoarthritis, I think three times a week he’s actually ideal.

Michael Dermansky Okay, so exercising two, three times a week, doing strength work as well. What else should they be doing? I mean, is there anything else around that too? We’ve to talk about the strength work. What else is a great thing to do to manage this as well?

Will Ryan I think it’s really important talking to another… whether it’s your doctor or a dietician or a nutritionist about weight management. Weight management is a critical part of all osteoarthritic management. The less pressure we have going through those joints, the better they begin to feel and the easier it gets to do the exercise as well. So they kind of again, play off each other. Talking to a, I guess, a professional like a dietician or a nutritionist as well, they can actually give you advice on anti-inflammatory foods and anti-inflammatory diets as well, which will help the whole thing. And like I said, if that’s under control, then the exercise becomes easier and all in all, you get a really good positive response. I think that’s super critical as well.

Michael Dermansky Yep, yep, that’s really important as well. Absolutely as well. So I mean, we talked about when we talk to Tracy Davis, who’s a nutritionist, well, she said, know, every kilogram in reduction in load on the cartilage, there’s a four time reduction in load on the area too. So it’s not a one to one relationship. It’s actually a larger relationship than that too. and doing things to reduce inflammation as well. that as you’re carrying more weight, your general state of inflammation is higher. So that has a direct effect on the joints, not just the mechanical load, but the inflammatory effect on it too. It’s a really big deal. What about pain management strategies as well? So panadol, anti-inflammatories, where do they fit into the picture?

Will Ryan Yeah, so it’s a tricky one to work with because some, I guess, analgesics work well for some people and some they don’t. So it’s definitely a conversation to have more with your GP. They are professionals on this type of thing. But… Generally, they should be looked at as like a second line treatment, pharmaceutical relief, and should only be used in conjunction with exercise weight management. If you’re just taking painkillers and expecting to get better, you definitely won’t. Look, they do have a role to play because it can help us mitigate the pain, help us exercise better, all that sort of thing, which again has a positive effect. But if you’re just taking it in isolation, they won’t work.

Michael Dermansky There is nothing wrong with taking pain medications if you wouldn’t conduct your exercise. So if you need to take pain at all… before your exercise as well to help you manage the irritation as well or afterwards as well. So both anti-inflammatories and Panadol can work really well to manage the pain. It’s not gonna fix it, as you said, but it helps the process as well. So there’s nothing wrong with taking those medications to help manage the pain as well. So you can get on with your life as well. It’s not there to mask it, there’s to manage it better. So you can do the things that you need to do in a more sustained manner. But being very specific about the load is super important. As we said, we don’t want to exercise into heavy pain. We to have a small degree of that settles down that we know we’re working at the right levels.

Will Ryan Yeah, that’s exactly right. Yep.

Michael Dermansky What about, can I run, can I cycle? Are those things okay if I want to do those things as well? And I’ve got arthritis in my hips and knees.

Will Ryan Yeah, those things are completely fine to do. Again, you’ve got to let pain kind of be your guide a little bit. Running is quite a lot of load through the joint. It can be up to four times normal body weight per leg when you are running. through each joint. if that’s not tolerable, then I would recommend something a bit gentler like cycling. I think cycling is a great exercise for… osteoarthritis so yeah I think cycling in particular is a really good one to do. Running is something you just have to be a little more careful with but there’s you know it still has a good positive effect on the health of the cartilage on the health of the joint as well you’ve just got to be smart with it in terms of your pain levels.

