Healthy Wealthy & Smart 473: Dr. Howard Luks, Knee Osteoarthritis
On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Howard Luks on the show to discuss knee osteoarthritis. Dr. Howard Luks, MD is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability.
In this episode, we discuss:
-What is knee osteoarthritis and how is it diagnosed?
-Modifiable risk factors for developing knee osteoarthritis
-Indications for a total knee replacement
-The importance of managing expectations for good patient outcomes
-How to strengthen the physician therapist relationship for more patient centric care
-And so much more!
Resources:
A big thank you to Net Health for sponsoring this episode!
Check out Optima’s Top Trends For Outpatient Therapy In 2020!
For more information on Dr. Luks:
Howard Luks, MD - @hjluks - is a patient centric, Orthopedic Surgeon who has been in clinical practice for 20 years. Dr Luks utilizes his passion for patient engagement and his expertise in medicine and social media to educate a global audience through his website, twitter, facebook page and YouTube channel. He serves as a consultant, board member and adviser to many companies in the mobile health, online health platform, and medical decision making start-up spaces. He served on the External Advisory Board of the Mayo Clinic for Social Media - a recognized leader in this space.
“Technology is not about replacing physicians ... instead, we must remember, change brings opportunity — and we must use these changing times to scale great physician thought leaders.” - Howard Luks
Howard Luks, MD (@hjluks) is an Orthopedic Surgeon practicing in Westchester and Dutchess Counties in New York. He specializes in the management of complex knee and shoulder injuries with a focus on ACL injuries, Patella Dislocations and Shoulder Instability.
As an early adopter of Twitter, Howard Luks MD also runs a blog (>100,000 unique monthly viewers), a Facebook Page, a YouTube channel and a personal site to educate, interact and engage a worldwide audience.
Read the full transcript below:
Karen Litzy: 00:01 Hi, Dr. Luks. Thank you so much for coming on the podcast and really looking forward to this today.
Howard Luks: 00:06 My pleasure, Karen. I'm looking forward to it too.
Karen Litzy: 00:09 Okay. So today we're going to be talking about osteoarthritis. You had a great tweet thread back in, I believe it was the end of June, beginning of July, 2019 on osteoarthritis and got a lot of positive responses from people and I really wanted to talk to you a little bit more about osteoarthritis. First thing is what it is and what it isn't. So I will hand it over to you.
Howard Luks: 00:40 So the reason why I decided to put that thread up was based on the fact that I keep hearing people become worried thinking that their body is wearing out and that our arthritis is a mechanical process and wear and tear process. So they're going to stop walking. They're gonna stop riding, they're gonna stop running, they're gonna stop their exercise. So in other words, they're going to increase their risk of dementia, heart disease, hypertension, diabetes, and other metabolic disorders because they think they're saving the lifespan of their knee. So in order to get across that osteoarthritis is really a biological process where the articular cartilage is starting to degenerate for various reasons and that their activity actually, if anything is beneficial is what led me to write that whole series of tweets. And I followed up with another one a few months later. That then started to throw in all the exercise patterns and activities that people can in fact pursue, especially with respect to runners. See, since I seem to attract a lot of runners, I wanted to be known that running is not damaging for a knee that doesn't have any significant mechanical issue or is recovering from a fracture.
Karen Litzy: 02:22 And when we talk about osteoarthritis, oftentimes people will come to us as physical therapists and they'll say, Oh, well, you know, it's bone on bone. That's what the x-ray shows bone on bone. So how do you respond to that? And how should a physical therapist respond to the patient in those scenarios? And in a way that doesn't undermine the physician that referred them to us, but being consistent with the evidence.
Howard Luks: 02:51 It's quite a challenge, right? I mean, yeah. The interesting thing I always talk to our residents about is that, you know, I'm 56 now and I'm just starting to get really good at patient interactions and discussions and conversations in the office just in time for me to retire. And I talk about the fact that words harm, images, harm, and you really can't unsee your MRI or xray report. So it all comes back to communication and education. And that's one of the biggest problems in healthcare today, right? We're RVU driven. You guys are strapped if you're a network, you know, you can't make a living of $40 per hour. And so we're all seeing more people in less time and that really threatens our ability to have a good, actionable and meaningful conversation with people. Yet it's absolutely critical that we do so.
