Hi, I'm Dr.

Chrisa Kaidy, a hospitalist with Aspirus St.

Luke's and faculty member in the department of family medicine and biiobehavioral health at the University of Minnesota Medical School here in Duth.

I am your host for this episode tonight on care and treatment of the lower extremities.

The success of this program is very dependent on you, the viewer.

So, please call in with your questions or send them in to our email address askpbsnorth.org.

Our panelists this evening include Dr.

Kenji Sudo, Essentia Health, Dr.

Katherine Schnell, Orthopedic Associates, and Dr.

Joe Signarelli, Tamarak Health.

Our UMD medical student phone volunteers tonight are Jessica V Bratton from Newfolden, Minnesota, Elizabeth Lizzyrandle from Sartell, Minnesota, and Matthew not Matt Chanel from Alura, Minnesota.

And now on to tonight's program on care and treatment of the lower extremities.

Welcome friends.

Glad to have you here.

Um why don't we start with you telling our audience something about yourself maybe your practice and anything you want PBS North to know.

We can start with you Dr.

Sudo.

All right Sudo and I work at Essentia and in medical orthopedics.

I've been practicing for almost 20 years now.

So feel like I'm a local here in very good Katherine.

I'm Dr.

Katherine Schnow.

I work at Orthopedic Associates.

So I'm one of two foot and ankle surgeons there.

Um, it's a private practice which is great.

Originally from Duth, so it's nice to be back.

I've been here just under eight years.

Nice.

Dr.

Signarelli.

And I'm Joe Signarelli.

Born and raised in Duth.

Um, I work at Tamarack Health, small uh independent healthcare organization out of northwest Wisconsin that serves the whole Arrowhead region.

Good.

And I'm an orthopedic surgeon and uh arthroplasty surgeon.

So that means I just spend my whole career taking care of patients with uh hip and knee replacement needs.

Very good.

So, you just do the lower extremity specifically?

Yep.

Just those perfect those two surgeries over and over.

Awesome.

Okay.

Well, I thought we would get started.

I'm gonna go out on a limb and I'm going to I'm going to ask you guys if you could answer the question that I'm asked a lot.

Couldn't can running give you knee arthritis?

Maybe I'll ask you that.

Do you want to answer that?

I can start.

And it is a common question.

I think it's one of those where you think that with running depending on the running but usually it's marathon running that people are talking about and overuse activity definitely does cause more wear in a joint but when we talk about activity we want people to be active and to be doing things and so running itself it keeps you in shape if you're um have good technique and you're able to run well well it shouldn't cause issues if you're somebody who's just starting to and you're older, you're overweight, you might not have that strength that may not, you know, be the best for your joints.

So, it's kind of individual person depends on if that's good or not.

Thank you.

That gives me reassurance from all my running.

Dr.

Snell, I have one for you about the foot.

So, the foot is such an interesting little appendage.

It's got 26 bones, I think.

So, that gives you 52 total, which is a fourth of your bones.

Yep.

So tell me what is the most common injury you see with feet or pathology?

Um I guess probably the largest one for foot um and ankle stuff just in general and you might attest this too is there's a lot of planer fascitis and back to activities a lot of heel pain that comes in.

That's probably one of the more common ones people are getting back into activity or there's a different shoe gear that comes up um that they want to try out or change um and they might go at it a little bit too fast um or maybe they start a new running routine um and they don't kind of ease things into it.

Um, that's a really common one that we see.

Good.

So, let's go into that a little more.

That's a perfect topic.

Let's talk about planter fasciitis.

If I'm your patient, how would you treat me?

I plant.

So, most people are coming in.

The most common symptoms are pain with first steps in the morning.

Um, again, the change in activity that's usually there.

Maybe they have old shoes and they threw on their old running shoes from last year and they're getting out training again.

Um, so what I'm checking for just kind of in general is if they're having a really um tight planter fascia, a tight band in the bottom part of the foot.

Um, I'm also checking, we're also making sure they're not having a stress fracture.

Usually that's a squeeze kind of of the heel where they'd have more pain.

I'm also looking at contributing factors that might be um a tight calf muscle that we need to stretch out.

Um, and they usually have a lot of pain right at the bottom part of the heel and it's it's pretty easy actually to diagnose it.

Good.

Yeah.

Thank you.

We can't leave Dr.

Signarelli out.

So, I'm going to ask you a few questions about as a surgeon, um I'm assuming there's a lot of our our um viewers that have a lot of orthopedic issues regarding their their hip and their knee.

How do you assess a patient and how do you know when they need a surgery?

Uh it's a great question.

