Good evening and welcome to Doctors on Call.

I'm Dr.

Ryan Harden, faculty member from the department of family medicine and biobehavioral health at the University of Minnesota Medical School Duth campus and family medicine physician at the Gateway Family Health Clinic in sandstone and Moose Lake.

I'm your host for our show tonight on arthritis and joint pain.

The success of this program is very dependent on you, the viewer, so please call in your questions tonight.

The telephone numbers can be found at the bottom of your screen.

Our panelists this evening include Dr.

Jay Allen, a family medicine physician with Palisad Direct Primary Care, Dr.

Anna Fernandez, a rheatologist with Essentia Health, and Dr.

Dylan Wyatt, an emergency medicine physician with Aspire St.

Luke's and faculty member at the Medical School Duth.

Our medical students answering the phones tonight are Ava Hill from Aurora, Minnesota, Lauren Marshall from Redwing, Minnesota, and Ian Ross from Steuartville, Minnesota.

And now on to tonight's program, Arthritis [clears throat] and Joint Pain.

Well, welcome physicians.

I appreciate you being here and I I know that I'm not only speaking for myself.

I know you're all busy, so I appreciate you um sharing your expertise with us tonight.

Um Dr.

Allen, can you you just give us a little idea what your practice is like?

Yeah.

Uh I just started a direct primary care practice here in Duth down on Superior Street um by the uh Walgreens and CVS in the plaza.

Uh direct primary care is just a model of primary care that allows for uh you to access your doctor without needing to use your insurance.

Wonderful.

And Dr.

Fernandez, can you talk a little bit about your practice?

Um, I am a rheatologist.

That is a um arthritis specialist.

I at Essentia.

Um, I tend to work along with uh primary care and our team of physicians to be able to take care of our patients and keep them active and in motion.

Well, thank you.

Dr.

Wyatt, can you talk a little bit about your practice?

Well, I work in the ER, so the question is, what don't I see?

Uh the ER is wonderful because we get to take care of people at all, you know, at some of the toughest moments in their lives.

Um whether that be they fell and they hurt their knee or whether that be that they're having a heart attack and it's really a wonderful and very privilege to do that.

So plenty of joint pain in the ER, a shocking amount.

And we only anticipate for it to increase as our population ages.

Well, I've put together some questions that I've had from patients in my practice over the past couple weeks.

So Dr.

Allen, we'll start with you.

I live with chronic pain in my hip.

How do I know when my hip should be replaced?

That is a really good question.

Um, I guess my first question would be if the patient were in front of me is where is that hip pain?

Because a lot of people say hip pain, they really mean the outside of their leg.

Well, that's not really something that's going to be helped with a joint replacement.

But if your pain is deep in your groin and you're still having, you know, the largely the answer to that question is up to you.

Like when is the pain to the point where you would consider doing a serious procedure and uh talk to your primary care doctor about it and talk to um a specialist to see if they think that that would be the best thing to help with your pain.

That's a really good point because sometimes it's referred pain and people think that it's could be coming from the back uh and it could be coming from a disc as opposed to the hip joint and the toenterantic bersa like he was saying.

So it's always good to have that idea of where's the location, the triggers, how long how much is limiting you and and then your doctor will decide okay maybe an X-ray can help us determine whether you really need that next step.

Wonderful.

Thank you.

Um Dr.

Fernandez, one of my patients asked me the other day, "My joints are stiff and painful in the morning.

Is this serious or is it just because I'm getting old?"

Um, all of the above.

But [laughter] it it is important to pay attention to how long the stiffness.

Most of us will notice that we get up in the morning and our hands and our fingers are a little stiff and you move them and within 30 minutes you get get going.

That tends not to be the arthritis that we worry about.

We worry about the inflammatory arthritis.

Those are the ones that the stiffness lasts one two hours all day.

Our patients will tell us that they cannot move, that it's very difficult to get going.

And so, uh, if it's less than 30 minutes, it is possible that it could be, you know, part of the aging process, but we like to fight it.

