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Wisdom from the Orthopedic Office: focus on bone

Hello dear community. I hope that you all are finding ways to support your physical and emotional wellness during this time.

I have been thinking so much lately about what change requires. And the truth is, of course, that impermanence is the one constant. Whether we are thinking about the economy, our physical bodies, our world- change is the one constant we can rely on.

Given that change is inevitable, how do we participate with it? I am especially curious about this as it applies to the physical body. If there is one tissue that highlights the inevitability of change and our capacity to engage with it, it is bone. And if there is one area of the body that highlights the incredible functionality of bone tissue, it is the foot.

Let’s examine two concepts today- the inevitability of change in our bones and how we can work with our bones to modify those changes.

People are often given a message about inevitability and their bony tissues. Folks might be told “you developed osteoarthritis because you ran”. I was told at age 11 that by the time I was 30 I would be riddled with osteoarthritis by my orthopedic doc whom I greatly respected (I am not for the record).

These messages are final and they imply there is nothing to be done.

And yet, bone has a property that makes it so dynamic, it is changing all the time in regard to what we ask of it. Think of young, healthy astronauts become quickly osteoporotic after just weeks in space (indeed, they often cannot stand on their own at their return photo ops).

Anisotropy is a beautiful term which engineers and scientists apply to materials (not just mammalian tissues) that can change and assume different properties in different directions dependent on forces that act across it. Bone is one of the best examples of anisotropic tissue in the human body. Bone adapts and changes to forces that are placed across it. Bones learns from the force it endures, and makes changes to better support those forces.

Because gravity is a constant acceleration acting on our bodies (that we can manipulate when we lie down or jump in the pool), we have forces a plenty to help guide bone growth and change throughout our lifetime.

Think about this for just a moment.

When most of us think about bone, we think about inert material that is hard and unchanging. Perhaps, at the most, we think of bone as changing when we are young and growing and then becoming dormant in an adult stasis.

In fact, bone is considered to be a connective tissue- a class of tissues defined by specific cells within an extracellular matrix. Bone functions as protection to our vital organs, serves to store important fats and minerals and (with muscle action) helps us create meaningful movement.

In my field of orthopedics, bone is one of the most impacted tissues when we age by the diagnosis most of you have heard of which is osteoarthritis. And pain from osteoarthritis results in tremendous chronic pain and billions of dollars spent on MRIs, total joint replacements and pharmaceuticals for pain.

In my work with Parkinson’s clients, musculoskeletal pain- specifically osteoarthritic in nature, continues to be one of the greatest barriers to educating my clients in movement programs that adequately stimulate their brains and nervous systems.

In some ways, the hormones relating to and cellular functions of bone is still being discovered. There is wonderful research emerging from the field of osteoimmunology that will hopefully help govern how we care for bone throughout our lifespan.

But there are many, well established ways to support bone that we do not seem to practice as a community.

1) Joints formed by the ends of bones coming together need to have excellent muscular control in order to function properly

In my work in 13 years of practice I have met maybe 1 or 2 clients who had enough strength across a joint segment in order to stabilize their joint. Too much movement and lack of control across the joint surfaces (especially with weight bearing) can create havoc on joints. We need to establish strength and control- enough control at least to support our joints under body weight through their movements.

2) The ends of our bones are lined with cartilage. Cartilage lacks active blood supply, and is nourished instead by compression ( a squeezing out of waste products which naturally happens as we load cartilage surface with weight) and imbibition ( a drawing in of new nutrients which naturally occurs as we unload)

This compression and imbibition means that weight bearing and movement are again, required for us to preserve the health of cartilage .

Let’s take for example bunions. Bunions are growths on the medial aspect of our first metatarsal head. In my years of practice, I have heard many people say “ I have bunions because my mom did” and “I am having bunion surgery when it gets bad enough”. Neither of these models account for our capacity to change bones by understanding its anisotropic qualities.

I was lucky enough to have been exposed to a different model very early in my education. In 2003, I was in my first year of graduate school to earn my clinical doctorate in physical therapy. During our first semester, we had a course in biomechanics with the chair of our department who was a PhD in biomechanics. She explained her challenge with bunions she endured as a PhD student. She was unable to have surgery, as she was busy with research and pregnant. She was forced to come to other options. She used her biomechanics training and the quality of anisotropy and transformed her feet through being adherent to a series of 5 exercises.

There is a fantastic study published in 2016 in our orthopedic sports journal about the exercises to teach to prevent bunions from forming.

The researchers studied common alignment issues in the foot (most of which surrounded loss of mobility and strength) and how to address each of these. Their hypothesis surrounded, changing forces, thereby changing bone growth.

Wouldn’t you know it, the exercises suggested were the same that my biomechanics instructor arrived at 13 years prior to the article!

This is because biomechanics is a science. It can be reproduced by different people, across different times and we can arrive at the same solution.

So why is it that bone is so misunderstood? Why do we not take accountability for the processes happening to our bones as we move?

Some of this is poor media coverage on the part of my profession. Physical therapy is not known for being easily accessible outside of one on one care at the clinic, making larger messages more challenging to get out.

Part of the challenge is that the science is still developing. As I stated previously, there is still much to learn about bone. There may be some inherited traits that inform some bone to behave differently from other. And also, movement science or biomechanics is also still developing.

A darker reason for this lack of grass roots education, is that joint replacement is a big business. Surgeons, implant device companies, pharmaceutical companies all stand to benefit financially by providing these expensive tertiary surgeries.

That is all ok. Let's start today. Please start taking steps toward the changes you would like to make in your bone today. Think of yourself as needing to participate in your own primary care.

If you are osteoporotic, there are many things you can do to strengthen your bone (please consult with a personal PT and your physician). If you are concerned with osteoarthritis, please see a physical therapist before you start to have pain or notice deformity.

Redesigning our bone requires insight, collaboration across multiple disciplines, a willingness to create a practice around change, and consistency. In many ways, it is like running water over rock to carve it.

The change in your body and specifically bone will happen irrespective of your participation. Why not get involved to the degree you can? You have nothing to lose and everything to potentially gain.

Happy and healthful moving!


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