Michael Dermansky So again, using that guide of, know, I can run with three or four and a pain, 10 pain, in terms of the hip joint pain when I’m running, but when I stop it settles down, if I run five kilometers, I’m okay. If I run 10, then I’m really flare up as well. Your body is giving you a guide of where you’re at. And there’s nothing, there’s no, it doesn’t mean you can’t do that too. It just means you have to really manage the load management as well. start. Just a reminder to listeners as well, I’m talking about Will Ryan is one of our senior physio representatives at B Health as well. We’re talking about a very important topic about what does arthritis mean you have to surgery? The answer as a physio is usually no, but it’s usually not no forever. It might be no for now, but maybe later, but maybe not later as well. It really depends on individual. As we talked about, really important as well, that arthritis is not just a mechanical problem, it’s both a mechanical an inflammatory problem and the inflammatory part is probably a really major part of it. So managing the inflammatory part of it is super important. Strength training is a key two to three times a week, ideally three times a week for arthritis and other aspects that are important as well, both nutrition, making sure you’re… your weight to manage as well, but that affects the loads on the cartilages and also the inflammatory process and then the appropriate times for taking analgesic medications such as Panadol and anti-inflammatories as well. They all have a role to help manage the process and they’re often all and things to work on as well. So when is it time for surgery and what type of surgery should people have? So should they get a clean out of their hip joint or their knee joint? Should they get a hip or knee replacement? What are the operations and when should they be done?

Will Ryan I would say… Look, the most successful operations for osteoarthritis are total joint replacements. It’s quite a big surgery. So ideally you put it off as long as possible, or you can, know, we’ve worked with people who haven’t, who’ve come in, who have expected this to be their final outcome and they’ve never had to actually have the surgery. So look, total joint replacements, they do work really well. They work even better if you have done the exercise leading up to it, getting strong in those muscle groups we spoke about earlier, you’ll find your recovery is much, much, much faster. And nearly every orthopedic surgeon you talk to will say the exact same thing. Generally, I would say get a good three to six months of strength training work done before you consider surgery anyway. It’s cheaper, it’s safer. you know, you might find your symptoms improve and you don’t have to go down the surgical route. That’s the general advice I give to most people who suffer from this.

Michael Dermansky Yeah, it’s a really big deal. mean, everything you said, I’ve seen for 20 years as well is that people, they do, they’re considering surgery as well. It’s not the last straw, it’s a part of the process. And so if you’ve done a good three months of strength work as well, and you’re still really not changed, you the big deal is that with arthritis as well, is it affecting your life that you can’t do the things that you want? That’s a real… tipping point to have that thinking about the conversation. And then have I done enough strength work for the last three months that actually shows whether that’s going to make a difference or not. So if you’ve done three months of strength work, good quality strength work for three, not I did strength work, how did you do it? Well, I went to a session here, a session there, I did one there, that doesn’t count. We’re talking about three months of three times a week structured exercise as well to make the area stronger. we’re down the track three, six months and I can level up. I can’t do the things I love, can’t run, can’t, you know, it’s really affecting the ability to drive as well, then it’s worth having a conversation. You know, and then any opinion, is it time to have a hip or knee replacement as well? And then if you’ve done that work, You know, the outcomes are so different, so, different. We’ve seen so many people where they’ve done the three months of strength work beforehand. And it’s not always, but they’re at a hospital three, four days, depending on the operation, the outcome is great. Six weeks later, we can barely tell if they’ve an operation done. Where if they haven’t done the work, it’s such a hard slog. You know, it takes years, can often take years to recover. We’ve seen people a couple of years down the track where they haven’t done the rehab work.

Will Ryan Mm.

Michael Dermansky beforehand and we’re doing the work two years later that should have been done two years prior and they you know that even though had a joint replacement as well so we’re just not seeing the outcome we should see if they haven’t done the work it’s not the surgery and that’s it there’s the bits that go around that make the difference really a great outcome and then really average outcome it’s a very interesting study that was done in the US and they looked at people who had knee replacements done And the reason why they an replacement done was for pain. And the theory was that the pain stopped them from doing things. So if they have a joint replacement done, that the pain would go away so they can do more things. Two years in the track, most of those people had no better life than they had before the operation. They made the most out it all. So what they could do beforehand was exactly the same as what they did afterwards. There was no better outcome in their life. If they do the work three months of strength work beforehand, the outcome is very, very different. You actually get what you want out of the operations world, the better life that you have. So, know, joint implants are going to last these days anywhere between 20 years to 30 years. These are the ones that were put in 20, 30 years ago. I think roughly now I’m seeing about 25 years is a rough timeframe for a joint implant. So you’re, if you’re sitting in your 60s and 70s, you’re oh, it’s affecting my life. can’t do all the things I want as well. Well, this is going to last them 25 years. And that’s the one thing putting 25 years ago and the materials now better than they were 25 years ago. So it’s going to last a lot of people the rest of their lives.