So, I need to make sure that you're staying active, careful with your diet, careful with your salt intake, because all of those are things that can really make the stiffness in the joints a lot worse.

I appreciate that you brought that up because there's a lot of non-medical things we can do that can treat and prevent joint pain.

Absolutely.

Um, Dr.

Wyatt, a caller, we don't have the town that the patient's calling in from, but left toe joint gets sore and red with walking.

Is there a treatment for this?

It depends.

As is always the answer here.

I think the the bigger thing to wonder is, is it only with a large amount of walking?

Is it every time you move around?

Are there certain other things that make the toe worse?

For instance, after eating certain things during your meals, are there any medication changes that happened along the time when you had this pain?

It's definitely something I would talk to someone about.

And of course, if you have fever to the area, if there's significant skin discoloration, if you lose sensation to the toe, that'd be something that you'd more want to see us in the ER about.

But that sounds like something you should talk to your primary care doc about.

Thank you, Dr.

Allen.

Uh, this is a good question.

Are CBD or THC gummies used for treatment for arthritis or joint pain, I'm assuming, especially at night?

That is a really good question.

Um, I think the way that I can answer that question is that because THC has been what we call a schedule one substance for such a long time, which means that the DEA really has not allowed for any studies on it.

We don't really have much research when it comes to THC and other forms of uh cannabis when it comes to chronic pain.

However, the research that we do have seems to show that it it might help with a little bit with pain um and it certainly can help with sleep.

My concern is that it also can have some habit forming um potential and honestly anxiety and other problems frequently do become worse with chronic THC THC use.

So when it comes to pain at night, I would probably like my uh my patients to come and talk to me as their primary care doctor about what other options are available that are less risky than THC.

Excellent.

One thing I will just say quick as the ER doctor plug there, remember THC takes a long time to break down in your body, right?

And so that means especially when you're first starting to use it, the effects can linger far beyond uh what you'd hope.

If you just take it before you go to bed, you'd expect by morning it might be out of your system, but especially when you go up on dose or you're just starting it for the first time, um that can still be in your system for quite a while, even up to 18 24 hours, and that could impair your ability to operate machinery or drive.

So, please just if you're going to choose to do that, be very careful about it, especially initially.

So, maybe there's some safer and more effective treatments for joint pain other than CBD or THC gummies.

Certainly.

And if someone wants to do that then to just start very low and be very careful about going up in your dosing and being careful about operating heavy machinery and driving around that same time.

Wonderful.

And maybe it would be ideal to try some of the topicals that we have over the counter.

Uh they are used for joint pain and but we have you know methyl salicellate, we have dicloanac gel, we have lidocaine, we have patches.

So there's a lot of other options.

We have an ice pack, we have a heating pad.

There's a lot of things that our patients can also use that can give them relief without putting them at risk for other side effects.

Toxicity, episodes of psychosis, falls because you're confused.

So, uh, let's take advantage of some of these other topicals that are out there to help our patients.

Yeah, absolutely.

Thank you, Dr.

Allen.

This is a question that I get in the clinic a lot.

What's the difference between rheumatoid arthritis and osteoarthritis?

Yeah, that that's a really great question.

So anytime you see itis at the end of something it just means inflammation.

So uh derm skin atitis skin inflammation.

Hep is liver.

Hepatitis is liver inflammation.

Arth is the Greek root for joint.

So arthritis is simply a word that means joint inflammation.

And that joint inflammation can be coming from a whole bunch of different things.

It can be coming from uh what we call wear and tear arthritis, which is more the osteoarthritis.

It's more complicated than that.

But wear and tear arthritis is osteoarthritis.

Rheumatoid arthritis is where your immune system actually is going and attacking your joint and uh making the cartilage breakdown.

And the treatment for that is actually more focused on weakening your immune system so that your joints can heal from that um inflammation.