I think uh it's a whole spectrum of care and Dr.

Pseudo, you know, in the sports medicine side of things, I think, sees a lot of people early in that spectrum and I tend to see him later.

uh during their course of care.

But in general, uh I think it's always best advice if you can if you can keep your own hardware and keep your own joints, that's the best.

And so the first line of treatment is always how can we maximize non-operative management to keep your pain under control, keep your function where you want it to be.

It's really only when you get to a point where you do have pain that bothers you on a daily basis.

You can't do the things you want to do and need to do, and it really starts to interrupt important parts of life like like your ability to sleep.

And we've exhausted all non-operative options.

we really talk about replacement options.

Good.

Um Jim from Hibbing asks, maybe we can expound on this.

He asks, "What are the main reasons to get a full knee replacement?"

I guess maybe he's talking about pathology that leads to it, what kind of arthritis, that kind of thing.

That brings up a couple topics.

There's uh just in the question, he mentioned full knee replacement.

So there are different types of knee replacements.

There's a partial replacement, there's a total replacement.

About 80% of uh knee replacements in the United States are done as a whole replacement where you're replacing all three major parts of the knee, but about 20% are partial replacements where if you just have one part that's worn out, you can just replace that part of the joint.

And really again, that the reason that you would proceed to such a drastic step as as a as a major surgery would be if you've tried to optimize non-operative management.

That includes things like over-the-counter medications.

uh to Kenchi's point, staying in good shape and and making sure that you're taking the best care of your body that you can and that includes strengthening programs.

The stronger the muscles are around the joint, the more the force goes through the muscle, the less it goes through the joint, like putting better shocks in your car.

Good.

Um there's a question that asks, can you run on a knee replacement?

I'll I'll uh I'll take that one.

Uh can you and should you?

I think two different questions there.

So, uh, there's only a couple of things that we really, I would say, as an arthroplastier joint replacement community would would pretty uniformly say are not the best idea after a joint joint replacement.

And that's really a conversation you have to have before you have surgery.

So, if someone's an adamant runner and they really want that to be part of their life, they should make sure that they're doing everything they can everything they can to keep their their knee prior to replacement.

But, um, the repetitive impact of running is one of the few things that uh over a long period of time can uh cause problems like a loosening of a joint replacement.

So there's so many other low impact activities like uh biking and swimming and uh elliptical machine or anything where uh you don't have that pounding is probably a better uh activity to do long term really heavy power lifting which which puts a lot of torque and and stress on the joint is probably the one other thing that we would uniformly say is not the best idea after a joint replacement.

That makes sense.

All right.

Well, let's stick with the knee.

There's a question about what is a Baker's cyst and maybe Dr.

Pseudo can answer that.

And how is it treated?

Yeah.

So, Baker cyst um in the joint when you start getting some arthritis or somewhere in the joint, the body reacts and it wants to protect itself and it does things to try to protect what the joint is and it starts making extra fluid in the joint.

And when you start making extra fluid, then you start building up more and more fluid within a joint and it has to go somewhere.

So, that pressure then can lead to these different cysts that we see in different joints.

And so a Baker cyst is behind the knee where the fluid leaks behind the knee and um you can get these pockets of fluid that feel like some pressure behind the knee.

Most of the time the cyst isn't necessarily the problem.

It's the arthritis or the things that are causing the extra fluid in the knee that cause the cyst or the baker cyst that's behind the knee.

So similar to treatments that we do for arthritis, that's kind of the main treatment for bers or this baker's cyst.

So things like physical therapy, exercise, um trying to protect the knee with activity and trying to keep the fluid down.

And so with that, that's the main part of the treatment.

A lot of people ask, well, is this something that can be drained or can we remove the cyst?

One of the problems is that's just a pocket of fluid that's there.

So if we drain the cyst, a lot of times it'll fill up again.

So again, the most important thing is treating the cause of what's causing the cyst.

And why is it called a baker cyst?

Well, do we know that?

Anybody is do bakers get them or was it a Dr.

Baker?

Dr.

Baker.

All right, let's go with that.

Total guess.

All right, I have a podiatry question for you, Dr.

Schnell.

Pain in the left great toe, redness in the joint, and worse with walking.

What causes this?

Wayne wants to know.

Okay.

All right.

Good question, Wayne.

So, I mean, a couple different thoughts.

Um, a lot of it, if it's some type of overuse, um, type of a thing, could be fulfill could be something like a stress fracture.

um you don't want to rule that out, but most likely sounds like it's some type of arthritis um that's causing that.

Sometimes if there's more redness um could be a type of arthritis called gout um that you would want to do some medical management for as well.