Will Ryan Yeah.

Michael Dermansky So if that’s what’s stopping you like oh it’s a last straw when how long do I delay it well when is this time to really affect your life you know how old am I now and what’s it gonna mean if I have it now done down now how much longevity do I have so I’m 65 now if I have it done now it’s gonna last me till I’m 90 you know maybe it’s a good idea because you want to have a better life. I’ve done the work, only if you’ve done the work that the outcomes will be great.

Will Ryan I agree with that for sure. think, yeah, the work pre-op, post-op are just as important as each other.

Michael Dermansky Yeah, absolutely. I I’ve talked about it this now too, but a lot of people think, oh, the issue is the last straw, and if they have the last straw, it’s gonna fix it. I know we talked about it minute ago as well, but it’s not. You and I know it’s not gonna fix it. It’s part of the journey.

Will Ryan Yeah. Yeah, I think, I think surgery and rehab and prehab, pre-op rehab should be seen as a whole one entity really. Yeah, I think it’s all part and parcel of the actual recovery for this issue. Whereas one in isolation, you know, often like just surgery, it fixes the mechanical phase, but not all the other stuff we’ve spoken about today. you know, putting the work in pre and post-op is super, super important.

Michael Dermansky Yeah, and the reason why people have joint replacements done is to get a better life. They want, it’s to do the things that you want to do that’s affecting you, that you stopped you from having the life that you want. It’s not the final straw, it is a part of the journey for you to have a better life. Otherwise, there’s actually no point in having the operation done. If it’s not gonna give you a better life, then why you doing it? It’s to give you the life that you want that’s been restricted. And if you do the work beforehand, that’s giving you the best chance of that happening as well. Otherwise, it’s just a hard spell. You don’t get the result you want and you wonder why you the operation in the first place. Um, and we’ve seen both examples many, many times. In fact, the same people were the first time around, didn’t have the operation, didn’t have the work and it was such a long recovery. Second time around and often they’d be very scared of the second, second side. And because of them, the work the second time around, it’s a completely different, uh, experience. Um, a lot faster recovery, lot shorter time hospital as well in a much better long term outcome as well, which is what we really, you know, want to see. And we, you know, as physios, we’re not afraid to tell people, you know, it’s time to have a conversation about joint replacement. Because I can see it affecting your life significantly. We want you to have a better life. It’s now time to have that next step or you’re not ready for it. There’s a lot more work to be put in before you’re ready for that step.

Will Ryan Yeah, I think that’s exactly right.

Michael Dermansky any other final comments before we finish up the video.

Will Ryan I don’t think so. just think like the key takeaways we spoke about before, exercise is beneficial and safe if it’s done correctly and done well. Strength training should be the biggest focus around the exercise program. know, anti-inflammatories and analgesics like Panadol can help, but they should be taken in conjunction with exercise and weight management processes. then, you know, surgery can help as well, but you have to the work in pre and post. Yeah.

Michael Dermansky And that was the discussion. think we expect the surgeon here as well. said the same thing as well. It’s not come to surgeon yet we’ll operate. It’s a discussion. When is the right time for you? And it’s a collaborative choice between the patient, the surgeon, the doctor, the allied health professional, physio. It’s a conversation together. like, is the right time for that individual as well? Not this is you have pain, have this much wear and tear. This is the time. It’s not. It’s a choice at the right time for the right person in the right place. Well thank you very much for your time. think that’s some wonderful information as well. And I hope it gives some real practicality to how to manage arthritis. That it’s not on off, not, you know, it’s spectrum. It’s where it’s at for you, how you manage it, and when you make the choices that you do, that I’ve got to give you the best life outcome.

Will Ryan Yeah, that’s exactly right. Again, thanks for having me today.

Michael Dermansky Great. Thank you very much.