And then there's also gouty arthritis or crystalloid arthritis where with gout you have crystals forming in your joints and then that actually is the inflammation or causes the inflammation that makes it so incredibly painful and hot and uh red.

Well, thank you.

And Dr.

Fernande, as a follow-up to that question, how about seroriatic arthritis?

How does that differ?

So seroriatic arthritis is also what of what we call inflammatory arthritis.

So think of it as the umbrella of inflammation.

So the joints are red or warm, they're tender to the touch.

Um the difference between seriatic arthritis and rheumatoid arthritis is that our patients will have a skin rash that is typically of psoriasis a red scaly rash typically at the elbows or behind the ears or in the belly button area.

Uh we treat them with similar agents uh uh what we call disease modifying drugs and biologic agents because the goal is to really shut down the inflammation before the joints are destroyed.

So there's a lot of new things that have come out in the last decade or two that we did not have before.

So it's very inter important that our patients recognize that there are things that they can do before the damage is done.

Um and so that's why it's important to recognize the the degenerative component versus the inflammatory component.

So Dr.

Wyatt, the a patient was asking about gout.

So if you could just remind us what gout is and how do we prevent it if we've had it before.

Great question.

Gout is essentially the deposition or or crystals that form in your joints.

If you've ever done the science experiment with kids or as a kid where you took sugar and dissolved it in water and let the water evaporate and crystals were left behind, essentially that sort of thing happens in the joint, but with crystals that primarily come from proteins.

And so they come from protein.

So whenever you consume large amounts of things that are like cheese, certain types of meats that will precipitate or form within those joints.

They tend towards certain joints, the big toe, knees, ankles, and if you've had it in a joint before, it's more likely it will happen again.

So, avoiding those causible food agents, as well as keeping in touch with your primary doctor about do you need to start on certain other agents to reduce inflammation and prevent things from getting bad once you notice the beginning of an attack to prevent it from getting as severe.

Yeah.

And I'll add that there uh are one of the biggest causes for gout precipitation is alcohol.

So avoiding alcohol as much as possible can prevent gout flares and also certain medications.

So for instance, if you're on a blood pressure medication, very common, very normal, very good blood pressure medication called hydrochloroioide, that can also cause your uh gout flares to worsen.

And there's a lot of coorbidities with gout.

Our patients will have hypertension, our patients will have diabetes.

And so there's a lot of coorbidities that come with gout.

So there's a role in the diet, there's a role in your weight uh that can help you, but there's a genetic component and that one you cannot fight.

So make sure that you're educated if you have family members who have gout because you may see it and the younger generations particularly our young men will see it and they tend to ignore it and gout acute attack is terrible.

It's tremendous amount of pain that takes you to Dr.

Wyatt's emergency room.

Yeah.

And so if they learn how to treat it and if they know what to do, we can take care of the acute attack of gout but also the chronic component which is the one that actually destroys the joints and it's one of the easiest ones that we can control because we have medications for it.

So the person who called earlier who who was asking about toe pain that might have actually been gout correct why does gout affect the toes?

I don't know exactly why it affects that joint specifically.

Answer that [laughter] question.

One of the reasons is because it's distal.

So it's a cooler temperature, farther away from our body, precipitation of the crystals in the distal uh toes.

And so it tends to be recognized, everybody, we call it podigra, tends to be very recognized, but it's typically because of the cooler temperatures and the gout tends to attack in the middle of the night.

You'll get a twinge, a twinge of pain.

Don't ignore it.

Go take your medication.

Otherwise, in the morning, the attack will be terrible.

So that's usually the the rationale that it's farther away from our body, cooler temperatures, deposition of the crystals.

Now wondering if it's more common up here because we have cold winters.

I'm going to read more about that.

We're learning more all the time.

This is and our alcohol use.

Yeah.

[laughter] Yeah.

I re and when I was in medical school, they recommended one or two drinks alcoholic beverages a day was good for you, but now there's no medical society that's recommending it for any for any medical benefit.

Um, as a primary care physician, I'm glad this this question came up.