Howard Luks: 04:02 So if I put an X Ray up showing bone on bone arthritis, I then immediately enter into a conversation about how you really treat people, not an image. And that even though they're bone on bone, you know, most likely I'm talking to someone who doesn't have severe quality of life limiting knee pain more often than not, and you know, a bone on bone knee that's relatively dry, meaning it doesn't have a significant effusion, it's really not going to be too terribly painful. You know, the bone itself isn't what hurts, you know, bone marrow edema hurts, synovitis, hurts. But not the bone itself. So I explained that I've run with people that I know have bone on bone arthrosis yet. I explained that I've also replaced knees in those with less severe arthritis because they had severe synovitis or bone marrow lesions that just wouldn't go away.
Howard Luks: 05:16 So it's important to talk about the fact that the xray has only one small part of the overall evaluation and a very small part in determining what the treatment or treatments could be or should be. And that it really it's their story. It's their history, it's what they're telling us. And you know, when it hurts, how often it hurts and how severe that pain is. That's more important in terms of how we craft our treatment plan. And when, you know, I had a patient today actually asked me, well, when, when do you know, as the patient, when do you know that you need to have a joint replacement surgery and we'll stick with the knee.
Karen Litzy: 05:58 So when your patients come in and they asked you that question or you talk to them about the possibility of a total knee replacement or a partial knee replacement, what do you say and how does the patient know?
Howard Luks: 06:23 Huh, that's a great question. And it's one that I'll get probably 15 times tomorrow so the discussion usually goes as follows. It's, you will know you're going to wake up one day and say, I just can't take this anymore. I've tried X, Y, and Z. I've done my exercises, I've lost weight, I have adjusted my diet. I've tried over the counter medications, Savage's bombs, ointments, suction cups, tape and everything else that their friends have told them to try and their pain is limiting their quality of life. So that's, you know, a very important part of the decision making process is you have to dive into their goals, right? You can run into a lot of trouble with people between 40 and 65, 40 and even 70, depending on how active they were, because you might have someone who's miserable, but it's simply because they can't play singles tennis anymore.
Howard Luks: 07:37 Right? It's like having someone with shoulder pain in your office because they can't hit a second lob as like they used to. You know, that person who's going to be really unhappy with the results of surgery. Same with the knee replacement in someone who can't play a second set of tennis but could easily finish, you know, a three set doubles match. So we have to determine when the patient feels that their quality of life has suffered long enough that they wish to move forward. Then we need to dive into what their goals are. It should be simply that they want to get through their day without this horrible knee pain. Because if it's anything other than that they may not be all that satisfied with the end results of the surgery.
Karen Litzy: 08:33 Yeah, that makes a lot of sense. There's a big difference between the person who's having trouble walking from, you know, their bedroom to the bathroom or like you said, the person who can't get in another set of singles tennis. They're very, very huge quality of life differences there. Although that second set of tennis might be disappointing. It's different than not being able to walk a block.
Howard Luks: 08:57 Correct. And we know, you know, both of us know there are significant number of knee replacement patients who have persistent pain after surgery and who are not happy with the overall results. And many times that might trace back to false expectations. So it's a really important discussion to have. And we also know there are many different patients out there. You know, there are some who have achiness and pain when they roll out of bed, but by the time they're done with their morning shower, they feel fine. Yet those people, some of those people might tell you that they want to have their knee replaced. So again, it's really important to dive deep into the reason why these people want to move forward and what their goals are.
Karen Litzy: 09:54 Yeah, I think that's a great point. Thank you for that. And now I just want to go back to one thing. When we were talking about osteoarthritis, one thing we didn't talk about were factors that may lead people to be at risk for osteoarthritis. Do we know what some of those factors are? And if so, are they modifiable?
Howard Luks: 10:14 Sure. So first, you know, the, the big category now that requires everyone's attention is our metabolism. You know, we are bombarded daily now, especially on Twitter with all the ELA facts associated with a typical or standard American diet full of ultra processed foods. I'm not gonna get close to the Quito vegan world and subdivided. However, it's really important that people start to read this literature about the dangers of ultra processed foods. It's very clear that a calorie is not a calorie and that a hundred calories of ultra processed foods versus a hundred calories of real food is going to have very different metabolic affects on us. And we're finding that people with high homocysteine levels have a higher incidence of heart disease, cardio metabolic issues as well as joint related issues. We're finding the same with uric acid levels, which will my car lay with your fructose intake.