Um otherwise it's really just stiff sold shoes to kind of help with that surgical options.

Um there's just like the knee, there's little tiny joint replacements you can do, not always favorable at that that joint.

Um or joint fusion options or bone spur removals.

Um, and I consider that after a series of injections and other conservative options first.

Sure.

All right.

Um, question.

There's um actually two questions about muscle cramping.

So, I think we can go there.

Let's talk about that.

What causes muscle cramps and um specifically someone is wondering if they're having cramping of their feet?

If there's something we do.

So I I mean that's I guess we could talk about cramping in general and then if there's any specific you want to field that one for me.

Yeah.

So cramping I think the hard thing is again like we're talking about vakerysis.

What is causing the cramping the source of the cramp?

When we talk about cramps people think okay the muscles end up getting very tight but there's a lot of different reasons to have cramping.

One can be just an electrolyte imbalance.

One can be the muscle just being overworked and then gets tight, especially at night or when people aren't at rest.

Um, and so those are kind of the main two things.

Some people can have a deficiency in magnesium or some people have just things at night, restless leg syndrome or other types of syndromes that can cause muscle spasming.

And so I think as a you know general question, what is cramping or how do you treat the cramping?

First is trying to figure out what causes cramping.

That's true.

And sometimes it's just idiopathic.

We can't figure it out.

Comes from the stem root word for idiot.

All right.

Um, do you want to feel any No, I think I would echo everything that was said.

Just trying to figure out the root cause of it.

Um, and then getting things, you know, stretched out, whether that's physical therapy, you know, some other something else to try.

Sure.

Um, okay.

Question about hips.

Um, it's can hip pain present like back pain and how do you decipher the difference?

Maybe we'll ask our surgeon.

Yeah, that that's where I spend uh a lot of my time in clinic is helping people sort through those two problems.

If if you really think of like this as hip pain and this is back pain.

They're they're two syndromes of pain that don't really live in isolation, there's often so much overlap between the two that it can be very very difficult to figure out is this pain really coming from your hip.

Is it coming from your back or do you have a little bit of both?

Um I think it's uh it can be very convincing to someone that they have hip pain and that the problem is in their hip because that's what they feel.

But if you pinch a nerve in your back, the signal that gets sent to your brain saying, "I have a problem with my hip there, that that nerve doesn't know if that pain is coming from a pinched nerve in the back or from the the nerve that supplies the hip joint."

So, it can be can be a really tricky task, but it's uh unbelievably important.

The last thing you want to do is go through a major surgery like a hip replacement, find out your pain's not better because that wasn't the problem in the first place.

For sure.

Good.

I think that's something that we run into all the time is again that's why people come to see the specialist and say is this really the diagnosis is this correct or not and when I look at orthopedic problems I think of you know different pockets or categories and so there's typically six things I'll say six but I have five fingers because that sixth thing is kind of the general everywhere else right I got it and so you know a big thing is one is this the bone that's causing problem is the joint that's causing problem.

Is it um some type of a tissue issue, muscle issue, is it a nerve problem or is it a vascular problem?

And so those five things if we can try to sort out and the hard part is that a lot of people have multiple of these five things and the last thing would be this kind of overarching is there infection or other things that might be there and so and Dr.

Signali was saying that okay you have these two pockets that are there but a lot of people have both going in at the same time.

So, it's trying to figure out which is causing most of the pain at that time.

Good.

Um, there's a we're getting a lot of questions, which is wonderful.

So, maybe let's um have a short answer on bunions.

This is a good one.

Um, if you have bunyions, does it automatically need mean that you need surgery?

And how long is the recovery?

And what are some of the uh alternative treatments for bunyions?

Yep.

So, bunyions pretty common.

Um, mostly alternative treatments and conservative stuff is a lot of times supportive shoe gear or wider shoes.

Um, I always tell people take the insert out of the shoe and stand on it.

And if you're going on both sides, over overflowing on both sides, need a wider shoe.

Um, sometimes like a stiffer insert is helpful as well.

Um, sometimes people will confuse a bunion with more of that arthritis and the big toe that we talked about.

So, kind of deciphering between the two of those.

Um, if there's more arthritis type symptoms, again, we could try injections into the joint.

And then bunion surgery really depends a lot on where you're having a lot of your pain.

Um kind of the full full exam of the foot and how much mobility is there.

Um as well as X-rays.

So I get X-rays on all bunions to figure out um exactly what we're doing for surgery.

Um and then the recovery from different types of bunion surgeries are usually very different.