So, Dr.

Allan, is walking a couple days a walking a couple miles a day to keep your legs healthy beneficial?

Absolutely.

Like without question, the more exercise that you do, the longer uh honestly, the longer your life expectancy is.

Um so yes, if you have if you're doing absolutely nothing and you start walking to a couple miles a day, that's going to do wonders for your life expectancy.

It's going to do wonders for your your joints and your uh just general strength in your legs.

even moving into the moderate to high intensity exercise which the way that I like to think about it is if I can talk but I can't sing or rather let me start over if I can talk and sing I'm in low intensity if I can uh talk but I can't sing I'm in moderate intensity and if I can neither talk nor sing I'm in high intensity and this has been studied as a good way to think about it if you're able to do that for even I mean 90 minutes a week but even I don't know half hour a week you're going to be in a much better place not just for for your leg health and joint health, but also for just your cardiovascular health, your mental health.

So many things are going to be better.

And remember, we tend to be aggressive and we need to give ourselves grace.

It's okay to start slow and build up and it's okay to walk around your living room and it's okay to walk around your house and then gradually build up, but go don't don't sit.

Go.

The research shows going from zero to 30 minutes a week is a much much better uh jump than going from 30 to 60 minutes.

So like just going from nothing to something.

Just do something, get active, and your body will thank you.

So the more exercise the better, but to a degree.

Yeah.

Okay.

Excellent.

Dr.

Fernandez, uh, caller from, we don't have the town on this one, but asking about hydroxychloricquin as a treatment for rheumatoid arthritis.

Yes.

Um, hydroxychloricquin has been around for a long time.

Is an antimmalarial drug that it's used for rheumatoid arthritis.

It has anti-inflammatory properties.

It's one of our mildest uh in the category of medications that we have as disease modifying drugs but can be pretty effective for people.

We have other coorbidities that can they cannot be on the stronger medications like methtoresate or lelunamide or the biologics.

We also use hydroxychloricquin for lupus is one of our um main drugs to manage lupus which is another autoimmune uh disease that affects a lot of young women.

So hydroxychloroquin can be very effective again depending on the range.

If someone is very inflamed, it may not be enough for them.

Uh, but for some people, it may take care of the arthritis and keep them in good shape.

Thank you.

Dr.

Wyatt, a caller is asking about SI joint pain or sacral iliac joint pain.

So, if you could talk a little bit about what that is and how do we treat it?

That's a tough one because in the same way that we were talking about how hip pain can be easy to have a hard time differentiating that yes, this is my hip versus my back versus my leg.

SI joint or the sacral iliac joint.

That's basically where your the the pelvis meets the tailbone.

There's a joint there and there can be some chronic inflammation and any other thing that can affect the joints can affect that joint.

it can be hard to diagnose because it's just there in your back, right?

Is it my lower back, my spine?

Is it my legs?

Um, and so it's very challenging to diagnose.

As with any kind of joint inflammation, if you are starting to experience those symptoms, try and keep track of what am I doing that's making this better?

What am I doing that's making this worse?

What are the bad days?

What are the good days?

Was there anything that changed when I started this?

Any trauma, medications, new foods?

that will help who you see for it, whether it's your primary doctor, an orthopedic surgeon, a physical therapist, be able to better differentiate and rule things out.

But SI joint pain can be tough.

And it's important because in the types of arthritis that I treat, it could be a signal for some patients who are developing seroriatic arthritis with sacraliac involvement, ankylosing spondilitis.

And so the pattern that you were saying is very important.

Some of these patients the SI pain is worst thing in the morning and they prefer to be active and and that improves their pain and so that's a hint sometimes to us that they're dealing with something more than just SI pain.

Yeah.

So it could be a sign of an inflammatory arthritis.

Correct.

Okay.

Excellent.

Uh it could be an overuse injury just like any but it's it's a tougher one because the symptoms can be so broad.

Yeah.

Excellent.

Dr.