Howard Luks: 11:38 So high fructose corn syrup, we find a correlation with lipid disorders and the prevalence of osteoarthritis people's weight will certainly have an impact. A lot of people don't know that what each step you take, you're putting, you know, five to seven times your body weight across the knee with each step. If you're achieving 10,000 steps a day, you weigh 250 pounds, you have an extra 60 pounds on your knee across 10,000 steps. That's a lot of an added weight across that knee. Now for those who do not have osteoarthritis already, that might not initiate the process for those in whom the process has started. An MRI studies on asymptomatic people show that the process has started in a majority of us over 50, then that excess weight and force or stress burden is certainly going to increase the risk of developing a more rapidly progressive arthrosis.
Howard Luks: 12:50 Now by far the most common causes are genetics and people with structural issues. So a varus or Bodine or valgus or knock kneed that will set you up for unit compartmental changes or changes in either the middle or the lateral compartments. Why we seem to see a pretty severe patellofemoral disease and in some middle aged women, I'm not exactly sure, perhaps it's some degree of underlying map tracking. But in terms of the modifiable risk factors, without a doubt, our weight, our activity level, it turns out as we, as we just said, that's right. This is less common in runners. Cartilage likes that cyclical loading and likes to be exposed to force in a cyclical manner. I think we hit on many of them.
Karen Litzy: 13:54 Yeah. And then the only other thing I can think of is previous surgeries. So we know like ACL having an ACL surgery or ACL disruption, the majority of those people do develop osteoarthritis later in life. Especially if you're, you know, most of them happen when you're younger, usually.
Howard Luks: 14:13 True. So you're absolutely correct. So upwards of 50% of people who have had an ACL tear will go on to develop arthritic changes. Even having just one Hema arthrosis, you know, blood in your joint elevates your risk of developing osteoarthritis because it changes the chemical compounds that's present in the knee. Once that has happened, now you'd go ahead and you add a mechanical issues such as a meniscus tear and your risks really start to go up dramatically.
Karen Litzy: 14:54 Yeah. And, I mean I have seen patients in their forties you know, who have had multiple ACL reconstructions on their knees cause they were high level athletes in their younger years. And those are people who, you know, we were talking about the people who can't play tennis versus the ones who are having trouble walking down the street. Those are the people that are having trouble walking down the street and they know it, but they're doing everything they can to not have the surgery as well. So it's, it's an interesting group.
Howard Luks: 15:25 Correct. And they're not harming themselves. I don't care if you're limping if you can get away without having your knee replaced, you should do so.
Karen Litzy: 15:37 Absolutely. Absolutely. Certainly, certainly I think, you know, oftentimes people will hear, Oh, it's knee replacements are not that bad. It's not like it was years ago, but I mean, it's not great.
Howard Luks: 15:49 Huh? Yeah. So there's, you know, the only surgery without risk is a surgery on somebody else. Yeah. If you're assuming an infection after a knee replacement has a low incidence, right. A 0.7 0.8%, but it's a life altering permanent problem. You know, you're going to need one to three operations to try and eradicate that infection. And if it's a nasty bug, it's going to end in an amputation. So, you know, are there a lot of amputations that happen each year because of knee replacement infection? No, but there are not zero. And there are a significant number of people who have persistent pain. I've looked, I perform a lot of knee replacements and I think it's a great operation for the right person. So there are significant upsides to a well functioning knee replacement and the vast majority of people are not going to get infected. However, when you start to push indications and you start to stretch them if you get into trouble with one of those people, that's an awful place for them to be.
Karen Litzy: 17:06 Yeah. Yeah. No question. No question. And now what I'd like to do is we've got a couple of questions from listeners that some of them are about you in particular and the way that you practice others. Again, continuing on the osteoarthritis subject. So one was from physical therapy and they're all from physical therapists. Gina Kim said, how do you set expectations for patients, especially for active busy ones, that conditions such as osteoarthritis, frozen shoulder can take months to resolve or can be something that you're managing, let's say. Because I would say osteoarthritis is something that you're managing.
Howard Luks: 17:49 Correct. And sometimes the frozen shoulders too. So any of our patients with these longterm chronic conditions can get into trouble, especially when they're used to being high level weekend warrior as an athlete. The, you know, my goal is to keep that runner running. And most runners, if you sit down and say, look, we don't think that arthritis, we know that arthritis is most likely not caused by running. We really don't think that you know, running five miles at a reasonable pace is going to cause her arthritis to worsen more than it already has and more than the normal disease course will worse than that. So we think it's okay for you to keep running. 90% of real runners are going to take that and run with it, so to speak. They are not going to stop. And there's really no reason for them to stop, cut, stop.