Um so that can range to you're just in a stiff sold shoe or insert for a couple weeks just getting incisions to heal to you're walking in a walking boot.

um or you're completely off of it if we're doing larger fusions or different types of things to correct that that structure.

Um and then we always I always take a look at people when they stand to see if they have a flatter foot structure that's contributing or something else that may be contributing or causing and contributing to that bunnion to make sure that gets addressed.

Good.

Very good.

All right, we're going to move back to the knee.

We're all over the place because I have so many questions which I'm so grateful for.

Um Diane from Pike Lake asks for constant knee swelling that isn't arthritis but hasn't been diagnosed.

What's the next step for Diane?

What do we do or whomever Diane is calling on behalf of?

Yes.

Well, I think the first thing is definitely getting looked at and seeing what type of swelling is going on.

When we talk about swelling in the knee, there's lots of different pockets or areas within the knee that can get swelling.

If it's not necessarily arthritis, it could be things like a berscitis.

It could be um a different pocket on the front of the knee that we see quite a bit of patella bcitis that can cause some swelling that's there.

The other parts of the swelling is is it lower down in the leg?

Is it something that is causing swelling on both legs or not?

Could be something different as a circulation type of an issue.

That's a good intern workup actually.

Yes.

So yeah.

So what type of swelling I think is first to determine what that is, right?

That is true.

All right.

Good.

Another one for Dr.

Signarelli.

How long do hip replacements last?

Uh that that's a great question and uh I I think when someone gets to the point of having a joint replacement, they're really looking at it as a long-term investment.

And thankfully of the advances that have occurred in joint replacement over the last couple of decades, the longevity of joint replacement is is one of the big success stories.

Um the really the best way to look at it is kind of when do they fail?

And there's two pockets of failure with joint replacement.

There's getting through the recovery process of surgery.

So basically, if you make it through the first 12 weeks and you don't have a problem, then hopefully it lasts for uh decades.

And so we're really trying to get patients as healthy as we can to get through that first uh um kind of window of of risk.

And then the longer end of things, joint replacements tend to fail at about 1 half% per year.

So an easier way of looking at it is if you go out 20 years, about 90% of joint replacements are doing fine.

We have information now out to close to 25 years showing that people are really doing well.

Most of that has been adv advancement in the plastic liner that uh is part of the articulation where they've made some really significant advances over the last couple of decades.

Oh, I I learned something.

That's very good.

I didn't know the failure rate.

So, question also um I was thinking about um I was we should probably talk about before a joint replacement sometimes we do injections and there's a question about injections.

Could we go through the different things that we put in joints that might help and why we do them and maybe just stick to the big categories like steroids and cartilage, you know?

Yeah.

To take it take it from several years things have really changed.

Um, you know, one thing that people talk a lot about is cortisone injection and you know for years that was a mainstay injection that people would use for decreasing inflammation in the joint.

The problem with cortisone is that it doesn't fix arthritis.

It doesn't slow it down.

doesn't stop arthritis.

It's an anti-inflammatory.

And one of the issues is that well, you can get more arthritis from cortisone.

A couple reasons.

One is your joint feels better and you do things you probably shouldn't be doing.

The other is that just cortisone itself can be irritating to the joint or to the cartilage as well.

And so getting cortisone injections frequently and really close together, we know is a really bad thing for joints.

And so that again when we use cortisone we really have to be cautious or careful of why we're using it and how often that we're using it and also has other effects within the body that your own body produces certain types of cortisone.

And so if you get too much exposure to an artificial cortisone then your body gets tricked of saying oh well I don't need to produce my own cortisone.

So there's a lot of side effects or problems that can come with that.

So we be careful with that.

Um, other injections though that have been coming out, people talk about the hyaluronic acid injection.

Used to be made out of rooster comb, so people call it the chicken shot.

And so it's a pretty common one that we use and it's a lubricant that's put in the joint.

It's uh it's commonly used.

It's one of these that are typically very expensive.

So we want to make sure that we're using, you know, the the proper medication.

Insurance covers these things, but it's not 100% as far as that these things will work.

Um people are getting into other types of injections.

Uh you hear about stem cell injections or platelet injections and the research out there is still uh you know limited as far as the benefit of it.

We know that with stem cell injections we're not growing new cartilage.

It's that's one of the things that people think is that medicine is far enough along where you can grow a new joint by injecting something in there.

And so we're not there yet.

There's research on that.

But yeah, stem cell injection isn't all of a sudden you get a new knee by doing this injection, right?

And so those are kind of the main ones that are out there.

There's another question that asks if it would be useful to do an injection if you're feeling well as like a prophylaxis.