Allen, a caller from Hayward.

Could severe right groin and inner thigh pain be hip pain instead of low back pain?

Yeah.

Uh one of the arguments that I've heard as to why primary care is important is that if somebody walks into the clinic and says I have leg pain, what specialist are they going to see?

Um and the reason that I think that that's so important is that like leg pain can present as a vascular problem.

It can present as a nerve problem.

It can present as a muscle problem.

It can present as so many different problems.

So to the question of is this inner thigh groin pain uh from your hip possibly, but it also could be from a blood vessel, it could be from a clot, it could be from a lot of different things.

So that's where I would really like to as a physician examine them and actually like do a physical exam, find out what's going on.

Um it could possibly from the be from the back and sciatic or not probably not sciatic pain, but a pinched nerve somewhere in the back.

Um, but it's just really hard to tell without actually seeing the patient in front of you.

So, we need more information.

Absolutely.

An exam, maybe some labs, imaging.

Very good.

Um, Dr.

Fernandez, a caller from Duth is wondering, I have swollen knuckles on both hands and cold makes it worse.

Is this arthritis?

Um, it could be.

Uh, swollen knuckles, uh, we look at the location.

Are they closer to the hand?

Are they distal to the fingers?

Is it swollen that the bones are bigger and you touch it and it feels bony as opposed to feels um cushioned like a fluid?

Uh so it could be it could be that there that there could be a component of arthritis.

Sometimes the cold weather makes it worse.

Uh most people like to keep it warm.

Uh but yeah, it's a possibility, but again we need to make sure that we evaluate uh um our patients.

And we talked about that a little bit before the show that changes in weather.

Well, how does how do changes in weather affect joint pain?

Well, we speculate that it's going to be the changes in the barometric uh pressure and our patients tell us.

So, I believe that they have to feel something when we have our strong uh winds coming through.

Excellent.

Uh Dr.

Wyatt, a caller is wondering about Nabumatone for the treatment of arthritis.

Is that an effective treatment?

Boy, that's not that is not something I have ever sent out of the ER.

Nabumatone [laughter] is an anti-inflammatory medication and NSAID.

Uh so it is like uh ibuprofen, al leave, motrin [clears throat] um it can be very effective but remember side effects of anti-inflammatories like nabumatone include stomach ulcers, include kidney damage, if you worsening of your hypertension, you cannot take them if you're taking a blood thinner.

So they can be effective but we'd like to be cautious with them because they have a lot of side effects that can come with them.

Excellent.

Uh Dr.

Allan, a a caller is wondering, caller from Grand Rapids actually, stationary re recumbent bike as an alternative to walking during the winter months.

Is that an effective alternative?

Great question.

Yes, absolutely.

Especially up here in the Northland where we say, "Hey, go outside and walk."

Actually, you just slipped and broke your hip.

You know, so um it's really Yeah, our doctor is laughing.

Uh sadly, we don't want anyone to break.

Please wear ice spikes and be careful, guys.

the um recumbent bike or any kind of thing, any activity whatsoever is going to be great.

We were talking before the um show about how yeah, low impact exercises like biking, like swimming are really good for joints and good for um strengthening of the legs.

So, I would absolutely recommend uh stationary bikes in the winter time.

Yeah.

Yeah.

And I'm I'm a fan of stationary bikes, too, because it's it is low impact, like you said, and it's not doesn't have that repeated like impact on the joint when you're exercising or running or something like that or walking.

So, well, thank you.

Um, Dr.

Fernandez, this is a great question.

I think are there dietary recommendations for 80 year olds with hip pain?

Can a change in their diet help treat their pain?

All right, so we're not just going to limit to our 80 year olds.

So, the answer is yes.

[laughter] The answer is yes.

So, uh, we do think that there is such a thing as a healthy anti-inflammatory diet.

So, we're talking fruits and vegetables.

We're talking low carbs.

We're talking low sugar.

We're thinking not a whole lot of uh meat products, processed foods.