Howard Luks: 18:54 Cause a runner that stops running is not a whole person anymore. It's really embedded in our psyche. They're very unique people to deal with. So oftentimes we’re seeing a runner with a little swelling after a run, we're seeing them a little, a little achiness and pain the next day. Perhaps they can't run as fast as they used to or they have pain going down Hill. So they will very readily work with you. So what I will immediately start doing is dive in to their typical week. How many miles are they running? What pace are they running, what zone are they running in? Are they Hills or are they technical trails and the carriage are they road? I don't necessarily push people onto trails or onto roads but I might pull them off a technical trail or off of steep Hills. And I'll try to work with them. Craft a workout pattern and running strategy with them that will lead to very much acceptable or tolerable levels of knee pain. And then once they understand that the etiology of a cause of their arthritis and they understand you really didn't do anything wrong, it's not the running that led them to this point, most are okay and most will fight through again, a reasonable level of discomfort in order to allow them to run.
Karen Litzy: 20:35 Yeah, and I think that's the last thing you said is so important because oftentimes when people have more persistent pain, and I can say this from my own experience is when, when we, I guess I can say we, I'm part of that group. Oftentimes when we do things and it results in pain, we think that we're causing more damage. And I think it's really important that last point that you made that, Hey, listen, you might have a little bit of pain, a little bit of swelling, but from what we can tell, we know this isn't doing further damage. It isn't sort of creating more wear and tear. And I think that's really important to get across to the patient.
Howard Luks: 21:16 I agree. I mean, if I start to get stress fractures and stress reactions and book painful bone marrow edema, lesions, you know, I'm going to change. But as I alluded to earlier, you know, imagine a runner who stops running out of fear not because of the level of pain. You know, they're now increasing their risk of any number of chronic diseases, right? Alzheimer's and heart disease and hypertension, diabetes and on in the, you know, in the hope that maybe they're going to save their knee and save the knee from what? So if, you know, a lot of them, even if, even if we knew that running caused it, they would sacrifice their need to keep, you know, their head clear from the benefit that they derive from their weekly run.
Karen Litzy: 22:21 Yeah, they're a motivated bunch, that's for sure. And, and motivated because like you said, it's the running. So when you're a runner, it's your running that allows you to do the rest of the things in your life. That may be work. It may be dealing with family, it may be dealing with colleagues that keeps your head clear. It could be meditative. So you're taking all of that away by saying you just have to rest. You don't, you shouldn't run anymore.
Howard Luks: 22:46 Correct.
Karen Litzy: 22:47 Dangerous. Okay. Dangerous stuff. So let's go onto another question, Miranda Henry, and I think this is a nice question is how do you see the evolution of the patient doctor physiotherapist role in the care of osteoarthritis? Cause we know we've got baby boomers getting older, osteoarthritis is most likely going to be more prevalent. So how do you see that evolution of care from those roles?
Howard Luks: 23:15 Sadly, in this environment I see it dwindling, which is really unfortunate, right? Because it should be increasing. There should be a direct electronic or otherwise communication between our offices. You know, we both have these five page electronic medical record nightmares that our office produced that we fax to each other, you know, for signatures to send back. Yet it doesn't have much actionable, useful and meaningful information. I have a number of a number of therapists who are my go to people in my region. And you know, we're on the phone a lot. Trying to share details about certain people in terms of progress yeah. Or roadblocks or other issues and what and why they're sending them back or why they're not. And it's, you know, an open channel of communications is just so critical. And we just have to keep in mind regardless of how busy and crazy our lives get as healthcare providers, that it really is a patient's life and wellbeing that's sitting at the end of these phone calls and things that are easily perceived as nuisance irritation. And so yeah, it is worth it in the end to go the extra mile and make that phone call.
Karen Litzy: 24:51 Yeah. And I think you just answered that with that answer. The next question is what do you see as the best way for that PT doctor patient to align themselves for best patient outcomes? Which I think you just answered. Just having good communication channels and being able to keep in mind that the patient is at the center.
Howard Luks: 25:13 Correct. Yeah. Can't forget that.
Karen Litzy: 25:15 No, that makes perfect sense. I think you just answered it. And then finally, this is from Mark Rubinstein said what or who inspired you in your holistic approach to promoting health? Combining traditional orthopedic medicine with sort of lifestyle medicine?