Uh that's again going back to the question where you want to be really cautious or careful of why we're doing shots because they do have side effects and they can cause more problems down the road.

So you have to be very careful.

If you don't mind, I'm going to steal the show a little bit.

As an internist, I would plug that.

Um, of course, it could raise your blood sugar, raise your blood pressure, all of those squle of the things that we do because our tools are not always benign, the things we do to patients.

So, we must think about the whole picture and our patient.

And that's the whole thing with these injections is it's just a part of the treatment.

It's one little tool, but the other more important things are things like the physical therapy or activity modification, sometimes even different braces that we use as far as a non-surgical treatment.

Sure.

I would I would totally echo that point.

I think that's important to just look at injections as uh is really kind of a second line treatment.

We should be doing all of the I think any intervention that has some real promise of helping with little to no risk are the things that we should be focusing on and then the things that have the most evidence behind them.

So there are what I call PRL uh clinical practice guidelines which are kind of the um a distillation of all the research that's been done in a field and gives uh physicians and providers a framework for uh what we should be doing uh for our patients and things like physical therapy uh weight maint uh weight uh management and uh use of anti-inflammatories are really first-line treatments and we should only be looking at injections as a second line treatment.

Okay.

There is a going off of that too as far as the weight management.

I think that was a a big hurdle and issues that we would run into as far as trying to treat arthritis.

But now there are so many more options or opportunities for weight loss even with medication and different treatments as you know.

Yes, that I see that in clinical practice all the time.

I think we should maybe talk about that a little bit.

Are there anything any rules that you have for your patients to for for example lose some weight before they can get their surgery?

Do you there is a question asking about like what is the incidence of needing a joint if you are overweight and and so I wonder could you talk about do yeah it's a great great question.

I think, you know, on a on a program where we're talking about lower extremity, it's it's important to talk about overall factors that affect whether it's the foot, the ankle, you know, all the way up all the weight bearing joints that they're very susceptible to additional force and weight.

And so, I think there's very strong evidence that uh um struggling with high body weight over a long period of time definitely decreases the longevity of our natural joint and replace joints as well.

So, not only does it make it more likely that someone needs a joint replacement early in life, but how long that joint replacement lasts can be up to a decade shorter based on body weight.

So, um I I think we're we're getting to a healthier place in medicine where we can really talk about the overall impact of of weight on somebody's health and how we need to be advocates for overall health.

and I may be a hip and knee replacement surgeon, but really what's important is to get a patient healthy uh hopefully to avoid surgery in the first place or so that if they have surgery, they're at lower risk because all the risks associated with um with hip replacement are marketkedly elevated if somebody is not as healthy as they could be going into surgery.

So, there's been a big emphasis on what's known as medical optimization and trying to get a patient as healthy as they can going into surgery.

Right.

And often, do you ever hear I'll hear from a patient, they'll say, "I can't lose weight because I need a new knee."

Yeah.

And that's such a um misunderstood or I like a myth, you know, we're going to get the new knee, we're going to exercise our weight off.

And um I think now with some of our new tools, it gives us more hope for helping our patients when we have something to offer them so that they can lose the weight and enjoy the new knee, but not rely on a new knee as a way to lose the weight.

Yeah, that's that's an important uh important kind of fact about joint replacement is I think a lot of people they kind of see the chicken or chicken or the egg issue.

I can't lose the weight until I have the joint replacement.

And I think one thing we can say is joint replacement in itself without lifestyle changes is not a good form of weight loss.

Patients are actually more likely to gain weight rather than to lose weight if they don't make other lifestyle interventions.

So again, I think it's very important to look at uh overall health maintenance as a way to avoid needing surgery in the first place as well as to incorporate into joint replacement as part of kind of overall body care.

Good.

Well, we're coming to the close of our show now and so I'm I'm going to have a public service message and ask everyone to be careful tonight because it is a very icy night and we'd hate to have you break a hip.

So I want to thank our panelists.

Um we have Dr.

Katherine Schnell, um, podiatrist, Dr.

Joe Signarelli, orthopedic surgeon, and Dr.

Kenji Sudo, sports medicine physician.

I've enjoyed all of you very much.

Please join Doctors on Call next week where Mary Mohouse will be joined by regional experts for a panel discussion about mental health and healthy boundaries with experts from around the region.

And if you're look looking for more tips, tricks, and conversation around health and wellness in the Northland, make sure to check out Northern Balance on the PBS North YouTube channel.

Thank you for watching.

Be careful and join us for session 70 or sorry, 44 of Doctors on Call.

Have a good night.