So, those are all things that can that can help our patients have less pain in their joints.

Uh, some people feel that it's gluten, some people feel that it's dairy.

And I don't have an objection in people trying certain things, but I think it's important that we're young, starting to make sure that we have a healthy diet because if we start this when we're younger, we'd have a much better chance of having good joints when we are in our 80s.

So, not limited to our 80 year olds.

All of us should be doing that, right?

And a big part of that is maintaining a healthy weight, eating a healthy diet and not overloading your joints.

Yeah.

And another question that's come up in my practice is GLP1s.

Dr.

Alan, GLP1s for the treatment of of arthritis.

Yeah, GLP-1s are a big hot button issue right now or at least topic and all across medicine and all across our society.

Um, GLP1s have been shown to be incredibly effective for decreasing arthritis or at least arthritis pain uh in the knees for a lot of patients.

The biggest problem with GLP1s is that they're new and we don't know what the long-term effects of them are going to be.

We are uh concerned that it might lead to bone problems.

We've definitely seen muscle loss in a lot of patients.

So, anytime anyone starts a GLP-1 or I start anybody on a GLP-1, I always walk through what a what a strength training recommend uh uh strength training regimen is going to look like for them.

Um, and then I make sure that we talk about a high protein um good nutrition diet.

Uh because yeah, it might help with your joint pain now, but also we want to make sure that it's not going to cause problems down the road.

So, good medicines effective for weight loss.

Incredibly effective.

Still not really 100% certain about the long-term effects, but there's a lot of studies going on that may even help people with inflammatory arthritis, but it's just we're not there yet, right?

Getting close, but not there yet.

Dr.

Wyatt, uh, what imaging do you do to diagnose arthritis?

Depends on the type of arthritis.

Generally, we like to start with X-rays because looking at the surface of the joint, the articular surface can tell us a lot about whether it's been worn down.

Is it an osteoarthritis or a bony arthritis in someone that's old that's just the joints worn out, right?

It's like a tire that's the treads are worn down.

Or are there changes that look more in line with immune activity that could be more of a a rheumatoid arthritis or something of that nature?

Um, or is it that you have a small break, a small fracture there that you didn't know about, that you've been walking on for a long time and hasn't healed properly?

Those are all things we can identify with X-rays.

Depending on the joint, we may also use CTS, MRIs, even ultrasounds, depending on where the area is, and that can help us make a better decision what the the joint itself looks like, can help inform how we treat it.

Well, thank you.

We have about a half a minute left.

Uh, Dr.

Allan, when a caller from Superior is wondering, when you have the sensation of your hip slipping out of the joint, is that temporary or permanent and should I see a doctor for this?

Yes.

Uh, but more importantly, I think like we are physicians, we are here talking about the medical stuff.

There is a whole slew of other health care professionals out there that are awesome.

And this is a circumstance where I am going to rely heavily on my physical therapist friends who will help you strengthen the right muscles to keep your leg where it needs to be.

All the physical therapists out there, I hope your pillow's cold tonight because you deserve it.

Yeah, it's great.

So, another caller is wondering, "What lifestyle choices can I make to prevent arthritis?"

And I think we've touched on that at length.

The the genetics that we're given Yeah.

can't change that.

I would say for the rheumatoid arthritis population particularly if you have a family member with rheumatoid arthritis is make sure that you have good teeth because gingivitis seems to be a trigger and do not be a smoker because that also is a trigger.

Those are the two things that we have control of that can help lower the risk of rheumatoid arthritis in patients who have family history.

So well thank you everybody.

I appreciate it.

I want to thank our panelists Dr.

Jay Allen, Dr.

Anna Fernandez and Dr.

Dylan Wyatt and our medical student volunteers, Ava Hill, Lauren Marshall, and Ian Ross.

Please join Mary Mohouse next week for a program focused on exploring the emotional and behavioral challenges facing children and families today with a round table of local mental health professionals.

Thank you for watching.

Good night.