Howard Luks: 25:32 Ha. Good one. As I alluded to, as I said before, you know, you start to get much better at determining talking to people, listening to people asking the right questions. You know, my exam starts when I watch them walking in the hallway, you know, before you sit down on your stool, you know more about that patient. Then half the words they're going to say are going to tell you and you learn how to craft your messages and craft your, you know, your treatment plans accordingly and you find out that non-surgical management is often really effective. Then you realize, okay, you're 56, you know, what are you doing to change your life? So, you know, probably about six years ago I started to optimize my own lifestyle for my, not only longevity but health span, right? I want to go to the very end, hopefully running and then just drop off. I don't want to spend my last 10 years on cane's going to doctor's offices, being hobbled, being frail, et cetera. So as I started, you know, a lot of the more recent blog posts that I've written, I've just done in an effort to help me learn the topics.
Karen Litzy: 27:12 That's a great way to, it's a great way to learn.
Howard Luks: 27:14 Right? Because I'm pulling all these papers and I'm doing all this reading. I might as well write it down on my website and share it. And so it started with my diet and then it started with a sleep. I read Matthew Walker's book and then it started to, it was exercise and muscle mass and atrophy, sarcopenia and everything else written about. And then you start to dive into the metabolic literature and you realize, Hey, you know, this is really important for our patients. And that's another motivation to get it up and get it on the website. And as we all know, it's really hard to change many people's habits, but if they have actionable information, if they have a thorough understanding of why they need to do this I'm getting a lot further with people in terms of committing them to dietary change, lifestyle changes, activity changes than I ever had in terms of success before in my career. And I think maybe it's just cause I'm communicating it better and perhaps cause I'm leaving it up on my website for them afterwards to revisit and share it amongst their family.
Karen Litzy: 28:48 Yeah. And they can kind of take a deeper dive into it after they leave the office and say to themselves, Oh, okay, now I think this is making more sense. Cause like we've all been to doctors. I mean sometimes you go in and you're like, Oh man, I really wanted to ask this question and I didn't. Or Oh he said this thing but I forgot. And so to have that backup on your website I think is probably really helpful. And like you said, is most likely helping you get some greater buy in from your patients do I think is fantastic. And I think it's also important to note that when you're writing that you're, at least, this is what I get from your writing style, is it's very relatable and approachable and it's so, it's very, I think patient forward.
Howard Luks: 29:33 You'd be amazed at the comments that I get from editors editors or publishers or writers through channels, how unhappy they are with my writing style. I'm like, just, you just have to leave it alone. It is what it is.
Karen Litzy: 29:50 Yeah. And if it's relating, if it's relatable to your patient population, great. Correct. Great. All right. So before we wrap up, what are the big takeaways you want people to leave with this discussion today?
Howard Luks: 30:06 So yeah, in an effort to save your knee, don't throw the rest of your health under the bus. You're not gonna save your knee. You can't stop arthritis from progressing. You can't cure it. You're not gonna waste your money on $10,000 in STEM cells cause that isn't going to work. You will know the day that you need your knee replaced. And hopefully your surgeon or therapist will help you better define what your goals can and should be following a knee replacement. Don't forget how important our entire lifestyle is in shaping how much pain we are going to have, how long we're going to have that pain and how long we're going to suffer with it. Our sleep matters. Our diet matters, what we stick in our mouth matters and our activity levels matter. If you don't optimize for your wellness today, you're gonna end up preparing for your illness and frailty later. So there's no better time to get moving.
Karen Litzy: 31:18 Great advice. And now last question I ask everyone is knowing where you are now in your life and in your career, what advice would you give yourself as a newly minted doctor? A new graduate from medical school.
Howard Luks: 31:34 Yeah. you're not as good as you think you are. Right? You know, all these young docs on Twitter, I get a kick out of them, you know, they're great, but, and I wasn't any different. You know, the world is far more black and white when you're younger then as you get older but yeah, pay more attention to your elders. Pay more attention to your patients. You don't always have the right answer, you know, and just be willing to admit sometimes you don't know. And then look for the person with the knowledge and experience who can help you.
Karen Litzy: 32:22 Great advice. Now, where can people find you if they want to read your blogs and find you on social media? Very important.
Howard Luks: 32:28 Just put my name on Google. I think I own the first 10 pages.
Karen Litzy: 32:33 Perfect. And we'll also have links under this episode at podcast.healthywealthysmart.com So if you want to get all of Dr. Luks’ info, it'll be right on the website here as well. Awesome. All right, well thank you so much for taking the time out. This is a great conversation and I hope you have a great start to your 2020. And everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.
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